Claim_Test

Claim Optimiser

Medical schemes have co-payments or upfront payments that apply to certain procedures or tests (eg MRI/CT scans) that must be paid by members before undergoing the treatment or tests.

To assist Cinagi members, we have established the Co-Payment Claim Optimiser, where we will guarantee the payment directly with the relevant facility prior to you having the procedure/treatment. This means that you do not need to make any out-of-pocket payments and we will pay the provider directly on your behalf.

Please note that this service is not available if your policy is still subject to a waiting period – kindly read the ‘Important Notes’ below on how and when the Co-Payment Claims Optimiser service can be utilised.

How does it work?

1. Obtain the pre-authorisation letter sent to you from your medical scheme.
2. Complete this form at least 72 hours before your admission by clicking on the ‘Next’ button at the bottom of this page.
3. Fill in the details on the form and upload the above pre-authorisation letter when requested.
4. Once your request has been reviewed and approved by us, we will provide a payment guarantee to the facility.
5. You will receive a confirmation letter from us which can be presented to the provider on the day of admission/treatment.

Important

• The Co-Payment Claim Optimiser is not available if your cover is still within a waiting period.
• This facility is only applicable to defined co-payments or upfront payments (as per your medical scheme rules) and that are covered in full by your Cinagi Gap Cover policy. Examples are:
• Radiology (eg, MRI and CT scans)
• Scopes (eg, gastroscopy, colonoscopy, sigmoidoscopy, proctoscopy, etc)
• Wisdom teeth extraction
• Defined Co-payments on specified surgical procedures
• Any additional shortfalls that arise after your procedure/treatment that are not covered by the Co-Payment Optimiser, will require you to submit a separate claim, you can intiate the claim HERE.
• By making use of this service you agree to cede to us the benefits relating to co-payments under your Cinagi Policy for this procedure. This only applies to co-payments or upfront payments that have been approved by Cinagi.

Policyholder Details

Procedure Details

Employment Confirmation Requirement – Optimiser Claim. Making use of the Optimiser claim requires members to provide proof of current employment with their employer. One of the following documents must be submitted:

• The latest payslip (please note: we do not require any financial details, only the date of employment and the date on the payslip), or
• an official letter from the employer’s HR department confirming current employment status.

Declaration & Submission

I hereby provide explicit consent to Cinagi (Pty) Ltd, its subsidiaries, associates, sub-contractors and/or its underwriters to:

• Use my personal information and all the information relating to this claim in order to provide me with administrative and insurance services;
• Negotiate with my medical service providers on the fees that they have charged;
• Engage with my medical service providers on whether their fees are compliant with prevailing legislation;
• Disclose information to persons and entities that it is necessary to disclose this information to in order to provide me with the aforementioned services;
• Communicate with me electronically about any changes or general information relating to administrative processes or changes to my policy, benefits, benefit costs and/or claims processes;
• Transfer my personal information outside South Africa if I have provided an email address that is hosted outside South Africa or to administer certain services, for example, cloud services;
• Obtain any medical records, medical claims or personal information of myself or my dependants from my/our medical scheme and/or my/our medical service providers, including their sub-contractors who process or transfer the relevant medical records, medical claims and/or personal information;
• Obtain any medical records, medical claims or personal information for myself or my dependants from any medical data bureau or credit bureau who respectively act as aggregators of medical and credit information.

By providing the information in this form and making use of the Co-Payment Optimiser you further agree that:

• Subject to approval of the benefit guarantee by Cinagi, all benefits relating to the co-payment in question will be ceded to Cinagi.
• Any additional claim/s that relate to this medical event will need to be submitted by yourself on the standard Cinagi claim form - Claim Form.
• You will assist Cinagi in obtaining any documentation relating to the fee/s charged by the facility and/or any other medical service provider.
• Cinagi is providing the Co-Payment Claim Optimiser guarantee based on full disclosure as required on your original application for cover.
• If Cinagi has provided any guarantee under this service and it is subsequently discovered that non-disclosure of pertinent information would have resulted in a waiting period being applicable to your cover, then you agree that the guarantee can be withdrawn or that if any benefit payments have been made to a provider by us on your behalf, that such amounts will be paid back to us.
• That all details above as well as any supporting documentation supplied with this claim, are true and correct and that you are aware that any non-disclosure or misrepresentation of any details may result in this claim being rejected or your policy cancelled or voided from inception.
• By submitting your dependents’ relevant personal information, you hereby confirm that you are duly authorised to share such information with us.
• If you are submitting this claim for a person under the age of 18 years (a minor), you confirm that you are a competent person and that you have the authority act on their behalf.
• We will furthermore process their information for the purposes and in the manner as set out in our Privacy Statement.
• You also acknowledge that that you have read and agreed to the Cinagi Privacy Statement, which can be found here Privacy Policy.