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|
MEDISCOR
(PTY) LTD |
NOTIFICATION 22OF2009 |
10/12/2009
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|
Medical Scheme |
Medihelp Medical Scheme |
|
Administrator |
Medihelp Medical Scheme |
|
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 Medical Medical Scheme as outlined below.
Herewith the detail for submitting medicine claims to
Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0010
|
|
2. |
Switch Destination Code |
2. |
MGFM0001
|
|
3. |
EDI Activation Code (Dispensing Doctors) |
3. |
256P |
|
4. |
MMAP© |
4. |
Yes - Acute/Savings/Chronic |
|
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. |
7 Numerical |
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16. |
Payments to Providers |
16. |
Medihelp |
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17. |
Chronic/PMB pre-authorisation |
17. |
Medichron |
|
18. |
Reimbursement structure |
18. |
Medihelp Reimbursement Rate |
ICD-10 coding - information available on
www.medicalschemes.com
MEDIHELP REIMBURSEMENT RATE:
Medihelp will reimburse medicine claims based on
the following 4Tier-pricing model.
|
Single Exit Price (incl. VAT) |
Fixed Fee |
% |
|
<R75 |
R 4 |
33% |
|
R75 -
<R250 |
R25 |
6% |
|
R250 -
<R1000 |
R33 |
3% |
|
>R1000 |
R50 |
1.5% |
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 MEDIHELP effective
from 1 January 2010:
MEDIHELP OPTIONS:
Medihelp Plus
Dimension Elite
Dimension Prime 1 – Prescribed Minimum Benefit (PMB) option only
Dimension Prime 2
Dimension Prime 3
|
BENEFITS APPLICABLE |
LEVY / |
MMAP© |
EXCLUSIONS |
|
Acute Benefit |
20% Levy |
Yes (MMAP only applicable to Savings / Acute / Chronic and OTC Benefit
not to PMBs) |
4,5,7-9,17,24-25,27,30-31,
61-62 (Each benefit has its own complex Exclusion
List. See the real-time response to
verify) |
|
Chronic Benefit |
20% Levy |
||
|
Savings Benefit |
No Levy |
||
|
Prescribed Minimum Benefits (PMB) |
Medihelp Formulary Products: No Levy (subject to Medihelp Therapeutic
Reference Price) Medihelp Non-Formulary Products: Medihelp Therapeutic Reference Price Difference |
||
|
Core Benefit |
No Levy |
||
|
OTC Benefit |
Medihelp Plus
20% Levy Dimension Elite
20% Levy Dimension Prime2
No Levy Dimension
Prime3
20% Levy |
MEMBER CLAIMS:
|
1. |
Surgical appliances |
3. |
Medical appliances |
|
2. |
Orthopaedic appliances |
4. |
Oxygen and delivery systems |
PRESCRIBED MINIMUM BENEFITS (PMBs):
Members need to apply for PMBs and Chronic Medicine Benefits with Medichron/Medihelp
0860 100 678
If you require any assistance, please contact:
Mediscor’s Share Call Centre Helpline : 0860 113 238 or 0860 117 705
Kind regards
JACK PEREL