| 1. |
All service providers should be registered on The Compensation Fund claims processing system in order to capture medical invoices and medical reports. |
| 2. |
Medical reports and medical invoices should ONLY be submitted/transmitted for claims that The Compensation Fund has accepted liability for and reasonable medical expenses are payable. |
In terms of Sec 74(1)(2)(3)(4) and (5) of COID Act, submission of Medical Report; Medical service provider are advised to take note of the following:
| a. |
The First Medical Report (W. CL 4), completed after the first consultation must confirm the clinical description of the injury/disease. It must also detail any procedure performed and any referrals to other medical service providers where applicable. |
| b. |
All follow up consultations must be completed on a Progress Medical Report (W.CL5). Any operation/procedure performed must be detailed therein and any referrals to other Medical Service Providers where applicable. |
| i. |
A progress medical report is considered to cover a period of 30 days, with the exception where a procedure was performed during that period, then an additional operation report will be required. |
| ii. |
Only one medical report is required when multiple procedures are done on the same service date. |
| c. |
When the injury/disease being treated stabilises, a Final Medical Report must be completed (W.CL 5F). |
| d. |
Medical Service Providers are required to keep copies of medical reports which should be made available to The Compensation Commissioner on demand. |
| a. |
The ICD-10 validations will apply as per the national ICD-10 phase 3 and phase 4.1 requirements. Note that these phases were implemented on 01 July 2014 and entailthe following: |
| i. |
Valid and ICD-10 codes as the SA ICD-10 Master Industry Table |
| ii. |
Maximum level of specificity: ICD-10 codes to be valid at the correct 3rd, 4th or 5th |
| iv. |
Valid ICD-10 primary codes, codes not valid as primary will be rejected |
| v. |
Comply with the dagger and asterisk rule |
| vi. |
Comply with the sequelae coding rules |
| vii. |
Age edits for ICD-10 codes that have age requirements |
| ix. |
All injury and poisoning codes must be accompanied by external cause codes |
| b. |
The Compensation Fund allows the submission of invoices in 3 different formats: |
| i. |
Switching of invoices: Medical invoices should be switched to The Compensation Fund using the approved format/electronic invoicing file layout. It must be noted that the corresponding medical report must be uploaded online prior to the invoice data being switched, to avoid system rejections on receipt. |
| ii. |
Direct uploading of invoices onto the processing application (External APP): The processing system has an online guide available to guide Medical Service Providers for the direct uploading of invoice on the application. |
| iii. |
Receipt of manual invoices by Labour Centres. |
The first two options are encouraged for ease of processing.
| c. |
The progress of claims/invoices may be viewed on The Compensation Funds processing system. |
| d. |
If invoices are partially or wholly outstanding with no reason indicated after 60 days of submission, a medical service provider should enquire by completing an Enquiry Form W.CI-20 and submit it ONCE to nearest Labour Centre. Details regarding Labour Centres are available on the website (www.labour.gov.za) |
| 5. |
When a Medical Service Provider claims an amount less than the published tariff amount for a code, The Compensation Fund will pay the claimed amount. |
| 6. |
When a Medical Service Provider claims an amount more than the published tariff amount for a code, The Compensation Fund will pay the Gazetted amount. |
| 7. |
Medical Service Provider are required to keep copies of medical invoices, medical report and any other claim documents and make these available to The Compensation Commissioner on request. |
| 8. |
Medical Service Provider should not generate multiple invoices for services rendered on the same date i.e. one invoice for medication and the second invoice for other services. |
NOTE: Medical forms are available on the Department of Employment and Labour website (www.labour.gov.za)
| • |
First Medical Report (W.CL 4) |
| • |
Progress/Final Medical Report (W.CL 5) |
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