How to claim with AGS Health

General Practitioners (PAMC) Pharmacies (MEDISCOR)

Preferred provider claims
General Practitioners
    • Kindly visit www.pamc.co.za/AGS/LookUp to access the general practitioner provider list. This list is also accessible through your Mobi-App. Please note that the provider list might change, please confirm with your doctor whether he/she is a preferred provider of AGS Health.
    • All preferred provider accounts are submitted directly to AGS Health, and payment is directly made to them.
Pharmacies
    • AGS Health has a network of various preferred providers. Confirm with your Pharmacist whether he/she is a preferred provider of AGS Health.
    • All preferred provider accounts are submitted directly to AGS Health, and payment is directly made to them.
Non-Preferred provider claims
    • AGS Health believe that its members should have the freedom of choice to make use of any Doctor or Pharmacy.
    • In a case where a member makes use of a non-preferred provider you will be required to pay for your account and claim back from us within 90 days of service date. Ask for a Statement which contains the following information and, send it through to claims@agshealth.co.za and we will reimburse you within 14 Working Days, according to your available benefits:
      1. AGS Health policy number
      2. Patients name
      3. Providers practice number
      4. ICD10 code(s)
      5. Tarif code(s)
      6. Amount charged per item
        Proof of payment if you made a payment towards the claim

It remains the client’s responsibility to send us the full invoice/statement.

Investigation procedures, Specialist visits ,Blood tests, Radiology

Non-Preferred provider claims
  1. Patients name
  2. Providers practice number
  3. ICD10 code(s)
  4. Tarif code(s)
  5. Amount charged per item
  6. Proof of payment if you made a payment towards the claim
It remains the client’s responsibility to send us the full invoice/statement.
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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.

Ambulance Services

All insured members enjoy the benefit of road ambulance services. This service is for Emergency Medical Service in a life-threatening event where transportation is required to and between medical institutions. The benefit is limited to a maximum of R35,000 per event. Pre-authorisation must be obtained from AGS Health prior to the dispatch of an ambulance. Where no pre-authorisation has been obtained, the claim will be declined.

There is a 12-month waiting period if the life-threatening event relates to a pre-existing condition. The following contact details can be used to obtain pre-authorization:

Telephone: 010 140 1516 Email: auths@agshealth.co.za

Planned Procedures

You will need to contact AGS Health 48 business hours prior to your admission into hospital for any planned procedure. Where no pre-authorisation has been obtained, the claim will be declined. The following contact details can be used to obtain pre-authorization: Telephone: 010 140 1516 Email: auths@agshealth.co.za
Please note: There is exclusions and limitations, kindly refer to your policy document.

Accidental Benefits

An unforeseen event which could not reasonably have been expected to occur.
The following contact details can be used to obtain pre-authorization: Telephone: 010 140 1516
Email: auths@agshealth.co.za

Please note: There is exclusions and limitations, kindly refer to your policy document

Casualties(Emergency and Trauma Room)

An Emergency / Trauma Room Stated Benefit is payable per life threatening event, illness event or an accident event. Once authorization is granted, the benefit, up to a maximum of R15,000 will be available for life-threatening events such as a heart attack or stroke.
Where the medical team advises the member to consult a doctor after hours in the Emergency room, we may pay up to R2,000 toward such medical expenses. This benefit is limited to 1 event per year.
The following contact details can be used to obtain pre-authorization: Telephone: 010 140 1516
Email: auths@agshealth.co.za

Optometry benefits (PPN)

Preferred provider claims

      • Kindly visit any Specsavers. If you do not have access to a Specsavers in your area, kindly contact us: 010 140 1516

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


Non-Preferred provider claims

AGS Health believe that its members should have the freedom of choice to make use of any provider.
In a case where a member makes use of a non-preferred provider you will be required to pay for your account and claim back from us within 90 days of service date. Ask for a Statement which contains the following information and, send it through to claims@agshealth.co.za and we will reimburse you within 14 Working Days, according to your available benefits:

        1. AGS Health policy number
        2. Patients name
        3. Providers practice number
        4. ICD10 code(s)
        5. Tarif code(s)
        6. Amount charged per item
        7. Proof of payment if you made a payment towards the claim

Dental Benefits(DRC)

Preferred provider claims
  • Dentistry is a very specialized field and due to the complexities with regards to its claims, AGS Health has contracted with the Dental Risk Company to ensure optimal management of your benefits.
  • We make use of a network of Dentists which can be viewed through a link on your Mobi-App, or through the following link: pamc.co.za/AGS/LookUp
  • We require that you submit a quotation to the Dental Risk Company prior to any specialized dentistry via auth@dentalrisk.com.
  • Any claim enquiries as well as paper-based claims may be sent to claims@dentalrisk.com.
  • You may alternatively contact the claims or pre-authorizations department on 0879439615.
Click here to view Dental Providers

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