Smartchoice Contracts

Connect Contract Terms Directly to Claims Adjudication

Negotiating competitive hospital network agreements, preferred specialist tariffs, and primary care capitation models creates real commercial value only if those terms are executed flawlessly on the administration floor. When contract terms live in static PDFs or isolated spreadsheets, claims assessors face manual calculation overhead, billing disputes multiply, and schemes suffer systematic claims leakage.

Smartchoice Contracts bridges provider contracting and automated claims adjudication. It translates complex provider agreements into deterministic, auditable business logic—ensuring that every line item is priced accurately according to agreed tariffs, date-of-service validity windows, and network tiers.

What Your Team Can Do

Flexible Reimbursement Methodologies

Support the full spectrum of healthcare provider reimbursement models used across the South African private healthcare market:

• Fee-for-Service & Tariff Multipliers: Configure base tariff schedules with discipline-specific percentage uplifts, agreed discount structures, or negotiated procedural rates.
• Facility & Day-Clinic Per Diems: Administer flat per-day rates, tiered length-of-stay pricing, and variable step-down arrangements for acute and sub-acute facilities.
• Case Rates & Baskets of Care: Manage fixed global fees, bundled surgical packages, and Diagnosis-Related Group (DRG) style case payments.
• Capitation & Value-Based Care: Structure primary healthcare capitation models with risk adjustments and performance targets.

Hierarchical Contract & Tariff Configuration

Organise multi-layered reimbursement arrangements without duplicating configuration work. Associate multiple scheme options, benefit groups, and employer business segments with master contracts, while applying specific tariff schedules, conversion factors, or relative value units (RVUs) to distinct clinical categories.

Network Tiering & Validity Controls

Govern provider networks with temporal accuracy and role clarity:

• Participation Tiers: Distinguish between contracted network providers, non-participating practitioners, and Designated Service Provider (DSP) facilities across individual benefit options.
• Date-of-Service Versioning: Manage effective dates, scheduled rate escalations, and contract sunset dates so claims are always priced against the rates active on the date service was rendered.
• Authorisation Dependencies: Link preferential reimbursement rates to pre-authorisation requirements, ensuring contracted benefits apply only when clinical protocols are met.

Deterministic Rules & Exception Routing

Enforce fine-grained adjudication criteria based on service location (in-hospital, day theatre, consulting rooms), provider speciality codes, and BHF practice numbering. Claims that fall outside contracted parameters are routed into dedicated supervisor review queues with explicit discrepancy annotations—preventing unverified payment freezes.

How It Connects

Smartchoice Contracts operates as the centralized pricing engine for your claims operations:

• Native Adjudication Integration: Delivers real-time tariff and rate logic directly into Smartchoice Claims or an existing third-party adjudication switch via secure APIs.
• Provider Data Synchronization: Cross-references active practice details, facility locations, and banking profiles maintained in Smartchoice Provider.
• Financial Traceability: Supplies line-item calculation breakdowns to remittance advices and general ledgers, providing a single source of truth for financial reconciliations.

Configured for the South African Healthcare Environment

Configured specifically to navigate the regulatory and operational dynamics of the South African medical scheme sector:

• Post-NHRPL Tariff Autonomy: Maintain independent scheme rate schedules, BHF tariff structures, and private provider agreements with complete audit lineage.
• DSP & PMB Compliance: Protect statutory Prescribed Minimum Benefit entitlements under Medical Schemes Act Regulation 29(4), ensuring that emergency care and services without accessible DSPs are handled according to statutory mandates.
• Section 59 Procedural Fairness: Support transparent provider engagements by documenting unambiguous reason codes whenever billed amounts diverge from contracted rates.
• POPIA-Compliant Security: Granular access permissions protect commercially sensitive practitioner reimbursement schedules and negotiated discount terms.

Scope Notice: Network participation does not automatically confer Designated Service Provider (DSP) status under scheme rules. Legal contract drafting, commercial negotiation, and electronic signature workflows are managed via enterprise legal systems and remain outside the software capabilities described here.