Medical Claims Assessing
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Medical Claims Assessing
SAQA Qualification Title: FETC: Medical Claims Assessing Level 4 qualification
150 credits

This qualification is an excellent foundation for all new people working in the medical scheme environment, and not just for claims assessors.


This qualification is intended specifically for all people who require medical scheme industry, administrative and medical knowledge in a Medical Scheme Administrator or Managed Care Company as a foundation course. It will also be useful as a bridging qualification for learners with medical and paramedical qualifications who wish to move into administrative positions in Healthcare Benefits Administration and managed care like case managers, and for learners in call or service centres that are required to respond to queries regarding medical schemes. 

Training options:

  1. Learnership run by a company for previously unemployed people or for the company’s employees;
  2. Skills programmes.

The number of facilitation days will depend on the entry level knowledge and experience of the learners. The training programme will be jointly decided upon between IHRM and the company.  The costs will depend on the number of learners and the number of facilitation days. 

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Learner responsibilities

Learners must register on the programme understanding that they must dedicate their personal time to studying and completing assignments. They will be required to submit individual assignments per module, and also to write exams. IHRM will be there to support them through the process. 

Why partner with IHRM for your training needs:

IHRM is an independent training company that specialises in the healthcare industry with ten years’ experience in training. All training is facilitated by subject matter experts. IHRM is accredited by INSETA as a training provider and their assessors and moderators are registered with the necessary scope to facilitate and assess this qualification. IHRM has the ability to administer the INSETA administrative requirements including the registration and verification process to ensure you obtain your credits should you be deemed competent.

Unit Standards/Modules

The qualification is made of a number of unit standards or modules. They are listed below. A skills programme will allow you to select a number of unit standards.

  • Describe healthcare cover in South Africa
  • Analyse new developments reported in the media that could impact on long term insurance
  • Research the medical scheme administrator sub sector in 
  • South Africa
  • Apply knowledge of the current Medical Schemes Act and the accompanying regulations
  • Explain the Medicine and Related Substances Control Amendment Act, 59 of 2003,  as it impacts on medical schemes
  • Explain the use of coding in healthcare benefits administration
  • Describe managed care as it is applied in medical scheme 
  • administration
  • Assess a medical claim
  • Explain the cycle of a medical claim
  • Use an electronic system as a tool in a financial services context
  • Describe issues of compliance or non-activity that could result in civil or criminal  liability in terms of business law
  • Demonstrate knowledge and application of ethical conduct in a business environment
  • Describe the control of fraud in healthcare benefits administration
  • Apply knowledge of HIV/Aids to a specific business sector and a workplace
  • Analyse cancer as an impairment and the associated impact on the assessment of risk
  • Analyse cardiovascular related impairments and their impact on the assessment of long- term risk
  • Analyse impairments related to blood disorders and the associated impact on the assessment of risk
  • Analyse respiratory related impairments and their impact on the assessment of long-term risk
  • Analyse musculo-skeletal related impairments and their impact on the assessment of long-term risk
  • Analyse impairments of the reproductive system and their impact on the assessment of  long-term risk
  • Analyse impairments related to the digestive and urinary systems and their impact on the assessment of long-term risk
  • Analyse impairments related to the endocrine system and their impact on the assessment of long-term risk
  • Analyse neurological related impairments and the associated impact on risk assessment
  • Analyse psychological and psychiatric impairments and the associated impact on the assessment of risk
  • Describe and apply the basic principles of personal income tax
  • Interpret basic financial statements

Investigate ways of managing financial risk in own lives

Note: This qualification does require the learner to have a matric with two languages one of which must be English at a grade E or higher

Maths  RPL concessions can be granted if the learner has matric mathematics  at a grade E or higher. Alternatively the learner will be required to do these unit standards.

  • Use mathematics to investigate and monitor the financial aspects of personal, business, national and international issues
  • Apply knowledge of statistics and probability to critically interrogate and effectively communicate findings on life related problems
  • Represent analyse and calculate shape and motion in 2-and 3-dimensional space in different contexts

Email info@ihrm.co.za for further details.