Medical Schemes Act, 1998 (Act No. 131 of 1998)RegulationsRegulations in terms of the Medical Schemes ActChapter 2 : Administrative requirements6. Manner of payment of benefits |
| 1) | A medical scheme must not in its rules or in any other manner in respect of any benefit to which a member or former member of such medical scheme or a dependant of such member is entitled, limit, exclude, retain or withhold, as the case may be, any payment to such member or supplier of service as a result of the late submission or late re-submission of an account or statement, before the end of the fourth month— |
| a) | from the last date of the service rendered as stated on the account, statement or claim; or |
| b) | during which such account, statement or claim was returned for correction. |
| 2) | If a medical scheme is of the opinion that an account, statement or claim is erroneous or unacceptable for payment, it must inform both the member and the relevant health care provider within 30 days after receipt of such account, statement or claim that it is erroneous or unacceptable for payment and state the reasons for such an opinion |
| 3) | After the member and the relevant health care provider have been informed as referred to in subregulation (2), such member and provider must be afforded an opportunity to correct and resubmit such account or statement within a period of sixty days following the date from which it was returned for correction. |
| 4) | If a medical scheme fails to notify the member and the relevant health care provider within 30 days that an account, statement or claim is erroneous or unacceptable for payment in terms of subregulation (2) or fails to provide an opportunity for correction and resubmission in terms of subregulation (3), the medical scheme shall bear the onus of proving that such account, statement or claim is in fact erroneous or unacceptable for payment in the event of a dispute. |
| 5) | If an account, statement, or claim is correct or where a corrected account, statement or claim is received, as the case may be, a medical scheme must, in addition to the payment contemplated in section 59(2) of the Act, dispatch to the member a statement containing at least the following particulars— |
| a) | The name and the membership number of the member; |
| b) | the name of the supplier of service; |
| c) | the final date of service rendered by the supplier of service on the account or statement which is covered by the payment; |
| d) | the total amount charged for the service concerned; and |
| e) | the amount of the benefit awarded for such service. |