Unpaid inhospital pathology claim for newborn child by Medshield.

Dear Medschield.

i am still awaiting a responce regarding the decision of funding the test that my newborn receieved whilst in hospital - see previosu communication below.

my complain and request for claims to be reviewed as PMB as my newborn was admitted into hospital was sent 17/12/2019 - only response was the below. i have email medshield again on the 02/06/2020 requesting a reimbur*****t of the account i had to pay for as these test were done whilst she was inhospital. i requested for PMB review however no feedback was receieved since the last reply.

With reference to your enquiry regarding: 171219QT25BL

Thank you for your enquiry, the pathology code 4439 and 3974 that rejected as rate to be confirmed was rejected correctly at this point in time.

Our Clinical Risk Management is in is in communication with the laboratory’s regarding this Multiplex and Bio fire testing.

We awaiting a decision on these codes the rejection will remain as is. Queries regards this will only be reviewed once a different decision is received to the existing rule.

You will be informed by the provider on the outcome of this decision until then this query is seen as concluded. When the status change you may log a new query and we will review these codes based on the new information.

We trust you find the above in order

Should you require any further assistance please contact the Medshield Medical Scheme Contact Centre on ***. Yours sincerely Mafedi Tladi ======================================== Sent: Tuesday, 17 December 2019 17:15 To: ***; *** Subject: Urgents Pathology claims unpaid whilst in hospital.

Good day Provider: pathologist (***) Referring specialist: (paediatrician) *** Hospital Auths number: ***

Claim date: 28/08/2019 (rejected)

Tariff 3974 - R1193.40 Tariff 4434 - R1193.40

My Daughter at the time of admission was 1month and a few days old when she was urgently admitted to Gatesville medical centre as she has a high fever which was a risk due to her age and my paediatrician done a few test that was required.

I have been informed by a few consultants that the scheme is in negotiations with the pathologist about the tariff codes that have been claims however I as the client I am now being held responsible for the account and pathologist are awaiting for payment. Today I was told that an amended account is required with correct tariff codes in order for the claims to0 be reprocessed, I then called the pathologist who advised that the correct codes were billed and that they cannot change the codes as Dr has requested for these test to be done whilst my daughter was ill in hospital.

Could I please request that these accounts be paid as PMB as my daughter was extremely ill and we received relevant hospital authorisations before she was admitted.