Medical Scheme Submission Summary
Patient: MC-004 (synthetic) • Scheme: Example Health (Option: Core) • Date: 2025-10-25
1) Beneficiary & Provider
Beneficiary
MC-004 (synthetic), Member No: 1234567890
Provider
Practice: Example Neuro Inc. • Discipline 62 • Practice No: 0123456
Contact
Auth Team Email: auth@examplehealth.co.za (placeholder)
Authorization Ref
Pending • To be assigned by scheme
2) Clinical Summary
Adult with cervical radiculopathy and imaging-confirmed C5/6 nerve root compression. Conservative therapy attempted with partial response. Surgical decompression considered if progressive deficit or refractory pain.
3) Diagnosis and PMB Indicator
| ICD | Description | PMB | Notes |
|---|---|---|---|
| G55.1 | Nerve root compression syndrome | Yes (subject to scheme protocols) | Based on clinical + imaging evidence |
| M48.02 | Cervical spinal stenosis | Yes (subject to scheme protocols) | DTP chronic spinal conditions with neurological deficit |
4) Proposed/Performed Itemisation (RPL/NHRPL)
| RPL Code | Description | Units | Notes |
|---|---|---|---|
| 5763 / 5764 | Anterior cervical discectomy (level-dependent) | 1 | C5/6 decompression |
| 0970 | Anterior plating | 1 | If intra-op stability requires |
| 5770 | Microscope-assisted surgery | 1 | Technique modifier |
Note: RPL/NHRPL refer to the same SAMA/MDCM coding set. Tariff values vary by scheme; tariff lookup is coming soon and any values shown will be indicative only.
5) Required Attachments
- Clinical notes summarising neurological findings
- MRI report with level and laterality
- Conservative treatment history
- Signed consent for data processing and treatment
6) Submission Instructions
- Submit via your practice management system or scheme portal
- Include this summary and all required attachments
- Reference PMB indicators and applicable clinical protocols in your motivation
MedCascade provides billing assist only and does not submit claims. This summary is provided to help you prepare a submission-ready packet for your medical scheme.
Generated by MedCascade • Billing assist only • Sample data • Not medical advice