Medical Scheme Appeals / Complaints

What to do if your PMB claim is refused, and how to escalate it.

1

Appeal internally, with your scheme, first

The Council for Medical Schemes (CMS) requires you to exhaust your scheme's internal dispute process before they'll accept a complaint. Submit your appeal in writing, citing the PMB regulations, with a signed, completed appeal form (from your scheme's PMB/appeals department), supporting clinical documentation and motivation from your doctor/prosthetist, and detailed invoices and referral letters. Most schemes resolve internal appeals within ~30 days. Most denials are procedural (missing documentation, wrong codes) rather than valid refusals — a properly-motivated appeal usually succeeds at this stage.

2

Escalate to the Council for Medical Schemes (CMS)

If your scheme's internal appeal doesn't resolve it, or you disagree with the outcome, escalate to CMS — the independent statutory regulator. Submit via email (complaints@medicalschemes.co.za), post (The Council for Medical Schemes: Complaints Adjudication Unit, Private Bag X34, Hatfield, 0028), or in person at CMS offices. You'll need: the completed CMS complaint form, a detailed account of the facts and what you want resolved, proof you already escalated internally, and any clinical reports/statements.

3

What happens after you submit

Within 6 working days: written acknowledgement, reference number, and assigned contact person. Within 4 working days of that: your complaint is analysed and referred to your scheme. Within 30 days: your scheme must respond in writing. Within 120 calendar days total: CMS aims to resolve the matter.

Key Contacts
CMS Phone0861 123 267
CMS Phone (alt)+27 12 431 0500
CMS Emailcomplaints@medicalschemes.co.za
HoursMon–Fri, 8:00–16:30