Why PMB claims get rejected.
Most PMB rejections are administrative rather than clinical. These are the patterns that show up most often.
When a PMB claim comes back rejected, the instinct is often to assume the scheme has taken a position on the treatment. More often, the claim never got far enough for that. It was assessed as something other than a PMB claim, because nothing in the submission told the scheme to treat it as one.
The patterns that repeat
- The diagnosis and the treatment are not linked in a way that matches a Diagnosis and Treatment Pair
- Supporting documentation the scheme asked for was never sent, or was sent after the file was closed
- The claim was submitted under a benefit category that does not trigger PMB assessment
- A request for further information arrived and was not answered within the scheme's timeframe
- The member's details on the claim do not match the scheme's records
Reading the rejection properly
A rejection reason is usually a code with a short description, and the description rarely explains the underlying problem. Working out which of the patterns above applies is the difference between a claim that can be corrected and re-submitted, and one that simply ages.
What a practice can do
Read every remittance rather than filing it. Keep a record of which claims were queried, when, and with whom. Correct and re-submit while the claim is still current. None of that is complicated, but all of it takes uninterrupted time, which is exactly what a working practice does not have.
This article is general information about healthcare administration in South Africa. It is not legal, clinical or financial advice, and it does not describe the rules of any particular medical scheme. Always check the position that applies to a specific claim.