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Medical Schemes Act, 1998 (Act No. 131 of 1998)


Regulations in terms of the Medical Schemes Act

Chapter 2 : Administrative requirements

5. Accounts by suppliers of services


The account or statement contemplated in section 59(1) of the Act must contain the following—

a) The surname and initials of the member;
b) the surname, first name and other initials, if any, of the patient;
c) the name of the medical scheme concerned;
d) the membership number of the member;
e) the practice code number, group practice number and individual provider registration number issued by the registering authorities for providers, if applicable, of the supplier of service and, in the case of a group practice, the name of the practitioner who provided the service;
f) the relevant diagnostic and such other item code numbers that relate to such relevant health service;
g) the date on which each relevant health service was rendered;
h) the nature and cost of each relevant health service rendered, including the supply of medicine to the member concerned or to a dependant of that member; and the name, quantity and dosage of and net amount payable by the member in respect of the medicine;
i) where a pharmacist supplies medicine according to a prescription to a member or to a dependant of a member of a medical scheme, a copy of the original prescription or a certified copy of such prescription, if the scheme requires it;
j) where mention is made in such account or statement of the use of a theatre—
i) the name and relevant practice number and provider number contemplated in paragraph (e) of the medical practitioner or dentist who performed the operation;
ii) the name or names and the relevant practice number and provider number contemplated in paragraph (e) of every medical practitioner or dentist who assisted in the performance of the operation; and
iii) all procedures carried out together with the relevant item code number contemplated in paragraph (f); and
k) in the case of a first account or statement in respect of orthodontic treatment or other advanced dentistry, a treatment plan indicating—
i) the expected total amount in respect of the treatment;
ii) the expected duration of the treatment;
iii) the initial amount payable; and
iv) the monthly amount payable.