Electronic Claims Submission

MediSwitch’s core business lies in the switching of transactions between healthcare professionals and medical schemes.

Primarily, the business offers the ability for a healthcare professional, pharmacist, practice manager or hospital administration staff to submit an electronic claim on behalf of the patient, to the appropriate medical scheme. But there are many other services around this core competence that provide substantially more than just switching of claims. Each of these services is discussed here.

Electronic Claims/Transaction Switching:

MediSwitch offers various transaction-based services to both the healthcare professional and the medical schemes / administrators. These include:

Electronic claims delivery in batch and online1 with a varying degree of validation checks. Claims are submitted through the MediSwitch to the medical scheme in various ways depending on the implementation by the software vendor of the practice. All pharmacy claims are submitted in an online environment. The submission of practice and hospital claims forms a seamless part of validating the information related to the patient encounter. The validation process enables MediSwitch to supply the healthcare facility with an online ability to identify problems and incorrect- or absent claim content. This provides a mechanism for the healthcare facility to rectify and resubmit these claims to the destination. MediSwitch does not charge a fee for any claim until it is accepted and delivered to the destination.

Online membership status validation (MSV):
This provides the healthcare professional with the means to check that the patient is indeed a valid member of the medical scheme he or she states they belong to.

Capitated patient encounter claims:
Certain schemes have begun forming provider networks for capitated products, or outsourcing this function to a third-party. (see the Claims Management and Information System under Healthcare Informatics for more on this type of service/transaction).

electronic Remittance Advices (eRA:
Receive electronic remittance advices (eRAs) from participating schemes. This is returned to the practice, laboratory or pharmacy and the latest integrated PMAs and Hospital Information Systems (HIS) have the ability to auto-allocate these payments.

1 Online – instantaneous processing of a request or claim. The healthcare professional remains connected to the network whilst the claim is processed and the resultant reply is fed directly back into the provider’s system.