SAQA All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.
SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD THAT HAS PASSED THE END DATE: 

Assess and process a medical claim 
SAQA US ID UNIT STANDARD TITLE
12298  Assess and process a medical claim 
ORIGINATOR
SGB Insurance and Investment 
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY
-  
FIELD SUBFIELD
Field 03 - Business, Commerce and Management Studies Finance, Economics and Accounting 
ABET BAND UNIT STANDARD TYPE PRE-2009 NQF LEVEL NQF LEVEL CREDITS
Undefined  Regular  Level 4  NQF Level 04  6 
REGISTRATION STATUS REGISTRATION START DATE REGISTRATION END DATE SAQA DECISION NUMBER
Passed the End Date -
Status was "Reregistered" 		 2004-12-02  2007-12-02  SAQA 1657/04 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2008-12-02   2011-12-02  

In all of the tables in this document, both the pre-2009 NQF Level and the NQF Level is shown. In the text (purpose statements, qualification rules, etc), any references to NQF Levels are to the pre-2009 levels unless specifically stated otherwise.  

This unit standard does not replace any other unit standard and is not replaced by any other unit standard. 

PURPOSE OF THE UNIT STANDARD 
This unit standard requires learners to have the background knowledge required and to use insight in applying that knowledge to process a medical claim.

The qualifying learner is capable of:
  • Using current industry tariff guidelines to process a claim.
  • Using medical payment guides to access information
  • Describing the top ten medical conditions in South Africa.
  • Explaining the concept of generic alternatives.
  • Explaining basic medical terminology relating to medical claims.
  • Processing a medical claim. 
    		•

    LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    There is open access to this unit standard. Learners should be competent in Communication and Mathematical Literacy at Level 3. 

    UNIT STANDARD RANGE 
    The typical scope of this unit standard is:

    1. The structure standard tariff guidelines used in Healthcare Benefits Administration means tariff codes, modifiers, rules relating to doctors visits, procedures, confinements, length of stay in hospital, etc.
    2. Irregularities in a claim include procedures by gender and age, exceptionally high claims, cosmetic claims, anesthetics, over servicing and over utilisation.
    3. User rights and confidentiality relate to information, staff, health status information and membership status. 

    Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Demonstrate knowledge & understanding of the use of current industry tariff guidelines. 
    OUTCOME NOTES 
    Demonstrate knowledge and understanding of the use of current industry tariff guidelines in processing a claim. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    1.The structure of the standard tariff guidelines used in Health Benefits Administration is explained and an indication is given of the kind of information contained in each section. 

    ASSESSMENT CRITERION 2 
    2.Standard tariff guidelines are used to access information and access a claim. 

    SPECIFIC OUTCOME 2 
    Use medical reference guides to access information. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    1.Price lists are used to access information on the prices of medication. 

    ASSESSMENT CRITERION 2 
    2.MIMMS is used to access information relating to medication, its use and contra indications. 

    ASSESSMENT CRITERION 3 
    3. A medical dictionary is used to establish the meaning of medical terminology. 

    ASSESSMENT CRITERION 4 
    4.Recognised and approved medical reference guides are used to access information relevant to the assessment of medical claims. 

    SPECIFIC OUTCOME 3 
    Demonstrate knowledge and understanding of how scheme rules apply to payment of a claim. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    1.Rules prescribed by the Medical Schemes Act that are common to all scheme rules are named and identified in the rules of two different schemes. 

    ASSESSMENT CRITERION 2 
    2.The rules of two schemes are analysed and compared in terms of benefits and exclusions. 

    ASSESSMENT CRITERION 3 
    3.Scheme specific rules that relate to processing a claim are identified and applied to the payment of a claim. 

    SPECIFIC OUTCOME 4 
    Demonstrate basic knowledge & understanding of medical conditions in SA. 
    OUTCOME NOTES 
    Demonstrate basic knowledge and understanding of the most commonly occurring medical conditions in South Africa. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    1.The top ten chronic medical conditions in South Africa are named and described in terms of diagnosis and treatment. 

    ASSESSMENT CRITERION 2 
    2.The most commonly occurring medical conditions claimed for under a specific scheme are compared to the top ten medical conditions in South Africa and possible reasons are suggested to explain any variances. 

    ASSESSMENT CRITERION 3 
    3.The concept of generic medication is explained with reference to the Medical Substances Act. 

    ASSESSMENT CRITERION 4 
    4.Generic alternatives for the original medication for a particular condition are explored and an indication is given of the difference in price for the original and generic medication. 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
    This unit standard will be internally assessed by the provider and moderated by a moderator registered by INSQA or a relevant accredited ETQA. The mechanisms and requirements for moderation are contained in the document obtainable from INSQA, - INSQA framework for assessment and moderation. 


    Critical Cross-field Outcomes (CCFO): 

    UNIT STANDARD CCFO IDENTIFYING 
    Learners are able to identify and solve problems in which responses show that responsible decisions using critical and creative thinking have been made in identifying irregularities in claims. 

    UNIT STANDARD CCFO WORKING 
    Learners are able to work effectively with others as a member of a team, group or organisation in assessing claims and identifying and referring irregularities. 

    UNIT STANDARD CCFO ORGANISING 
    Learners are able to organise and manage themselves effectively by becoming responsible citizens in assessing medical claims accurately and fairly. 

    UNIT STANDARD CCFO COLLECTING 
    Learners are able to collect, organise and critically evaluate information in order to process a medical claim. 

    UNIT STANDARD CCFO COMMUNICATING 
    Learners are able to communicate effectively using visual, mathematics and language skills to process a claim, access information from medical texts, explain medical terminology and make comparisons. 

    UNIT STANDARD CCFO SCIENCE 
    Learners are able to use science and technology effectively and critically showing responsibility towards the environment and the health of others in using a computer system to assess a claim. 

    UNIT STANDARD CCFO DEMONSTRATING 
    Learners are able to demonstrate an understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation in understanding the long term effects of chronic conditions and the use of medication. 

    UNIT STANDARD CCFO CONTRIBUTING 
    Learners are able to participate as responsible members of the community by respecting user rights and confidentiality in Healthcare Benefits Administration. 

    QUALIFICATIONS UTILISING THIS UNIT STANDARD: 
      ID QUALIFICATION TITLE PRE-2009 NQF LEVEL NQF LEVEL STATUS END DATE PRIMARY OR DELEGATED QA FUNCTIONARY
    Core  20639   National Certificate: Healthcare Benefits Administration: Claims Assessing  Level 4  NQF Level 04  Passed the End Date -
    Status was "Registered"     		 2004-12-05  INSETA 


    PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS UNIT STANDARD: 
    This information shows the current accreditations (i.e. those not past their accreditation end dates), and is the most complete record available to SAQA as of today. Some Primary or Delegated Quality Assurance Functionaries have a lag in their recording systems for provider accreditation, in turn leading to a lag in notifying SAQA of all the providers that they have accredited to offer qualifications and unit standards, as well as any extensions to accreditation end dates. The relevant Primary or Delegated Quality Assurance Functionary should be notified if a record appears to be missing from here.
     
    NONE 


    All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.