Simple & Efficient Claims

Find out how the Episodic Health Insurance claims process works for rapid and pain-free claims handling

Claims

Your Claims are Paid Directly to the Medical Provider

The Administrator will settle claims directly where possible. Some providers expect upfront payment in which case your claim will be reimbursed. Here is what you need to know.

Hospital Claims

Pre-Authorisation

Call Africa Assist on 0861 911 011.
Identity yourself as an EssentialMED member with your Policy Number.
They will guide you further on what information they need.

Paperwork

You may need to supply the Medical Report from your doctor and sign acknowledgement documents for the hospital.

The Administrator will issue a Guarantee of Payment to the hospital (according to your benefits) that lets the hospital know how much money is available for treatment.

Admission

Get admitted and treated at the hospital or casualty ward.

Claim Submission

The hospital will submit the claim directly to the Administrator, EssentialMED, and the providers will be paid according to the acknowledged benefits.

See also:

FAQ: How to use your plan at a hospital

Hospital Network

Hospital Cover Details

Doctors Claims

Identify Yourself

Give your EssentialMED Policy Number to the practice clerk of the network doctor.
If you need to pre-authorise your visit then first call Africa Assist on 0861 911 011.

Treatment

Receive treatment. If you are referred for radiology, pathology or to a specialist then make sure the network GP is listed on the referral script.

Claim Submission

The doctor will submit the claim directly for payment. You will receive a Remittance Notice once the claim is processed.

Out-of-Network Claims

For visits to non-network doctors, you will need to submit the claim invoice directly to EssentialMED at claims@essentialmed.co.za and they will reimburse you up to the limits define in your Day-to-Day cover.

See also:

Day-to-Day Cover

Doctor Network

Dentistry Claims

Identify Yourself

Give your EssentialMED Policy Number to the practice clerk of the network dentist.

Treatment

Receive treatment. If you are referred for radiology, pathology or to a specialist then make sure the network dentist is listed on the referral script.

Claim Submission

The dentist will submit the claim directly for payment. You will receive a Remittance Notice once the claim is processed.

See also:

Day-to-Day Cover

Dentist Network

Acute Medication Claims

Get Your Script

A dispensing network doctor will give you medication directly from the practice. A scripting doctor will write a prescription that you take to the pharmacy. Over-the-Counter medication does not require a script.

Identify Yourself

Show the pharmacy your membership card or tell them the scheme is EssentialMED and provide your policy number.

Receive Medication

The pharmacy (or dispensing doctor) will issue your medication. They will inform you if the medication on the script is covered under the formulary or not.

Claim Submission

The pharmacy (or dispensing doctor) will submit the claim directly to the administrator and the claim will be paid directly according to the formulary on your benefits.

You can also submit your pharmacy invoice directly to the administrator for reimbursement by simply sending it to claims@essentialmed.co.za

See also:

Day-to-Day Cover

Pharmacy Network

Optometry Claims

Identify Yourself

Give your network optometrist your Policy Number and tell them the scheme is EssentialMED.

Get Treatment

The optometrist will guide you as to what frame, glasses or contactact lenses are available to you according to your benefits.

Claim Submission

The optometrist will submit the claim directly to the administrator and the claim will be paid directly according to the formulary on your benefits.

You can also submit your invoice directly to the administrator for reimbursement by simply sending it to claims@essentialmed.co.za

See also:

Day-to-Day Cover

Optometry Network

Other Claims

Referral

For radiology, pathology and specialist referrals, make sure that your network doctor is listed as the referring provider.

Treatment

Receive the treatment or procedure that you require.

Claim Submission

The provider may need you to submit your claim yourself. The provider might also require that you settle the claim upfront, in which case the administrator will reimburse you according to your benefits.

Network

A Network You Can Depend On

Access private healthcare when you need to see a doctor, visit a dentist, get medication or go to hospital.

Nationwide Network

Private Hospitals & Doctors

Explore the Network

FAQ

You have Questions, We have Answers

Find answers to the most common questions about our Network below. You can find many more answers to Frequently Asked Questions on our Help pages.

What if my doctor or dentist is not on the network?

The doctor and dentist network is constantly growing as more providers agree to join.

You can nominate your family doctor or dentist to join the network by filling in a request. Simply email info@essentialmed.co.za with the following information:

Doctor/Dentist name and Practice Number
Their contact details: phone & email
Their address

It is ultimately the decision of the doctor and the product administrator when a provider is nominated to the network. We cannot make a guarantee that they will join as it is their choice.

How are Episodic and EssentialMED related to each other?

Episodic offers a retail health insurance product for individuals that is provided and administered by EssentialMED. The Episodic Health Insurance product is an EssentialMED product.

EssentialMED is the product administrator for our health insurance product and they are responsible for managing the network, processing claims and enhancing the product.

What are "managed visits"?

The GP benefit is unlimited in that you can visit a network doctor as often as is medically necessary. This needs to be managed to make sure that it is you or your family using the benefit and not someone else.

Preauthorisation is required from:

the 5th consecutive visit for Single policies
the 12th consecutive visit for Family policies

by calling Africa Assist on 0861 911 011

This protects you and us from fraud on your policy as well as helping us make sure you are getting real value from the network of providers.

What happens if I visit a doctor that is not on the network?

The Day-to-Day benefits cover consultations with network doctors. You are allowed 3 visits to out-of-network doctors a year. These visits will be reimbursed up to a maximum amount defined in the GP Visits benefit.

How do I submit a claim myself?

If, for whatever reason, you need to submit a medical expense claim yourself then all you need to do is send an email to claims@essentialmed.co.za with the following information:

Your name and policy number
A copy of the invoice

The administrator will guide you from there.

Is there a hospital network?

No. Our health insurance product works with all major public and private hospitals, as well as day clinics.

This is because health insurance and medical aids work differently. We are not contracted to the hospitals for rates and tariffs, the underwriter guarantees the payment of the stated amounts in your benefit limits.

We have a helpful blog article that explains why the hospital does not need to recognise the health insurance product (unlike a medical aid).

Where can I find a list of network hospitals?

Episodic Health Insurance can be used at any hospital. There is no hospital network. We advise making use of NetCare, Busamed and Life hospital groups as well as Cure Day Clinics for the most seamless experience with the product.

This is because Episodic Health Insurance is not a Medical Aid. It offers stated limits for defined events which can be pre-authorised with the hospitals as a Guarantee of Payment.

You can read about how this works in our helpful blog article and FAQ page about authorisations.