GENERAL IMPORTANT INFORMATION FOR YOUR PRACTICE
Dear Heritage Health Healthcare Provider,
First and foremost, thank you for your continued support by attending to all the members of Heritage Health Medical Aid Fund. Your service plays a key part in the well being of all our members.
It is important for us to ensure that you remain well informed regarding Heritage Health’s members and ensuring that your interactions with the Administrator of the Fund meets your expectations. Accordingly, we have decided to address this letter to your practice detailing general information which may assist you when dealing with your patients and who are members of Heritage Health Medical Aid Fund.
1. Heritage Health Pays at 100% Amount Charged
2. Making Management of Invoices Easy for Your Practice
Heritage Health undertakes weekly payments. Valid invoices are being paid within ten working days and which has made the Fund the leader when it comes to the timely payments of invoices to both our members and the healthcare disciplines.
We provide statements to your practice with each payment run via your email address. You are also able to view the statements via our website at www.heritagehealth-namibia.com by registering under the icon which refers to “Service Providers Login”. You are required to use your practice number, only the last seven digits, and by creating your own password. It is important to remember your password, and which is to be used every time that your practice logs-in. We have strict security measures and hence only one password is applicable for each practice number.
You are thus able to gain access to the details of your practice at the time which is most convenient for you. The Administrator of Heritage Health uses a live real-time system reflecting up to date information.
3. Submitting Invoices
Healthcare providers can submit their invoices by using one of the following formats:
- Hand delivery to our office situated at Heritage Square, 100 Robert Mugabe Avenue, Windhoek.
- By Facsimile: +264 61 271 287
- Heritage Health members by using the Heritage Health Application on their smartphones can take a picture of your invoice at your practice and which is then submitted directly onto the system to be processed - a first in Namibia.
When submitting an invoice via email you will always receive a confirmation and it is important for you to ensure that you do receive such a confirmation, because if you do not, then it implies that the email address that you have used is incorrect.
When submitting an invoice via EDI you will also receive confirmation whether it was successful or not. In the event where the submission is not successful you will always receive a reason why the submission is unsuccessful and the information which is required to ensure a valid submission. It remains important for your administration person to always attend to the feedback thereby ensuring a valid submission and timely payment(s) of your invoice(s).
It is important to note that in terms of the Medical Aid Funds Act, 1994 and pertaining Regulations invoices must be submitted within four months from the actual date of service. It is not the date of invoice. It remains important for your practice to abide to this regulation and which will prevent your practice from incurring bad debt as claims which are submitted beyond four months from the date of service without a valid proven reason will be declined for payment.
Kindly note that where no proof of PAID is being indicated on the invoice, the amount due will always be paid to your practice. It is thus important to indicate whether the invoice has been paid or not.
4. Validity of Membership
It remains important for your practice to always ensure the validity of the membership of our members. If you do not check the validity of the membership of our members you will be exposing your practice to bad debt where the membership may have been terminated or has been suspended due to arrear monthly medical aid contributions. Certain members are also subjected to underwriting conditions pending waiting periods and/or exclusions of cover for certain in-hospital conditions. To assist you to manage this we encourage you to use the following methods:
- Request the member to show you their membership card and where at the back all relevant information is displayed.
- Login onto our system by using your practice details as explained under clause 2 on page one of this letter and where you can validate the membership of your patient.
- Heritage Health has launched an Application which is available to all our members free of charge and which they can download onto their smartphones and which allows them to present their “virtual” medical aid card to you.
- Contact the office of the Fund.
5. Contact Details Including Banking Details
It is of utmost importance that we have the correct contact details of your practice to ensure that you do receive the payment statements and any other important information between your practice and the Fund’s administrator. You can view the details that we have on our system by logging in under your portfolio as detailed under clause 2 on page one of this letter. We rely on the NAMAF office to provide us with the information relating to your practice and where it is in error then obviously, we will not know. You are also able to amend the details directly on the system.
It is also import that you ensure that the banking details that we use to ensure reimbursements to your practice are correct.
6. Benefit Plans under Heritage Health
The benefit plans under the Fund consists of four hospital plans including provision for chronic medication, specialised radiology, oncology (both in or out of hospital and a casualty benefit. Members who have opted for one of these hospital plans are able to include day to day benefits. They have three day to day benefit plans to choose from and which includes taking out more than one plan pending their needs.
Then there is also two traditional plans which makes provision for both in-hospital benefits and day-to-day benefits and where members may opt to include additional day-to-day benefits pending their needs.
7. Registration of Chronic Medication
It is important to note that members are required to register their chronic condition(s) to ensure that the required medication is being dispensed from their chronic benefits. Members have a choice between branded and generic medication items and by choosing a branded item they will be subjected to paying a co-payment of 15%. By choosing generic medication the members are not subjected to any co-payments and will be extending their chronic medication. Members are however encouraged to manage their costs within the framework of available benefits that they have opted for and to ensure that they do not run out of benefits during the year.
It is important to note that the only applicable co-payment under Heritage Health is the 15% for branded chronic medication items. No other co-payments are payable for the Heritage Health members.
To obtain a pre-authorisation number prior to admission your practice must contact the Fund and provide the necessary clinical details. Alternatively, there is a pre-authorisation form to be completed which is available via the website or can be obtained from the Fund. It is important to notify the Fund at least 48-hours in advance for non-emergency procedures to obtain a pre-authorisation number.
An emergency is a medical condition which is of sudden and unexpected onset that requires immediate medical or surgical treatment where failure to provide this treatment would result in serious impairment of bodily functions, serious dysfunction of a bodily organ or part, or would place the Person’s life in serious jeopardy. In such cases the hospital and the treating doctor needs to contact the Fund as soon as possible after admission.
It is important for your practice to consider the underwriting conditions (waiting periods or exclusions) prior to submitting a member for a non-emergency procedure to ensure that no bad debt results.
Case management by our duly appointed clinical team is used to track the treatment and costs while in hospital and which adds value to your practice when the case is outside of the allocated length of stay (LOS); level of care (LOC) or for high-cost cases. (E.g. Organ transplants, Neurological cases, Cardiac cases, Poly trauma) and in cases where special medication is required. (E.g. Polygamy V-fend, Tractocile, Xigris)
Once invoices are received, claims are clinically audited and paid in accordance with the relevant benefit rules and clinical policies. When charges on an account are deemed clinically inappropriate these may be rejected when the claim is processed for payment and the provider is notified.
Items such as telephone costs, TV/earphone hire fees or Personal toiletries such as aftershave cream or soap will not be paid by the Fund.
Heritage Health will not pay for any extra stay in hospital besides the allocated LOS (Level of Stay) unless it is clinically motivated by the attending doctor. Any extra stay which has not been approved will be paid by the member, out of own pocket.
When a pre-authorisation is approved then:
- An authorisation number is provided, and which is to be used for the procedure
- The approved number of days in hospital (if a stay is required) will be indicated
If the initial hospital stay requires to be extended, the hospital case manager will inform the case office of the Fund with the substantiating clinical information which meets the clinical criteria, is within the Rules of the Fund and where benefits remain available.
While every effort is made to establish member eligibility and availability of funds, authorisation is not a guarantee of payment. It is also important to note that the Fund will not pay for tests in a hospital while such a member has opted not to include out of hospital benefits and which tests do resort under out-patient services. Kindly note that pre-admissions are also not approved under the Rules of the Fund.
9. Utilisation of Benefits
The utilisation of benefits plays a key role at the end of each year to determine the monthly increases to the contributions of our members to ensure membership cover. It is important to note that your practice plays a key role to assist our members not to incur annual increases beyond what they can afford and where they are then required to either downscale their benefit plans at a time when clinically least appropriate or where they need to terminate their membership and become state patients as they no longer have the funding to be a private member of a medical aid fund.
We are often faced with high cost tests as a first option when more affordable tests will provide the same results. We are also often faced with incident where first an x-ray was charged, then a CT scan followed by a specialised radiology request and finally a Laparoscopy and Gastroscopy all within a very short period. You will agree that it is very rarely that this is clinically justified.
Accordingly, we have a joint responsibility to ensure proper and affordable utilisation of the member’s benefits to allow our members to gain access to affordable clinical care and ensuring future treatments. Please may we request that every effort is implemented to assist us to ensure that our members can afford their membership and at the same time remain to support your practice.
10. Joining Heritage Health
Being the only medical aid fund who pays at 100% of the actual amount being charged and who does not use the NAMAF tariffs or a portion thereof and who has weekly payments and a live real-time system you may opt to join the Fund as members. It will be great to welcome you on board and have you experience our service to you as members of the Fund. You may contact our office and where one of the consultants will assist you with quotes which meets your needs. You may also wish to view our website at www.heritagehealth-namibia.com and even view our exciting Facebook detailing up to date information.
Kindly note that should you require any more details, please contact our office. We encourage you to use the website allowing you to manage your portfolio and where information is readily available.
You will also be able to view this letter on your portfolio should you wish to refresh yourself with the details at a later stage.
It is important to note that our office hours are from Mondays to Fridays from 08:00 to 16:30. We are closed on the weekends and on Public Holidays.
At the same time, we look forward to hearing your suggestions, receiving your input good or bad, as it will enable us to improve our service to you.Go Back To Newsletters