Beware! ******* non-payment of PMB claims

<p>My father underwent Coronary Artery Bypass under DTP 907E (ICD 10 I25.9) and the anesthetist billed at 200% medical aid rates. All PMB events are to be covered at FULL cost irrespective of the rates used by the treating doctor. Medihelp are refusing to cover the full 200% stating that the ICD10 code used is one used for CDL conditions for out of hospital medicine management and therefore is not a PMB condition. Perhaps Ronatta from the PMB department should consult the treatment guidelines and ICD 10 codes list by the CMS for DTP 907E. Not only do they not cover doctor's account in full for a PMB, but Pathology accounts too. They impose limitations and then take over 2 weeks to reprocess them as PMB. They only reprocessed them because of the fact that I am an informed member and disputed the accounts as PMB despite them telling me that they only cover certain number of tests a year, etc. This medical aid processes everything as non-PMB and banks on the fact that the members is stupid enough not to know that the claim qualifies for PMB cover. Your system should pickup PMB claims based on the ICD10 code alone which clearly Medihelp's system does not.</p> <p>The consultants attending to your disputes is also only an admin person and replies with generic answers. The consultant i spoke to today confirmed that they are "admin" staff. Maybe Medihelp should train and educate their staff and claim related disputes should not be answered by "admin" staff particularly in PMB cases. Furthermore, Chrystal, the consultant i spoke to today stated that medical aids have 30 working days from receipt of the claim to pay claims and therefore the claims I am disputing are not late. Legislation states that all claims are to be paid within 30 days of receipt (not working days). The fact that you have purposefully delayed the correct processing of PMB claims on more than one occassion and therefore this matter is not an isolated event, I am left with no other choice but to report your misconducts to the CMS for further action.</p>