Discovery Health Medical Scheme (DHMS) claims process for Infertility
By now you are probably aware that IFAASA has been in discussions with Discovery Health Medical Scheme (DHMS) regarding the coverage offered for the diagnosis and treatment of infertility.
In a recent meeting with DHMS, it was agreed that a claims process needs to be documented and communicated to members.
The process is explained below. Should you have any further questions in this regard, please let IFAASA know at firstname.lastname@example.org.
PMB Claims process:
With regards to out of hospital tests and procedures as listed below in Annexure A of the Medical Schemes Act:
- the following blood tests:
- Day 3 FSH/LH
- Thyroid function (TSH)
- Day 21 Progesterone
- surgery (uterus and tubal)
- manipulation of ovulation defects and deficiencies
- semen analysis (volume; count; mobility; morphology; MAR-test)
- basic counselling and advice on sexual behaviour, temperature charts etc.
- treatment of local infections.
DHMS will initially deduct the out of hospital claims from the member’s medical savings account until a definitive infertility diagnosis is made. Once the diagnosis is made it is the member’s responsibility to complete the DHMS form ‘Application for out-of-hospital management of a Prescribed Minimum Benefit condition’ and ensure the treating physician completes the relevant parts. Once DHMS has received this form from the member and processed it, the claims for the above procedures will be reimbursed to your savings account. If your Medical Savings account is depleted of funds you are required to pay for the diagnostic tests yourself and once the application form has been completed DHMS will reimburse the member directly.
In the case of escalated claims, DHMS has appointed Rishana Singh email@example.com as the dedicated person who will deal with infertility claims.
Discovery Health Medial Scheme (DHMS) claims process for members wanting to use their medical savings account funds to cover treatment that fall outside of the PMBs and which are not covered by the Scheme (namely Fertility treatment)
If the member has been with the Scheme for more than a year, the member is able to access the full balance in their MSA and use it for funding of their fertility treatment. There has to be available funds within the Medical Savings Account, this application does not apply to the Above Threshold Benefit.
Members have to complete the form ‘Application for special payments made from the Medical Savings Account’ and submit the form to DHMS.
In the case of escalated claims Rishana Singh firstname.lastname@example.org is the dedicated person who will deal with infertility claims.
Content courtesy of IFAASA (www.ifaasa.co.za)