General Practitioners (PAMC) & Pharmacies (MEDISCOR)

Preferred provider claims

General Practitioners

Please visit www.pamc.co.za/AGS/LookUp
to access the list of preferred general practitioners. This list is also available via your Mobi-App.
⚠️ Note: The provider list may change, so always confirm with your doctor whether they are a preferred provider for AGS Health.

All accounts with preferred providers are submitted directly to AGS Health, and payment is made directly to them.

Pharmacies

AGS Health has a network of preferred pharmacies. Confirm with your pharmacist whether they are a preferred provider.

All accounts with preferred pharmacies are submitted directly to AGS Health, and payment is made directly to them.

Non-Preferred provider claims

AGS Health believes its members should have the freedom to use any doctor or pharmacy.

If you use a non-preferred provider:
You are required to pay the account upfront.
You can submit a claim to AGS Health within 90 days of the service date.

To claim reimbursement, please send a statement containing the following information to claims@agshealth.co.za:

-AGS Health policy number
-Patient’s full name
-Provider’s practice number
-ICD10 code(s)
-Tariff code(s)
-Amount charged per item
-Proof of payment (if applicable)
Reimbursement will be processed within 14 working days, according to your available benefits.

⚠️It remains the member’s responsibility to submit the full invoice/statement for processing.

Investigation procedures, Specialist visits ,Blood tests, Radiology

Non-Preferred provider claims

AGS Health believes its members should have the freedom to use any provider.

If you use a non-preferred provider:
You are required to pay the account upfront.
You can submit a claim to AGS Health within 90 days of the service date.

To claim reimbursement, please send a statement containing the following information to claims@agshealth.co.za:

-AGS Health policy number
-Patient’s full name
-Provider’s practice number
-ICD10 code(s)
-Tariff code(s)
-Amount charged per item
-Proof of payment (if applicable)
Reimbursement will be processed within 14 working days, according to your available benefits.

⚠️ It remains the member’s responsibility to submit the full invoice/statement for processing.

Dental Benefits (DRC)

Preferred Provider Claims

Dentistry is a highly specialized field. To ensure optimal management of your benefits, AGS Health has partnered with the Dental Risk Company (DRC).

It is mandatory to use a dentist from the DRC network. You can view the network of preferred dentists:
-On your Mobi-App

Before undergoing any specialized dental procedure, you must submit a quotation to the Dental Risk Company at auth@dentalrisk.com

For claims or paper-based enquiries, email claims@dentalrisk.com, or contact the claims and pre-authorizations department at 087 943 9615.

Optometry Benefits (PPN)

Preferred Provider Claims

Members are encouraged to visit any Specsavers or Execuspecs for optometry services. If there is no Specsavers or Execuspecs in your area, please contact us at 010 140 1516.

All accounts with preferred providers are submitted directly to AGS Health, and payment is made directly to the provider.

Non-Preferred Provider Claims

AGS Health believes its members should have the freedom to use any provider.

If you use a non-preferred provider:
You are required to pay the account upfront.
You can submit a claim to AGS Health within 90 days of the service date.

To claim reimbursement, please send a statement containing the following information to claims@agshealth.co.za:
-AGS Health policy number
-Patient’s full name
-Provider’s practice number
-ICD10 code(s)
-Tariff code(s)
-Amount charged per item
-Proof of payment (if applicable)
Reimbursement will be processed within 14 working days, according to your available benefits.

⚠️ It remains the member’s responsibility to submit the full invoice/statement for processing.

Ambulance Services

All insured members are covered for road ambulance services in the event of a life-threatening emergency requiring transportation to or between medical facilities.
-The benefit is capped at R35,000 per event.
-Pre-authorization from AGS Health is required before dispatching an ambulance. Claims submitted without prior authorization will be declined.
-A 12-month waiting period applies if the emergency is related to a pre-existing condition.

To obtain pre-authorization, contact AGS Health:
Telephone: 010 140 1516
Email: auths@agshealth.co.za

Hospital Benefits

It is important to note that pre-authorization is required for any Hospital admissions as well as dispatching of an ambulance. Failing to obtain authorization might result in a claim not being approved.

To obtain pre-authorization, contact AGS Health:
Telephone: 010 140 1516
Email: auths@agshealth.co.za

Planned Procedures

For any planned hospital procedure, you must contact AGS Health at least 48 business hours prior to admission.
⚠️ Claims submitted without prior authorization will be declined.

To obtain pre-authorization, contact AGS Health:
Telephone: 010 140 1516
Email: auths@agshealth.co.za
Please note: Exclusions and limitations may apply. Refer to your policy document for full details.

Accidental Benefits

Accidental benefits cover events that are unforeseen and could not reasonably have been expected.

To obtain pre-authorization, contact AGS Health:
Telephone: 010 140 1516
Email: auths@agshealth.co.za
Please note: Exclusions and limitations apply. Refer to your policy document for full details.

Casualties(Emergency and Trauma Room)

The Emergency / Trauma Room benefit provides cover for life-threatening events, illness events, or accident events.
-Once pre-authorization is granted, a benefit of up to R15,000 per event is available for life-threatening situations such as a heart attack or stroke.
-If the medical team advises a member to consult a doctor after hours in the Emergency Room,

AGS Health may cover up to R2,000 toward these medical expenses. This is limited to one event per year.

To obtain pre-authorization, contact AGS Health:
Telephone: 010 140 1516
Email: auths@agshealth.co.za