|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 1
OF
2012
|
24 January 2012
|
|
Medical Scheme |
Commed – Fundamental Option |
|
Administrator |
Enablemed |
|
Information Relevant to |
New Scheme Option for
2012 |
|
Effective Date |
1 February 2012 |
With effect 1 February 2012, Mediscor has been
exclusively contracted by Enablemed to process all pharmacy claims for the Commed
Fundamental option.
Herewith the details for submitting medicine claim to
Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0072 |
|
2. |
Switch Destination Code |
2. |
CFOP0001 |
|
3. |
EDI Activation Code (Dispensing Doctors) |
3. |
No |
|
4. |
Reference Pricing |
4. |
Yes |
|
5. |
Maximum supply of medicine |
5. |
30 Days |
|
6. |
Days supply of the dispensed medicine |
6. |
Yes /Compulsory |
|
7. |
Membership number as per membership card |
7. |
Yes / Compulsory |
|
8. |
Dependant code as per membership card |
8. |
Yes / Compulsory |
|
9. |
Dependant first name as per membership card |
9. |
Yes / Compulsory |
|
10. |
Dependant date of birth |
10. |
Yes /Compulsory |
|
11. |
Dependant’s gender (male/female) |
11. |
Yes / Compulsory |
|
12. |
Practice number of the prescriber |
12. |
Yes / Compulsory |
|
13. |
ICD-10 diagnosis code |
13. |
Yes / Compulsory |
|
14. |
9 digit NAPPI code of medicine dispensed |
14. |
Yes / Compulsory |
|
15. |
Membership number requirements |
15. |
8 Numerical digits |
|
16. |
Payments to Providers |
16. |
Enablemed |
|
17. |
Chronic pre-authorisation |
17. |
Enablemed |
|
18. |
Reimbursement structure – Dispensing Doctors |
18. |
N/A |
|
19. |
Reimbursement structure –
Pharmacies |
19. |
SEP + 28%/R28 |
- SEP (VAT Incl.) and dispensing fee (VAT Excl.)
- Reimbursement structure will be applied on
scheduled medicines (0 – 8) and unscheduled products.
- Mediscor Reference Price (MRP®) – information
available on www.mediscor.net
- ICD-10 codes – information available on www.medicalschemes.com
IMPORTANT: The details below serve as a GUIDELINE ONLY. Due to the complexities of various Levy,
Co-payment, Formulary and Exclusion criteria;
service providers must refer to our on-line
responses to apply the correct rules.
Herewith the scheme rules for Enablemed
- Commed Fundamental option effective from 1 January 2012:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Fundamental |
Acute |
No Levy |
Yes |
Subject to
Formularies |
|
Chronic |
||||
|
Oncology |
||||
|
HIV/AIDS |
||||
|
Prescribed Minimum Benefits (PMB) |
PRE-AUTHORISATION RULES:
Please contact Enablemed for all information regarding the
pre-authorisation of medicines on 0860 002 400.
|
Mediscor’s Call Centre Mediscor E-Mail |
: : |
0860 113 238
or 0860 117 705 |
Kind regards
JACK PEREL