Letters
Medical aid claim submission letter template
By Naledi Mokoena · 5 min read · Updated 24 June 2026
To submit a claim yourself, send your scheme a claim submission letter with the original detailed account, proof of payment, and your membership and dependant details. This is for claims a provider did not submit directly, for example when you paid cash or saw an out-of-network doctor.
Use the template below. Replace every [PLACEHOLDER] and attach a detailed invoice that shows the practice number, ICD-10 codes and tariff codes.
Schemes set a deadline for claims, often around four months from the date of service, so submit promptly.
When you submit a claim yourself
Most providers submit claims straight to your scheme. You only need to submit yourself when:
- You paid the provider cash and want a refund into your bank account.
- The provider does not submit electronically.
- A claim was lost or never reached the scheme.
In each case the scheme needs a detailed account, not just a till slip or a card receipt.
Claim submission template
[Your full name]
[Membership number]
[Email] | [Cellphone]
[Date]
The Claims Department
[Scheme name]
RE: Claim submission - member [MEMBERSHIP NUMBER]
Dear Sir or Madam,
Please process the attached claim for payment.
Patient: [PATIENT NAME AND DEPENDANT CODE]
Date of service: [DATE]
Provider: [DOCTOR / PRACTICE NAME AND PRACTICE NUMBER]
Amount claimed: R[AMOUNT]
I attach:
1. The detailed account showing the practice number, ICD-10 code(s) and tariff code(s).
2. Proof of payment / receipt (I paid this account myself).
3. A referral or script, if relevant.
As I have already paid the provider, please refund the approved amount to:
Bank: [BANK]
Account holder: [NAME]
Account number: [ACCOUNT NUMBER]
Branch code: [BRANCH CODE]
Please confirm receipt and a claim reference number.
Yours faithfully,
[Your full name]
[ID number]
What makes a valid detailed account
A valid account is more than a receipt. It must show:
- The provider's name and practice number.
- The patient's name.
- The date of service.
- ICD-10 diagnosis code(s).
- Tariff or procedure code(s) and the amount per item.
A card slip or a quote will not pay. Ask the provider for a detailed statement or invoice if you only have a payment receipt.
Submit before the deadline
Schemes apply a claims submission deadline, commonly around four months from the date of treatment, though it varies by scheme. Claims received after the cut-off are often rejected as stale. If you are close to the deadline, submit what you have and follow up, rather than waiting to gather every document.
Frequently asked questions
How do I submit a medical aid claim myself?
Send the scheme a detailed account showing the practice number, ICD-10 and tariff codes, plus proof of payment and your banking details for a refund. Use the letter above, email it to the claims department, and keep the reference number.
What is the deadline to submit a claim?
Most schemes accept claims up to about four months from the date of service, but the exact period varies. Submit as soon as possible. Late claims are usually rejected as stale, and that rejection is hard to reverse.
Why was my claim paid only partially?
Schemes pay at scheme rates. If your provider charges above that rate, you cover the shortfall. Other reasons include using day-to-day benefits that are exhausted, or a co-payment on the plan. Gap cover is designed to bridge rate shortfalls.
Can I claim a cash payment back from my medical aid?
Yes, if the service is a covered benefit and you have a detailed account plus proof of payment. The scheme refunds the approved amount to your bank account, at scheme rates. Provide your banking details in the claim letter.
Is a card receipt enough to claim?
No. A card receipt or till slip is proof of payment but not a detailed account. The scheme needs the provider's statement with the practice number and the ICD-10 and tariff codes. Ask the provider for a detailed invoice.
What if my claim is rejected?
Ask for the reason in writing first. Many rejections are fixed by correcting a code or supplying a missing document. If the rejection is unfair, use our appeal template and, if needed, escalate to the scheme's disputes team and the CMS.
