SAQA All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.
SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD: 

Assess a medical claim 
SAQA US ID UNIT STANDARD TITLE
118010  Assess a medical claim 
ORIGINATOR
SGB Insurance and Investment 
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY
-  
FIELD SUBFIELD
Field 03 - Business, Commerce and Management Studies Finance, Economics and Accounting 
ABET BAND UNIT STANDARD TYPE PRE-2009 NQF LEVEL NQF LEVEL CREDITS
Undefined  Regular  Level 4  NQF Level 04 
REGISTRATION STATUS REGISTRATION START DATE REGISTRATION END DATE SAQA DECISION NUMBER
Reregistered  2018-07-01  2023-06-30  SAQA 06120/18 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2024-06-30   2027-06-30  

In all of the tables in this document, both the pre-2009 NQF Level and the NQF Level is shown. In the text (purpose statements, qualification rules, etc), any references to NQF Levels are to the pre-2009 levels unless specifically stated otherwise.  

This unit standard does not replace any other unit standard and is not replaced by any other unit standard. 

PURPOSE OF THE UNIT STANDARD 
This unit standard is intended for medical claims assessors and learners in service centres who are required to respond to queries about medical claims. It requires learners to use insight in applying medical knowledge to process a medical claim.

The qualifying learner is capable of:
  • Using medical reference guides to access information
  • Explain how scheme rules apply to the payment of a claim.
  • Investigate the most commonly occurring medical conditions in South Africa.
  • Explain basic terminology relating to medical claims.
  • Process a medical claim. 

  • LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    There is open access to this unit standard. Learners should be competent in Communication and Mathematical Literacy at Level 3. 

    UNIT STANDARD RANGE 
    The typical scope of this unit standard is
  • Current codes include procedural, diagnostic and consumable codes and related tariffs/guidelines.
  • Irregularities in a claim include, but are not limited to, procedures by gender and age, exceptionally high claims, cosmetic claims, anesthetics, over servicing and over utilisation.
  • User rights and confidentiality relate to information, staff, information on medical conditions and membership status.
  • Conditions applied to Prescribed Minimum Benefits refer to service providers and medication.
  • Price lists and other documents may be electronic or hard copy. 

  • Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Use medical reference guides to access information. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Price lists are used to access information on the prices of medicines. 

    ASSESSMENT CRITERION 2 
    Information relating to medication, its use and contra indications is accessed from standard industry sources. 

    ASSESSMENT CRITERION 3 
    A medical dictionary is used to establish the meaning of medical terminology. 

    ASSESSMENT CRITERION 4 
    Recognised and approved medical reference guides are used to access information relevant to the assessment of medical claims. 

    ASSESSMENT CRITERION 5 
    Formularies are used to determine payment of a claim. 

    ASSESSMENT CRITERION 6 
    Designated provider guides are used to determine payment of a claim. 

    SPECIFIC OUTCOME 2 
    Explain how scheme rules apply to payment of a claim. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Rules prescribed by the Medical Schemes Act that are common to all scheme rules are named and identified in the rules of two different schemes. 

    ASSESSMENT CRITERION 2 
    The rules of two schemes are analysed and compared in terms of benefits and exclusions. 

    ASSESSMENT CRITERION 3 
    Scheme specific rules that relate to processing a claim are identified and applied to the payment of a claim. 

    SPECIFIC OUTCOME 3 
    Investigate the most commonly occurring medical conditions in South Africa. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The top ten chronic medical conditions in South Africa are named and described in terms of diagnosis and treatment and an indication is given of why these are prescribed minimum benefits. 

    ASSESSMENT CRITERION 2 
    The most commonly occurring chronic medical conditions claimed for under a specific scheme are compared to conditions classified as chronic prescribed minimum benefits and possible reasons are suggested to explain any variances. 

    ASSESSMENT CRITERION 3 
    The concept of generic medication is explained with reference to the Medical Substances Act. 

    ASSESSMENT CRITERION 4 
    Generic alternatives for the original medication for a particular condition are explored and an indication is given of the difference in price for the original and generic medication. 

    ASSESSMENT CRITERION 5 
    Conditions that qualify for prescribed minimum benefits are identified and an indication is given of the conditions applied by a specific scheme or option. 

    SPECIFIC OUTCOME 4 
    Explain basic terminology relating to medical claims. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The different medical disciplines are named and a brief description is given of each discipline. 

    ASSESSMENT CRITERION 2 
    Common abbreviations and terminology on medical claims are identified and used to determine payment of benefits according to rules of Scheme and company procedures. 

    SPECIFIC OUTCOME 5 
    Process a medical claim. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The current coding systems and tariff guidelines are applied to assess a claim. 

    ASSESSMENT CRITERION 2 
    The claim is validated according to specific company procedures. 

    ASSESSMENT CRITERION 3 
    The concept of user rights and confidentiality are explained and an indication given of how these are applied in the Healthcare Benefits Administration environment. 

    ASSESSMENT CRITERION 4 
    Medical claims covered by a third party are identified and referred to the relevant party. 

    ASSESSMENT CRITERION 5 
    Irregularities in a claim are identified and referred to the relevant authority. 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
    This Unit Standard will be internally assessed by the provider and moderated by a moderator registered by a relevant accredited ETQA or an ETQA that has a Memorandum of Understanding with the relevant accredited ETQA. 

    UNIT STANDARD ESSENTIAL EMBEDDED KNOWLEDGE 
    N/A 

    UNIT STANDARD DEVELOPMENTAL OUTCOME 
    N/A 

    UNIT STANDARD LINKAGES 
    N/A 


    Critical Cross-field Outcomes (CCFO): 

    UNIT STANDARD CCFO IDENTIFYING 
    Learners are able to identify and solve problems and make decisions in identifying irregularities in claims. 

    UNIT STANDARD CCFO WORKING 
    Learners are able to work effectively with others as a member of a team, group or organisation in assessing claims and identifying and referring irregularities. 

    UNIT STANDARD CCFO ORGANISING 
    Learners are able to organise and manage themselves effectively by in applying codes correctly and assessing medical claims accurately and fairly. 

    UNIT STANDARD CCFO COLLECTING 
    Learners are able to collect, organise and critically evaluate information in order to process a medical claim. 

    UNIT STANDARD CCFO COMMUNICATING 
    Learners are able to communicate effectively in processing a claim, access information from medical texts, explain terminology related to medical claims and make comparisons. 

    UNIT STANDARD CCFO SCIENCE 
    Learners are able to use science and technology effectively in using a computer system to assess a claim. 

    UNIT STANDARD CCFO DEMONSTRATING 
    Learners are able to demonstrate an understanding of the world as a set of related systems in understanding the long term effects of chronic conditions and the use of medication. 

    UNIT STANDARD CCFO CONTRIBUTING 
    Learners are able to participate as responsible members of the community by respecting user rights and confidentiality in Healthcare Benefits Administration. 

    UNIT STANDARD ASSESSOR CRITERIA 
    N/A 

    REREGISTRATION HISTORY 
    As per the SAQA Board decision/s at that time, this unit standard was Reregistered in 2012; 2015. 

    UNIT STANDARD NOTES 
    Practical work experience

    Before being credited with this unit standard learners are required to have a minimum of 120 hours experience in claims assessing and processing. 

    QUALIFICATIONS UTILISING THIS UNIT STANDARD: 
      ID QUALIFICATION TITLE PRE-2009 NQF LEVEL NQF LEVEL STATUS END DATE PRIMARY OR DELEGATED QA FUNCTIONARY
    Core  49356   Further Education and Training Certificate: Medical Claims Assessing  Level 4  NQF Level 04  Reregistered  2023-06-30  INSETA 
    Elective  66389   Higher Certificate: Diagnostic and Procedural Coding  Level 5  NQF Level 05  Reregistered  2023-06-30  HW SETA 


    PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS UNIT STANDARD: 
    This information shows the current accreditations (i.e. those not past their accreditation end dates), and is the most complete record available to SAQA as of today. Some Primary or Delegated Quality Assurance Functionaries have a lag in their recording systems for provider accreditation, in turn leading to a lag in notifying SAQA of all the providers that they have accredited to offer qualifications and unit standards, as well as any extensions to accreditation end dates. The relevant Primary or Delegated Quality Assurance Functionary should be notified if a record appears to be missing from here.
     
    1. The Institute of Health Risk Managers (Pty) Ltd 



    All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.