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National Health Act, 2003 (Act No. 61 of 2003)


National Health Insurance Policy towards Universal Health Coverage

Chapter 8 : Purchasing of Health Services

8.4 Provider Payment Mechanisms

8.4.2 Provider Payment for ambulatory private specialist services


296. Services purchased from private specialists will initially be reimbursed using a capped case-based fee adjusted for complexity where. This will be continuously reviewed taking into account access and budget impact assessment. Purchasing of diagnostic services such as pathology and radiology services will employ a cost-based tariff schedule and volume contracts based on the needs of the catchment population and using a capitation based reimbursement model. These contracts will specify the expected volume of services to be provided and the cost that will be reimbursed for the specified volumes. Such contracts will also specify the case-based fee that will be paid for services above the specified volume threshold, which is usually set at the marginal cost of providing these services.