1. Overview
Purpose of the
section
To be able to process a paper claim correctly, applying your knowledge
of the Scheme's Rules, SLA and BHF tariff guide. Assess claims for
validity in terms of Scheme's Rules and Regulations, using discretion
and a degree of reasoning to be able to make a choice whether to
accept or reject the claim.
Composition of the
section
The following is covered:
i. Assessing
ii. Optical Enquiries
iii. SLA
iv. BHF Tariff Guide
v. Scheme's Rules
vi. Scheme's training Module
The areas above will be covered in more details in the next section.

2. JOB TITLE:
CLAIMS ASSESSOR
ORGANISATION STRUCTURE / REPORTING LINES:
Team Leader Position to whom you report
Claims Assessor This position
Positions reporting to you
YOUR JOB OBJECTIVE:
The objective of the section is:
To enable effective, accurate and timeous assessing of claims by applying your
knowledge in accordance with the well interpreted schemes rules and prescribed
procedures as provided by business partners, e.g. BHF, SAMA.

3. QUALIFICATIONS AND EXPERIENCE
QUALIFICATIONS (MINIMUM)
SCHOOL:
POST SCHOOL:
MINIMUM EXPERIENCE (TYPE & PERIOD – THIS AND/OR OTHER JOBS):
(Minimum time & type of experience before appointment into this job – not what you
possess, but what the job requires)
Minimum requirement:
i) A fully trained assessor with comprehensive knowledge on all aspects of paper assessing,
i.e. completed the claims training school successfully.
iv) Thorough knowledge of claims system
v) Comprehensive knowledge of the interpretation and application of the scheme's rules,
SLA, BHF, SAMA
(Minimum time required after appointment to the job to reach a level of competence. Not
how long it took you, but what is considered to be typical/average)
6 months
Matric
Basic computer skills -
Claims related systems

4. CPA 1
CLAIMS ASSESSING
Assessing of paper claims
Job Categories
i. Ordinary, i.e. GP's, Specialists and procedures
ii. Optical
iii. Dental and Orthodontics
iv. Nursing
v. Hospitals
vi. Electronic Claims

5. A) KEY FUNCTIONS: Claims Assessing
* To be able to process accurately under correct in-house codes.
* Read the Claim:
• Check the doctor's claims history
• Determine what's settled and what must be processed for payment
• If there is a bookkeeping error reflected on the account, the assessor must pend the
account to the Erroneous Investigation clerk
• Assessor must at this stage to the necessary rejections e.g. proof of payment,
duplicate, specified account required, etc.
• These rejections will generate computer letters
• Computerized letters are attached to the appropriate rejected claims and sent to the
claims inquiry section for checking and signing.
* Capture the Claim:
• Capture membership number, doctor's practice number, claim number, reference /
account number, payee code, total
• Capture dependant code, date of service, tariff code, fees charged and using units,
modifiers and multipliers in the appropriate fields, when applicable
• When necessary, make decisions whether the claims should be forced through.
• If in order, enter an X (e.g. if doctor overcharged & charges tariffs at private rates)
• Should a doctor quote the words Scale of Benefits of S.O.B. on the account and then
still charge more than the S.O.B., the account must also be forced, i.e. enter an X.
• Each medication claim to be entered per item, per individual amount, using applicable
Nappi code which must be selected from the Nappi file
• Discounts on claims must also be calculated
• SPLIT Chronic medication and Acute medication.
• Identify claims to be pended and refer to the appropriate clerk of authority for
investigation. These claims are handed back to the assessor for processing once the
investigation is completed
• Detect any fraudulent charges, e.g Duplication of services, overpricing of medicines
and changing of dates
Dental:
• In addition to ordinary assessment of claims, receive training from the Dental
Consultant on correct assessment methods and procedures of dental accounts.
• Check the validity of the claim using the guidelines laid down by the Dental Consultant
e.g. historical correctness of the claim
• Scrutinize accounts for various tariff combinations which may / may not be charged
together in accordance with the guidelines laid down by the Dental Advisor
• Use applicable dental rejection code
• Capture individual tooth numbers per tariff item
• When assessing orthodontic acc, check the case and use the correct case number
• If there is no case Pend it G on paper acc or reject it DQ on EDI

6. Optical:
• Receive training on correct handling of optical claims
Pro-Paper Claims:
• Return to PPN by using ERROR code "RO"
Visicare Claims:
Check whether the regular price rates were charged on lenses and lens additions, if not
reject the entire account
Hospital:
• Receive training on correct handling of hospital claims
• Scrutinize accounts thoroughly for non-chargeable and not covered items e.g. water
for irrigation is not chargeable on CABG (cardiac artery bypass graft)
• Distinguish between medication received in ward and tto medication and apply
applicable nappi codes to tto medication
• Ensure that correct diagnosis codes are used for the relevant procedures
• Ensure that credit notes passed by the hospital is properly accounted for
• Identify whether non-emergency surgery were performed after hours (Cold Cases)
• Each province have their own tariff codes for gases - assessor to apply correct codes
(Namibian accounts to be override)
• Ensure that all documentation e.g motivation letters for specialized units, invoices for
prosthesis, are attached
• Identify claims to be pended and refer to the appropriate clerk of authority for further
investigation

7. * Capture the Claim:
• Capture membership number, doctor's practice number, claim number, reference /
account number, payee code, total
• Capture dependant code, date of service, tariff code, fees charged and using
units, modifiers and multipliers in the appropriate fields, when applicable
• When necessary, make decisions whether the claims should be forced through.
• If in order, enter an X (e.g. if doctor overcharged & charges tariffs at private rates)
• Should a doctor quote the words Scale of Benefits of S.O.B. on the account and
then still charge more than the S.O.B., the tariff rate must be reduced to the tariff,
"TT".
• Each medication claim to be entered per item, per individual amount, using
applicable Nappi code which must be selected from the Nappi file
• Discounts on claims musm819(c)-0.2s15( )-4.77819(c)-0.2773(m)-4.47687( )-4.77687(b)1.31968(e)12.1
•

8. Visicare Claims:
Check whether the regular price rates were charged on lenses and lens additions, if
not reject the entire account
Hospital:
• Receive training on correct handling of hospital claims
• Scrutinize accounts thoroughly for non-chargeable and not covered items e.g.
water for irrigation is not chargeable on CABG (cardiac artery bypass graft)
• Distinguish between medication received in ward and tto medication and apply
applicable nappi codes to tto medication
• Ensure that correct diagnosis codes are used for the relevant procedures
• Ensure that credit notes passed by the hospital is properly accounted for
• Identify whether non-emergency surgery were performed after hours (Cold Cases)
• Each province have their own tariff codes for gases - assessor to apply correct
codes (Namibian accounts to be override)
• Ensure that all documentation e.g motivation letters for specialized units, invoices
for prosthesis, are attached
• Identify claims to be pended and refer to the appropriate clerk of authority for
further investigation
Electronic Submissions (EDI):
• System automatically accepts all valid claims and rejects all exclusions and invalid
claims e.g possible duplicate, invalid membership no, stale claims, no nappi
codes, tariff / modifier / practice combination does not exist, etc.
• Where medical practitioners dispense medication, split the medication (tariff 0200)
from the materials (tariff 0201) and capture these items separately, since it is
calculated from different benefit categories
• Split chronic medication from acute medication
• Work online (Type online)
• System will accept rectified claims and reject claims which require further attention
e.g. accounts with additional error messages
• Deal with additional rejections until all claims have either manually been rejected

9. or accepted by the system.
* Medicredit Submissions:
• Follow the same procedure as for EDI
• In the case of patients who get chronic medication it is very important that the
correct dependant code is used to ensure that the correct benefit is given.
OUTPUT: (Processed Claims)
Claims per Hour:
• Ordinary - 96
• Optical - 96
• Dental - 96
• Hospital - 70
SUCCESS MEASURE:
Timeous and accurate processing according to pre-determined standards
TIME ALLOCATION:
100% .

10. CPA II
KEY FUNCTIONS: Optical Unit
Deal with routed enquiries from assessors and client services
Check appropriate reports on a daily basis
Compile and follow-up on accounts returned to Preferred Provider Network for re-pricing
on a daily basis.
Deal with all enquiries from Preferred Provider Network.
Generate letters to members with regards to incorrect billing from Suppliers
Manage and rectify erroneous payments
Handle account queries
Assess special batches within the Service Level Agreements.
Investigate stale claims generated from Assessors and take appropriate action
Interpret the enquiry and determine appropriate plan of action.
Utilise information as contained in the Scheme Rules, system, training modules and
liase with other Departments (Preferred provider) where information is not readily
available.
Investigate and analyse the enquiry and extract appropriate information and determine
response to client (internal and external).
Investigate tariff enquiries and initiate correct action utilising the applicable people
Ensure immediate resolution of enquiry or do the necessary investigation / follow-up
and revert back to client as per the set standards
Alert Team Leader timeously of operational and system problems that impede on the
successful and efficient administration of your duties or that of the company thus
enabling urgent corrective action.
Audit at least two schemes optical accounts at random to ensure that correct
assessing procedure is followed thus enhancing quality.
Act as a mentor and support to trainees, assessors and client services agents on
technical related issues.
Keep accurate logging of enquiries and records for statistical, performance management
and trend analysis purposes.

11. OUTPUT: (Claims Inquiries):
• Problem Solving
• Correspondence
• Communication
SUCCESS MEASURE:
• Handling of Optical claims
• Efficient and accurate problem solving
• Satisfied members / suppliers of service / PPN
TIME ALLOCATION:
100%

12. CPA III
SLA
The assessor must understand the SLA with the Scheme regarding the processing of
paper claims.
The assessor must understand the implications to the business unit, should the SLA not
be adhered to.
OUTPUT:
• Timeous and correct processing of paper claims

13. CPA VI
BHF TARIFF GUIDE
The assessor must have a sound knowledge and understanding of the BHF guide.
The assessor must know how to interpret the BHF guide.
OUTPUT:
• Timeous and correct processing of paper claims

14. CPA V
SCHEME'S RULES
The assessor must have a sound knowledge and understanding of the Scheme's Rules.
The assessor must know how to interpret and apply the Scheme's Rules.
OUTPUT:
• Timeous and correct processing of paper claims

15. CPA VI
SCHEME'S TRAINING MODULE
The assessor must have a sound knowledge and understanding of the Bankmed
Scheme training module.
OUTPUT:
• Timeous and correct processing of paper claims

16. Standards for various functions
Function Standard
Assessing of ordinary / hospital
batches
Within 5 working days
Assessing of special batches Within 5 working days
Telephone enquiries Immediate within 24hrs
Telephone enquiry resulting in an
investigation
Response within 48hrs, and if not resolved,
communicate progress to client within 48hrs
Written Correspondence 7 working days
Pendings within 48hrs

17. NATURE OF LIAISON AND CONTACTS
PEOPLE/PARTIES/INSTITUTIONS/CLIENTS NATURE OF CONTACTS
Internal:
Assessors
Team leaders
Management
External:
Members
Service Providers
Business partners
Provide support and coaching
Receive Instruction
Provide Feedback
Attend to enquiries