SAQA

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SOUTH AFRICAN QUALIFICATIONS AUTHORITY

REGISTERED UNIT STANDARD THAT HAS PASSED THE END DATE:

Explain the cycle of a medical claim

SAQA US ID	UNIT STANDARD TITLE
118014	Explain the cycle of a medical claim
ORIGINATOR
SGB Insurance and Investment
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY
-
FIELD			SUBFIELD
Field 03 - Business, Commerce and Management Studies			Finance, Economics and Accounting
ABET BAND	UNIT STANDARD TYPE	PRE-2009 NQF LEVEL	NQF LEVEL	CREDITS
Undefined	Regular	Level 4	NQF Level 04	2
REGISTRATION STATUS		REGISTRATION START DATE	REGISTRATION END DATE	SAQA DECISION NUMBER
Passed the End Date - Status was "Reregistered"		2018-07-01	2023-06-30	SAQA 06120/18
LAST DATE FOR ENROLMENT		LAST DATE FOR ACHIEVEMENT
2026-06-30		2029-06-30

In all of the tables in this document, both the pre-2009 NQF Level and the NQF Level is shown. In the text (purpose statements, qualification rules, etc), any references to NQF Levels are to the pre-2009 levels unless specifically stated otherwise.

This unit standard does not replace any other unit standard and is not replaced by any other unit standard.

PURPOSE OF THE UNIT STANDARD

This unit standard is intended for learners who assess medical claims. It will be useful for intermediaries and service centre agents in Healthcare Benefits Administration.

The qualifying learner is capable of:

Explaining the origin of medical scheme claims.

Describing the different routes followed by medical claims.

Analysing a complex medical claim.

Investigate the storage and retrieval of claims related documents in a Healthcare Benefits Administrator.

LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING

There is open access to this unit standard. Learners should be competent in Communication and Mathematical Literacy at Level 3.

UNIT STANDARD RANGE

The typical scope of this unit standard is:

Complex claims include, but are not limited to, MVA, ex gratia, foreign claims and special cases such as orthodontic, oncology, trauma and HIV/AIDS.

Control measures include, but are not limited to, the Medical Schemes Act, Scheme Rules, options and limitations of benefits.

Specific Outcomes and Assessment Criteria:

SPECIFIC OUTCOME 1

Explain the origin of medical scheme claims.

ASSESSMENT CRITERIA

ASSESSMENT CRITERION 1

The different ways in which a claim may be received are explained and an indication is given of how the origin impacts on the cycle of a claim.

ASSESSMENT CRITERION 2

The process followed in admitting a claim to a system is explained with examples.

ASSESSMENT CRITERION 3

The consequences of non-compliance with the process are explained with reference to the service provider, member and administrator of the scheme.

SPECIFIC OUTCOME 2

Describe the different routes followed by medical claims.

ASSESSMENT CRITERIA

ASSESSMENT CRITERION 1

The route followed by a standard claim is explained for a specific scheme and an indication is given of the control measures at each stage in the cycle.

ASSESSMENT CRITERION 2

The route(s) followed by complex claims are explained for a specific scheme and an indication is given of the control measures at each stage in the cycle.

ASSESSMENT CRITERION 3

Possible errors that could occur in the cycle of a medical claim are investigated for two different routes.

ASSESSMENT CRITERION 4

Different ways in which a claim may be paid are explained for three case studies.

ASSESSMENT CRITERION 5

The importance of confidentiality throughout the claims cycle is explained with reference to a member's rights, current legislation and an organisation's policies and procedures.

SPECIFIC OUTCOME 3

Analyse a complex medical claim.

ASSESSMENT CRITERIA

ASSESSMENT CRITERION 1

A complex claim is analysed to determine the route that it should follow and a decision is substantiated with reference to the type of claim, member information and supporting documentation.

ASSESSMENT CRITERION 2

The stages along the route are identified and an indication is given of the actions, decisions and recommendations made at each stage.

ASSESSMENT CRITERION 3

Control measures are identified and an indication is given of the consequences of non-compliance at each stage along the route.

ASSESSMENT CRITERION 4

Documents required to support a complex claim are identified, accessed, completed and validated according to the rules of the scheme and requirements of the administrator.

SPECIFIC OUTCOME 4

Investigate the storage and retrieval of claims related documents in a Healthcare Benefits Administrator.

ASSESSMENT CRITERIA

ASSESSMENT CRITERION 1

The claims storage system for a specific administrator is investigated and an indication is given of the controls in place to maintain confidentiality.

ASSESSMENT CRITERION 2

Claims related information is accessed from a system to resolve a query or provide supporting documentation.

UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS

This Unit Standard will be internally assessed by the provider and moderated by a moderator registered by a relevant accredited ETQA or an ETQA that has a Memorandum of Understanding with the relevant accredited ETQA.

UNIT STANDARD ESSENTIAL EMBEDDED KNOWLEDGE

N/A

UNIT STANDARD DEVELOPMENTAL OUTCOME

N/A

UNIT STANDARD LINKAGES

N/A

Critical Cross-field Outcomes (CCFO):

UNIT STANDARD CCFO IDENTIFYING

Learners are able to identify and solve problems in selecting a route for a complex claim.

UNIT STANDARD CCFO COLLECTING

Learners are able to collect, organise and critically evaluate information in investigating the storage and retrieval system in an organisation.

UNIT STANDARD CCFO SCIENCE

Learners are able to use science and technology effectively and critically in using a computer system in tracking the cycle of a claim.

UNIT STANDARD ASSESSOR CRITERIA

N/A

REREGISTRATION HISTORY

As per the SAQA Board decision/s at that time, this unit standard was Reregistered in 2012; 2015.

UNIT STANDARD NOTES

N/A

QUALIFICATIONS UTILISING THIS UNIT STANDARD:

	ID	QUALIFICATION TITLE	PRE-2009 NQF LEVEL	NQF LEVEL	STATUS	END DATE	PRIMARY OR DELEGATED QA FUNCTIONARY
Core	49356	Further Education and Training Certificate: Medical Claims Assessing	Level 4	NQF Level 04	Passed the End Date - Status was "Reregistered"	2023-06-30	INSETA
Elective	49649	Further Education and Training Certificate: Long-term Insurance	Level 4	NQF Level 04	Passed the End Date - Status was "Reregistered"	2023-06-30	INSETA
Elective	57613	Further Education and Training Certificate: Short-Term Risk Management	Level 4	NQF Level 04	Passed the End Date - Status was "Reregistered"	2012-06-30	INSETA
Elective	66613	Further Education and Training Certificate: Wealth Management	Level 4	NQF Level 04	Passed the End Date - Status was "Reregistered"	2023-06-30	As per Learning Programmes recorded against this Qual
Elective	66389	Higher Certificate: Diagnostic and Procedural Coding	Level 5	NQF Level 05	Passed the End Date - Status was "Reregistered"	2023-06-30	HW SETA

PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS UNIT STANDARD:

This information shows the current accreditations (i.e. those not past their accreditation end dates), and is the most complete record available to SAQA as of today. Some Primary or Delegated Quality Assurance Functionaries have a lag in their recording systems for provider accreditation, in turn leading to a lag in notifying SAQA of all the providers that they have accredited to offer qualifications and unit standards, as well as any extensions to accreditation end dates. The relevant Primary or Delegated Quality Assurance Functionary should be notified if a record appears to be missing from here.

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