Your Claims are Paid Directly to the Medical Provider
The Administrator will settle claims directly where possible. Some providers expect upfront payment in which case your claim will be reimbursed. Here is what you need to know.
Call Africa Assist on 0861 911 011.
Identity yourself as an EssentialMED member with your Policy Number.
They will guide you further on what information they need.
You may need to supply the Medical Report from your doctor and sign acknowledgement documents for the hospital.
The Administrator will issue a Guarantee of Payment to the hospital (according to your benefits) that lets the hospital know how much money is available for treatment.
Get admitted and treated at the hospital or casualty ward.
The hospital will submit the claim directly to the Administrator, EssentialMED, and the providers will be paid according to the acknowledged benefits.
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.
The doctor will submit the claim directly for payment. You will receive a Remittance Notice once the claim is processed.
For visits to non-network doctors, you will need to submit the claim invoice directly to EssentialMED at email@example.com and they will reimburse you up to the limits define in your Day-to-Day cover.
Give your EssentialMED Policy Number to the practice clerk of the network dentist.
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.
The dentist will submit the claim directly for payment. You will receive a Remittance Notice once the claim is processed.
Acute Medication Claims
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.
Show the pharmacy your membership card or tell them the scheme is EssentialMED and provide your policy number.
The pharmacy (or dispensing doctor) will issue your medication. They will inform you if the medication on the script is covered under the formulary or not.
The pharmacy (or dispensing doctor) will submit the claim directly to the administrator and the claim will be paid directly according to the formulary on your benefits.
You can also submit your pharmacy invoice directly to the administrator for reimbursement by simply sending it to firstname.lastname@example.org
Give your network optometrist your Policy Number and tell them the scheme is EssentialMED.
The optometrist will guide you as to what frame, glasses or contactact lenses are available to you according to your benefits.
The optometrist will submit the claim directly to the administrator and the claim will be paid directly according to the formulary on your benefits.
You can also submit your invoice directly to the administrator for reimbursement by simply sending it to email@example.com
For radiology, pathology and specialist referrals, make sure that your network doctor is listed as the referring provider.
Receive the treatment or procedure that you require.
The provider may need you to submit your claim yourself. The provider might also require that you settle the claim upfront, in which case the administrator will reimburse you according to your benefits.
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.
You have Questions, We have Answers
Find answers to the most common questions about our Network below. You can find many more answers to Frequently Asked Questions on our Help pages.
What if my doctor or dentist is not on the network?
The doctor and dentist network is constantly growing as more providers agree to join.
You can nominate your family doctor or dentist to join the network by filling in a request. Simply email firstname.lastname@example.org with the following information:
- Doctor/Dentist name and Practice Number
- Their contact details: phone & email
- Their address
It is ultimately the decision of the doctor and the product administrator when a provider is nominated to the network. We cannot make a guarantee that they will join as it is their choice.
How are Episodic and EssentialMED related to each other?
Episodic offers a retail health insurance product for individuals that is provided and administered by EssentialMED. 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.
What are "managed visits"?
The GP benefit is unlimited in that you can visit a network doctor as often as is medically necessary. This needs to be managed to make sure that it is you or your family using the benefit and not someone else.
Preauthorisation is required from:
- the 5th consecutive visit for Single policies
- the 12th consecutive visit for Family policies
by calling Africa Assist on 0861 911 011
This protects you and us from fraud on your policy as well as helping us make sure you are getting real value from the network of providers.
What happens if I visit a doctor that is not on the network?
How do I submit a claim myself?
If, for whatever reason, you need to submit a medical expense claim yourself then all you need to do is send an email to email@example.com with the following information:
- Your name and policy number
- A copy of the invoice
The administrator will guide you from there.
Where can I find a list of network hospitals?
Episodic Health Insurance can be used at any hospital. There is no hospital network. We advise making use of NetCare, Busamed and Life hospital groups for the most seamless experience with the product.
This is because Episodic Health Insurance is not a Medical Aid. It offers stated limits for defined events which can be pre-authorised with the hospitals as a Guarantee of Payment.
What is a dispensing doctor?
A dispensing doctor is a doctor on our network that also has an in-house pharmacy. They are able to supply medication directly to you.
If you have Day-to-Day cover then formulary medication is covered through dispensing doctors just as if they were a pharmacy.
What is a scripting doctor?
A scripting doctor is a doctor that does not have an in-house pharmacy and will issue a script for medication that can be fulfilled at a pharmacy.
Which Specialists are covered?
The type of specialist you can visit is extensive and includes:
- Obstetrics & Gynaecology
- Specialist Physician
- Physical Medicine
- Plastic & Reconstructive Surgery
- General & Cardio Thoracic Surgery
What Health Plan are you going to build?
Get a quote and find out. Talk to us or build your own.