Does CompCare pay for both positive and negative COVID-19 tests, and will it affect my day-to-day benefits?
the correct diagnosis code (ICD10 code). The diagnosis code should reflect the COVID diagnosis code, as opposed to the general “Z” diagnosis code under which blood tests are submitted. The claim will not pay correctly if the diagnosis code is not correct.
Subsequent negative tests will be paid from your day-to-day benefits, subject to the availability of funds.
What are the criteria for a COVID-19 test?
If a member has been in close contact with a COVID-positive person or is experiencing symptoms of an acute respiratory infection such as a sore throat, cough, shortness of breath or a temperature higher than 38°C, they need to contact their treating healthcare provider who will refer them to
a pathology laboratory for testing. With the Delta variant, symptoms such as a headache, sore throat, and runny nose, and potentially a fever and a cough have been reported. If you are concerned about your symptoms, seek medical advice.
Is there a limit to the test that CompCare will pay for?
There is no limit to the number of tests paid for by the Scheme from risk when the test results are positive.
Does CompCare have additional benefits to the Prescribed Minimum Benefit for members who tested positive for COVID?
Will CompCare pay for the vaccine?
Yes. The vaccine is a Prescribed Minimum Benefit and will be paid from risk. It will therefore not impact your day-to-day benefits.
Why can I not obtain my vaccine through CompCare?
The vaccine drive is a government initiative for all South Africans, irrespective of whether they are on a medical aid or not. All South Africans will therefore be vaccinated whether they are on a medical scheme or not.
All “branded” vaccinated sites are not exclusively for their members. It remains a government registered site and members who are not members of that specific brand, but live close to the site, are directed there when they register on the EVDS system. All citizens should register on the EVDS site (irrespective of their Scheme membership or special arrangements made by their Schemes).
All Scheme members still have to follow the same process as non-medical scheme members by registering on the EVDS system). Upon registration you will be directed to a site closest to you – in urban areas within a radius of 10 kilometers and in rural areas 30kms.
If another “branded” site is within 10 kilometers of you and you are not a member of that company or a medical aid member, you can still be directed there. The only source for registration is the EVDS site.
How do I update my banking details?
How do I add an additional dependant?
Please note that the following documents need to be attached to the application form if applicable to the dependant:
- Previous medical scheme membership certificates.
- Copy of IDs for adults and birth certificates for children.
- Marriage certificate.
- An affidavit should surnames differ or a common law spouse or partner are added as dependant.
- Adopted children – legal documentation to be provided.
- Student certificate and / or proof of registration from the university or college if a child dependant is studying.
When do I get my membership card?
On joining members will receive a single card when joining without any dependants. Two cards are issued when a member registers dependants.
Please remember that you can keep your CompCare Medical Scheme card with you at all times by downloading your membership card on the Mobi App.
How do I report complaints or disputes?
Members may lodge their general queries and complaints telephonically (0861 222 777) or in writing ([email protected]) to the scheme. Call centre agents will assist the member immediately where possible. Should the query or complaint remain unresolved, members can escalate the query to [email protected] (please remember to quote the reference number provided when the complaint or query was initially logged). Complaints received in writing will be responded to by the scheme within 30 days of receipt thereof.
How are day-to-day claims paid on MUMED?
- Step 1 – Claims are paid from Annual Flexi Benefit (AFB).
- Step 2 – Balance of GP consultations payable from risk once your AFB has been depleted.
Through which benefit is specialised radiology, MRI scans and PET scans paid from on MUMED?
Claims are paid from Risk and pre-authorisation is required.
How many chronic conditions are covered on the PINNACLE option?
74 conditions (27 CDL + 47 chronic conditions).
How is the specialist reimbursed on the PINNACLE and the other plans?
Specialists on PINNACLE are reimbursed at 200% of Agreed Tariff and other options reimbursed at 100% of Agreed Tariff.
How does the day-to-day benefit work on PINNACLE?
- Step 1 – Medical savings account (MSA): Claims are initially paid from MSA.
- Step 2 – Annual flex benefit (AFB): Once MSA is depleted claims are paid from your AFB.
- Step 3 – Self-payment gap (SPG): Once MSA and AFB have been depleted you must pay cash and hand in your claims as they are accumulated to reach your threshold.
- Step 4 – Threshold level: When you have reached your threshold, ‘Above Threshold’ kicks in.
- Step 5 – Claims are now paid from ‘Above Threshold’.
How does CompCare’s Member Mobi App work?
Our Member App is your mobile gateway to information. Access and view your option, benefits and claims anywhere, anytime.
- CLAIMS — Submit new claims and view your claims history.
- HOSPITAL PRE-AUTHORISATION — Submit new pre-authorisation requests and view your pre-authorisation history.
- QUERY — Submit queries and view important contact details.
- MEMBERSHIP CARD — See a digital version of your membership card and never be caught without it again.
- BENEFITS — View all your benefits, annual limits and your available balances.
- MUCH MORE — Request your Tax or Member certificates. See all your registered chronic conditions, register for new conditions, update your scripts and apply for an extended supply of medicines. Access your personal details, your dependant details and your Scheme details. You can also search for a Network Specialist in your area.
Can I register dependants anytime during the year?
A newborn has to be registered within 30 days of birth to ensure that no waiting periods are applied to the child’s membership, and membership will then be activated from the date of birth.
The Scheme needs to be notified of all other changes in status (for example when the principal member gets married or divorced) as soon as possible. All additions are effective from the 1st of a month and waiting periods (underwriting) may be applied in terms of the Medical Schemes Act.
Terminations are effective on the last day of the month. A member who has not joined the Scheme as part of a participating employer group may terminate membership by giving one (1) month’s written notice.
When does my cover end if I resign from the Scheme?
A member who has not joined the Scheme as part of a participating employer group may terminate membership by giving one (1) month’s written notice. Membership will be terminated at the end of the third month.
Who may I register as a dependant?
The following may qualify to be registered as dependants on CompCare in terms of the Scheme rules:
- Your spouse or partner who is not a member of a medical scheme. Copies of the following documents are to be submitted with the application form:
- Marriage Certificate or an affidavit confirming your relationship, copy of the dependant’s Identity Document and Membership Certificate of previous medical scheme(s).
- Child dependants (a member’s biological children, stepchildren or legally adopted children) under the age of 21, but not older than 27. Copies of the following documents to be submitted with the application form:
- Biological child – birth certificate and an affidavit if the child’s surname is different from the principal member;
- Stepchild – birth certificate and an affidavit to confirm the dependency status;
- Legally adopted child – birth certificate and adoption papers.
Please contact our membership department for more information on eligibility for membership.
What is the difference between the “Standard” and ED options?
All options on CompCare, with the exception of the UNISAVE, SELFNET and SELFSURE options, have Efficiency Discounted (ED) Options which
Which options do not have an over-the-counter medication benefit?
Which Designated Service Provider (DSP) hospitals and pharmacies must the ED option members use?
Netcare hospitals and Dis-Chem pharmacies.
What is the DSP ambulance or emergency assistance service for CompCare?
It is Netcare 911.
Hospital related queries? Take a look at the FAQ’s listed below. If your question isn’t there, drop us a line.
Please note. All non-emergency hospital admissions should be
Emergency admissions must be
What is Managed Care?
Managed Care consists of processes and policies that most medical schemes apply in an effort to manage the increasing costs of healthcare as well as to prevent the over utilisation of benefits and to ensure quality of care. Managed Care ensures that members are able to access healthcare services that will provide cost effective, clinically appropriate care.
The focus is not only on
What is Hospital Benefit Management?
The purpose of CompCare’s Hospital Benefit Management team is to assist members in obtaining pre-authorisation for hospital admissions and to manage access to care that is affordable, appropriate, safe and quality healthcare. This is not only to improve the quality of care that you receive while in-hospital, but extends to improving your health status after you have been discharged.
Can I use Private Hospitals of my choice?
What am I required to do if I need to be admitted to hospital in the case of an elective (non-emergency) admission?
All hospital admissions must be pre-authorised by the Scheme at least 48 hours prior to admission. The process of pre-authorisation is where you inform the Scheme of your admission to hospital and obtain approval for your stay.
Please have the following information at hand in order to obtain pre-authorisation:
- Medical aid number
- Dependent number
- The practice number for the hospital that you are being admitted to
- The practice number of the doctor who will be treating you
- The admission date
- The diagnosis and procedure codes for your admission (the treating provider usually provides this information)
In the case of an emergency, pre-authorisation should be obtained on the first working day after your admission. Where you are unable to contact the Scheme yourself, a family member or the hospital may do so on your behalf.
Failure to obtain pre-authorisation may result in a co-payment or the non-payment of the account.
Does pre-authorisation guarantee payment?
Pre-authorisation is not a guarantee of payment. Payment will depend on your membership
How will my hospital account be paid?
The hospital account will be paid at the negotiated rate, which is a fee negotiated by Universal Healthcare, the Scheme’s Administrator, on behalf of CompCare.
How are specialists paid for in-hospital treatment?
Your related in-hospital accounts (specialist,
What are co-payments?
A co-payment, is the amount that you have to pay from your pocket for a specified treatment or procedure and varies according to the option that you have selected.
A co-payment can either be a fixed amount (e.g. R4 330 for a Gastroscopy) or a percentage of the cost of your medical expenses (e.g. 30% of the account should you not make use of a Designated Service Provider if you have selected an Efficiency Discounted (ED) or the SELFNET option).
Please refer to your benefit guide for specific information on the relevant co-payments.
When can I incur a co-payment?
A co-payment may be incurred for certain treatment procedures and is defined in the Scheme rules. If you have selected an Efficiency Discounted (ED) or the SELFNET option, you may have a further co-payment when you use another healthcare provider that is not a Designated Service Provider on these options (Netcare Hospitals and DisChem pharmacies).
You will not be liable for a co-payment for on a Prescribed Minimum Benefit (PMB) condition / treatment, as long as you use the Scheme’s Designated Service Provider (DSPs) or use medicine on the medicine formulary applicable to CompCare.
What alternatives to Hospitalisation are covered?
The following is covered from the in-hospital benefit, although not performed in a hospital:
Procedures in a General Practitioner or Specialist’s rooms
Step-down facilities, hospice and rehabilitation facilities
Will emergency transportation be covered?
Emergency transportation (ambulance services) is contracted to Netcare 911. You should therefore always phone 082-911 should you require emergency transportation. Netcare 911 will dispatch the closest, appropriate ambulance to you (please note that it may not be a Netcare 911 ambulance). You are however required to always phone Netcare 911 when emergency transportation is required, unless it is an emergency, in which case the first ambulance on scene will be paid. Non-emergency cases will require pre-authorisation by Netcare 911 at the time of transport or within 24hrs thereafter.
What is GAP cover?
GAP cover is a short-term insurance product designed to provide extended
A GAP cover product does not form part of your medical scheme benefits and is not managed or administered by your medical scheme.
What are the limits for a Mammogram?
One test per female beneficiary over the age of 35 every second year.
What is Specialised Radiology?
How is Specialised Radiology paid?
Please refer to your
Do I need pre-authorisation for Specialised Radiology?
All Specialised Radiology (both in and out of hospital) requires pre-authorisation.
What are the limits for Pathology?
In-hospital Pathology is paid at 100% of the Scheme rate, subject to Scheme protocols. It is unlimited on the PINNACLE and DYNAMIX options and limited on the other options (refer to the
Pathology out of
Please refer to your
How is Specialised Radiology paid?
Please refer to your
Do I need to register on the Maternity Programme?
You can contact the call
Please also remember to register your newborn baby within 30 days from the date of birth to avoid waiting periods.
How is Maternity covered?
CompCare has various benefits that are paid for by the Scheme that will not impact your day-to-day benefits for all options. Please refer to your guide for more information.
The maternity benefit includes cover for 12 antenatal visits with your General Practitioner, Specialist or midwife (paid at the Scheme tariff) on the options that offer this benefit.
In addition to this, there is also a benefit for ante-natal classes (subject to specified Rand limits), as well as a breastfeeding consultation with a midwife after birth.
The birth (confinement) in
Is there a benefit for Infertility?
Although Infertility is a Scheme exclusion, some aspects form part of the Prescribed Minimum Benefits (PMBs), and
What is the benefit for psychiatric hospitalisation?
Please contact out pre-authorisation department for more information.
How will Psychologists be paid?
Psychologists or any registered mental health professional are paid from your available day-to-day benefits and subject to sub-limits according to the benefit option that you have selected.
In addition to this, the Scheme has a telephonic counselling benefit available for all members and their registered dependants 24 hours a day, 7 days a week, 365 days a year. The counselling is provided by registered counselling professionals (psychologists, social workers and registered counsellors) and is completely confidential.
Members can access this benefit by calling 0800 390 003 (toll free from a landline) or by sending a “Please call me” to *134*952#.
Is Optical Refractive Surgery covered?
Refractive Surgery is covered with specified sub-limits on PINNACLE, DYNAMIX and SYMMETRY.
On MEDX Refractive Surgery is covered in terms of the Prescribed Minimum Benefit protocols.
Refractive Surgery requires pre-authorisation.
What are my Optical Benefits?
Your Optical benefits are paid from your day-to-day benefits according to the option that you have selected.
What is a Prosthesis?
A Prosthesis refers to an artificial body part or device to replace or augment a missing or impaired part of the body such as a limb, a heart, etc.
Please refer to your
What are the limits for Prosthesis?
Surgical Prosthesis, Electronic and Nuclear appliances are covered from the Prosthesis benefit and are subject to specific sub-limits for your chosen option. Please note that this requires pre-authorisation and is funded in terms of Scheme protocols.
How are out-of-hospital GP visits paid?
Visits to your General Practitioner are paid from your available day-to-day benefits according to the option that you have selected.
In addition to this, members on PINNACLE, DYNAMIX, SYMMETRY, MUMED, UNISAVE, SELFNET
Which Practitioners are covered under the Auxiliary / Allied Services Benefit?
The following Healthcare providers are covered under the Auxiliary/ Allied services benefit:
Audiologists, Dieticians, Physiotherapists, Occupational Therapists, Speech Therapists, Social Workers, Homeopaths/ Naturopaths, Chiropractors and Biokineticists.
Kindly note that these service providers should be registered with the Board of Healthcare Funders and have valid practice numbers in order for the Scheme to make payment to these providers.
What is the Auxiliary / Allied Services Benefit?
This is a benefit where the services of healthcare providers other than your doctor or specialist are covered and
This benefit is usually paid from your available day-to-day benefits according to the option that you have selected as this benefit has a combined in and out of hospital benefit limit.
How are Medicines paid?
Members are required to register chronic medicine with Universal to have access to the Chronic Medicine Benefit. In order to register your medicine, your doctor or pharmacist is required to contact Universal or to send an e-mail.
Please refer to your
Acute Medicine refers to prescription medicine, schedule 3 and higher, for which you require a prescription from your doctor.
Acute Medicine is usually covered from your available day-to-day benefits. Please refer to your
Over-the-Counter Medicines (OTC)
What is the Chronic Medicine Management Programme?
The Chronic Medicine Management Programme
- Medicines for life-threatening illnesses (e.g. hypertension).
- Medicines used on an ongoing basis to treat disabling chronic illnesses that significantly affect productivity and quality of life (e.g. arthritis).
What is the difference between Conservative and Specialised Dentistry?
Conservative (or basic) dentistry refers to the diagnosis, prevention and treatment of tooth and gum diseases as well as the repair of defective teeth. This usually includes the consultation, scale and polish, fillings, x-rays and extractions and is work usually performed by a General Dentist.
Specialised (or advanced) dentistry refers to dental services not covered under basic dentistry and is usually performed by a ‘specialist’ Dentist for example an Orthodontist, Periodontist, Maxillofacial and Oral Surgeon. This usually occurs when teeth need to be replaced or repaired. This includes orthodontic treatment, crowns and bridges.
Not all options cover specialised dentistry and it is therefore important to refer to your benefit guide for option specific information.
How is Dentistry covered?
Dentistry is usually covered from your available day-to-day benefits according to the option that you have selected.
In addition to this, members on PINNACLE, DYNAMIX, SYMMETRY, MUMED, UNISAVE
CompCare offers a pre-authorisation service through Universal Care for
What Preventative Care is covered?
CompCare is known to have one of the best preventative care and wellness
And we cover many more. Please refer to your member guide for more information or contact our call
What information must be present for a Claim to be processed and paid?
Service providers submit claims electronically, directly to CompCare which provides for a seamless member experience. Members do however sometimes need to submit claims to the Scheme for example in instances where they have paid upfront for a claim. For member r
- The surname and initials of the member;
- The surname, first name and other initials of the patient;
- The name of the medical scheme concerned;
- The membership number of the member;
- The practice code number, group practice number and individual provider registration number issued by the registering authorities for providers, if applicable of the supplier of service, and in the case of a group practice, the name of the practitioner who provided the service;
- The relevant diagnostic and such other item code numbers that relate to such relevant health service;
- The date on which each relevant health service was rendered;
- The nature and cost of each relevant health service rendered; including the supply of medicine to the member concerned or to a dependant of that member; and the name, quantity and dosage of and net amount payable by the ember in respect of the medicine;
- Where a pharmacist supply medicine according to a prescription to a member or to a dependant of a member of a medical scheme, a copy of the original prescription or a certified copy of such prescription, if the scheme requires it.
The Act further specifies requirements in cases where a theatre was used (usually in
What is the Scheme Rate?
The Scheme rate is determined by the Board of Trustees and is adjusted from time to time following consultation with suppliers in the industry. It is important to note that providers are under no obligation to charge the scheme rate and that it is important for you to understand that you may be liable should there be a difference between what is charged on the account and the scheme rate. It is therefore advisable to confirm the rate that your doctor will be charging
How do I submit a claim?
- You can e-mail your claim to [email protected]
- Post your claims to: CompCare Claims Department, P.O. Box 1411, Rivonia, 2128
- Submit your claims via the Member Mobi App
How do I make sure that my claim is correctly paid?
- Your banking details are updated and correct.
- You submit a detailed account and proof of payment where you have paid the account upfront.
- Check your claims statement to verify the status of your claims.
- Check your claims statement to ensure that service providers claim for relevant services or services rendered.
Please remember that you have four months from the date of service to submit a claim for payment.
How will I know what has been paid or rejected?
Claims payments are communicated to members on the CompCare claims statements. It is therefore very important that you review your claims statements carefully to ensure that you know whether a claim was paid, short-paid or rejected. It is therefore important that the Administrator has your updated email address to ensure that you receive your claims statements when you have submitted a claim. This is the only way that the Scheme communicates to you with regards to claims received.
You can also track the status of a claim on the Mobi App.
How do I query a Claim or Benefit?
You can query a claim by contacting the call
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