Claims procedure
Day-to-day benefits:
Your GP visits, prescribed medication and other listed day-to-day benefits are 100% covered when your premium is paid. You are not required to pay for the services and medication up front.
To claim for emergency or out-of-network GP consultations, minor procedures and or medication, you can either download a reimbursement claim form or you can call on 0861 632 123 and request that a claim form be faxed or emailed to you.
The following information should be contained in a mediation claim in order for it to be processed:
- A script with the name, quantity, dosage as well as the relevant national pharmaceutical product interface (NAPPI) code and ICD-10 code,
- Non-electronic accounts payable by the client must also be accompanied by a copy of the original prescription made out by a person legally authorised to prescribe the medicine (if applicable),
- Proof of payment.
The following information should be contained in a doctor’s consultation claim in order for it to be processed:
- Reimbursement form,
- A detailed account providing information on the reason for the consultation,
- Proof of payment.
Hospital cover:
Once you have been discharged from hospital (i.e. after your pre-authorised admission), you can either download a claim form from this website or you can call us on 0861 632 123 and request that a claim form be faxed or e-mailed to you.
The following information should be contained in a hospital claim in order for it to be processed:
- Claim form with surname and initials of the member,
- Policy number,
- Identity number or date of birth of the patient,
- Doctor’s practice number and
- A detailed account providing the nature of service, relevant codes, including ICD-10 code, service date and cost of each service rendered or item supplied,
- Proof of payment
Please email the completed form to claims@essentialmed.co.za
or fax it to:
0865 327 661
or post it to:
PO Box 1058
Cape Gate
7562
Claims are paid out promptly however claims must be submitted within three months from the end of the month in which the service was rendered. If not submitted within this period, the account will not be paid.
