Circular no. 9 of 2025

1. These circular serves to inform all healthcare stakeholders of the Informed Consent Form that was adopted by the ICD-10 Implementation Task Team.

2. Regulation 6 of the Regulations made in terms of section 44 of the Medical Aid Funds Act, 1995 (Act No. 23 of 1995) provides requirements for a valid claim and its relevant text was noted as reproduced below:
(1) Provider of healthcare services should furnish to a member a statement of account showing –
(g) the nature and cost of each medical service rendered, including, where applicable, the item code number relating to such service, and, if any medicine was supplied to the patient the name thereof and particulars of the quantity and dosage and the net amount payable in respect thereof.
3. To give effect to regulation 6 (g) above, NAMFISA approved amendment of Fund Rules to provide for Namaf Coding structure (ICD-10, Procedural Coding Structure and NAPPI) as a requirement for valid claims.
3. Fund Rules are binding, as between a member and a registered Medical Aid Fund.

4. The ICD Implementation Task Team respects the duty of healthcare providers not to pass on any personal and confidential information he or she acquires in the course of his or her professional duties, unless the member agree to disclosure, or the healthcare provider has a good and overriding reason to do so.

5. To protect providers, members will be required from the funders perspective to expressly permit providers to disclose their diagnosis to Funds through ICD-10 coding system by signing consent forms. All health care providers in Namibia who have rendered a medical service to a member of a registered Medical Aid Fund or to a dependent of such a member are required to furnish such a member a statement of account including diagnosis information in the form of ICD-10, treatment procedure codes and NAPPI codes for medicine prescribed, if any. This applies to all claims that are submitted directly to Funds by providers of healthcare services or accounts paid directly by the member/beneficiary to providers of healthcare services and which are then claimed back from the Fund.

6. All diagnosing providers are required to provide ICD-10 diagnostic codes on statements, claims, referral notes and pharmacy scripts/prescriptions.
7. Non-diagnosing providers are encouraged to submit either a referral diagnosis from the diagnosing provider, a sign or symptom code, or a Chapter XXI (Z-code) where appropriate.
8. The ICD-10 Task Team has developed a standard consent form (Annexure A), which may be adapted by healthcare provider associations or groups to meet their internal requirements.
9. To address non-disclosure matters, provisions have been made through the use of codes U98.0: Patient refusal to disclose clinical information and U98.1: Service provider refusal to disclose clinical information. Stakeholders are advised to take note of the following provisions:
9.1 Code U98.0 is a valid entry in the ICD-10 Master Industry Table (MIT).
9.2 These codes are to be used when a medical scheme member refuses to provide consent for disclosure of their diagnosis to the healthcare provider or when a service provider is unable to disclose clinical information.
9.3 Claims submitted with U98.0 and U98.1 are considered valid for reimbursement under the Phase 2.2 implementation.
9.4 Medical Aid Funds are expected to actively monitor the use of this code and may, at their discretion:
9.4.1 As part of their risk management protocols, directly contact the member to determine the reason for refusing disclosure and explain the implications of such refusal, especially with regard to the enforcement measures in Phase 3 and beyond.
9.4.2 Set monetary thresholds within their fund rules to guide whether a claim should be paid or rejected, provided they have first engaged the member via direct telephonic communication.
10. Namaf encourages all healthcare stakeholders to take note of the information in this circular and align internal business processes to comply with the Phase 2.2 ICD-10 requirements.