How to read your claims statement

 

Below is information about how to read your claims statement.

Understanding a summary claims statement

The summary claims statement provides a concise overview of your medical benefits and claims. Here are the critical components you will find:

1. The first item outlines the specific benefit option you have selected, which is essential for understanding the coverage available to you.

2. Next, you will see the total amount that the Scheme has disbursed from the Major Medical Benefit during the current month. This reflects the financial support you received for significant medical expenses.

3. The statement will also indicate the amount paid from the Chronic Benefit for the month, which is crucial for those with ongoing medical conditions requiring regular treatment.

4. Additionally, you will find the total amount that the Scheme has paid from the Major Medical Benefit throughout the entire calendar year, giving you a broader view of your healthcare expenses over time.

5. Similarly, the amount paid from the Chronic Benefit for the calendar year is also included, allowing you to track your chronic medication expenses cumulatively.

6. The statement will show your Personal Medical Savings Account (PMSA) balance that has been carried over from the previous benefit year, which is important for understanding your available savings.

7. You will also see the contributions made to your Savings (PMSA) within the current calendar year, which reflects how much you have added to your medical savings.

8. The amount advanced from your Savings (PMSA) for the remaining months of the calendar year will be detailed. This indicates how much has been pre-allocated for your future healthcare needs.

9. Any interest earned on your Savings (PMSA) balance will also be reported, providing insight into how your savings are growing over time.

10. The total claims paid from your Savings (PMSA) in the current month will be included, and this figure will match what is shown in the Medical Savings column of your Detailed claims statement.

11. Additionally, the total claims paid from your Savings (PMSA) for the entire calendar year will be listed, helping you understand your overall spending from your savings account.

12. Finally, the statement will clarify whether there is an amount you owe to the Scheme or an amount payable to you. If the Scheme owes you, the payment date and relevant bank details will be provided in a message field below this line.

Understanding a detailed claims statement

The detailed claims statement offers a more comprehensive breakdown of each claim transaction. Here’s what you can expect to find:

1. The Payment Information columns will detail any payments made for each claim transaction, whether those payments were made to healthcare providers or directly to you. It will also outline any amounts that you owe to the Scheme, ensuring transparency in your financial interactions.

2. The Benefit Information columns will specify which benefit was utilized for each claim transaction, categorized as follows:

   1.1 The Major Medical Benefit covers claims related to in-hospital treatments and specific procedures, but these claims are subject to prior authorization to ensure they meet the Scheme's criteria.

   1.2 The Medical Savings Account (PMSA) is dedicated to covering day-to-day medical expenses from your available savings, providing a flexible option for routine healthcare costs.

   1.3 The HealthSaver account is a voluntary option that allows you to manage additional medical expenses not covered by your primary benefit option. Transactions from this account will also appear on your separate HealthSaver statement, which is generated on the 1st of each month.

   1.4 The Chronic Medicine Benefit is specifically designed to cover registered and approved chronic medications and treatments, ensuring that you receive the necessary care for ongoing health conditions.

3. The Pay Code column will display the specific pay code linked to each claims transaction, along with an explanation of what each code signifies, enhancing your understanding of the billing process.

4. You will also find the name and practice number of the relevant healthcare provider associated with each claim transaction, which adds a layer of accountability and traceability.

5. The total amount disbursed from your Medical Savings Account (PMSA) for the claims listed will be provided, and this figure will also be reflected under Note 10 in your Summary claims statement for consistency.

6. The total for your HealthSaver account will match the total indicated in Note 7 on your HealthSaver statement, providing a comprehensive view of your finances across different accounts.

Submit claims: You can easily submit a photo of your claim through the Momentum App. Alternatively, you can email your claims to [e-mail]. If you have any queries regarding your claims, please reach out via email at [e-mail] or contact us through WhatsApp or by calling 0860 11 78 59.

As a member of the Momentum Medical Scheme, you have the option to access additional products offered by Momentum Metropolitan Holdings Limited (Momentum) to enhance your medical aid experience. It is important to note that Momentum is not a medical scheme and operates as a separate entity from the Momentum Medical Scheme. The complementary products provided are not considered medical scheme benefits, and you can be a member of the Momentum Medical Scheme without enrolling in any of these additional offerings.