Configure and Manage Medical Aid Schemes in Sigma HMIS

Configure the medical aid schemes and insurers your clinic bills through Sigma Health HMIS, including payer codes, claim addresses, and fee schedules.

Before you can submit insurance claims, Sigma needs to know which schemes your clinic accepts. Each scheme has its own codes, rules, and fee structures that affect how claims are prepared and billed. Setting these up accurately upfront prevents claim rejections caused by incorrect payer identifiers or missing authorisation flags.

Adding a New Scheme

Add every medical aid scheme or insurer your clinic bills to before you begin submitting claims. Sigma uses these records to route claims correctly and apply the right fee rates.

1. Open Insurers & Schemes

   Navigate to Settings → Insurers & Schemes. The page lists all schemes already configured for your workspace.

2. Create a new scheme record

   Click Add Scheme to open the scheme configuration form.

3. Enter scheme name and payer code

   Enter the scheme’s full name as the insurer uses it, and the payer code issued by the insurer to identify your clinic as a registered provider. This code is printed on claim submissions.

4. Set the claim submission method

   Choose how claims are submitted to this scheme:

   • Electronic portal — Claims are submitted via the insurer’s online claims portal.
   • Email — Claims are generated as structured documents and sent to a designated claims address.
   • Paper — Claims are printed for manual submission. Sigma formats the output to match standard claim layouts.
5. Enter the submission address or portal URL

   Provide the email address or portal URL where claims for this scheme are sent. Sigma uses this as the default destination when you submit a claim linked to this scheme.

6. Set the authorisation requirement

   Select whether pre-authorisation is required before services are rendered for this scheme. When set to Required, Sigma prompts claims staff to capture an authorisation number before finalising the claim.

7. Save the scheme

   Click Save. The scheme is now available for selection when creating patient records and submitting claims.

Scheme codes and authorisation rules vary by insurer and can change when insurers update their provider agreements. If you are unsure of the correct payer code for a scheme, contact the insurer’s provider relations team before adding the record to Sigma.

Scheme Fee Schedules

Different schemes often reimburse at different rates for the same procedure. A scheme fee schedule in Sigma lets you capture these variations so that invoices and claims are calculated correctly for each payer.

• Attach a fee schedule to each scheme — From the scheme record, open the Fee Schedule tab and link it to a schedule or create a scheme-specific one.
• Set scheme-specific prices per service code — For any service where the insurer’s reimbursement rate differs from your base price, enter the scheme rate. Sigma uses this rate when calculating the scheme-payable portion of a claim.
• Patient and scheme portions — When an invoice is split between the patient and the scheme, Sigma applies the scheme’s fee schedule to the scheme portion and the base fee schedule to any patient co-payment. This ensures both figures are accurate before submission.

Linking Patients to Schemes

A patient’s scheme membership must be recorded before Sigma can build a claim on their behalf.

From the Patient Record, open the Medical Aid section and enter:

• Scheme — Select from the schemes you have already configured.
• Membership number — The patient’s unique identifier with that scheme.
• Effective date — The date from which their current membership is valid. Sigma validates that the claim date falls within the membership period.
• Dependant code (if applicable) — Required by some schemes when the patient is covered under a principal member’s plan.

Once linked, Sigma automatically associates the patient’s scheme details with every claim created for them. You can update membership details at any time from the patient record.

Updating Scheme Details

Insurers periodically update their payer codes, claim submission addresses, and authorisation requirements — typically at the start of a new contract year. When this happens, update the scheme record in Sigma promptly.

To update a scheme, go to Settings → Insurers & Schemes, select the scheme, and edit the relevant fields. Changes apply to all claims prepared after the update. Claims already submitted are not affected.

Changing a payer code

Open the scheme record and update the Payer Code field. Notify your claims staff of the change so they can verify any claims that were in draft status when the old code was active.

Changing a submission address

Update the Submission Address or Portal URL field. Test by submitting a low-value claim manually before processing a batch to confirm the new destination is correct.

Updating authorisation rules

Toggle the Authorisation Required setting. If switching from not required to required, brief your clinical and reception staff so they begin capturing authorisation numbers at the point of service.

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Claims Module

Learn how to prepare, submit, and track insurance claims using your configured schemes.

Workspace Setup

Review clinic details, locations, and base fee schedules that underpin your claims configuration.