Administration Service Level

1. The administration of the Fund and managed care arrangements will be conducted in full compliance of the rules of the Fund and the principles of sound corporate governance.
2. GetMed will employ sufficient and suitably qualified and trained staff, infrastructure information technology and systems to provide the services and to effect the contractual obligations to the Fund.
3. All data remains the property of the Fund and copyright of the data vests in the Fund. GetMed will take such steps as may be required to protect the confidential nature, integrity and assignment of data as far as it relates to the administration of the medical scheme. The data shall be kept and disclosed as per industry norms and standards and as may be required from time to time.
4. GetMed will also meet the following criteria:  

• GetMed will be put in a financially sound position and will appoint an auditor to examine the accounting records and annual financial statements of the company in accordance with the South African Auditing Standards and in compliance with South African Statements of Generally Accepted Accounting Practice (“GAAP”).
• GetMed will fully declare all co-administration or subcontracting arrangements/agreements between the organisation and other entities.
• Payment for services forming part of specified functions being co-administered and/or sub-contracted by GetMed will form part of the agreed administration fee paid by the Fund to GetMed. No additional fee shall be charged to the Fund.
• GetMed will demonstrate the system functionality and operational efficiency in terms of client services, call centre and financial management.
• GetMed will demonstrate how administration systems will integrate with the accounting system.
• GetMed is willing and able to constructively engage, integrate, interface and participate with all other service providers that are contracted by the Fund.

1. The scope of work required from GetMed include the following as presented below (this is not an all inclusive list):  

• Member record management  
• Maintain and operate an effective membership management system that is fully integrated, accurate and is real time compliant.
• Ensure that proper and robust mechanisms for the registration, maintenance and updating of member records is in place.
• Integrate individual member record system with all other administration systems in use, allowing the member records to be fully utilised for contributions, claims and financial management.
• Manage member records down to the individual member level, including the ability to keep and monitor appropriate dependant details.
• Respond to changes to membership/dependant details and update records prior to any claims being made against an adjusted benefit or contribution profile.
• Audit trails exist for all changes to member records.
• Issue membership cards, certificates of membership and Income tax information for members.

• Contribution Management  
• Establish and maintain a system of contribution management that comply with the registered benefit options as per the schemes rules.
• Integrate the membership management system and the member billing system.
• Timeously collect, allocate and reconcile all contributions registered in terms of the rules of the scheme at individual member level.
• Ensure accuracy prior to generating a billing run by interfacing the contribution collection system with the individual membership record.
• Generate complete and accurate billing runs.
• Reconcile the debtor’s age analysis (billings ledger) to the general ledger control account on a monthly basis.
• Member debtor management and suspension and/or termination as provided for in the scheme rules, the guidelines laid down by the trustees and the audit committee.
• Supply members with accurate monthly billing and contribution statements. Establish appropriate and robust credit control measures.

• Claims management  
• and maintain a claims management system with parameters that comply with the registered benefit options as per the schemes rules.
• Ensure that the system interfaces with the individual member record before paying a claim, so as to establish the member’s entitlement to benefits.
• Receive, validate and pay all claims received in accordance with the registered benefit options of the scheme rules.
• Demonstrate ability to incorporate the correct tariff codes, e.g. ICD10 coding, medicine pricing, etc.
• Maintain a claims history at the individual member level and allocate valid claims payments.
• Ensure that members receive regular, detailed and accurate claims statements and communicate timeously in the event of claims being queried or rejected.
• Administer and manage flexible medical savings accounts according to the provisions of the rules of the medical scheme, with particular regard to the allocation of claims between the risk pool and savings accounts.

• Information management and data control  
• Manage the schemes data in a manner that promotes integrity and protects the interests of the scheme and its members.
• Maintain the confidentiality, security and integrity of data and information.
• All right title and interest in data and personalized information pertaining to the scheme rests at all times in the scheme and the administrator has no claim of any nature in and to such data.
• Steps as may be required to protect the confidential nature, integrity and assignment of data as far as it relates to the scheme under administration.
• Employ sufficient and suitably qualified and trained staff, infrastructure information technology and systems to provide the services and to maintain and update tariffs & benefits master files (including preferred provider networks).
• Provide measures to ensure that the system complies with international retrieval capacity practices.
• Ensure that all the operational processes are integrated to ensure the rapid reconciliation and utilisation of data.
• Integrate with any outsourced service provider that is contracted by the scheme.
• Provide comprehensive off-site data storage, backup and disaster recovery process in compliance with accepted industry norms and standards.
• Establish and implement processes for the early detection and mitigation of irregularities and illegal acts by employees, members and providers.

• Client services  
• Notify the principal officer promptly of difficulties experienced with contribution collection process & significant outstanding amounts (member/group/ employer/providers).
• Assign a key account manager who will be responsible for reporting on all aspects of the administrator’s services and for managing the interaction between the scheme and administrators.
• Liaise with and co-ordinate the activities of the Fund’s external auditors and audit committee as and when required.

• Customer services  
• Provide members with relevant and professional customer care services that are accessible and available.
• Provide a dedicated postal address; fax number; and contact email for members wishing to contact the scheme and administrator.
• Operate and manage a Call Centre enquiry service for members and service providers to address enquiries and complaints.