Know your dental and optometry benefits

May 2019

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If you want to avoid having to make co-payments on your dental or optical claims, make a point of familiarising yourself with how your benefit option design caters for these services. Read on to find out how your dental and optometry benefits work, which processes you should follow when submitting a claim, and where to find a network provider.

Medihelp's dental and optometry networks

To ensure that you receive the best possible benefits, Medihelp has partnered with accredited dental and optometry benefit management service providers who are well-established and experienced:

Dental Risk Company (DRC) is Medihelp’s dental benefit management partner. Necesse members must use a dentist in the DRC network to avoid out-of-pocket expenses, while members of all other options (including the Prime network options) may visit any dentist of their choice.

Preferred Provider Negotiators (PPN) manages Medihelp’s optometry benefits for all options except Unify and Prime 1 (network and non-network). Members of all other options must use an optometrist in the PPN network to avoid out-of-pocket expenses.

Remember: Visiting a network provider can save you money, since their tariffs are usually more in line with the Medihelp tariff. You can search for a DRC and PPN network provider here.

Your benefit schedule

You will find everything you need to know about your dental and optometry benefits in your member guide. To access your guide online, log in to Medihelp’s Member Zone, click on “Benefits” and select “My benefit option” in the dropdown menu.

Before you make an appointment at your dentist or optometrist, read your member guide and find out the following:

  • Confirm from which benefit the services will be paid. Will the claim be paid from your insured benefits, which are available separately from your pooled day-to-day benefits, or will it be deducted from your medical savings account? Will you perhaps have to pay for the services yourself?
  • Understand what the benefit entails. If your benefit states that you are covered for “one pair of standard clear Aquity single vision or bifocal lenses per beneficiary per 24-month cycle (multifocal lenses paid at the cost of bifocal lenses)” it means that PPN will only cover those specific lenses. Should you receive any other lenses or anything in addition, it will be for your own account, including tinted lenses, custom frames or accessories.
  • Get a quotation and first confirm what your benefit option will cover and what not, before you receive the service. Otherwise, you may end up with unexpected out-of-pocket expenses or you may have to use your savings account funds to pay for these expenses.
  • Remember to pre-authorise your procedure, otherwise co-payments may apply.

Submitting a dental claim

Depending on your dentist, you will either be required to pay upfront and claim from DRC later, or the practice will submit the claim on your behalf.

Submit your claim in any of the following ways:

1. Log in to Medihelp’s Member Zone, select “Claims” and choose “Submit claim” from the dropdown menu. Make sure your statement contains all the required information before submitting.

2. Email your statement to claims@dentalrisk.com

If you have gap cover, you can claim any shortfalls or co-payments on in-hospital treatments from the insurer. Your gap cover provider will need a statement from DRC before reimbursing the amount to you. é

Contact details: DRC

Tel: 087 943 9618
Fax: 086 687 1285
Email: auth@dentalrisk.com, claims@dentalrisk.com, medihelp@dentalrisk.com
Website: www.dentalrisk.com

Contact details: PPN

Tel: 086 1103 529 / 086 1101 477
Email: info@ppn.co.za
Website: www.ppn.co.za

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