|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 26OF2009 |
14/12/2009
|
|
Medical Scheme |
Netcare Medical Scheme |
|
Administrator |
Momentum Medical Scheme
Administrators (MMSA) |
|
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 Netcare Medical Scheme as outlined below.
Herewith the detail for submitting
medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0046 |
|
2. |
Switch Destination Code |
2. |
NPMS0000
|
|
3. |
EDI Activation Code (Dispensing Doctors) |
3. |
067P |
|
4. |
MMAP© |
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
4 numerical including dependant code |
|
16. |
Payments to Providers |
16. |
MMSA |
|
17. |
Chronic pre-authorisation
Mediscor ChroniLine™ |
17. |
MMSA |
|
18. |
Reimbursement structure – Dispensing Doctors |
18. |
SEP + 30% / R20.00 |
|
19. |
Reimbursement structure – Pharmacies |
19. |
SEP +
26% / R26.00 |
|
20. |
Scheduled 0 or Unscheduled |
20. |
SEP +
max mark-up of 31% (VAT Excl.) |
·
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 Netcare Medical Scheme effective from 1 January 2010:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MMAP© |
EXCLUSIONS |
|
Netcare |
Acute |
No Levy |
No |
3-5, 14-15, 24-25, 27, 30-32, 35, 45, 53, 61 |
|
Chronic |
No Levy |
Yes |
||
|
PMB |
No Levy |
Yes |
||
|
OTC |
No
Levy |
No |
||
|
HIV/Aids |
No Levy |
No |
||
|
Appliance |
No Levy |
No |
||
|
Organ Transplant |
No Levy |
No |
||
|
Oncology |
No Levy |
No |
||
|
Homeopathic |
No Levy |
No |
||
|
Flu Vaccines |
No Levy |
Yes |
||
|
Maternity |
No Levy |
No |
LIMITATIONS
AND SPECIAL REQUIREMENTS:
Pre-authorisation
for the following is required from MMSA:
- Oncology
- Immunosuppressive
- Growth Hormones
- Erythropoietin
- Surgical, medical and
orthopaedic appliances
- Diagnostic agents and
appliances
- Oxygen and delivery
systems
- Stomacare
- Medicines for
Prescribed Minimum Benefits (PMB)
(Prescription refill every 24 days)
CLINICAL DUR CHECKS
APPLIED TO ALL CLAIMS
(Please check the on-line response)
·
Drug to diagnosis/disease
·
Dosage range check
·
Drug to age checking
·
Drug to gender
·
Duplicate therapy
IF YOU REQUIRE ASSISTANCE, PLEASE CONTACT:
Mediscor’s
Share Call Centre Helpline
: 0860 113 238
or 0860 117 705
Netcare Medical Scheme Call Centre Helpline : 0860 103 406
Netcare
Pre-authorisation
: 0860 103 406
MMSA Health Benefit Checker (24 Hours)
: 0860 104 040
Kind regards.
JACK PEREL