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Tips for problem-free claims processing |
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| When you’ve consulted
a doctor (i.e. a
general practitioner),
it is important that PATHFINDER
receives the claim for services
rendered to you and/or your
dependants within 120 days
from the date of the consultation.
If your doctor (in this case
the general practitioner) doesn’t
submit claims electronically to
PATHFINDER, it is your
responsibility to ensure that the
claim reaches PATHFINDER on
time. If a claim doesn’t reach
the Scheme within the 120
days, it will be rejected as a
‘stale claim’ and will not be
paid. |
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| When you are sending in
the claim, please make sure
that you have checked that all
the relevant details – as
required by PATHFINDER – are
on the claim and that you have
signed it. To make it easier for
you to follow up on payment of
your claims, keep a copy of all
claims you have submitted and
check it against your member
statement to see which claims
have been paid and which are
still outstanding. |
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| To make it easier for you,
herewith a list of all the details
that should be on any claim
sent to PATHFINDER for
payment. Keep this list at hand
when sending your claim to
ensure problem-free processing
of your claim. |
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The surname, first name
and other initials of the
principal member |
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The surname, first name
and other initials of the
patient (the person who
consulted the doctor) |
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The membership number of
the principal member |
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The name of the
PATHFINDER Option you
and your dependants belong
to (i.e. Trail, Lane, Terrace) |
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The date of service (the
date of the consultation) |
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The nature of the patient’s
illness |
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The cost of the service (in
this case, how much the
doctor charges for the
consultation) |
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Tariff code |
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A valid ICD 10 code (also
called a diagnosis code) |
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The doctor’s practice
number (where applicable) |
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The name of the referring
doctor or dentist (if
relevant) |
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The name, quantity and
price of each supply of
medicine/apparatus. |
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| Please note that, if any of
the above details is missing
from a claim, the claim cannot
be processed. |
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| The address for submitting
claims: |
PATHFINDER Claims Department:
PATHFINDER Medical Scheme
P.O. Box 11465
CENTURION
0046 |
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PATHFINDER, Calabash and Mx® Health:
Who’s who? |
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| For the first time in the
beginning of this year,
you heard the name
Calabash Health Solutions.
Many of you contacted us,
asking who exactly Calabash
is and what they do. You also
wanted to know where Mx®
Health fitted into the picture.
So, herewith your guide to
who these role players are
and what they do. |
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| Mx® Health is the
administrator of the scheme and
is responsible for all membership
processes. Calabash Health
Solutions as a health
maintenance organisation is
responsible for receiving,
adjudicating and payment of
claims. Calabash Health
Solutions is also responsible for
issuing member statements. This
statement keeps you up to date
on the status of your claims and
the benefits you and your
dependants still have available.
Calabash Health Solutions
is responsible for all managed
health care programmes.
These programmes include
hospital pre-authorisation and
disease management. |
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| With the Calabash
network of providers that is
available to members and
their families, members are
assured of services close to
where they live. Calabash
ensures that these network
providers deliver good and
professional care to
PATHFINDER members. |
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| The Scheme Rules are
applied by Calabash Health
Solutions to ensure that your
benefits are managed correctly
and effectively and that you
and your families receive health
care when you need it. This
means that you, as the member,
belong to PATHFINDER your
scheme, and that Calabash
acts on behalf of you and the
scheme. |
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If you need more
information, please call the
PATHFINDER Customer Care
Centre at 0861 147 741 with
all medical scheme queries. |
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Obtaining medicine: it’s as easy as |
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| Members on all
PATHFINDER options
benefit from the A, B,
C, D, E list of medicine, which
makes applying for medicine,
especially chronic medicine,
quicker and easier. It also
ensures that all members have
easy access to cost-effective
medicine. Calabash Health
Solutions, PATHFINDER’s health
maintenance organisation, has
successfully implemented the A,
B, C, D, E list of medicine for
other medical schemes. |
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| The A, B, C, D and E on
the list refer to the categories
medicine has been divided into. When a PATHFINDER
member goes to a pharmacy
and presents a prescription,
the A, B, C, D, E list classifies
and approves medicine,
online and real-time, while you
wait. |
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| The purpose of putting the
medicine in one of the
categories is to tell the
pharmacist whether preauthorisation
is necessary
and, if so, how preauthorisation
should be
obtained before a medicine
item can be given to the
member. |
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| Application forms:
only for medicine
on the C and D lists |
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| Most medicine will be
a u t o m a t i c a l l y
available on the
acute or chronic medicine
benefit. This means that – for
this medicine - members will
not have to submit an
application form. However, for
medicine that appears on the
C and D lists, application
forms are still required. |
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| Application forms are
available from: |
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The PATHFINDER fax-ondemand
service (please dial 082 239 2865 from a tonedialing
fax machine) – a list
of the application forms (with
their numbers) available from
the service appears below. |
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The PATHFINDER Client
Service Centre (please call
0861 147 741) |
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The PATHFINDER Website
www.pathfinderhealth.co.za |
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PATHFINDER |
| Fax-on-demand
number |
082 239
2865 |
| Chronic
medicine |
2201 |
| HIV
registration |
2207 |
| HIV medicine |
2206 |
| Cancer
treatment |
1004 |
| In-hospital
medicine |
2622 |
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| The ABCDE
principle: |
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Auto List: |
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(No chronic medicine
application required)
This list refers to the most
cost-effective therapy in a
specific therapeutic class and
contains items that will
automatically, without preauthorisation,
be paid from the
appropriate benefit (chronic
medicine, acute medicine,
etc., subject to the availability
of funds). |
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| Payment is made in full,
except for: |
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MMAP where appropriate
In certain instances, step
therapy may be applicable
and a specific medicine will
only be allowed by the
system in certain instances,
e.g. when used together
with another. If the
prescription does not
adhere to the required
specifications, the claim will
immediately be rejected. |
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MAC (Maximum Allowable Cost): |
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(No chronic medicine
application required)
This list of medicine refers
to items where a more costeffective
alternative exists on
the Auto (A) list. This list also
contains items to be paid from
various benefits (chronic
medicine, acute medicine,
etc.). MAC is applicable to
items where alternative
therapy is available and
preferred as first-line treatment.
The member has to pay the
difference between the more
expensive item and the item
on the A list. Furthermore, copayments
apply for acute
medicine. |
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Chronic List: |
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| (Telephonic authorisation
required for chronic (long-term)
use. Available on acute medicine
benefit for short- term use) |
| Some medicine will
automatically be paid from the
acute medicine benefit if there
is no proof of a registered
chronic condition being
treated. In order to make use
of the chronic medicine
benefit, Calabash Health
Solutions requires an
application as before. Please
ensure that the diagnosis is
specified on the application form and that the specific
clinical requirements (test
results, pathology reports, etc.)
are attached to the
application. This list has been
kept to the minimum to limit
unnecessary administration on
your behalf. |
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Auth List: |
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| (Pre-authorisation required.
Diagnosis with appropriate
diagnostic and other test results
requested where appropriate) |
| A limited number of
conditions and treatments
require pre-authorisation to
qualify for funding (on any
benefit), based on the Scheme
Rules. These conditions are usually uncommon, treatment
very expensive and they
require extensive management.
In such cases, to ensure that
the patient receives treatment
without delay, please ensure
that the diagnosis is clearly
indicated on the form and
attach the specific clinical
requirements (test results,
pathology reports, etc.) to the
application. Once received,
the application will be subject
to a clinical assessment (drug
utilisation review or funding
guideline). This ensures that the
treatment conforms to the latest
international standards with
regard to safety, efficacy and
cost-effectiveness. |
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ExClusions: |
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| (Items not available) |
| Such items are not usually
paid by administrators,
however, if health-related, it
may be paid from savings (e.g.
contraceptives, anti-smoking
preparations or contact lens
preparations). |
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What to do if your personal details changed?
Notify
PATHFINDER at:
P.O. Box 11465, Centurion, 0046
or send a fax to 012-663 9981 |
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