Simple & Efficient Claims

Episodic Health Insurance pays claims directly to providers. Find out how the claims process works for rapid and pain-free claims handling.

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Your Claims are Paid Directly to the Provider

EssentialMED will settle the claim directly where possible. Some providers expect upfront payment in which case your claim will be reimbursed.
Here's what you need to know.

Hospital Claims

Identification

Pre-Authorisation

Call Africa Assist on 0861 911 011. Identify yourself as an EssentialMED member with your Policy Number. They will guide you further on what information they need.
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Paperwork

You will need to supply the Medical Report from your doctor. You may need to sign further acknowledgement documents for the hospital.
Hospital bed

Admission

Get admitted and treated at the hospital or casualty ward.
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Claim Submission

The hospital will submit the claim to EssentialMED and the providers will be paid directly according to the acknowledged benefits.
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Doctors Claims

Identification

Identify Yourself

Supply your EssentialMED Policy Number to the practice clerk of the Network Doctor. If you need to pre-authorise the visit then call 0861 911 011
Doctor

Treatment

Receive treatment. If you are referred for radiology, pathology or to a specialist then make sure the network GP is listed on the referral script.
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Claim Submission

The Network Doctor will submit your claim directly for payment. You will receive the Remittance Notice by email when the claim is settled.
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Out-of-Network Claims

For visits to non-network doctors, submit the claim invoice directly to EssentialMED at claims@essentialmed.co.za and they will reimburse you up to R250 per claim a maximum of 3 times per year.
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Dentists Claims

Identification

Identify Yourself

Supply your EssentialMED Policy Number to the practice clerk of the Network Dentist
Dentistry

Treatment

Receive treatment. If you are referred for radiology, pathology or to a specialist then make sure the network dentist is listed on the referral script.
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Claim Submission

The Network Dentist will submit your claim directly for payment. You will receive the Remittance Notice by email when the claim is settled.
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Medication Claims

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Get your script

A dispensing network doctor will give you medication directly from the practice. A scripting doctor will write a prescription that you take to the pharmacy. Over-the-Counter medication does not require a script.
Identification

Identify Yourself at the pharmacy

Show the pharmacy your membership card or tell them the scheme is EssentialMED and provide your policy number.
Medication

Receive Medication

The pharmacy (or dispensing doctor) will issue your medication.
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Claim Submission

The pharmacy or network doctor will submit the claim to EssentialMED and the claim will be paid directly according to the formulary on your policy benefits.
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Optometry Claims

Identification

Identify Yourself

Provide the network optometrist with your Policy Number and tell them the scheme is EssentialMED.
Optometry

Get your eye test or glasses

The optometrist will guide you as to what frames, glasses or contact lenses are available to you according to your benefits.
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Claim Submission

The optometrist will submit the claim to EssentialMED and the claim will be paid directly according to your policy benefits.
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Other Claims

Identification

Referral

For radiology, pathology and specialists referrals, make sure that your network GP is listed as the referring provider.
Pathology

Treatment

Receive the treatment or procedure that you require.
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Claim Submission

The provider may need you to submit the claim yourself. The provider might also require you to settle the claim upfront, in which case EssentialMED will reimburse you according to your benefits.
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Ready to build a plan?

Getting a quote is quick and easy. We are here to help you every step of the way.
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How to Submit Your Own Claim

If you need to submit the claim yourself then simply email your policy number and a copy of the invoice or statement to claims@essentialmed.co.za.

Your claim will be processed according to your benefits.

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Managed Visits Explained

The GP Benefit under Day-to-Day cover gives you unlimited managed visits to a network doctor. This is a phenomenally rich benefit that needs to be risk managed. What that means is:

From the 5th consecutive visit for Single policies
From the 12th consecutive visit for Family policies
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Pre-Authorise your next consultation by calling Africa Assist on 0861 911 011
This protects you from fraud by ensuring that it is you utilising your benefits and not someone else.

The purpose of the managed process is not to stop you from seeing a doctor but rather to ensure that the unlimited value of the benefit is not being abused.

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Pre-Authorisation Explained

To preauthorise a hospital procedure, call Africa Assist on 0861 911 011 and identify yourself as an EssentialMED member with your Policy Number. They will guide you further on what information they need.

In general, all Hospital claims for planned procedures need to be pre-authorised at least 48 hours before you can use the benefit. This is a simple procedure where we determine whether the procedure you need is covered under your benefits and whether you still have available amounts left over after previous claims.

Events covered under the Accident Hospitalisation benefit may require immediate hospitalisation or result in the person affected being unconscious or otherwise unable to obtain pre-authorisation. In these events, medical personal will always stabilise a patient before being generally admitted, at which point your next of kin can assist with identifying you and your available medical cover.

If you can't practically pre-authorise a hospital visit due to an accident or emergency then you must inform EssentialMED within 48 hours about the accident event.

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Pre-Existing Conditions Explained

When you apply for a new policy there is an underwriting stage where you are asked to disclose your medical history. Certain disclosures may result in condition specific endorsements to your hospital benefits which means that claims related to that pre-existing condition may carry a longer waiting period or be excluded from the policy.

This is because the insurer can't take on a known risk for medical conditions that you are already aware of for the same premium.

Day-to-Day benefits and claims not related to those pre-existing conditions are not affected by this additional underwriting.

Pre-authorisations: 0861 911 011
Client Services: 021 001 2490
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A Network You Can Depend On

Access private healthcare when you need to see a doctor, visit a dentist, get medication or go to hospital.

Nationwide Network of Doctors & Dentists
Private hospitals across South Africa
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Answers to Your Questions

What happens if I visit a doctor that is not on the network?

The Day-to-Day benefits cover consultations with network doctors. You are allowed 3 visits to out-of-network doctors a year. These visits will be reimbursed up to a maximum of R250 per visit.

Must I pay providers upfront before claiming?

In general, this is not required. EssentialMED will pay providers directly on the submission and processing of a claim. The provider will either submit the claim or you can yourself on their behalf.

However, there are some providers that force clients to settle their bills before being treated. These claims will be reimbursed according to the benefits.

Are there any co-payments needed?

In general, this is not required. EssentialMED will pay providers directly on the submission and processing of a claim. It is important, though, to understand your benefits and the limits that they cover.

The Medication Benefit, for example, does have medicine on the formulary that may require a co-payment. It is not practical to publish the entire formulary so it is best to ask us, your network doctor or EssentialMED if there is anything specific that you'd like to look up.

How are Episodic and EssentialMED related?

The Episodic Health Insurance product is an EssentialMED product.

EssentialMED is the product administrator for our health insurance product and they are responsible for managing the network, processing claims and enhancing the product.

Where can I find a list of network hospitals?

Episodic Health Insurance can be used at any hospital. There is no hospital network. Find out more on our network page.