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 QUALIFICATION THAT HAS PASSED THE END DATE: 

National Certificate: Healthcare Benefits Administration: Claims Assessing 
SAQA QUAL ID QUALIFICATION TITLE
20639  National Certificate: Healthcare Benefits Administration: Claims Assessing 
ORIGINATOR
SGB Financial Services 
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY NQF SUB-FRAMEWORK
INSETA - Insurance Sector Education and Training Authority  OQSF - Occupational Qualifications Sub-framework 
QUALIFICATION TYPE FIELD SUBFIELD
National Certificate  Field 03 - Business, Commerce and Management Studies  Finance, Economics and Accounting 
ABET BAND MINIMUM CREDITS PRE-2009 NQF LEVEL NQF LEVEL QUAL CLASS
Undefined  120  Level 4  NQF Level 04  Regular-Unit Stds Based 
REGISTRATION STATUS SAQA DECISION NUMBER REGISTRATION START DATE REGISTRATION END DATE
Passed the End Date -
Status was "Registered" 		 SAQA 0639/01  2001-12-05  2004-12-05 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2005-12-05   2008-12-05  

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 qualification does not replace any other qualification and is not replaced by any other qualification. 

PURPOSE AND RATIONALE OF THE QUALIFICATION 
The purpose of the qualification is to build knowledge and skill required by employees in Healthcare Benefits Administration who have had schooling at or below NQF level 4. It is intended to empower learners to acquire knowledge, skills, attitudes and values required to operate confidently as individuals in the South African community and to respond to the challenges of the economic environment and changing world of work in the financial services industry. It should add value to the qualifying learner in terms of enrichment of the person, status and recognition.

As a qualification that covers Healthcare Benefits Administration and insurance related learning, it provides a framework for learners to develop competencies that will give them insight into the Healthcare Benefits Administration sub sector. It includes a basic study of the financial services industry and the insurance sub sector. It introduces a basic understanding of the key terms, rules, concepts and principles of the field that will enable learners to be informed workers in the industry. It provides a balanced learning experience that allows flexible access to life long learning, higher education and to productive employment in Healthcare Benefits Administration. It provides an opportunity for learners to learn and apply academic skills in relation to the workplace and will allow for multi-skilling. The focus is on basic information gathering, analysis, presentation and the ability to apply knowledge of the field to solve routine problems within given frameworks.

Qualifying learners are capable of:
  • Carrying out basic research, information gathering and analysis.
  • Interpreting current affairs and their influence on Healthcare Benefits Administration.
  • Managing risk in their own lives.
  • Describing fraud in an Healthcare Benefits Administration environment and identifying fraudulent medical claims.
  • Explaining the concepts of managed care as applied in Healthcare Benefits Administration in South Africa.
  • Operating a computer for business purposes.
  • Assessing and processing medical claims including the use of coding.
  • Explaining Healthcare Benefits Administration, the products marketed and the role of intermediaries in this sector.
  • Showing insight into legislation that regulates Healthcare Benefits Administration.
  • Differentiating between medical schemes and medical insurance.

    Depending on the unit standards selected as electives, the learner will become competent in basic skills relating to:
  • Use of word processing and spreadsheets.
  • Administering Employee long term benefits
  • Explaining compulsory statutory insurance in South Africa
  • Applying legislation that regulates Healthcare Benefits Administration.
  • Call centres
  • Sales and marketing
  • The processing of numerical and text data
  • Managing an information system
  • The relationship between needs and Healthcare Benefits Administration products
  • Marketing and Healthcare Benefits Administration product to a niche market.

    These unit standards are intended as building blocks for the further development of skills that will make the learner a more fulfilled, informed, efficient and cost effective worker in the industry. This should result, in turn, in more effective and efficient service to the consumer and should make the industry more competitive in the global market.


    Rationale of the qualification:

    The National Certificate in Healthcare Benefits Administration: Level Claims Assessing designed to meet the needs of medical aid assessors and people in call centres within the Healthcare Benefits Administration sub sector.

    It provides an introduction to the assessing of claims in Healthcare Benefits Administration and is the first step on career path for learners who
  • Have attained the National Certificate in Insurance: Level 3 and wish to continue on a path of life-long learning.
  • Were previously disadvantaged or who were unable to complete their schooling and were therefore denied access to Further Education and Training.
  • Have worked in the Healthcare Benefits Administration sub sector for many years, but have no formal qualifications in claims assessing.
  • Wish to extend their range of skills and knowledge of the industry so that they can become knowledge workers in the industry.
  • Are in a learnership agreement in the Healthcare Benefits Administration sub sector.
  • Have recently taken up a position in claims assessing in Healthcare Benefits Administration.

    The National Certificate in Healthcare Benefits Administration: Level 4: Claims Assessing, allows the individual to work towards a nationally recognised qualification. It is flexible enough to accommodate both learners in formal education and learners already employed in the Healthcare Benefits Administration sub sector. It aims to develop informed and skilled learners in the Healthcare Benefits Administration and insurance sectors. The qualification at this level is the start of a career path in Claims Assessing, but is still generic enough to allow maximum mobility within Healthcare Benefits Administration and between the different sub-sectors of the financial services industry. Skills, knowledge, values and attitudes reflected in the qualification are building blocks that will be developed further in Level 5. The intention is
  • To promote the development of knowledge and skills that are required in the Healthcare Benefits Administration sub-sectors of the insurance industry.
  • To release the potential of people.
  • To provide opportunities for people to move up the value chain.
  • To provide opportunities for lifelong learning for people who work in Healthcare Benefits Administration Claims Assessing for which there was previously no recognised qualification.

    Learners already employed in the Healthcare Benefits Administration sub sector and insurance at this level do work that requires a well developed knowledge of the industry in general, the Medical Schemes Act and accompanying regulations and a range of skills. The work roles are linked to the assessment of medical claims and call centres. They include, but are not limited to:
  • Claims assessors
  • Healthcare Benefits Administrators
  • Internal Broker Consultants
  • Client Service providers
  • Insurance Centre agents
  • Intermediaries/Brokers

    The National Certificate in Healthcare Benefits Administration: Level 4: Claims Assessing should produce knowledgeable, multi-skilled workers who are able to contribute to improved productivity and efficiency within the insurance industry in general and the Healthcare Benefits Administration sub sector in particular. It should provide the means for current workers to receive recognition of prior learning, to upgrade their skills and achieve a nationally recognised qualification. It should also assist new entrants to the industry. The qualification is structured in a way that exposes learners to different aspects of Healthcare Benefits Administration in general and to claims assessing in detail. It is anticipated that this qualification will promote the notion of a life long learning. 
    		•

    LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    There is open access to this qualification. Learners should be competent in Communication, Mathematical Literacy and Financial Literacy at NQF level 3

    Recognition of Prior Learning

    The National Certificate in Healthcare Benefits Administration: Level 4: Claims Assessing allows open access. Provision has been made for prior learning to be recognised if a learner is able to demonstrate competence in the knowledge, skills, values and attitudes implicit in this qualification. Application for Recognition of Prior Learning (RPL) should be made to INSQA or a relevant accredited ETQA.
  • Recognition of Prior Learning (RPL) may allow for accelerated access to further learning.
  • Credit towards a unit standard is subject to quality assurance by INSQA or a relevant accredited ETQA and is conducted by a workplace assessor. 
    		•

    RECOGNISE PREVIOUS LEARNING? 
    Y 

    EXIT LEVEL OUTCOMES 
    Qualifying learners should be capable of:
  • Co-ordinating with others.
  • Applying the methods, procedures and techniques of claims assessing.
  • Analysing new developments in the industry and researching aspects of Healthcare Benefits Administration
  • Operating as informed employees in the Healthcare Benefits Administration sub sector.
  • Understanding the structure and the market of Healthcare Benefits administrators and their role and place in that structure.
  • Gathering, analysing and presenting information. 
    		•

    ASSOCIATED ASSESSMENT CRITERIA 
  • Rules applicable to different options are applied in a variety of situations in order to assess medical claims.
  • Work output is in line with an agreed mandate, relevant service agreements, the Administrator`s customer service standards and legislative requirements.
  • Methods, procedures and techniques of medical claims assessing are applied consistently in terms of specific scheme and Administrator practices and the Medical Schemes Act.
  • The consequences of non compliance are clearly indicated for practices required in Healthcare Benefits Administration.
  • New developments and trends in the Healthcare Benefits Administration are accessed, analysed and interpreted from reports in the media.
  • Knowledge of current developments in Healthcare Benefits Administration is discussed with reference to potential impact on claims.
  • The structure of the Healthcare Benefits Administration sub sector is analysed and an indication is given of the contribution of claims assessing to Healthcare Benefits Administration.
  • Information is gathered, analysed and presented in order to assess a claim and to identify fraud in a Healthcare Benefits Administration environment.
  • The Healthcare Benefits Administration market is described and an indication is given of the role that medical schemes / medical insurance play in the provision of healthcare benefits in South Africa
  • A computerised database is used to access information from electronic media in order to assess a medical claim.

    The learner is able to demonstrate ability to:
  • Identify and solve problems related to Healthcare Benefits Administration options in which responses show that responsible decisions using critical and creative thinking have been made. S/he is required to assess medical claims and apply the rules of available products to different situations.
  • Work effectively with others as a member of a team, group, organisation or community. As the qualification is intended to be part of a learner ship it is unlikely that the learner would work alone.
  • Organise and manage oneself and one`s activities responsibly and effectively in that it is expected that the learner will be responsible for his/her own learning and for organising his/her own work allocated tasks responsibly in the work environment. S/he is required to complete research assignments in time and to apply knowledge of different aspects of Healthcare Benefits Administration and insurance. S/he should be able to provide for his/her own financial security and manage his/her own finances.
  • Collect, organise and critically evaluate information. These competencies are built into the assessment criteria in many of the unit standards and the learner is required to do research projects and analyse information from the media.
  • Communicate effectively using visual, mathematics and language skills in the modes of oral and/or written presentations. These competencies are an integral part of all the unit standards and are built into the assessment criteria.
  • Use science and technology effectively and critically, showing responsibility towards the environment and the health of others, in that the Healthcare Benefits Administration environment is technology driven and very few activities take place without the application of technology. The inclusion of computer end user standards ensures that this Critical Cross Field Outcome receives attention. The learner is also expected to access information from electronic media and use a computerised database.
  • Demonstrate an understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation in that references are made wherever applicable to the learners` part in the big picture and how his/her actions have implications up and down the line.

    In addition this qualification contributes to the full personal development of each learner and the social and economic development of the society at large, by making it the underlying intention of any programme of learning to make the individual aware of the importance of
  • Reflecting on and exploring a variety of strategies to learn more effectively in order to become an informed worker in Healthcare Benefits Administration.
  • Being culturally and aesthetically sensitive across a range of social contexts in dealing with diverse people in the workplace including customers, co-workers and people who are surveyed or interviewed. The inclusion of an additional official South African language further supports this outcome.


    Integrated Assessment:

    Assessment practices must be fair, transparent, valid, reliable and should ensure that no learner is disadvantaged. Learners who wish to be assessed against this qualification should direct enquiries to the Insurance Sector Quality Authority, INSQA.
  • The focus of assessment must be on the assessment of the learning outcomes rather than learning outputs. The specific outcomes guide the learning and training process towards the outcomes on a continuous basis. The purpose is to determine whether the outcomes have been attained. Situations should present a wide range of options. Applications should require significant choices from a wide range of procedures and in a number of contexts.
  • Learning, teaching and assessment are inextricably linked. Where appropriate, assessment of knowledge, skills, attitudes and values indicated in the various unit standards should be integrated. Assessment in communication, mathematical literacy and financial literacy should use authentic insurance contexts wherever practical.
  • Assessment has a formative monitoring function. Formative assessment should be used to assess gaps in the learners` skill and knowledge and to indicate where there is a need for expanded opportunities. The goal is to promote learning and to assess the efficacy of the teaching and learning process. Feedback from assessment informs teaching and learning and allows for the critique of outcomes, methodology and materials. Formative assessment is diagnostic and as such it should guide the learner and the trainer. It is continuous and is used to plan appropriate learning experiences to meet the learner`s needs. It provides information about problems experienced at different stages in the learning process. As it is criterion referenced, if the learner has met the assessment criteria, s/he has achieved the outcomes.
  • Assessment should also have a summative component. Summative assessment may be used on completion of a unit standard, but should not be the only form of assessment. There should be a summative assessment based on the exit outcomes before the National Certificate in Healthcare Benefits Administration: Claims Assessing: NQF Level 4 is awarded.
  • A variety of methods must be used in assessment and tools and activities must be appropriate to the context in which the learner is working. Assessment should take place in an authentic context as far as is possible. Where it is not possible to assess competence in the workplace, simulations, case studies and other similar techniques should be used to provide a context appropriate to the assessment.
  • Integration implies that theoretical and practical components should where possible be assessed together.
  • Integrative techniques should be used to assess applied competence. Learners should be required to demonstrate that they can perform the outcomes with understanding and insight. In the unit standard Assess and process a medical claim learners are required to have a minimum of 120 hours practical experience before they are credited with the unit standard.
  • Assessment should ensure that all specific outcomes, embedded knowledge and Critical Cross Field Outcomes are evaluated. Assessment of the Critical Cross-Field Outcomes should be integrated with the assessment of the specific outcomes. The Critical Cross Field Outcomes are implicit in some unit standards and programmes should be designed to extend and further reflect the integration. 
    		•

    INTERNATIONAL COMPARABILITY 
    This qualification will be compared to international qualifications in terms of outcomes and assessment criteria, degree of difficulty and notional learning time. It will be benchmarked against:
  • FET level 4 in South African formal education.
  • Healthcare Benefits Administration NVQs from England. 
    		•

    ARTICULATION OPTIONS 
    The National Certificate in Healthcare Benefits Administration: Level 4: Claims Assessing is structured in a way that exposes learners to different aspects of the Healthcare Benefits Administration industry with a view to enabling them to make an informed choice of a career path in one of the sub sectors.

    The unit standards that make up the certificate are the building blocks of knowledge and skill that are necessary for the proposed level 5 diploma. Within the financial services sector articulation possibilities exist between long term insurance, personal accident and Healthcare Benefits Administration. 

    MODERATION OPTIONS 
    This qualification will be internally assessed by the provider and moderated by a moderator registered by the Insurance Sector Quality Authority (INSQA) or a relevant accredited ETQA. The mechanisms and requirements for moderation will be contained in the document obtainable from INSQA in 2001, INSQA framework for assessment and moderation.
  • Moderators, competent at the level of the qualification, are registered by INSQA or a relevant accredited ETQA to ensure that the standard across assessors is consistent.
  • Moderators are required to be competent in the generic moderation unit standards.
  • Moderators are required to report to INSQA or a relevant accredited ETQA. (See INSQA framework and guidelines for assessment and moderation for details.)
  • INSQA or a relevant accredited ETQA will monitor and quality assure moderation and assessment according to guidelines in the qualification and INSQA procedures. 
    		•

    CRITERIA FOR THE REGISTRATION OF ASSESSORS 
  • Assessors must be registered with INSQA or a relevant accredited ETQA.
  • Assessors, competent at the level of the qualification are registered by INSQA or a relevant accredited ETQA to ensure that the standard across assessors is consistent.
  • Assessors are required to be competent in the generic assessment unit standards.
  • Assessors are required to report to INSQA or a relevant accredited ETQA. (See INSQA framework and guidelines for assessment and moderation for details.)
  • Institutions and providers offering learning that will lead to the achievement of the National Certificate in Healthcare Benefits Administration: Level 4: Claims assessing must be accredited as providers with INSQA or a relevant accredited ETQA.
  • INSQA will assure the quality of all learning programmes in collaboration with other SETAS in different economic sectors. 
    		•

    NOTES 
    Fundamental Unit Standards:

    20 credits are required from Communication;
    20 credits are required from Additional language;
    16 credits are required from Mathematical literacy;
    10 credits are required from Financial literacy.

    Core Unit Standards:

    62 credits are required.

    Elective Unit Standards:

    9 credits are required. 

    UNIT STANDARDS: 
      ID UNIT STANDARD TITLE PRE-2009 NQF LEVEL NQF LEVEL CREDITS
    Core  7573  Demonstrate ability to use the World Wide Web  Level 2  NQF Level 02  3 
    Core  7571  Demonstrate the ability to use electronic mail software to send and receive messages  Level 2  NQF Level 02  3 
    Core  8103  Maintain an existing information system in an insurance environment  Level 2  NQF Level 02  3 
    Core  9004  Market a single need insurance policy to a niche market  Level 2  NQF Level 02  2 
    Core  9350  Process numerical data and text information in an insurance environment  Level 2  NQF Level 02  2 
    Core  9002  Describe healthcare funding in South Africa and the role of intermediaries in the sector  Level 3  NQF Level 03  3 
    Core  8991  Explain Healthcare Benefits Administration in South Africa  Level 3  NQF Level 03  2 
    Core  8994  Manage risk in own life  Level 3  NQF Level 03  3 
    Core  12326  Analyse new developments reported in the media that could impact on long term insurance  Level 4  NQF Level 04  10 
    Core  12298  Assess and process a medical claim  Level 4  NQF Level 04  6 
    Core  12335  Demonstrate knowledge and insight into the Medical Schemes Act (131 of 1998) and the accompanying regulations  Level 4  NQF Level 04  3 
    Core  12323  Demonstrate knowledge and understanding of different products marketed by Healthcare Benefits Administrators  Level 4  NQF Level 04  4 
    Core  12318  Describe managed care as it is applied in Health Benefits Administration in South Africa  Level 4  NQF Level 04  6 
    Core  12321  Describe the control of fraud in Healthcare Benefits Administration  Level 4  NQF Level 04  8 
    Core  12314  Explain the concept of coding as used in Healthcare Benefits Administration  Level 4  NQF Level 04  4 
    Core  12325  Research the Healthcare Benefits Administrator sub-sector in South Africa  Level 4  NQF Level 04  5 
    Fundamental  9302  Access information in order to respond to client enquiries in a financial services environment  Level 3  NQF Level 03  2 
    Fundamental  8968  Accommodate audience and context needs in oral communication  Level 3  NQF Level 03  5 
    Fundamental  8971  Analyse and respond to a variety of literary texts  Level 3  NQF Level 03  5 
    Fundamental  9303  Communicate verbally with clients in a financial environment  Level 3  NQF Level 03  3 
    Fundamental  8972  Interpret a variety of literary texts  Level 3  NQF Level 03  5 
    Fundamental  8969  Interpret and use information from texts  Level 3  NQF Level 03  5 
    Fundamental  8973  Use language and communication in occupational learning programmes  Level 3  NQF Level 03  5 
    Fundamental  8970  Write texts for a range of communicative contexts  Level 3  NQF Level 03  5 
    Fundamental  9015  Apply knowledge of statistics and probability to critically interrogate and effectively communicate findings on life related problems  Level 4  NQF Level 04  6 
    Fundamental  10389  Describe the basic principles of personal income tax  Level 4  NQF Level 04  3 
    Fundamental  10385  Develop a business plan for a small business  Level 4  NQF Level 04  5 
    Fundamental  8974  Engage in sustained oral communication and evaluate spoken texts  Level 4  NQF Level 04  5 
    Fundamental  8977  Evaluate literary texts  Level 4  NQF Level 04  5 
    Fundamental  10388  Interpret basic financial statements  Level 4  NQF Level 04  3 
    Fundamental  10386  Investigate the possibilities of establishing and running a small business enterprise (SMME)  Level 4  NQF Level 04  3 
    Fundamental  10387  Investigate ways of managing financial risk in own lives  Level 4  NQF Level 04  6 
    Fundamental  8978  Motivate judgements on selected literary texts  Level 4  NQF Level 04  5 
    Fundamental  8975  Read analyse and respond to a variety of texts  Level 4  NQF Level 04  5 
    Fundamental  9016  Represent analyse and calculate shape and motion in 2-and 3-dimensional space in different contexts  Level 4  NQF Level 04  4 
    Fundamental  8979  Use language and communication in occupational learning programmes  Level 4  NQF Level 04  5 
    Fundamental  7468  Use mathematics to investigate and monitor the financial aspects of personal, business, national and international issues  Level 4  NQF Level 04  6 
    Fundamental  8976  Write for a wide range of contexts  Level 4  NQF Level 04  5 
    Elective  9003  Administer long term employee benefits and healthcare membership  Level 3  NQF Level 03  2 
    Elective  8998  Describe the importance of a healthy lifestyle for members of medical schemes and explain the concept of corporate wellness  Level 3  NQF Level 03  2 
    Elective  9005  Explain the types of compulsory statutory insurance in South Africa  Level 3  NQF Level 03  2 
    Elective  8987  Indicate how different needs lead to the development of different insurance products  Level 3  NQF Level 03  4 
    Elective  7567  Produce and use spreadsheets for business  Level 3  NQF Level 03  5 
    Elective  7570  Produce word processing documents for business  Level 3  NQF Level 03  5 
    Elective  8986  Research the history of the Financial Services Industry in South Africa  Level 3  NQF Level 03  10 
    Elective  12332  Demonstrate knowledge and insight into the Policyholder protection legislation  Level 4  NQF Level 04  2 
    Elective  12164  Demonstrate knowledge and insight of the Financial Advisory and Intermediary Services Act (FAIS) (Act 37 of 2002)  Level 4  NQF Level 04  2 


    LEARNING PROGRAMMES RECORDED AGAINST THIS QUALIFICATION: 
     
    NONE 


    PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS QUALIFICATION: 
    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.
     
    NONE 


    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.