’s core business lies in the switching of transactions between various medical practitioners and institutions. Primarily, the business offers the ability for a medical practitioner to submit an electronic claim, on behalf of the patient, through to his or her medical scheme. But there are many other services around this core competence that provide substantially more than just switching the claim. Each of these services is discussed here.

Electronic Claims/Transaction Switching

offers various transaction-based services to both the medical service providers and the medical aid schemes and administrators. These include:

• Electronic claims delivery in batch and real-time¹ with a varying degree of validation checks. Claims are submitted through the switch to the medical scheme in various ways depending on the implementation by the service provider’s software vendor. In most cases this submission forms a seamless part of processing the information related to the patient encounter.
• Electronic membership eligibility checking in real-time. This provides the service provider with the means to check that the patient is indeed a valid member of the medical scheme he or she states they belong to. This check is ideally performed prior to rendering any service thus providing the service provider with a degree of certainty that the scheme will honour the resulting claim.
• Real-time electronic benefit booking. Certain medical schemes have allowed to include prior booking of benefits ahead of performing the service or procedure. This is particularly useful in hospital environments where pre-authorisation of intended procedures by medical schemes is necessary.
• Capitated patient encounter claims. Certain schemes have begun forming provider networks for capitated products, or outsourcing this function to a third-party. (see the Claims Management and Information System under Healthcare Informatics for more on this type of service/transaction).
• Smart Card Transactions. There is an ever increasing need to supply a higher degree of security to medical transactions and as a result of this has developed the means to interface its products with smart card technology that allows for absolute positive identification of an individual through various biometric devices such as fingerprint readers. There is more on this technology in the Healthcare Informatics section.

The company is currently in the process of implementing a number of new transaction types including but not limited to:

• Electronic Remitance Advices (eRA).
• Pre-authorisation Requests (PAR)
• Financial Transactions

¹ Real-time – instantaneous processing of a request or claim. The service provider remains connected to the network whilst the claim is processed and the resultant reply is fed directly back into the provider’s system.