Our company specialize in billing for South African physiotherapist. Medical aid claims for physiotherapists are sophisticated, complex and time consuming. Our billing system is streamlined for medical aid claim submission. Medical aid claims for physiotherapists are sophisticated, complex and time consuming. Our billing system is streamlined for medical aid claim submission, feedback and payment for your consultations.

Billing for physiotherapists is a totally different ball game when compared to doctors and psychologists. Doctors mainly use one or two consulting codes that depends on the time spent with the patient. Straight forward and easy to bill. On the other hand Physiotherapist billing becomes much more complex and sophisticated. Lets look at the claim process to understand why.

What makes up a medical aid claim

  • Patient information

  • Verify patient as a member of the medical aid

  • Practice details

  • Billing codes

  • Modifiers

  • Diagnostic codes

  • Practice number

  • Format

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What does a practice need to create an invoice, to claim from a medical aid?

It really depends on what the practice needs are. Are you a cash practice, or do you offer the option to claim on directly from the medical aid? Whichever payment options you provide your patients, you must ensure your patients remain happy with your business, by giving them the option how they’d like to pay.

Patient Information

Patients data is vital, there are numerous ways to collect their info. Paper forms are a hassle while the golden standard is an online registration form where all the details are checked and verified. Here are the HPCSA rules that must appear on a medical aid claim:


  • Name & Surname of patient

  • Date of birth (under 16 years)

  • ID number (South African issued card or green barcoded identification number)

  • Contact numbers (home, work or cell numbers)

  • Email address

  • Physical & Postal address

  • Name & Surname of the main member of the medical aid

  • Medical aid Name

  • Membership number of the medical aid

  • Medical aid option (not a requirement, but useful in advising treatment for patients)

Some details may be useful, but aren’t required. Details like next of kin, or contact number of a family member will be helpful in case a phone gets lost, patients move or you’re unable to get hold of your patient directly.

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Verify your patients

Ensure your patient belongs to the medical aid. A practice becomes very vulnerable to identity theft, fake details or even risk rejected claims. Make sure your patient is a member and secondly, who you are treating. This sounds so obvious, but we have encountered patients that bring along relatives to be treated under their name. So, make sure how your patients are, and check their identity.

Most medical aids these days offer online platforms where we are able to check their membership & details. Our system has this feature integrated into tour software. Easy & convenient.

Practice Details

This includes the letterhead what contains the logo and identification information which states your practice number, contact details like your address & phone numbers, and lastly statutory information specifically your practice number. Trading as names such as you Logo must be on your invoice.

Tariff Amounts

There are two ways to establish your tariff amount. One following the set tariff that the medical aids are willing to pay, or set your own fee for your treatment sessions. Depending on your billing policy, we are able to implement both these strategies.

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What determines Physiotherapy rates & price

If you are a registered service provider of a medical aid, certain conditions to the agreement may apply. Each medical aid is different. Every medical aid sets their own reimbursement rate for each code that physiotherapist use.

Treatment codes are universal, but price per code vary. To see a comparison between the top 5 biggest medical aids and how much they are willing to pay, see our article here.

Medical Aid Scheme Rate

This is the amount that the medical aid and SASP has established to be fair compensation for a particular assessment or treatment technique. The base rate is 100% of the scheme rate. Some patient’s option of medical aid determines if the medical aid covers 200%, or 300% of the scheme’s base rate.

Freedom to choose your own rate. Think carefully before you setup your own price without understanding the full weight of the decision. Each option has its benefits and drawbacks. Merely choosing the same rate as the physio down the road, may just be the worst decision you can make.

Treatment Details

The time, duration & date of service must be recorded. Especially when treating hospital patients which is seen twice a day.

The treatment location or address must reflect on each invoice. Multi-location practices share patients between locations.

Diagnostic Codes

Every patient must be diagnosed, therefore each diagnosis corresponds to a diagnostic code. Every diagnosis in existence is captured and allocated a certain code called an “ICD-10 code”. Some patient require more that one diagnostic codes depending on their problem. Multiple sites each may need with different diagnostic code.

For obvious privacy reasons the diagnosis description must not reflect on the invoice, only the diagnostic ICD-10 Code.

Treatment Codes

Treatment codes are treatment or procedure codes that physiotherapist must use so the medical aid understand that you’ve done to their member. Codes can be used in combination or alone, but there are specific rules when which of these codes may be used.

For more details and guidelines how to use treatment codes, please see our article that handles about the topic.


Modifiers are codes that adjust the value of the code amount. Some modifiers are required according to billing rules. See our article on billing codes to understand how and when you use these modifier codes.


Medical aids require all of these requirements in a set format in which this information of each treatment session must be set out. A page that merely contains the total paid by the patient, is inadequate. Medical aids will reject the invoice or statement and not reimburse your patient. SARS also requires these details in order to be a valid invoice to be used as a Tax deductible. This is a necessity why the format of of your invoices are correct.

Medical aids demand that all of the above, must be in-line with each other to avoid confusion at the medical aid

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If you take all of the above info consideration you will understand that there are many factors you must be aware of when submitting a physiotherapy claim to a medical aid.

Don’t even attempt a DIY project when it comes to medical aid claims. Rather team up with a billing company that understands all the aspects of the physiotherapy industry to help you reach your practice’s potential.

Once all the info are captured the claim is submitted to the medical aid. Either Electronically or manually.

Jaco Swart - Physio billing Legal & Growth Consultant

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