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How to Claim
Process
Most service providers submit their claims directly and are paid directly, which means you do not have to submit your account to the scheme.
A claim can be submitted through the below platforms.
– Electronic Submission (EDI)-for service providers only
– At our offices (Paper Claims)
– Mobile App- (Add Link)- for members only
– Member portal- (Add link)- for members only
Please note that every claim should be submitted with the following information:
– Patient’s Full Name
– Main Member’s Full Name
– Membership Number
– Date of Service/treatment date
– Procedure/Treatment Codes
– Diagnostic Codes
– Nappi codes for Medication/Drugs
– Original Receipt
– Original Invoice
– Referral Letter
– Medical Report/Motivation
Where a member has paid an account, he shall, in support of his claim, submit a detailed invoice and receipt as proof of payment (Reimbursement will only be done to a KYC compliant member)
The Scheme shall, where an account has been rendered, pay any benefit due to a member, either to that member or to the supplier of the relevant health service who rendered the account, within 30 days of receipt of the claim pertaining to such benefit.
Most service providers submit their claims directly and are paid directly, which means you do not have to submit your account to the scheme.
A claim can be submitted through the below platforms.
– Electronic Submission (EDI)-for service providers only
– At our offices (Paper Claims)
– Mobile App- (Add Link)- for members only
– Member portal- (Add link)- for members only
Please note that every claim should be submitted with the following information:
– Patient’s Full Name
– Main Member’s Full Name
– Membership Number
– Date of Service/treatment date
– Procedure/Treatment Codes
– Diagnostic Codes
– Nappi codes for Medication/Drugs
– Original Receipt
– Original Invoice
– Referral Letter
– Medical Report/Motivation
Where a member has paid an account, he shall, in support of his claim, submit a detailed invoice and receipt as proof of payment (Reimbursement will only be done to a KYC compliant member)
The Scheme shall, where an account has been rendered, pay any benefit due to a member, either to that member or to the supplier of the relevant health service who rendered the account, within 30 days of receipt of the claim pertaining to such benefit.
When must I submit a claim?
You must submit a claim as soon as possible after receiving the service. If you submit a claim later that the last day of the 4th month from the date on which medical treatment was provided, your claim will be stale and your account will not be paid
NOTE: A CLAIM IS VALID FOR ONLY 4MONTHS FROM THE DATE OF SERVICE
How will the scheme reimburse me for accounts already settled?
The account will refund you through EFT
Can I claim for medical expenses incurred outside Botswana?
For services rendered outside Botswana and South Africa, ONLY emergency claims will be covered. Members will pay upfront for all the medical services and claim back from the scheme.A retrospective authorization will be required within 24h of receiving the claim.
Claims will be paid subject to the Botsogo set tariffs and in the Botswana currency (BWP).
Points to remember
– Keep a copy of your records
– It is your responsibility as a member to ensure that your claims have been submitted to the scheme and to check whether they have been paid by the Scheme, even if your service provider submits the claim on your behalf.
– If your claim is rejected, you have 60 days in which to submit the correct claim or raise a query.
You must submit a claim as soon as possible after receiving the service. If you submit a claim later that the last day of the 4th month from the date on which medical treatment was provided, your claim will be stale and your account will not be paid
NOTE: A CLAIM IS VALID FOR ONLY 4MONTHS FROM THE DATE OF SERVICE
How will the scheme reimburse me for accounts already settled?
The account will refund you through EFT
Can I claim for medical expenses incurred outside Botswana?
For services rendered outside Botswana and South Africa, ONLY emergency claims will be covered. Members will pay upfront for all the medical services and claim back from the scheme.A retrospective authorization will be required within 24h of receiving the claim.
Claims will be paid subject to the Botsogo set tariffs and in the Botswana currency (BWP).
Points to remember
– Keep a copy of your records
– It is your responsibility as a member to ensure that your claims have been submitted to the scheme and to check whether they have been paid by the Scheme, even if your service provider submits the claim on your behalf.
– If your claim is rejected, you have 60 days in which to submit the correct claim or raise a query.