One platform for every part of your operations.

One system for every operational priority.

Members expect transparency. Providers demand certainty. Your teams need momentum.

High-functioning medical schemes run on data that flows without friction. When core systems are fragmented across legacy databases, custom spreadsheets, and disconnected batch pipelines, administrative execution slows to a crawl. Inquiries stall, claims bounce between dispute queues, and reconciliations take days of manual journal work.

Smartchoice unites the rules, records, and workflows behind these critical touchpoints—replacing disjointed handoffs with instant, reliable execution:

• Membership & Benefit Management:
  Real-time member validation, dependant tracking, and employer group subsidy management—with automated underwriting rules (Section 29A waiting periods and late-joiner penalties). Frontline service desks and digital portals see live MSA balances, threshold progress, and sub-limit accumulators with zero latency.
• Claims Assessment & Adjudication:
  High-throughput, straight-through processing at scale. Automate tariff pricing, clinical code validation (ICD-10, CPT/CCSA, NAPPI), and PMB funding pathways. Complex exceptions route deterministically to specialist clinical queues—with complete contextual history attached.
• Provider Networks & Reimbursement:
  A verified single source of truth for practitioner registries, BHF/PCNS numbers, and multi-facility hierarchies. Enforce DSP arrangements, negotiated tariff schedules, capitation models, and alternative reimbursement structures with absolute financial fidelity.
• Service Operations & Settlement:
  Give contact centre agents 360-degree enquiry logging, multi-request classification, and automated task routing. Move effortlessly from adjudicated claims to penny-for-penny settlement runs, Section 59 recovery offsets, and bank-grade electronic remittances.

Select the Components You Need

The Smartchoice Health Administration Suite is modular by design. Deploy the full end-to-end platform or integrate targeted modules alongside your existing core systems to eliminate specific operational bottlenecks:

Local Requirements — Built for South African Compliance

Every implementation is tailored to the statutory and operating framework of the South African healthcare financing industry:

• CMS Scheme Rules & Option Architecture: Configure multi-tiered option structures, corporate employer variants, and income-banded contribution tables matching official registered rules approved by the Registrar.
• Statutory Prescribed Minimum Benefits (PMBs): Enforce mandatory funding algorithms for Chronic Disease List (CDL) conditions and Diagnosis and Treatment Pairs (DTPs) at cost under Regulation 29(4).
• Coding Standards & Formularies: Full native support for ICD-10 diagnostic coding, CCSA/CPT procedural tariffs, NAPPI medicine registries, and scheme-specific formularies.
• Section 59 Due Process: Enforce procedural fairness in billing reviews with auditable holding periods, plain-language recovery notices, and documented dispute workflows.
• Domestic Cloud Sovereignty (POPIA): Hosted in South African Microsoft Azure hyper-scale facilities (Johannesburg), maintaining strict zero-trust perimeters and field-level encryption for Special Personal Information.

Compliance is the baseline. Measurable improvement is the proof.

We do not sell generic performance promises. During solution onboarding, Smartchoice establishes concrete, audited baselines derived from your historical operational data:

• Straight-Through Processing (STP) Yield: Measure the proportion of claims adjudicated instantly without manual touchpoints.
• Exception Resolution Velocity: Track the cycle time required for clinical and financial review queues to remediate flagged claims.
• First-Contact Enquiry Resolution: Monitor frontline service velocity, measuring how many member and provider queries are resolved completely on first interaction.
• Penny-for-Penny Settlement Accuracy: Eliminate unallocated credit balances and audit friction across banking batches and general ledger feeds.

Progress is tracked continuously against your own operational targets—giving executive leadership, trustees, and operational teams transparent proof of efficiency gains.