smeMetrics

Practice Management Software

edi

Loading EDI Credits on smeMetrics

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One of the most important things in your practice is billing or invoicing timeously to ensure that your claims reach the medical aid in time for the next payment run. The easiest way to do this would be to submit your claims via EDI (Electronic Data Interchange). 

Submitting claims through EDI means the claim goes directly into the scheme’s claims processing pool and does not still need to be manually processed by an agent at the scheme. These claims therefore hit the scheme immediately and are processed faster, resulting in a better cash flow for the practice. EG: A claim sent via EDI on a Saturday afternoon will be process for payment on the following weeks payment run, but a claim sent via email on the same day will only be processed for payment the week thereafter. 

Loading Prepaid Credits for your EDI submissions on smeMetrics

EDI claims on smeMetrics, work on a prepaid basis, so that you can track your usage and see what you have spent your credits on. To load credits you please follow the links below

Prepaid Credits (ZAR, R100) – 

Prepaid Credits (ZAR, R200) –

Prepaid Credits (ZAR, R500) – 

Once you have made payment please send the proof of payment to support@smemetrics.com in order for the accounts team to load the funds. 

If there are multiple practitioners on your account you will need to indicate in your email, which practitioner the funds need to be allocated to or how you would like the funds split between practitioners :: EG :: Split funds evenly between practitioners A, B and C or load R 200.00 to A, R 350 to B and R 100 to C

How to check your EDI Balance and usage on smeMetrics

Once you have loaded the credits you will receive a paid invoice for your records from smeMetrics, to check if the credits have been loaded, go to settings/ Mu Subscription info and you will be able to see your Pre-Paid balance. 

You can also set an minimum balance threshold and notification so that the system will send you an email when you reach the threshold, giving you time to reload funds before you run out of credits. My recommendation is to set this threshold for R 100.00 that will allow at least 20 to 25 claims before you run out of credits. 

To check what your credits have been used on click on the little speech bubble next to the balance amount. 

This will bring up the below pop up screen where you can see all transactions. 

Need Further Help from Our Team

You can either send an email with the description of your query to support@smemetrics.com, or you can book a training session with our team at https://www.smemetrics.com/demo/

Medical Aid Claims via EDI :: Sending Claims using EDI ( Switching)

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One of the most important things in your practice is billing or invoicing timeously to ensure that your claims reach the medical aid in time for the next payment run. The easiest way to do this would be to submit your claims via EDI (Electronic Data Interchange). 

Submitting claims through EDI means the claim goes directly into the scheme’s claims processing pool and does not still need to be manually processed by an agent at the scheme. These claims therefore hit the scheme immediately and are processed faster, resulting in a better cash flow for the practice. EG: A claim sent via EDI on a Saturday afternoon will be process for payment on the following weeks payment run, but a claim sent via email on the same day will only be processed for payment the week thereafter. 

How to switch to EDI on smeMetrics

To make the switch from email to EDI submissions you need to go to settings/ My Business info and scroll down to the section called “My Medical Aid Claim Preference”. You need to change the settings from Email to EDI.

Once you have made the change click the save button, you will be logged out of the system in order for smeMetrics to make the change on the back end, simply log back in and you will now be able to sent claims via EDI 

Claiming using EDI submissions

The important thing to remember when using EDI is that you need to make sure that you have the below information and that it is accurate otherwise your claim wont be submitted or will be outright rejected 

  1. Patient’s Name 
  2. Patient’s Date of Birth
  3. Dependent code for the main/principle member
  4. Dependent code for the patient. 


To invoice claims using EDI you will follow the same steps as your regular invoicing Click here for info the only difference is that in your billing/invoices section you will now have a button that says “submit” instead of “mail” an additional button called “Claim History” and an additional column called “Claimed Date” 

To check if your claim has been submitted successfully, click on claim history and the below screen will open up. 

If you click on “Claim response you will get a more detailed response advising if the claim has been accepted, rejected etc 

Full Acceptance :: Means that the scheme has accepted the claim but does not guarantee payment

Partial Acceptance :: Means that the scheme has accepted the claim but that it will be manually processed and does not guarantee payment. 
Rejected :: Means the claim has been rejected. 

Some scheme’s will give a more detailed message such as the example above. 

If a claim is rejected due to ICD-10 code, BHF code, Date of Birth ect the system will advise of the rejection reason and you can amend the claim and resubmit. 

Need Further Help from Our Team

You can either send an email with the description of your query to support@smemetrics.com, or you can book a training session with our team at https://www.smemetrics.com/demo/

Medical Aid Claims via EDI :: Member Benefit Check and Claim Reversals

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A medical aid claim submission via EDI offers one the ability to get a faster response on the claim receipt with each medical aid, and also the potential to get paid faster (since the claim is processed quicker and can make it’s way into the payment batches faster). Another two major benefits of EDI claim submissions rather than email based claim submissions is the ability to do a claim benefit check (ie. will the medical aid claim be accepted by the medical aid) and can you reverse the claim if there is a mistake. In terms of the latter benefit, the only way to reverse a claim on an email based claim or after the claim is outside the claim reversal window, is to phone the call-centre of the medical aid and get them to reverse this for you.

Three notes on this functionality:
1. The claim benefit check is only available for Discovery and GEMS medical aid schemes.
2. The ability to reverse an EDI submitted claim is only available in the day that the claim was submitted.
3. There is a cost for each claim benefit check, and for each claim reversal.

Claim Benefit Check

This functionality is available when you generate your invoice and click the Submit button.

Claim Reversal

This functionality is available when you have submitted your claim to the medical aid via EDI and then click on the Claim History button.

Need Further Help from Our Team

You can either send an email with the description of your query to support@smemetrics.com, or you can book a training session with our team at https://www.smemetrics.com/demo/