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Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)

Notices

Notice to Compensation Fund Medical Service Providers

Compulsory Invoicing Requirement in Medical Claims

 

The Compensation Fund is in the process of implementing the new claims management system. The system will go live on the 30th September 2019. This letter is to advise all medical service providers of upcoming changes that will be implemented on the system go live date. In the past and currently the Fund's systems have been accepting invoices as well as running accounts on medical claims. This has resulted in submission of duplicate invoices that clog the systems resulting in delays regarding timeous finalising of medical invoices.

 

With the implementation of the new claims management system and in an effort to improve service delivery the Compensation Fund will no longer be accepting running accounts or statement of accounts from 1 October 2019. The Fund will only accept medical invoices and statements of accounts that are resubmitted will not be accepted but will be rejected as duplicate invoices.

 

All medical service Providers are requested to note the requirement and compliance to the unique invoice number for each and every medical invoice that is submitted to facilitate the process of submission and processing of all medical invoices within specified time frames. Please note that running accounts /statements will not be received by the Compensation Fund systems but will be rejected upfront at the switch as duplicates. The Fund will not be liable for medical invoices that have been rejected for non compliance. The new SAP system will have a functionality to accept and process genuine short paid medical invoices.

 

As part of improved service delivery and efficiency the Compensation Fund will be implementing ICD -10 and tariff coding rules that need to be adhered to when submitting medical invoices. This will be implemented in a phased approach. For implementation on 30 September 2019, the following will apply:

 

(a) ICD-10

 

ICD-10 validations will apply as per the national ICD-10 phase 3 and phase 4.1 requirements as per attachment. Note that these phases were implemented on 01 July 2014 and entail the following:

 

Valid and ICD-10 codes as the SA ICD-10 Master Industry Table.
Maximum level of specificity: ICD-10 codes to be valid at the correct 3rd, 4th or 5th character level
Valid ICD-10 primary codes, codes not valid as primary will be rejected
Comply with the dagger and asterisk rule
Comply with the sequelae coding rules
Age edits for ICD-10 codes that have age requirements
Gender edits
All injury and poisoning codes must be accompanied by external cause codes

 

(b) Tariff Codes and Modifiers

 

Valid tariff codes and modifiers
Discipline type indicators where relevant
Valid primary codes
Codes not allowed
Tariff and modifier age edits
Tariff and modifier gender edits
Modifiers allowed per tariff code
Utilisation rules such as maximum number of items that can be billed per day, per patient, per treatment, per annum, etc.

 

Please ensure that you are familiar with the above to avoid unnecessary claim rejections.

 

The date and the requirements for the next phase will be communicated in due course.

 

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