|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 27OF2009 |
|
08/12/2009 |
|
Medical Scheme |
Optimum Medical Scheme (OPMED) |
|
Administrator |
Self Administration |
|
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 OPMED Medical Scheme as outlined below.
Herewith the
detail for submitting medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0050 |
|
2. |
Switch Destination Code
|
2. |
NASE0000 |
|
3. |
EDI Activation Code (Dispensing Doctors) |
3. |
142 P |
|
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. |
Membership number requirements |
8. |
10 Numeric Digits |
|
9. |
Dependant first name as per the membership card |
9. |
Not 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. |
No |
|
14. |
9 digit NAPPI code of medicine dispensed |
14. |
Yes / Compulsory |
|
15. |
Payments to Pharmacies |
15. |
Mediscor |
|
16. |
Payments to Dispensing Doctors |
16. |
OPMED |
|
17. |
Pre-authorisation - Chronic |
17. |
OPMED – Subject to formulary |
|
18. |
Pre-authorisation - Appliances |
18. |
OPMED |
|
19. |
Reimbursement
structure – Dispensing Doctors
|
19. |
SEP + 30% /
R20.00
|
|
20. |
Reimbursement structure –
Pharmacies |
20. |
SEP + 26% / R26.00 |
|
21. |
Reimbursement structure –
Schedule 0 and Unscheduled medicine |
21. |
SEP + max mark-up of 31%
(VAT Excl.) |
·
MEDISCOR REFERENCE PRICE (MRP®) – information available on
www.mediscor.net
Herewith the scheme rules
for OPMED Medical Scheme effective from 1 January 2010:
|
OPTIONS |
BENEFIT STRUCTURE |
LEVY / |
MRP® |
EXCLUSIONS |
|
OPMED |
Acute Benefit |
15% Levy |
Yes |
1-9, 11, 14-16, 19-27, 30-32, 40-45, 50-51, 58,
61-62 |
|
Chronic Benefit |
10% Levy |
|||
|
Oncology Benefit |
No Levy |
|||
|
HIV/AIDS |
10% Levy |
|||
|
OTC/PAT |
15% Levy |
|||
|
Prescribed Minimum Benefits (Subject to Formulary) |
No Levy |
IF YOU REQUIRE ANY ASSISTANCE, PLEASE CONTACT:
|
Mediscor’s Share Call Centre Helpline |
: |
0860 113 238 or 0860 117 705 |
|
OPMED’s Call Centre |
: |
(012) 427-5333 |
|
OPMED’s Call Centre Fax: |
: |
(012) 427-4545 |
|
OPMED Office Hours: |
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|
|
Monday to Friday (07h30 – 17h00) |
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Kind Regards