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With regard to Designated Service Provider (DSP) Contracts the following law is pertinent for service providers who are not a DSP:
- In terms of Section 59 (2) of the Medical Schemes Act 131 of 1998 the medical scheme must pay valid invoices within 30 days of receipt thereof or advise both the member and service provider of reasons why the invoice is not valid and provide the opportunity to correct the invoice.
- Where services are in respect of medical emergencies or involuntarily obtained services for PMB conditions, the scheme has to pay for the full cost of the services provided without deduction or co-payment or limiting the tariff amount. (Regulation 8 (1) of the Medical Schemes Act no. 131 of 1998.)
- DOH notice 214 of 2021 requires that a scheme pays for services provided at the same rate and in terms of the same rules as they pay their DSPs in respect of services voluntarily obtained, whether they are PMBs or not.
- The process followed in respect of appointing a DSP is required to be fair, equitable, transparent, competitive or cost effective as required in terms of Notice 214 of the DOH.
- The law protects the patient’s choice to use their laboratory of choice, even if it is not a DSP, and the scheme is still obliged to reimburse us at the scheme rate for valid claims.
- This is true for PMB conditions as well as non-PMB conditions.
- The medical scheme must pay valid invoices within 30 days or advise both the member and service provider of reasons why the invoice is not valid and provide the opportunity to correct invoice.
- A scheme must pay for the services provided at a tariff not less than what they would pay a DSP.
- Should any patient have a valid claim rejected because we are not a DSP, we can assist.
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