Many service providers will submit accounts for you. However, whether they do or not, you’re ultimately responsible for submitting your accounts. Regularly check your claims statements thoroughly to stay informed.

Your claim should include the following information:

• Your name and initials
• The patient’s name, as shown on the membership card
• Your membership number
• The treatment date
• The amount charged
• The tariff code(s) (where applicable)
• The ICD-10 code(s)

Members on the Essential Option who see a specialist must also ensure that the referring GP’s name is included.

If you’re submitting the claim, email, post, or deliver a clear and easily readable copy to the Scheme as soon as possible. Send a detailed invoice—please don’t send statements.

If you’ve already paid the claim, attach your receipt and mark the account “PAID.” Your claims statement, received when the Scheme processes a claim for you during that month, is important. Like a bank statement, it shows payments made to you or for you, with explanations of the various pay codes, so you understand why something may not have been covered.

You can submit your claims through the following methods:

• Email: claims@sabmas.co.za
• Post: PO Box 10436, Johannesburg, 2000

The Scheme has two statement runs per month for both members and suppliers; however, claims will be paid weekly.

• Accounts charged equal to our tariff will be paid directly and in full, once benefit rules have been applied, to the supplier.
• Accounts charged above our tariff will be paid directly to the provider at the Scheme Rate. The member will be liable to cover the difference between the Scheme Rate and the amount charged by the provider, in line with the Scheme Rules per Benefit Option.
• Accounts with a receipt to prove your payment will be refunded to you.
• Any co-payments owed by you to the Scheme will either be deducted from available savings (Comprehensive Option), deducted from your salary, or alternatively, deducted by debit order if you are a self-paying member (Comprehensive and Essential Options).
• However, if you are due for a refund, any co-payments that you make in the same payment run will be offset against the refund.*

Refunds are paid into your bank account because it is safest that way, so always inform the Scheme of any changes to your banking details.

To minimise out-of-pocket payments:

• Submit a clear and easily readable copy of your claim to the Scheme as soon as possible.
• Check which of your benefits are limited and whether you have available limits.
• Read your statements to understand the reasons why claims have not been paid, and contact your health professional if necessary to amend the account.
• Review your brochure to understand when you may need to pre-authorise your procedure.
• Minimise shortfalls on your claims by visiting your nominated GP on the Essential Option and use the “Find a Healthcare Provider” tool on www.sabmas.co.za to find a health professional we have an agreement with.

Please ensure your bank details are accurate to facilitate refunds to the correct account.