EVERYDAY – FREQUENTLY ASKED QUESTIONS:

Do I need a GP referral to see a Specialist?

• If you are on Comprehensive Select or Value Option you may only consult certain Specialists if referred by your GP. The GP must contact the Medscheme Call Centre on 0861 112 666 to obtain authorisation for you prior to your consultation with the Specialist.

Where do I find a Network GP?

• Contact AECI Medical Aid Society Customer Services on 0860 00 2103, visit the Member Portal on the Medscheme website or click on the Find a Healthcare Professional link at the bottom of the home page on the AECI website.

How do I submit my claim accounts?

• The Medical Schemes Act requires that the healthcare providers give full details on all accounts.
• You may submit your claim to claims@medscheme.co.za

How do I avoid non-payment of claims on Comprehensive Select?

• The Comprehensive Select option provides the same benefits as the Comprehensive option, but at a lower cost. It requires members to use Designated Service Providers (DSPs) and Networks for certain benefits and benefit categories. Click Here to view a document which spells out these requirements in greater detail, and can help you to avoid unnecessary out-of-pocket costs.

Can my doctor claim electronically?

• Yes, via the Electronic Data Interchange (EDI) system. If your doctor or provider claims by EDI you do not have to submit a claim at all – the Administrator will automatically process the EDI claim.

When can I expect payment?

• Medscheme has a regular payment cycle of three sometimes four payment runs per month to members and healthcare practitioners. An SMS message indicating the amount that will be credited to your account will be sent to you after the payment run.

Can I register my dependants on the member portal?

• The dependant can register (based on main member permissions) by clicking on ‘Register Dependant’.

What are chronic medicines?

• This is medicine that you need to treat a long-term illness, and that you will need to take regularly (usually daily).

Can I apply for chronic medicine?

• You, your doctor or pharmacist can register for, or update (where medicine is outside the approved basket) your chronic medicine telephonically or online. Have a copy of your current prescription with you. To register phone 0860 002 103 and select the chronic option or register Online at www.medscheme.com

Can I send Motivations or Clinical Appeals for medicine?

• Yes, your doctor should contact the Chronic Medicine Management Provider Call Centre on 0861 100 220 or submit a clinical motivation to aecicmm@medscheme.co.za

What if my medicine changes?

• lf you need to change or add a new medicine for your condition, you can do this quickly and easily at your pharmacy with your new prescription.

How does the Managed Care programme for HIV work?

• Members and dependants of the Society have access to benefits for the treatment of HIV. These benefits can be accessed by registering on the HIV management programme. Your doctor can also contact us on your behalf.
  Contact AfA:
  Tel: 0860 100 646
  Email: afa@afadm.co.za

What is the mental health programme?

• Our Mental Health Programme has been built on the principle of providing support to both you and your family practitioner to promote access to the best quality primary mental healthcare that is available.

How to access this benefit?

• To register your mental health condition, simply call 0860 106 155 or email membercare@medscheme.co.za to find out whether you meet the criteria for this programme.

How to access the cancer/oncology benefit?

• On diagnosis of cancer, you need to registered on the Oncology Disease Management Programme. Your treatment plan will be forwarded to the clinical team, as all oncology treatment is subject to pre-authorisation and case management. After the treatment plan has been assessed and approved, an authorisation will be sent to your treating doctor.

What is the treatment for neck and back pain?

• The DBC (Documentation Based Care) which is a back and neck rehabilitation programme, it concentrates primarily on back and neck problems, helping you manage severe neck and back pain. The programme consists of up to 12 sessions over a 6-week period at specific DBC centres.

How to access the Programme:

• Your specialist or GP may refer you to the Programme. You may self-refer by contacting the Member Contact Centre on 0860 002 103 should you experience chronic, ongoing back or neck pain.

Where are the DBC centres?

• Contact Centre 0860 002 103 or visit the AECI Member Portal on the Medscheme website.

Why should I go for screening tests?

• Screenings are medical tests that check for diseases before there are any symptoms. Screenings can help doctors find diseases early, when the diseases may be easier to treat. All claims are payable from the risk benefits and will not affect your other applicable benefits. All further treatment thereafter is subject to normal benefits.

What if I suspect fraudulent activity against the Scheme?

• If you suspect that a service provider, colleague or any other person or organisation may be engaged in fraudulent activities against your Scheme, please contact the Fraud Hotline on 0800 11 28 11.
• You can also email fraud@medscheme.co.za to report your suspicions. You can choose to remain anonymous.

What can I do if my benefits run out in the case of a serious illness?

If you find yourself or a beneficiary suffering from a serious illness that results in medical expenses that exceed the annual limits, you may apply in writing to the Board of Trustees for Ex Gratia assistance.
In order to apply you should:

• obtain the application form from Medscheme;
• ask your doctor to assist you in completing the form; and
• submit the completed form to Medscheme.