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MEDISCOR (PTY) LTD |
NOTIFICATION 19OF2011 |
|
01 December 2011 |
|
Medical Scheme |
Selfmed Medical Scheme |
|
Administrator |
Selfmed |
|
Information Relevant to |
Benefits
and Options for 2012 |
|
Effective Date |
1
January 2012 |
With effect 1 January 2012, Mediscor will be
applying the scheme rules for Selfmed Medical Scheme 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 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. |
Minimum 5 numerical including dependant code |
|
16. |
Payments to providers |
16. |
Selfmed |
|
17. |
Chronic pre-authorisation
|
17. |
Mediscor ChroniLine™ |
|
18. |
Reimbursement structure –
Dispensing doctors |
18. |
SEP + 30%/R23.40 |
|
19. |
Reimbursement structure – Pharmacies |
19. |
SEP + 28%/R28 |
|
20. |
Over the counter (OTC) |
20. |
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
·
Formulary
Reference Price (FRP) – 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 1 January 2012:
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 |
||
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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 |
||
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Oxygen |
No co-payment |
N/A |
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|
OTC |
20% co-payment |
MRP |
||
|
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 |
||
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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 |
||
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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 Call
Centre Mediscor ChroniLine™ Mediscor E-mail |
: : : |
0860 113 238 or 0860 117 705 0860 119 553 helpdesk@mediscor.co.za |
Kind regards.
JACK PEREL