A medical aid claim rejection can be frustrating, especially when you expected full payment from your scheme. Claims may be rejected or partially paid because of late submission, missing information, excluded benefits, incorrect codes, benefit limits or rules linked to your selected benefit option. Understanding the reason(s) will help you determine whether the claim can be corrected or whether the cost will remain for your own account.
Key Takeaways
- A partly paid or rejected medical aid claim is not always final.
- Some claims can be corrected by the healthcare provider and resubmitted.
- The rejection code(s) on your monthly member statement should guide your next step(s).
- For planned hospital admissions, a hospital admission reference number must be obtained at least 72 hours before admission.
- Your doctor advises on diagnosis and treatment. The Scheme provides guidance on benefits, Scheme Rules and the funding of healthcare services.
- Genesis Medical Scheme members may use any private hospital, doctor or specialist, subject to Scheme Rules, benefit option, Scheme Tariff, limits and exclusions.
What Does A Medical Aid Claim Rejection Mean?
A medical aid claim rejection code means the Scheme has assessed a claim(s) and is unable to pay the claimed amount(s) in full. This may happen for a number of reasons, for example when the claim falls outside your available benefits, was submitted late, contains incorrect billing details/information, or does not comply with the provisions of the Scheme Rules.
What Should You Do First After A Claim Is Rejected?
Depending on the benefits available on your selected benefit option (MED-100, MED-200 or MED-200 Plus), start by referring to the rejection code(s) on your monthly member statement.
If the rejection relates to an incorrect tariff code, modifier, ICD-10 code or dental code, ask the healthcare provider to correct the account. If it relates to an exclusion, limit or no available benefit, contact Genesis for clarity before taking further action.
Understanding Common Medical Aid Claim Rejection Codes
The table below details some of the more common claim rejection codes with some practical examples, as well as possible actions that can be taken (in certain instances) to have these claims amended.
How To Understand Common Medical Aid Claim Rejection Codes
The rejection code on your monthly member statement explains why a claim was rejected, amended or only partly paid by the Scheme. The table below outlines common rejection codes, what they mean and what members may need to do next.
| Rejection Code | What This Means |
|---|---|
| Rejection Code 13: Stale Claim Older Than 4 Months |
A claim may be rejected if it is submitted to the Scheme too late. To qualify for benefits, new claims must reach the Scheme not later than the last day of the fourth month after the month in which the service was provided. For example, if treatment took place in January, the claim must reach the Scheme by the last day of May. If it arrives later, it is treated as a stale claim and will not be paid by the Scheme. The member will be responsible for payment. To reduce this risk, check whether your healthcare provider has submitted the claim, review your monthly member statements from the Scheme and follow up before the claim becomes stale. |
| Rejection Code 16: Excluded Benefit In Terms Of Scheme Rules |
This code means the treatment, procedure, medicine, medical device or service is not covered by the Scheme Rules. When a benefit is excluded, the cost is for the member’s own account. Examples include experimental treatments, medicines or medical devices, or those not registered for use in South Africa; cosmetic surgery; gastric bypass surgery performed for the treatment of obesity; aptitude or IQ tests; sterilisation procedures; all forms of contraception, including the insertion or removal of intra-uterine devices; treatment or surgery for benign skin lesions; and diagnostic tests or examinations performed solely for routine monitoring, or where the results do not diagnose or confirm a medical condition that requires surgery. These are examples only. Members should refer to the Scheme Rules for a full list of exclusions, or contact Genesis when they are unsure whether a service or benefit is covered. |
| Rejection Code 18: Benefit Or Limit Was Exceeded |
This code applies when the available benefit has been used up, when a provider charges more than the Scheme Tariff, or when the Self-Managed Fund, where applicable, has been exhausted. For example, a specialist may charge 200% or more of the Scheme Tariff while the Scheme funds up to 100% of the Scheme Tariff. The member will then be responsible for the shortfall. This rejection does not always mean the whole claim is unpaid. It may mean the Scheme paid the qualifying portion and the balance is for the member’s own account. |
| Rejection Code 19: No Benefits Available |
Code 19 applies when the claim is for a service or benefit that is not covered by the member’s selected benefit option. For example, members on MED-100 or MED-200 may need to pay for certain day-to-day services if those benefits are not available on their option. This may include antibiotics bought at a pharmacy or out-of-hospital GP consultations, depending on the selected benefit option and Scheme Rules. To avoid unexpected costs, members should confirm whether a benefit or service is funded before receiving a healthcare service or other benefit. |
| Rejection Code 21: Invalid Or Discontinued Tariff Code |
Healthcare providers use standard tariff codes, published by the Board of Healthcare Funders, to identify medical services and procedures. If a provider submits a claim using an invalid or discontinued tariff code, the Scheme cannot process the claim. The member should request the provider to correct the tariff code or codes. The amended claim must then be resubmitted to the Scheme within 60 days. |
| Rejection Code 38: Ward Fees Amended For Early Admission Or Late Discharge |
This code may apply where a member was admitted to hospital too early or discharged too late. For example, the Scheme funds a morning admission only where the theatre is scheduled before 2 pm. If a procedure is scheduled for theatre after 2 pm, then only an admission after 12 pm on the same day will be funded. Under these circumstances, costs related to early admissions or late discharges will be for the member’s own account. |
| Rejection Code 65: Incorrect Billing Of Tariff Code Or Modifier |
All claims for services rendered by medical service providers are assessed strictly in terms of the billing rules set out in the Doctor’s Billing Manual (DBM), as published by the South African Medical Association (SAMA) and/or the South African Dental Association (SADA). A tariff code identifies the specific medical service, procedure or consultation that was performed. A modifier is an additional code that provides extra information about the service, such as whether it was performed after hours, was more complex than usual, or involved multiple procedures performed at the same time. When an incorrect tariff code or modifier is used, it means the healthcare provider submitted a claim using a code or modifier that does not match the treatment provided, or does not comply with the billing rules set out in the DBM. Members should contact their provider and request that the billing be corrected and resubmitted to the Scheme within 60 days. |
| Rejection Code 98: Account Information Or ICD-10 Code (Diagnosis) Does Not Match The Admission Or Treatment |
This rejection code is used when a healthcare provider submits a claim for a service that is not related to the primary diagnosis or reason for the hospital admission. For example, if a member is admitted to the hospital for the treatment of pneumonia, but also undergoes a sleep study during the same admission, the sleep study is not considered related to the treatment of pneumonia. As a result, the claim for the sleep study will be rejected, and the member will be responsible for the cost of that service. Amended claims to be resubmitted within 60 days. |
| Rejection Code 106: Co-Payment For MRI Or CT Scan |
This code applies where a co-payment is due for an MRI or CT scan. Members should check their scan benefits before the procedure so they understand what the Scheme will fund and whether an applicable co-payment will be for their own account. |
| Rejection Code 149: Set Benefit Limit Reached |
This rejection code applies to charges that exceed stated benefits, for example crowns, dentures, implants and scope benefits. If the cost of the service or treatment exceeds the stated benefit, the Scheme will pay up to the applicable benefit limit, and the balance will be for the member’s own account. |
| Rejection Code S5: Tariff Code Not Applicable To The History Of The Mouth Part Or Tooth Number |
This rejection code is used when a dental practitioner uses a tariff code that does not apply to the history of a patient’s mouth part or tooth number. For example, this may happen where a claim is submitted for a filling on a tooth that was previously extracted. The correct claim must be resubmitted to the Scheme within 60 days. |
| Rejection Code S8: Tariff Code Not Applicable To The Mouth Part Or Tooth Number For The Procedure |
This rejection code is used when a dental practitioner submits a claim using a tariff code that does not correspond with the part of the mouth or tooth number on which the procedure was performed. For example, if a filling is done on a front tooth, but the tariff code submitted is only applicable to a back tooth, the claim will be rejected. The correct claim must be resubmitted to the Scheme within 60 days. |
How To Fix A Rejected Medical Aid Claim
To fix or amend a rejected medical aid claim, the following checklist may be of assistance.
- Check the rejection code on your monthly member statement.
- Confirm whether the service is covered on your benefit option (MED-100, MED-200 or MED-200 Plus).
- Ask the provider for a corrected account if billing details are incorrect.
- Submit any missing documents requested by the Scheme.
- Keep copies of invoices, statements and correspondence.
- For planned admissions, check that the hospital admission reference number process was followed where required.
If the issue is a billing error, the provider may be able to correct and resubmit the account. If the rejection relates to an exclusion, no available benefit or a reached limit, the claim may remain partly or fully for the member’s own account.
How To Reduce The Risk Of Future Claim Rejections
The best way to reduce claim issues is to understand your selected benefit option before treatment takes place. Genesis offers three core plans: MED-100, MED-200 and MED-200 Plus. Members may access services from any private hospital, doctor or specialist, subject to the terms, benefits and limits of their selected benefit option as specified in the Scheme Rules.
Before treatment, ask the Scheme about available benefits, limits, possible co-payments and whether a hospital admission reference number is required. For planned hospital admissions, this process must be completed where required, generally at least 72 hours before admission.
Ask your provider to use the correct tariff codes, modifiers and ICD-10 codes, and to submit claims as soon as possible (before the four-month deadline).
Get Help Understanding Your Rejected Claim
A medical aid claim rejection code provides the reason why your claim was not paid in full or was only partially paid. Understanding the code is the first step towards resolving the issue, where possible. Some claims can be corrected and resubmitted, while others may remain for the member’s own account.
FAQs
What Does It Mean When A Medical Claim Is Rejected?
It means the Scheme did not pay the claim as submitted, or did not pay the full amount claimed. A rejected claim may need correction, while a shortfall is the balance left after the Scheme has paid the qualifying portion.
How To Fix A Rejected Claim?
First, identify whether it is a benefit issue or a billing issue. Benefit issues relate to Scheme Rules, limits or exclusions. Billing issues usually require that the provider must correct and resubmit the account within the required timeframe.
What Happens If Your Medical Aid Payment Bounces?
If a “medical aid bounces”, it refers to a failed debit order or unpaid contribution, which will adversely affect your access to benefits. If your monthly contribution is not paid, your membership will be suspended immediately. This means that your membership remains active, but you will not have access to any benefits until the outstanding contribution has been paid. Contact the Scheme as soon as possible to resolve the payment issue and confirm how it may affect your claims, benefits and membership status. The Scheme may terminate your membership.
What Are The Two Main Reasons For Denying A Claim?
Medical aid claims are commonly rejected because the service does not qualify for benefits, or because the healthcare provider submitted incorrect or incomplete billing information. The rejection code will show which issue applies.
