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Claims Submission Process

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Claims Submission Process

One does not need a form to submit a claim. Simply submitting a detailed account/statement from the healthcare provider will suffice. The following information needs to be on the account/statement:

Service provider

  • Name and practice number.
  • Referring doctor’s practice number.
  • In the case of a group practice, group practice number and the name of the practitioner who provided the service.

Member

  • Membership number.
  • Scheme name and benefit plan (Marine or Aquarium).
  • Main member’s initials and surname.
  • The patient’s name, other initials and surname (if it is not the principal member), as well as the dependant code (as it appears on the back of the POLMED membership card).
  • Date of birth of patient.

Other

  • Date of service.
  • Account/reference number.
  • Tariff code(s) – this is a code that refers to the pricing of a medical service/product.
  • ICD-10 code(s).
  • Cost of each treatment, item or procedure.
  • In respect of medication claims, the name, quantity, dosage and net amount payable by the member should be provided.

Click below for details about the POLMED claims submission process
How to submit a claim

Submit your claims correctly:

Claims must be submitted within 120 days of the service date. Claims received after this period will be rejected as stale. Copies of accounts will be accepted for processing or payment. In cases where the service provider charges above POLMED rates, you will be responsible for payment of the balance of the claim directly to the provider.

There are various ways of submitting claims to POLMED for processing:
Email: polmedcurrentclaims@medscheme.co.za
Fax: 011 758 7660
Post: POLMED, Private Bag X16, Arcadia 0007
Visit any of our regional walk-in branches.

Result

Once the claims have been assessed a claims statement will be sent to you that will reflect the outcome of the payment process. You can also view the outcome and your claims statement via the Member zone of this website.

Member Refunds

If you paid for a service directly and want to request a member refund, you need to submit your proof of payment (receipt or bank deposit slip) together with the service provider’s account that displays a zero balance for the claim.