Objectives

The primary objectives of this tender are to appoint a service provider capable of processing and collecting claims related to the KwaZulu-Natal Department of Health. This includes handling injury-on-duty claims, Road Accident Fund (RAF) supplier claims, and departmental debts. The provider must ensure efficient management, compliance with relevant legislation, and timely processing over a three-year period.

Scope

The scope encompasses:

• Processing and collection of claims for injuries-on-duty, RAF, and departmental debts.
• Management of claims from various hospitals and health facilities within KwaZulu-Natal.
• Reporting on claims, payments, outstanding balances, and age analysis.
• Reconciliation of claims data with RAF, COID, and departmental records.
• Handling supplier claims exceeding R3,000, including legal procedures where necessary.
• Providing technical support, system monitoring, and ad-hoc requests related to claims processing.
• Managing departmental debts and ensuring payments are deposited into the Department’s bank account.

Technical Requirements

The technical scope includes:

• Claims Processing: Submission of claims within 48 hours of patient admission/visit, covering motor vehicle accidents and injury-on-duty cases, compliant with Section 17(5) of the RAF Act and COID.
• Reporting: Monthly reports on payments, outstanding balances, age analysis, claims repudiated, paid, and overdue claims.
• Reconciliation: Regular reconciliation of claims data with RAF, COID, and departmental records, including electronic data exchange and detailed methodology.
• System Capabilities: Ability to handle high volumes (over R500 million in claims and 100,000 invoices), monitor claim progress, and generate ad-hoc reports.
• Claims Management: Manage claims exceeding R3,000, with the ability to process new and existing claims efficiently.
• Legal and Administrative Support: Facilitate legal procedures for repudiated claims, issuing summons, and recovery actions.

Skills Requirements

The successful bidder must demonstrate:

• Experience: Proven track record in managing large-scale claims processing, preferably with experience in RAF and COID claims.
• Technical Expertise: Robust IT systems capable of handling high claim volumes, with secure data exchange interfaces and reporting functionalities.
• Capacity: Ability to manage over R500 million in claims and 100,000 invoices, with sufficient IT and administrative resources.
• Local Presence: An established branch and dedicated project manager within KwaZulu-Natal for prompt support and communication.
• Legal and Administrative Skills: Competence in handling legal procedures related to claims repudiation, debt recovery, and compliance with legislation.
• Reporting and Reconciliation: Ability to produce detailed monthly reports, perform accurate reconciliation, and supply electronic claim data and scanned documents.