|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 21OF2009 |
03/12/2009
|
|
Medical Scheme |
Makoti Health Plan of The Good Hope Medical
Aid Society |
|
Administrator |
Enablemed |
|
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 Makoti Health Plan as outlined below.
Herewith the detail for submitting medicine claims to
Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0036 |
|
2. |
Switch Destination Code |
2. |
MHPL0001 |
|
3. |
EDI Activation Code (Dispensing Doctors) |
3. |
No |
|
4. |
MRP® |
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. |
12 Alpha number – Prefix
JGE |
|
16. |
Payments to Providers |
16. |
Enablemed |
|
17. |
Chronic pre-authorisation Mediscor ChroniLine™ |
17. |
No – Enablemed |
|
18. |
Reimbursement structure – Dispensing Doctors |
18. |
N/A |
|
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 Makoti Health Plan
effective from 1 January 2010:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Primary Comprehensive |
Acute |
No Levy |
Yes |
Primary option: 1-11, 14-17, 19-22,
24-25, 27-28, 30-35, 38, 40-41, 43-45, 47-48, 50-57, 59-60, 62-64 Comprehensive option: 1-11, 14-17, 19-22,
24-25, 27-28, 30-35, 38, 40-41, 43-45, 47-48, 50-57, 59-60, 62-64 |
|
Chronic |
||||
|
Oncology |
||||
|
Organ Transplant |
||||
|
HIV/AIDS |
||||
|
Prescribed Minimum Benefits (PMB) |
Mediscor Core Formulary Preferred Products: No Levy Non-Formulary Products: Reject |
PRE-AUTHORISATION RULES:
Please contact Enablemed for all information regarding the
pre-authorisation of medicines on 0860 002 400.
If you require any assistance, please contact:
|
Mediscor’s Toll-free Call
Centre Helpline |
: |
0860 113 238
or 0860 117 705 |
Kind regards
JACK PEREL