Medical aid - portion not payable

[extrusion]

Hi everyone,

Can someone clarify how the "portion not payable" should be handled on medical aid statements / claims ?
See screenshot - https://ibb.co/9bmcYfM

On the bottom of my medical aid statement it shows:
Portion Not Payable*** = The amount for which neither you nor the Scheme is responsible.

So if neither the scheme nor I am responsible, why am I in general always paying this amount ?

Thanks.

 

[Kosmik]

Hi everyone,

Can someone clarify how the "portion not payable" should be handled on medical aid statements / claims ?
See screenshot - https://ibb.co/9bmcYfM

On the bottom of my medical aid statement it shows:
Portion Not Payable*** = The amount for which neither you nor the Scheme is responsible.

So if neither the scheme nor I am responsible, why am I in general always paying this amount ?

Thanks.

You are supposed to go back and query with the provider why they are charging it. Did you actually pay it over? If so there is likely a overcharge or misallocation. Portion Not Payable indicates a error rather than a liability.

 

[Tomtomtom]

They're paying R 390.50, they are asking you to co-pay R 115, and the other R 494.50 is for the hospital to suck on.

I think it arises when the provider breaches their preexisting agreement with the scheme and overcharges either in error or just for laughs.

 

[eepr0m]

The Doctor prob charged more than the discovery health rate.(more than 100%). Get gap cover.

 

[Tomtomtom]

Get gap cover.

To pay a bill the MA is telling you you do not need to pay?

 

[Y'all Qaeda]

I always thought its the difference between what the hospital charges and the agreed rate with your provider. So if you were with a different medical aid or if you went to a out of network provider - they would've charged R1000. But because you went to an in network provider or one who has an agreement with them, they reduced the fee charged.

 

[eepr0m]

To pay a bill the MA is telling you you do not need to pay?

The Amount claimed was R1000. The discovery Health rate was R505.50 Based on the R505.50 theres a amount payable by the main member of R115 Labeled as "Your portion". The difference between R1000 and R505.50 (R494.50) is what was charged above the Discovery Health rate. "Portion not payable" actually means portion not claimable and wont be paid by Discovery hence this being the reason the main member needs to pay the difference and claim it back from Gap cover provided he has any. It's not rocket science.

 

[Tomtomtom]

I always thought its the difference between what the hospital charges and the agreed rate with your provider. So if you were with a different medical aid or if you went to a out of network provider - they would've charged R1000. But because you went to an in network provider or one who has an agreement with them, they reduced the fee charged.

Look up the "reason code" at the bottom. In this case 1520. A couple I've seen:

82 - This is a non-chargeable item. It will not be paid.
617 - Charging for the warm air blanket falls outside the agreed billing guidelines. You do not have to pay this cost

 

[Tomtomtom]

The Amount claimed was R1000. The discovery Health rate was R505.50 Based on the R505.50 theres a amount payable by the main member of R115 Labeled as "Your portion". The difference between R1000 and R505.50 (R494.50) is what was charged above the Discovery Health rate. "Portion not payable" actually means portion not claimable and wont be paid by Discovery hence this being the reason the main member needs to pay the difference and claim it back from Gap cover provided he has any. It's not rocket science.

If the main member needs to pay it would be under "your portion".