Smartchoice Payments

From Adjudication to Settlement: Absolute Financial Traceability

In medical scheme administration, calculating a benefit payout is only half the battle. The final step—disbursing funds to healthcare providers and members—requires rigorous financial controls, segregation of duties, and seamless bank reconciliation. When settlement workflows rely on disconnected spreadsheets or opaque batch jobs, schemes risk payment leakage, unallocated credit balances, and contentious provider disputes.

Smartchoice Payments provides an enterprise financial settlement engine that connects every electronic fund transfer (EFT) directly to its underlying claim lines. By combining automated selection rules with legally defensible recovery workflows, the platform eliminates manual journal overhead, protects scheme liquidity, and ensures complete compliance with South African regulatory and banking standards.

What Your Team Can Do

Configurable Payment Runs & Segregation of Duties

Structure and release disbursements with total operational governance:

• Granular Selection Criteria: Compile payment runs by scheme option, provider discipline, facility network status, payment cycle frequency, or currency threshold without IT assistance.
• Dual-Authorization Governance: Enforce strict maker-checker controls where financial controllers review and authorize settlement batches before payment instructions are dispatched.
• Automated Split Funding: Automatically parse disbursements between scheme risk underwriting reserves and member Medical Savings Accounts (MSA), ensuring accurate balance drawdowns.

Defensible Overpayment Tracking & Section 59 Offsets

Clawbacks and error corrections require procedural fairness, not arbitrary withholdings:

• Negative Balance Ledgers: Automatically log credit balances stemming from post-payment claim adjustments, tariff renegotiations, or billing corrections against the specific practice account.
• Configurable Holding & Notice Periods: Establish automated grace periods that allow providers to review disputed amounts before offsets are applied against subsequent payment runs.
• Transparent Offset Execution: Apply recoveries deterministically against live claims, providing transparent line-item explanations that clearly reflect both the new payment and the offset credit.

Claim-Linked Refund Reconciliation

When a healthcare practitioner or hospital group repays an overpayment via electronic deposit, Smartchoice Payments links the incoming refund directly to the historical claim record. This eliminates untraceable unallocated receipts, maintains clean general ledger integrity, and prevents duplicate collections.

Electronic Remittance Advices (ERAs) & Financial Exports

Generate high-clarity financial documentation for every stakeholder:

• Detailed Remittance Advices: Produce automated digital remittances breaking down claimed amounts, agreed scheme tariffs, member co-payments, tax withholdings, and recovery deductions at the line-item level.
• General Ledger Integration: Export balanced journal feeds formatted for your enterprise ERP (SAP, Sage, Oracle, or Microsoft Dynamics) with exact debit/credit balancing.

How It Connects

Smartchoice Payments operates as the final operational gate within the Smartchoice Health Administration Suite:

• Direct Link to Smartchoice Claims: Consumes finalized claim determinations instantly from Smartchoice Claims, ensuring that only fully adjudicated, non-disputed transactions enter the settlement pipeline.
• Synchronized with Smartchoice Contracts: Validates payment terms, negotiated prompt-payment discounts, and banking profiles maintained in Smartchoice Contracts and Provider.
• Domestic Banking Rails: Outputs standard payment instructions compatible with South African commercial banks and BankservAfrica clearing formats (ACB/Host-to-Host).

Configured for the South African Medical Scheme Environment

Engineered to uphold the legal, statutory, and operational requirements of local healthcare funders:

• Section 59 Due Process: Eliminates arbitrary payment freezes by implementing documented, auditable holding intervals and plain-language recovery notices that satisfy CMS procedural fairness expectations.
• Statutory Reserve Protection: Preserves the legal distinction between scheme risk funds and member personal savings balances, ensuring uncompromised fiduciary compliance under the Medical Schemes Act.
• POPIA & Banking Confidentiality: Field-level encryption and strict access controls safeguard practitioner banking mandates, member banking details, and financial transaction histories.

Scope Notice: Approval matrices, commercial bank host-to-host connectivity, debit-order clearing windows, and debt-recovery escalation policies are tailored and verified for each organisation during solution design. Foreign Medicare payment rules, sequestration deductions, and statutory prompt-pay interest formulas do not apply to South African medical scheme operations.