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|
MEDISCOR
(PTY) LTD |
NOTIFICATION 10OF2010 |
Date: 22 June 2010
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|
Medical Scheme |
Selfmed Medical Scheme |
|
Administrator |
Selfmed |
|
Information Relevant to |
New Mediscor Scheme |
|
Effective Date |
26 June 2010 |
With effect 26 June 2010, Mediscor has been
exclusively contracted by Selfmed Medical Scheme to
process all pharmacy and doctor claims as outlined below.
Herewith the detail for submitting medicine claims to
Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0052 |
|
2. |
Switch Destination Code |
2. |
SHSF0000 |
|
3. |
EDI Activation Code
(Dispensing Doctors) |
3. |
004P |
|
4. |
Reference pricing |
4. |
Yes |
|
5. |
Maximum supply of medicine |
5. |
30 Days |
|
6. |
Days of supply of the
dispensed medication |
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 the 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 diagnostic code |
13. |
Yes / Compulsory |
|
14. |
9 digit NAPPI code of medicine dispensed |
14. |
Yes / Compulsory |
|
15. |
Membership number requirements |
15. |
Minimum 5 numerical |
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16. |
Payments to Providers |
16. |
Selfmed |
|
17. |
Chronic pre-authorisation Mediscor ChroniLine™ |
17. |
Yes |
|
18. |
Reimbursement structure – Dispensing Doctors |
18. |
SEP + R20/30% |
|
19. |
Reimbursement structure –
Pharmacies |
19. |
SEP + R26/26% |
|
20. |
Scheduled 0 or Unscheduled |
20. |
SEP + max mark-up of 31%
(VAT Excl.) |
·
MEDISCOR REFERENCE PRICE (MRP®) – information available on
www.mediscor.net
·
MEDISCOR
FORMULARIES – 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 Selfmed
Medical Scheme effective from 26 June 2010:
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
REFERENCE PRICING |
EXCLUSIONS |
SELFMED
80
|
Acute |
20% co-payment |
MRP |
3-5, 7-9, 11, 14,-16, 19-25, 27,
30-32, 35, 41, 45, 47-49, 51, 53, 60-61 |
|
Chronic |
20% co-payment |
MRP |
||
|
PMB |
DSP: No co-payment Non-DSP: 40% co-payment |
MRP |
||
|
HIV/AIDS |
No co-payment |
MRP |
||
|
Organ Transplant |
20% co-payment |
MRP |
||
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Appliances |
20% co-payment |
N/A |
||
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Oncology |
No co-payment |
MRP |
||
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Renal |
20% co-payment |
MRP |
||
|
Oxygen |
No co-payment |
N/A |
||
|
OTC |
20% co-payment |
MRP |
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|
Vaccines |
20% co-payment |
MRP |
||
|
Contraceptives |
20% co-payment |
MRP |
||
|
Homeopathic |
20% co-payment |
MRP |
||
|
Procedures (0201) |
20% co-payment |
MRP |
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
REFERENCE PRICING |
EXCLUSIONS |
|
MEDELITE |
Chronic |
No co-payment |
MRP |
3-5, 7-9, 11, 14,-16, 19-25, 27,
30-32, 35, 41, 45, 47-49, 51, 53, 60-61 |
|
PMB |
DSP: No co-payment Non-DSP: 40% co-payment |
MRP |
||
|
HIV/AIDS |
No co-payment |
MRP |
||
|
Organ Transplant |
No co-payment |
MRP |
||
|
Oncology |
No co-payment |
MRP |
||
|
Renal |
No co-payment |
MRP |
||
|
Oxygen |
No co-payment |
N/A |
||
|
Procedures (0201) |
No co-payment |
MRP |
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
REFERENCE PRICING |
EXCLUSIONS |
SELFSURE
|
Acute |
No co-payment |
MRP |
3-5, 7-9, 11, 14,-16, 19-25, 27,
30-32, 35, 41, 45, 47-49, 51, 53, 60-61 |
|
PMB |
DSP: No co-payment Non-DSP: 40% co-payment |
FRP |
||
|
HIV/AIDS |
No co-payment |
FRP |
||
|
Organ Transplant |
No co-payment |
MRP |
||
|
Appliances |
No co-payment |
N/A |
||
|
Oncology |
No co-payment |
MRP |
||
|
Renal |
No co-payment |
MRP |
||
|
Oxygen |
No co-payment |
N/A |
||
|
OTC |
Limited to R170.00 maximum per
script |
MRP |
||
|
Vaccines |
No co-payment |
MRP |
||
|
Contraceptives |
No co-payment |
MRP |
||
|
Homeopathic |
No co-payment |
MRP |
||
|
Procedures (0201) |
No co-payment |
MRP |
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
REFERENCE PRICING |
EXCLUSIONS |
|
MEDXXI |
PMB |
DSP: No co-payment Non-DSP: 40% co-payment |
FRP |
3-5, 7-9, 11, 14,-16, 19-25, 27,
30-32, 35, 41, 45, 47-49, 51, 53, 60-61 |
|
HIV/AIDS |
No co-payment |
FRP |
||
|
Organ Transplant |
No co-payment |
MRP |
||
|
Oncology |
No co-payment |
MRP |
||
|
Renal |
No co-payment |
MRP |
||
|
Oxygen |
No co-payment |
N/A |
||
|
Procedures (0201) |
No co-payment |
MRP |
If you require any assistance, please contact:
|
Mediscor’s Share Call Centre Helpline |
: |
0860 113 238
or 0860 117 705 |
Kind regards.
JACK PEREL