How to claim Anglo Medical Scheme

Name of the Organization : Anglo Medical Scheme
Type of Facility : How to claim Anglo Medical Scheme
Head Office : Rivonia

Website : https://www.angloms.co.za/portal/

How to claim Anglo Medical Scheme :

** Here you will find everything you need to know about how to claim for medical services that you have purchased, which information you need to include and where to send your claims to.

Related : Profmed Medical Aid’s Claims Procedure : www.southafricain.com/3111.html

** To find out how to claim on Value Care Plan.
** To find out how to claim on Standard Care Plan.
** To find out how to claim on Managed Care Plan.

How to claim Value Care Plan :
** Value Care Plan members belong to a network plan and may only use Prime Cure facilities or Prime Cure network healthcare providers, or both. Prime Cure pays these healthcare providers to provide you with healthcare services. You do not have to pay any accounts unless you have not complied with the Rules or use a healthcare provider outside the network in an emergency.

If you receive healthcare services outside the network for an emergency, submit your claim and proof of payment to the address below:

Email: anglo AT primecure.co.za
Post :
Prime Cure Health Claims,
Private Bag X13,
Rivonia, 2128

What you may not claim for :
General Scheme and Value Care Plan exclusions :
** The following are some of the Scheme exclusions (for a full list please refer to the Rules).

These you would need to pay :
** Frail care treatment
** PET scans
** Deep brain stimulator devices for Parkinson’s disease or epilepsy
** Implant devices for chronic pain management

** Polysomnogram and CPAP titrations
** Facility fees
** No cover for medicine not found on the medicine list that is prescribed by a specialist
** Injury or illness that occur beyond the borders of the Republic of South Africa
** Dental extractions for non-medical purposes
** All costs related to radial keratotomy and refractive surgery
** Contact lenses, sunglasses and accessories

The following medicines are specifically excluded unless part of a PMB treatment :
** Erythopieitin (unless the beneficiary is eligible for renal transplantation)
** Interferons
** Biologicals and bio technological substances
** Immunoglobulins
** Roaccutane and Retin-A or any skin lightening treatments

Third-party claims :
** Anglo Medical Scheme Rules state that claims for costs that are recoverable from a third party (for example, the Road Accident Fund, or any other insurance fund) are not payable by the Scheme. However, Anglo Medical Scheme is aware that the time taken for these claims to be finalised can vary from a couple of months to years after the accident or incident.

** As a result, Anglo Medical Scheme will agree to settle these accounts on condition that you provide a letter of undertaking, which states that you will pay back any amount in respect of medical expenses that is recoverable from another source.

** On receipt of this letter, the Scheme will process the claim according to your available benefits and the Scheme Rules.

How do I submit the claim to the Scheme?
** If you settle the account, please insist on an accurate invoice that reflects your payment.
** You can send the invoice and your receipt to the administrator by post or email to the address listed below, and you will be reimbursed directly according to your benefits.

Ensure your claim is valid, you have received the treatment or services you have been charged for and that the following details are correct and complete :
** Full name of main member
** Membership number
** Name of patient (main member or registered dependant)

** Name of provider and practice number
** Treatment date
** Details of the service (tariff code, CPT code and explanation)
** The diagnosis code (ICD-10)
** Proof of payment if you have settled your account.