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Important information about specialist networks


  • pg 1
									                                                                             JULY 2007

Dear Member                 In our first newsletter for 2007, we bring you
interesting articles that we trust you will find useful and informative.
                                                                               in this issue
                                                                              J Important information about
                                                                                specialist networks

Important information                                                         J Frequency of claims runs

about specialist networks                                                     J Did you know?

                                                                              J Your medical cover after
During the 2006 road show presentation, we                                      retirement
informed members of the Scheme of the possibility of
implementing a network of preferred specialists. The
                                                                              J Member-elected Trustees in
intention was to contract a network of specialists who
                                                                                the different regions
would not charge above medical scheme tariffs on
services delivered in hospital.
                                                                              J Extended prescriptions
                                                                                when travelling
Due to the practical difficulties experienced in terms of
finding specialists across all disciplines and practising
in the areas where the Scheme’s members are resident,                         J Have you been the victim of
implementation of such a network will not happen with                           split billing?
immediate effect.
                                                                              J Checking your claims
We will continue to explore such a network in                                   statement
order to provide members with quality care
at an affordable price. In the meantime,                                      J Reminder: Dispensing fees
we advise all members to discuss                                                on medicine
and negotiate fees charged with
their treating specialists prior                                              J Important contact details
to booking a procedure.
 of claims runs
 As you are no doubt aware, the Scheme has a claims run every
 two weeks. However, in a five-week month, there will be a three-
 week period between claims runs.

 This is to allow the final claims run to take place as close as possible to the end
 of the month in order to ensure accuracy in the preparation of the specific month’s
 management accounts.

 The table below provides the claims run dates for the remainder of 2007 to assist
 you in ensuring that your healthcare claims reach us in time for a specific claims    Did you

 MONTH                  DAY               DATE                 DATE OF STATEMENT
                       Friday         13 July 2007                 13 July 2007        Application within 30 days of the
 July                                                                                  birth or adoption of a child will
                       Friday         27 July 2007                 27 July 2007
                                                                                       result in the child being registered
                      Friday        17 August 2007*              17 August 2007        from the date of birth or adoption.
 August                                                                                Registration of the newborn or
                      Friday         31 August 2007              31 August 2007
                                                                                       newly adopted child outside the
                       Friday      14 September 2007           14 September 2007       30-day period, will result in the child
 September                                                                             being registered from the date of
                       Friday      28 September 2007           28 September 2007
                                                                                       application only. No waiting periods
                      Friday        19 October 2007*             19 October 2007       will be imposed on a newborn or
 October                                                                               newly adopted child.
                      Friday        2 November 2007              31 October 2007

                       Friday      16 November 2007             16 November 2007       Application within 30 days of the
 November                                                                              date of marriage will result in the
                       Friday      30 November 2007             30 November 2007       spouse being registered from the
                      Friday       14 December 2007             14 December 2007       date of marriage. Registration more
 December                                                                              than 30 days after the marriage will
                      Friday       28 December 2007             28 December 2007       result in the spouse being registered
 * Three-week cycle                                                                    from the date of application only.
                                                                                       Normal waiting periods will apply, if
 Please note the following:                                                            applicable, on the registration of a
 E In terms of the rules of the Scheme, faxed accounts will not be accepted. The       spouse as a dependant.
   Scheme often receives unclear faxed copies, which are not only unsuitable for
   processing, but delay the payment of claims. This causes a lot of unnecessary         Should you register your new
   frustration for members and the person responsible for processing the claim.          spouse after 30 days, you
                                                                                         will be responsible for the full
 E Before capturing or processing can take place, claims need to be indexed,             portion of this beneficiary’s
   scanned and batched. The cut-off date for claims received before a claims             contribution. You will not
   run is five working days. We normally exceed this requirement and manage to           receive a company subsidy
   process claims within two days of receipt of the claim in our system, depending       towards your medical scheme
   on the volume of claims received for a specific claims run.                           contribution.
Your medical cover
              after retirement
This article addresses the general concerns and requirements of those members who are facing
retirement, in order to ensure a seamless transition from having daily access to the company’s
Intranet and human resources support to a stress free, pensioner environment.

                                  Do I need to advise the Scheme               Will I get a new membership
Any queries regarding             that I am going on retirement?               number when I become a
post retirement subsidies on      Yes, especially if you have been receiving   continuation member (pensioner,
medical scheme contributions,     your medical scheme communication            widow or widower)?
as well as general medical        via e-mail or if it has been posted to       No, you retain the same number when
scheme contribution queries,      your work address, you are required to       your status changes from active member
should be directed to the Human   update your contact details to ensure        (still working) to pensioner member. In
                                  that a breakdown in communication            the event of your becoming a widow or
Resources Department at your
                                  from the Scheme does not occur. You          widower, the membership number of
Operating Unit.
                                  should also provide the Scheme with          the late main member will automatically
                                  updated telephonic contact details, as       become your membership number. The
                                  we probably have your work telephone         widow or widower will be registered as
                                  number on file. Update your contact          the main member.
                                  details by calling the Call Centre on
                                  0860 101 280, or by sending written          Is there any special claims proce-
                                  notification to the Scheme via e-mail,       dure that needs to be followed?
                                  fax or post (see Important contact           The submission of claims remains the
                                  details).                                    same, irrespective of whether you are
                                                                               an active member (still working) or
                                  I have always received my medical            a continuation member (pensioner,
                                  scheme communication via e-mail              widow or widower).
                                  at work. How will I receive this
                                  now?                                           Claims should be posted to the
                                  You can update your contact details to         following address:
                                  a physical or postal address, or provide       Sappi Medical Aid Scheme
                                  us with your personal e-mail address if        PO Box 3535
                                  you have this facility available. Kindly       Cape Town
                                  note that it is your responsibility to         8000.
                                  advise us of any change in contact
                                  details so as to ensure no breakdown         You are also welcome to drop your claims
                                  in communication from the Scheme             in the internal mailboxes at the different
                                  occurs.                                      operating units for overnight delivery to
                                                                               the Scheme’s offices in Cape Town.
                                  If I decide to terminate my
                                  membership of the Scheme, will I             Can I fax my claims if I no longer
                                  be allowed to register again at a            have access to the internal mailbox?
                                  later stage?                                 In terms of the rules of the Scheme,
                                  Pensioner members terminating their          faxed accounts will not be accepted.
                                  membership will not be allowed to rejoin     The Scheme often receives unclear
                                  the Scheme at a later stage, irrespective    faxed copies, which are not only
                                  of the reason for termination.               unsuitable for processing, but delay
                                                                               the payment of claims, causing a lot of
                                                                               unnecessary frustration for members.
Member-elected Trustees
in the different regions                                                                 Extended
During our 2006 road show, we again realised that members were not aware they
have a Member-elected Trustee who represents their region at Board of Trustee
meetings.                                                                                when travelling
We therefore wish to confirm that your Member-elected Trustees who look after your       Members travelling overseas or in
interests and represent your region at the quarterly Board meetings, are as follows:     South Africa for longer than a month,
                                                                                         often enquire how they can get their
                                                                                         chronic medication dispensed for
REgION               MEMbER-ElECTED         CONTACT
                                                                  E-MAIl ADDRESS
                                                                                         longer than the allowed month.
REpRESENTED             TRuSTEE             NuMbER

Western/Eastern     Ms Karin                                                             Follow these steps to obtain an
                                        (041) 408 4111   karin.kleynhans@sappi.com
Cape Region         Kleynhans                                                            extended prescription for your
                                                                                         chronic medication:
Gauteng Region      Ms Suzette Coxen    (011) 360 0337   suzette.coxen@sappi.com
                                                                                         1    Contact the Call Centre on
Northern KwaZulu-   Mr Jabulane
                                        (032) 437 2222   jabulani.simelane@sappi.com          0860 101 280 and obtain an
Natal Region        Simelane
                                                                                              indemnity form.
Southern KwaZulu-   Mr Mike Machell
                                        (039) 973-8025   mike.machell-cox@sappi.com      2    Fax the completed from back to
Natal Region        Cox
                                                                                              the Scheme on 0860 101 480.
                    Mr Colin le Roux    (013) 712 9804   colin.leroux@sappi.com          3    Depending on your contact
                                                                                              details, you will receive
Pensioner Trustee   Mr Colin Kerr       (044) 871 3066   kerrc@mweb.co.za                     either a posted or e-mailed
                                                                                              authorisation letter from the
                                                                                              Scheme, authorising your
You have elected these Trustees to represent you at the Board of Trustee meetings.
                                                                                              extended chronic medication
It is their responsibility to provide you with feedback and deliver input at the Board
meetings. Please support them in their fiduciary responsibilities and their commitment
to ensuring that the Scheme runs smoothly and remains financially viable.                4    Provide a copy of the Scheme’s
                                                                                              letter that authorises the
In addition to the Member-elected Trustees in the different regions, each operating           extended prescription to the
unit has Direct Member Administration (DMA) Guardians in the respective Human                 pharmacy in order to obtain
Resources Departments, who have been trained to assist you with queries on                    more than one month’s supply
your contributions and registered dependants. Consult them directly if you have               of your medication.
enquiries regarding outstanding member debt due to the Scheme, medical scheme
contribution deductions from your salary and general enquiries regarding the             Authorisation for extended pre-
registration of beneficiaries.                                                           scriptions will only be granted on
                                                                                               chronic medication, including
                                                                                                  your Prescribed Minimum
                                                                                                   Benefit medication. It
   Congratulations to our pensioner-
                                                                                                    will not be granted for
   elected Trustee, Mr Colin Kerr, who
                                                                                                    acute medication.
   has been elected to serve another
   term as the Scheme’s pensioner
   Representative on the board of
                                                                                               Provide us with the
                                                                                               details by contacting the
                                                                                               Call Centre on
                                                                                               0860 101 280, or by
                                                                                               e-mailing the Scheme at

Have you been the
victim of split billing?
As stated in a ruling by the Health          The practice of split billing is detrimental to
Professions Council and in the Medical       patients who find themselves having to pay
Schemes Act, the full cost and nature of     increasing amounts out of pocket. This all
each service rendered by a healthcare        detracts from the efforts of government
professional must be reflected on the        and other stakeholders in the healthcare
account received by both the Scheme          sector to increase access to private health-
and the member and not, as in the            care funding for more South Africans.
practise of split billing, be divided into
separate accounts for each party.            If you have been a victim of split billing,
                                             as outlined in this article, you are
Healthcare practitioners are not allowed     kindly advised to provide us with the
to submit one account to the Scheme          details by contacting the Call Centre on
for the portion it covers and another to     0860 101 280, or by e-mailing the
the member for the portion not covered       Scheme at sappi@mhg.co.za.
by the Scheme. Furthermore, it is not
permissible for healthcare practitioners     Metropolitan    Health     Group,     the
to charge patients an amount upfront         Administrator of your Scheme, wishes
without including that amount on the         to address this matter with the relevant
statement which is sent to the Scheme
and/or patient.
                                             healthcare practitioners, but assures
                                             you that your personal information and             Reminder:
                                             membership details will not be disclosed.
                                                                                                Dispensing fees
                                                                                                on medicine
                                     Checking your                                              During April 2007, you would have

                                        claims statement                                        received communication regarding
                                                                                                the suspension of the “tiered”
                                                                                                dispensing fee structure that would
                                             When you receive your claims                       have come into effect on 1 January
                                             statement, check that:                             2007.
                                             E all your claims have been
                                                processed;                                      However, until further notification
                                             E all the claims indicated are for                 is received from the Department of
                                                healthcare services provided                    Health, the 26% fee on prescribed
                                                to you and/or your registered                   medicine under R100, and R26 on
                                                dependants; claims rejected                     prescribed medicine costing more
                                                for a particular reason must be                 than R100, will continue to apply.
                                                followed-up timeously.
                                     contact details
                                     Address for delivery of claims
                                     Sappi Medical Aid Scheme
                                     PO Box 3535
                                     Cape Town

                                     In-person queries
                                     61 St George’s Mall
                                     Cape Town

                                     Client Service Department
                                     Share call: 0860 101 280
                                     Fax: 0860 101 480
                                     E-mail: sappi@mhg.co.za
                                     Internet: www.mhg.co.za
                                     Electronic query facility: 0861 333 120

                                     MHg/KpMg Fraud Hotline
                                     Toll free: 0800 200 564
                                     E-mail: audit@mhg.co.za

                                     Qualsa hospital pre-
                                     Share call: 0860 101 380

                                     HIV/AIDS Disease Management
                                     Share call: 0861 888 300
                                     Fax: 0861 888 301

                                     Netcare 911 (24-hour emergency
                                     ambulance service)
                                     Tel: 082 911

                                     MAIl ORDER DISpENSINg
                                     pHARMACY - ORDER OR
                                     DElIVERY ENQuIRIES
                                     Chronicare Medicines:
                                     0860 102 304
                                     E-mail: info@chronicare.co.za
                                     (012) 426 4000
                                     E-mail: dispensary@medipost.co.za
                                     Chronic Medicine Dispensary:
If you have any                      0860 633 420
                                     E-mail: help@chronicmedicine.com
requests for topics or suggestions
about the format or content of       Admedgap Insurance administered
                                     by Alexander Forbes
the newsletter, please e-mail them
                                     Share call: 0860 102 936
to sappi@mhg.co.za or phone          Fax: (011) 269 1419
the Client Service Department on
                                     Admedgap claims:
0860 101 280.                        PO Box 61703
Kind regards

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