Objectives

This Request for Information functions as a market engagement and requirements-validation exercise rather than a formal procurement call. Its primary objectives are to gather industry insights, assess vendor capability, and evaluate service delivery models, implementation approaches, and support frameworks. The exercise aims to identify resource requirements, integration dependencies, budgetary considerations, and potential risks within a high-volume, regulated public-sector environment. Ultimately, it seeks to reduce procurement risk, refine functional and technical specifications, and determine the most appropriate future sourcing strategy.

Scope

The tender covers the delivery, configuration, implementation, and long-term support of a cloud-based Integrated Medical Management Solution designed for the Road Accident Fund. The solution must manage end-to-end medical benefits arising from motor vehicle claims, encompassing:

• Clinical rules engine, pre-authorisation, and hospital benefit management
• In-hospital, field, and office-based case management with rehabilitation and outcome tracking
• Serious injury assessment, past and future medical expense evaluation, and caregiver payment processing
• Medical bill review, provider network management, and multidisciplinary medical advisory workflows
• Fraud detection, secure communication logging, and advanced reporting/analytics
• Integration with internal systems, third-party platforms, statutory data sources, and dedicated provider/claimant portals

The system must be configurable, scalable, and fully aligned with South African healthcare, insurance, and data protection regulations.

Technical Requirements

Bidders must propose a resilient, cloud-native architecture (compatible with Azure, AWS, or Google Cloud) with guaranteed uptime, defined recovery time/objective points, and comprehensive disaster recovery protocols. Key technical mandates include:

• Security & Compliance: Encryption at rest and in transit, multi-factor authentication, single sign-on, role-based access control, segregation of duties, and adherence to POPIA, ISO 27001, and SOC 2 standards.
• Integration & Interoperability: Secure API connectivity for real-time claims submission, B2B data exchange, legacy system integration, and automated file processing. Capability to convert PDF invoices into structured electronic formats is mandatory.
• Scalability & Performance: Architecture must sustain high transaction volumes, concurrent users, exponential data growth, and complex analytical workloads without performance degradation.
• Reporting & Analytics: Native dashboards, configurable exportable reports (PDF, Excel, CSV), and seamless integration with Business Intelligence platforms for clinical, financial, and operational insights.
• Artificial Intelligence: Embedded AI for workflow automation, clinical risk stratification, fraud/waste detection, utilisation analysis, and predictive workload planning, governed by strict privacy, explainability, and auditability controls.
• Audit & Version Control: Tamper-evident logs for all user actions, data modifications, and approvals; automated version control for clinical guidelines, tariffs, and coding rules to ensure historical claim adjudication accuracy.

Skills Requirements

Vendors must demonstrate proven expertise in healthcare claims management, insurance operations, and large-scale public-sector deployments. Essential competencies include:

• End-to-end project governance, structured implementation methodology, and enterprise change management
• Specialised skills in cloud infrastructure deployment, secure API development, and complex data migration
• Experience coordinating multidisciplinary clinical advisory teams, medical expert networks, and regulatory tribunal communications
• Proficiency in South African medical coding standards, tariff structures, pharmaceutical indexing, and impairment assessment methodologies
• Dedicated support and maintenance capabilities, including helpdesk management, SLA monitoring, incident escalation, and continuous regulatory/tariff update deployment
• Comprehensive training, knowledge transfer, and user adoption facilitation for clinical, administrative, and executive stakeholders

Key Terminology & Regulatory Context

The solution operates within a highly specialised South African framework. Notable terms include:

• ICD-10/ICD-11: International disease classification codes used globally for standardising injury and diagnosis tracking.
• NAPPI & SAMA MDCM/RCF/RPL: National pharmaceutical pricing indexes and South African medical coding/tariff references used for billing validation and reimbursement calculations.
• WPI & Serious Injuries List: Whole Person Impairment thresholds and approved clinical criteria for identifying severe trauma cases requiring extended rehabilitation and general damages assessments.
• HPCSA Tribunal Process: Digital management of disciplinary and legal proceedings involving registered healthcare practitioners.
• POPIA: South Africa’s Protection of Personal Information Act, mandating strict consent, data minimisation, and security protocols for health and claimant information.