Balltron: FAQ's

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Hospitron™ FAQ´s

Where can I get an Application Form from? Where do I get a Membership Card from and what is the purpose of the card? Who can be registered as beneficiaries? What happens in the case of the death of the member? What does suspension mean? Can I change benefit options during the year? How do I change my address and bank details? How do I go about submitting a claim? How long does it take for payment of the claim? Who should submit the claim, the member or the service provider? If the Service Provider is ´contracted out´, will my claim be paid? Do accounts need to be signed, before being submitted? If a claim is rejected as being "Stale", what does this mean, and what action should I take in this regard? Do I have full cover in hospital? In what instance is pre-authorisation required? Are authorisations a guarantee of payment? What numbers do I need?

Answer:
You can call the Customer Relationship Centre on 0861 112233 and request an Application Form. Application Forms can be sent via fax or e-mail along with the product information benefit schedule. Once you have completed the Application Form fax it to 021 809 1890. You can also collect an Application Form from on of the Regional Marketing and Distribution Centres.

Answer:
Your Membership Card is issued by Resolution Health on your acceptance to the scheme. When you visit the doctor or the chemist or any other medical related facility they will request your card for proof that you are on the scheme. The card will contain the following information:

Your membership number;
Your Name and Surname;
The names of your beneficiaries; The date from which you and your beneficiaries are covered;
Benefit Option (plan details)

Your membership card should be kept with you at all times. It may not be used by any other person than you and / or your beneficiaries.

Answer:
Your spouse or partner and dependent children.

Answer:
The surviving beneficiaries may continue as members of the medical scheme, provided that they were registered on the scheme at the time of the main member's death. The surviving beneficiaries would have to continue with the payment of the contributions. However, should the widow/widower remarry, and he/she becomes a dependent on the new spouse's scheme, the membership will terminate.

Answer:
A member will be suspended from the medical scheme, for instance, when the member fails to pay the monthly contributions, or portions thereof in full. During the period of suspension, the scheme will not grant any benefits to the said member.

Answer:
No. In terms of the Rules of the medical scheme, a member may only change benefit options in December/January of each year. Note: The scheme's financial year runs from January to December.

Answer:
Changes can be done telephonically by calling Resolution Health Administrators on the following number: (011) 796 6400. It is however preferable that you do it by way of a written letter to PO Box 1555, Fontainebleau, 2032 or fax to 011 791 7049

Answer:
All claims and accounts must be posted or hand-delivered to the Scheme as soon as they are received. No faxed copies are accepted, and the original documents are required in all instances. This is done in an attempt to eliminate fraud. PO Box 1555, Fontainebleau, 2032.

If you have already paid the account up front, and are submitting it for reimbursement, the receipt must be attached to the account and clearly marked – settled (paid) by member.

Remember: All accounts must reflect the following information:

The name and surname of the principle member
The first name, initials and surname of the patient (if the patient is not the principle member)
The name of the Medical Scheme - Resolution Health Medical Scheme
Your membership number
The relevant diagnostic and other item codes that relate to the relevant health service provided
The date on which each health service was provided
The nature and cost of each health service rendered
Any name, quantity and dosage of any medication supplied to the member or dependent
The net amount payable by the member in respect of said medication

Answer:

Answer:
Claims are assessed on a daily basis and payment runs are done twice a month. Ensure that invoices and prescriptions have all the details to ensure that they are processed timeously and efficiently.

Answer:
The member is responsible for ensuring that the account is submitted If you have already paid the account, then you must submit the account to the address provided on your monthly statement. The service provider may submit the account to the administrators. The service provider will then be paid directly, and your benefits will be adjusted accordingly, however the member must confirm that the account has been received by the scheme.

Answer:
If the service provider you choose is ´contracted out´ (i.e. charges are above the NPRL), the Medical Scheme will pay its portion of the claim (the tariff covered by the scheme) over to the service provider. If the member has a savings account (MCA), the outstanding amount will be paid to the Service Provider, funds permitting.

Answer:
Yes.

Answer:
In terms of the Scheme Rules, a claim must be submitted within 4 months of date of service. If the claim is submitted after the 4 month period, the claim is then termed as stale. If this happens, you will either have to provide proof that the claim was submitted within the time frame, or alternatively, write to the Scheme, explaining the reasons for the late submission. The scheme will then consider the merits of the case and make a decision accordingly.

Answer:
Pre-authorisation is required in the event of hospitalisation(not in the case of hospitilisation), and the use of specified auxiliary services.

1.1	If you are on the Fundamental Plan, you have unlimited cover in Network Hospitals and Provincial Hospitals only for PMB related conditions
1.2	If you are on the Progressive Plan, a maximum of R150 000 per annum for a single person and r300 000 per annum for a family in any Hospital for any condition. if the hospital benefit is depleted (R150 000 or R300 000), member will have unlimited cover in Network Hospitals and Provincial Hospitals only for PMB related conditions.
1.3	If you are on the Prestige Plan, cover in respect of provincial and private hospitals is unlimited for any conditions and resolution Health will pay 100% of the NRPL

Answer:
Pre-authorisation is required in the event of hospitalisation(not in the case of hospitilisation), and the use of specified auxiliary services.

Answer:
No. Benefits and membership information is only as accurate as the information available to us. Resolution Health, its trustees, or employees cannot be held liable under any circumstances for any claims, loss or damage whatsoever, whether direct, indirect or consequential and whether arising out of delict, contract or any other cause whatsoever which may arise out of the provision of inaccurate information by the member to Resolution Health.

Answer:
Pre-Authorisation Tel Number: 0861 111 778

Evacuation and After Hours Emergency: 082 911

24 Hour HIV/Aids Helpline: CareWorks 0860 10 1110