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: 

Explain the cycle of a medical claim 
SAQA US ID UNIT STANDARD TITLE
118014  Explain the cycle of 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 learners who assess medical claims. It will be useful for intermediaries and service centre agents in Healthcare Benefits Administration.

The qualifying learner is capable of:
  • Explaining the origin of medical scheme claims.
  • Describing the different routes followed by medical claims.
  • Analysing a complex medical claim.
  • Investigate the storage and retrieval of claims related documents in a Healthcare Benefits Administrator. 

  • 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:
  • Complex claims include, but are not limited to, MVA, ex gratia, foreign claims and special cases such as orthodontic, oncology, trauma and HIV/AIDS.
  • Control measures include, but are not limited to, the Medical Schemes Act, Scheme Rules, options and limitations of benefits. 

  • Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Explain the origin of medical scheme claims. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The different ways in which a claim may be received are explained and an indication is given of how the origin impacts on the cycle of a claim. 

    ASSESSMENT CRITERION 2 
    The process followed in admitting a claim to a system is explained with examples. 

    ASSESSMENT CRITERION 3 
    The consequences of non-compliance with the process are explained with reference to the service provider, member and administrator of the scheme. 

    SPECIFIC OUTCOME 2 
    Describe the different routes followed by medical claims. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The route followed by a standard claim is explained for a specific scheme and an indication is given of the control measures at each stage in the cycle. 

    ASSESSMENT CRITERION 2 
    The route(s) followed by complex claims are explained for a specific scheme and an indication is given of the control measures at each stage in the cycle. 

    ASSESSMENT CRITERION 3 
    Possible errors that could occur in the cycle of a medical claim are investigated for two different routes. 

    ASSESSMENT CRITERION 4 
    Different ways in which a claim may be paid are explained for three case studies. 

    ASSESSMENT CRITERION 5 
    The importance of confidentiality throughout the claims cycle is explained with reference to a member's rights, current legislation and an organisation's policies and procedures. 

    SPECIFIC OUTCOME 3 
    Analyse a complex medical claim. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    A complex claim is analysed to determine the route that it should follow and a decision is substantiated with reference to the type of claim, member information and supporting documentation. 

    ASSESSMENT CRITERION 2 
    The stages along the route are identified and an indication is given of the actions, decisions and recommendations made at each stage. 

    ASSESSMENT CRITERION 3 
    Control measures are identified and an indication is given of the consequences of non-compliance at each stage along the route. 

    ASSESSMENT CRITERION 4 
    Documents required to support a complex claim are identified, accessed, completed and validated according to the rules of the scheme and requirements of the administrator. 

    SPECIFIC OUTCOME 4 
    Investigate the storage and retrieval of claims related documents in a Healthcare Benefits Administrator. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The claims storage system for a specific administrator is investigated and an indication is given of the controls in place to maintain confidentiality. 

    ASSESSMENT CRITERION 2 
    Claims related information is accessed from a system to resolve a query or provide supporting documentation. 


    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 in selecting a route for a complex claim. 

    UNIT STANDARD CCFO COLLECTING 
    Learners are able to collect, organise and critically evaluate information in investigating the storage and retrieval system in an organisation. 

    UNIT STANDARD CCFO SCIENCE 
    Learners are able to use science and technology effectively and critically in using a computer system in tracking the cycle of a claim. 

    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 
    N/A 

    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  49649   Further Education and Training Certificate: Long-term Insurance  Level 4  NQF Level 04  Reregistered  2023-06-30  INSETA 
    Elective  57613   Further Education and Training Certificate: Short-Term Risk Management  Level 4  NQF Level 04  Passed the End Date -
    Status was "Reregistered" 
    2012-06-30  INSETA 
    Elective  66613   Further Education and Training Certificate: Wealth Management  Level 4  NQF Level 04  Reregistered  2021-06-30  As per Learning Programmes recorded against this Qual 
    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. African Resources & Financial Training (Pty) Ltd 
    2. ALCARI 233 CC T/A ALCARI (Eversdal)(TP) 
    3. CKP Development Agency (Pty) Ltd. 
    4. De Vries Management & Training Services cc 
    5. DSBI (Pty) Ltd 
    6. Duxah (Pty) Ltd 
    7. Faisit (Pty) Ltd 
    8. Intec College 
    9. Invuya Institute of Learning (Pty) Ltd 
    10. Masifunde Training Centre (Pty) Ltd 
    11. Old Mutual Life Assurance Company South Africa 
    12. Ray Strodl Consulting (Pty) Ltd 
    13. RJM Educational Consulting PTY LTD 
    14. Sanlam Life Insurance Ltd 
    15. Sanlam Life Insurance Ltd. 
    16. 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.