How to claim

When sending claims to the Scheme, please make sure you do the following:

Check with your Healthcare Professional if they have sent your claims to us to avoid duplication

  • Send your claims within four months, otherwise we will consider them expired and will not pay them
  • When sending claims, please make sure the following details are clear:
    1. Your membership number
    2. The service date
    3. Your Healthcare Professional’s details and practice number
    4. The amounts charged
    5. The relevant consultation, procedure or NAPPI code and diagnostic (ICD-10) codes
    6. The name and birth date of the dependant for whom the service was done
    7. If paid, attach your receipt or make sure the claim says ‘paid’
  • Remember to always keep copies of your claims for your records                           

By law, each claim must contain the following information:

  • The surname and initials of the member
  • The surname, first name and other initials, if any, of the patient
  • The name of the medical scheme concerned
  • The membership number of the member
  • The practice code, group practice and individual provider registration numbers issued by the registering authorities for providers, if applicable, of the supplier of service and, in the case of a group practice, the name of the practitioner who provided the service
  • The relevant diagnostic and such other item code numbers that relate to such relevant health service
  • The date on which each relevant health service was rendered
  • The nature and cost of each relevant health service rendered, including the supply of medicine to the member concerned or to a dependant of that member; and the name, quantity and dosage of and net amount payable by the member in respect of the medicine

Choose from several ways to send claims

There are various ways of sending claims to the Scheme for processing:

  • Send your claim electronically– by email to claims@discovery.co.za, or fax to 0860 329 252.
  • Drop off your claim at Discovery Health’s offices or at any other assigned Discovery Health claims box. You can find these boxes at Virgin Active or Planet Fitness gyms, Dis-Chem pharmacies or at most private hospitals.
  • Post your claim to the Scheme.

What happens after you send your claim?

Once we receive your claim, we scan and capture it on our system. We will then assess the claim and make sure all the information on the claim matches the information we have on record for the patient.

It is then approved or declined for payment. Once we have made the payment, you will receive your claims statement detailing all the claims payments.

How to check on the status of your claim

To see the status of your claim, you can access the Claims Search tool or check your claim statement. Alternately you can contact the call centre on 0860 123 077.

If we have your email address, you can now receive a claims payment notification, that will provide you with all the information about the latest claims we have processed for you – how it was assessed against your available benefits, how it was paid and what the latest balances are.

Remember to log in and update your information on the website.

How to report fraudulent activities

Fraudulent claims affect not only the Scheme, but also your contributions.

Examples of fraud are:

  • belonging to two medical schemes at the same time and claiming more than once for the same claim
  • sunglasses being billed as prescription glasses
  • allowing your provider to claim for procedures /treatment that was not given
  • giving non-registered persons access to benefits through misrepresentation; that is when you give your membership card to your neighbour, who is not a TFG Medical Aid Scheme member, to undergo treatment under your name.

Check that all transactions related to your membership are true and correct. Report any suspicions you may have immediately, by contacting Discovery’s toll-free, tip-off line on
0800 004 500, email forensics@discovery.co.za or visit www.fraudline.co.za. All calls or contact will be handled strictly confidential. Any person caught committing fraud will be listed on a register and steps will be taken to recover any money you, or the Scheme, may have lost in the process.