Affinity Claims Process: How to submit

When utilising your health insurance to pay for your doctor visits and procedures, there is a particular process you will need to follow. Many people confuse the action of claiming from medical insurance with claiming from a medical aid cover to foot the bill at the hospital or surgery. 

The amendment to the Demarcation Act explains the difference between medical aid and medical insurance.

WHAT IS THE DIFFERENCE BETWEEN MEDICAL AID AND A MEDICAL INSURANCE CLAIM?

The Medical Schemes Act of 1998 regulates medical schemes, so by law, they must pay for the treatment of 270 prescribed minimum benefits (PMBs). This applies to patients who have an expensive comprehensive plan or a standard hospital plan. Medical Aid schemes are also liable for the treatment of 26 chronic conditions. So when you claim from medical aid, the scheme will pay the hospital directly, depending on the scope of cover and whether or not the patient received pre-authorisation.

Medical insurance focuses more on significant life events such as incidents of a stroke or heart attack. It covers accidental injuries, paralysis or illnesses that may occur after you have taken out the insurance, although it won’t necessarily cover pre-existing conditions. 

Different forms of treatment also have different claims processes when it comes to medical insurance. 

WHAT ARE THE DIFFERENT AFFINITY CLAIM PROCESSES?

There are many reasons you would need to claim from medical insurance: hospital visits, specialist consultations and day-to-day GP visits are but some of them—Call 0861 11 00 33 for assistance when obtaining pre-authorisation in each of these instances. 

Claim for GP Visits

General practitioner visits also need pre-authorisation. In the event of visiting a doctor who may not be on the Affinity Health network, you will need to pay the full consultation fee upfront. You can then claim up to R250.00 back from Affinity Health.

For assistance with reimbursement, please email the detailed account and a signed Affinity Health reimbursement form to claims@affinityhealth.co.za.

Out-of-network GPs are unfamiliar with cover rules, which means that they are unaware of exactly which medication is covered. Using an Out-of-Network GP may increase the chances of having to pay excess for medicine.

Network doctors can claim directly from Affinity Health. The practice may charge additional administration fees, which cannot be recovered from Affinity Health. These will be for the member’s account.

Procedures conducted in the rooms of Affinity Health network doctors are also covered, provided you have obtained pre-authorisation.

BUT WHAT IF I NEED TO SEE A SPECIALIST?

If you need to consult a specialist, you will have to get a referral letter from your GP, for the consultation to be eligible for cover by Affinity Health. Once you have your referral letter, you will need to call to get pre-authorisation before the actual consultation.

Bear in mind that only certain specialists are covered, who may require an upfront payment of the consultation fee. This can be paid by the member and claimed back from Affinity Health according to the maximum benefit amounts.

If no upfront payment was required, please ensure that the specialist’s account is sent to Affinity Health to claim benefits.

Should you be required to pay upfront, please email the detailed account and a signed Affinity Health reimbursement form to claims@affinityhealth.co.za.

AFFINITY HOSPITAL CLAIMS

The most requested information is how to claim from medical insurance when admitted to hospital. As previously mentioned, it is not the same as when you claim from medical aid. In the case of medical aid, the hospital will lodge the claim directly with the scheme and get the payment directly too. With hospital cover, the insurer will pay a set portion of the cost. The patient is still fully liable for the bill and will need to claim from the insurance to pay the hospital. 

As always, pre-authorisation is required before going into hospital. Affinity Health has a 24-hour hospital pre-authorisation line. 

GET YOUR AFFINITY CLAIM DOCUMENTS IN ORDER

Illness and planned admissions generally require specific documentation. You can email the admission letter, quotes from the treating provider and facility, pathology and radiology reports and a signed cession form to auth@affinityhealth.co.za.

For planned admissions, please contact Affinity Health at least 48 hours before the procedure/admission to ensure authorisation.

Affinity Health cannot pay any accounts without a signed cession form. Please remember to send it over to us!

Members should contact Affinity Health after admission to ensure that everything pertaining to their specific case is updated on the system to secure a smooth, hassle-free claims procedure.

Please email all related accounts to hospitalclaims@affinityhealth.co.za within 120 days of discharge.