Medical Aid Guide
Processing claims and managing your scheme on ELMED.
Getting started
How does ELMED connect to our scheme?
When a patient with your scheme linked to their ELMED profile completes a consultation or receives a prescription, a claim is automatically created and sent to your portal. Your team then reviews and processes it from the Claims section.
How do I get access to the medical aid portal?
Contact the ELMED admin team at support@elmed.healthcare. We will set up your scheme, plans, and an admin account for your team.
Processing claims
Where do I find incoming claims?
Go to Claims in the sidebar. All claims submitted for your scheme appear here with a status of Pending. You can filter by status, date, or member number to find what you need.
How do I approve or reject a claim?
Open the claim and review the details, including the ICD-10 diagnosis code, consultation notes, and invoice amount. Then choose one of the four options: Approve, Partial Approve, Reject, or Mark as Reviewing. You can add a comment to explain your decision. The patient and provider get notified automatically.
What is partial approval?
If a claim is partially covered by the benefit, you can approve only the covered portion. Enter the approved amount and the system will calculate the patient's co-payment automatically. The patient invoice is updated to reflect what they owe.
What is an EOB and how does it get sent?
An Explanation of Benefits (EOB) PDF is generated automatically whenever you make a decision on a claim. The patient can download it from their portal under My Claims. It includes your scheme branding, the claim details, and the decision.
SLA tracking
How does ELMED track claim SLAs?
Under the South African Medical Schemes Act, schemes must process claims within 30 days. ELMED tracks this automatically. Claims are flagged at 10 days, 20 days, and 30 days so your team can prioritise anything at risk of breaching the deadline.
Where do I see flagged claims?
In the Claims list, flagged claims are highlighted. You can also filter by SLA Risk to see only the ones approaching or past their deadline.
PMB conditions
How are PMB conditions flagged?
When a claim comes in with an ICD-10 code that falls under a Prescribed Minimum Benefit (PMB) condition, ELMED flags it automatically. If you try to reject a PMB claim, a warning appears reminding you of the scheme's obligations under the Medical Schemes Act.
Benefit limits
How do I set annual benefit limits?
Go to Benefit Limits in the sidebar. You can configure annual caps per benefit category for each plan. When a claim is approved, the amount is automatically deducted from the member's remaining benefit balance.
What happens when a member hits their limit?
Claims beyond the annual limit are flagged automatically so your team can process them correctly. The patient can see their remaining benefit on their ELMED dashboard.
Member verification and authorisation
How do I verify a member?
Go to Members and search by membership number or name. Click Verify to confirm their active status. The member gets a confirmation email and providers can see the verified status on their end.
How does pre-authorisation work?
Go to Authorisations to review pre-auth requests from providers. You can approve or decline the procedure. Approved authorisations are linked to the member's record so related claims process faster.