LEGAL & COMPLIANCE
BOARD OF TRUSTEES CHARTER
CLINICAL DISPUTE RESOLUTION
This process is for hospital, medicine & disease authorisation disputes
Polmed makes provision for members, healthcare providers and third parties to lodge complaints or enter into disputes should they disagree with a particular funding outcome. Here are the steps to follow when lodging an appeal or when entering into a dispute.
This is a formal letter that is sent either via post or as an email attachment, clearly indicating the purpose of the communication. A written appeal must be legible and contain all the relevant membership information, including personal information, a membership number and dependant codes, as well as Scheme option. The decision against which the appeal is being made must be clearly stated and all the supporting documents must be attached. The appellant must send the written request to the relevant department within 30 days of receipt of the outcome or decision:
Medicine (Polmed Chronic Medicine Management) – firstname.lastname@example.org
Hospital (Polmed Hospital Risk Management) – email@example.com
Specialised dentistry – firstname.lastname@example.org
Ambulatory prescribed minimum benefits (aPMBs) – Care Templates – email@example.com
Private Bag X16
By hand delivery:
To the nearest Client Service Centre in your region.
The appellant must always address the appeal to the relevant department; for example the Polmed Chronic Medicine Management programme for disputes related to medicine. The department will forward your appeal to the Clinical Committee. While your appeal is being processed, you may get a letter asking you to provide more information or documentation. If you send this information to us, we may be able to informally resolve your case fairly quickly.
For urgent matters, feedback on the resolution of the dispute is provided in writing within five working days after receiving all the necessary information.
Non-urgent matters are discussed at the Clinical Committee review meeting, which sits once a month. Feedback is provided in writing within five working days after the meeting.
Should you still not be satisfied with the outcome of the above processes, you may lodge a complaint with the Council for Medical Schemes by using one of the following channels:
This process is for membership and claims disputes
Polmed makes provision for members, healthcare providers and third parties to lodge complaints and disputes in cases where unfavourable outcomes were received.
Here are the channels to use as a first step to lodging a complaint or disputing a ruling:
Alternatively, visit our Client Service Centre in your region.
If you remain dissatisfied with the outcome, put your dispute or complaint in writing and send it to firstname.lastname@example.org. The dispute will be processed within a minimum of five working days, depending on the complexity of the enquiry.