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|
MEDISCOR
(PTY) LTD |
NOTIFICATION 12OF2009 |
03/12/2009
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|
Medical Scheme |
Altron Medical Scheme |
|
Administrator |
Allcare
Administrators |
|
Information Relevant to |
Benefits and Options
for 2010 |
|
Effective Date |
1 January 2010 |
With effect 1 January 2010, Mediscor will be
applying the scheme rules for Altron Medical Scheme as outlined below.
Herewith the detail for submitting medicine claims to
Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0024 |
|
2. |
Switch Destination Code |
2. |
ALAT0000 |
|
3. |
EDI Activation Code (Dispensing Doctors) |
3. |
033P |
|
4. |
MRP® |
4. |
Yes except HIV |
|
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. |
6 Numerical digits |
|
16. |
Payments to Providers |
16. |
Allcare Administrators |
|
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 Altron Medical Scheme
effective from 1 January 2010:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Basic and Enhanced |
Acute |
No |
Yes |
1-5, 7-9, 11, 14, 15, 17,
19, 20, 21, 22, 24, 25, 27, 30-35, 40, 41, 43-45, 50, 51, 53 |
|
Chronic (Enhanced
option only) |
No |
3-5, 7-9, 11, 14, 15, 17,
19, 20, 21, 22, 24, 25, 27, 30-35, 40, 41, 43-45, 50, 51, 53 |
||
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Immunosuppresive |
No |
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HIV / AIDS |
No |
No |
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Surgical |
No |
Yes |
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Prescribed Minimum
Benefits (PMB) |
Basic Applies Mediscor Basic Formulary Formulary products – No
Levy Non-Formulary products –
30% co-pay Patient not registered –
pay from Acute Enhanced Applies Mediscor Standard Formulary Formulary products – No
Levy Non-Formulary products –
20% co-pay Patient not registered –
pay from Acute |
|||
|
Oncology |
No |
PRESCRIBED MINIMUM BENEFITS (PMBs):
Members need to apply and register for PMBs and Chronic Medicine
Benefits with Mediscor ChroniLine™ on 0860 119 553 and for HIV/AIDS
approval please contact Calibre Clinical Consultants on 0800 203 551 or
(011) 858 9000.
If you require any assistance, please contact:
|
Mediscor’s Toll-free Call
Centre Helpline |
: |
0860 113 238
or 0860 117 705 |
|
Mediscor ChroniLine™ |
: |
0860 119 553 |
Kind regards.
JACK PEREL