Objectives

The primary objective of this tender is to appoint a service provider responsible for processing and collecting claims related to the KwaZulu-Natal Department of Health. This includes handling injury-on-duty supplier claims, Road Accident Fund (RAF) supplier claims, and the collection of departmental debts. The service provider will operate on behalf of the department for a contractual period of three years (36 months).

Scope

The scope of work encompasses:

• Processing and collecting claims for injuries-on-duty, RAF, and COID (Compensation for Occupational Injuries and Diseases Act) related health services rendered at department facilities.
• Submitting claims within 48 hours of patient admission or visit for motor vehicle accidents and injury-on-duty cases.
• Managing departmental debts, including age analysis, remittance, and reconciliation of claims and payments.
• Handling supplier claims exceeding R3,000, with regular handovers of new debts and claims.
• Monitoring and reporting on claim status, outstanding balances, and recovery results.
• Providing detailed reports on claims processed, payments, outstanding balances, and discrepancies.
• Ensuring compliance with relevant legislation, including the Road Accident Fund Act, PFMA, and NCR.

Technical Requirements

The technical scope includes:

1. Claims Processing for RAF and COID

• Claims must be submitted with full documentation within 48 hours of patient treatment.
• Reports required include monthly payments, outstanding balances, age analysis, and claim status.
• Reconciliation of claims with RAF and COID data, including handling discrepancies and repudiations.
• Electronic data exchange and interface capabilities with RAF and COID systems.
• Handling supplier claims in excess of R500 million and processing over 100,000 invoices.

2. Departmental Debts Management

• Reconciliation of departmental debts, including age analysis and proof of payments.
• Addressing discrepancies and correcting errors before subsequent reconciliations.
• Providing electronic files and scanned documents related to staff and departmental debts.

3. System Capabilities

• System must monitor the progress of claims until settlement.
• Ability to handle ad-hoc requests and short-notice queries.
• Support for managing claims and debts exceeding R3,000, with a volume of approximately R20 million in total debt and 100,000 invoices.
• Integration with existing hospital and departmental systems via electronic interface.

Skills Requirements

• Proven experience in processing large volumes of claims (over 100,000 invoices) and managing departmental debts.
• Demonstrated capacity to handle claims in excess of R500 million.
• Technical expertise in claims management systems, with detailed CVs and examples of similar work undertaken.
• Ability to provide comprehensive reports, including age analysis, claim status, and reconciliation results.
• Established local presence in KwaZulu-Natal, with a dedicated branch and project manager for effective communication and support.
• Experience in interfacing electronically with RAF and COID systems and handling complex reconciliation processes.
• Capacity to respond promptly to ad-hoc requests and short-notice queries, ensuring continuous claims monitoring and management.