|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 29OF2009 |
14/12/2009
|
|
Medical Scheme |
PG Group 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 PG Group Medical Scheme as outlined below.
Herewith the detail for submitting medicine claims to
Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0045 |
|
2. |
Switch Destination Code |
2. |
NMPS0000 |
|
3. |
EDI Activation Code (Dispensing Doctors) |
3. |
146P |
|
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 |
17. |
MMSA |
|
18. |
Reimbursement structure – Dispensing Doctors |
18. |
SEP + R20/30% |
|
19. |
Reimbursement structure –
Pharmacies |
19. |
SEP + R26/26% |
|
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 PG Group Medical
Scheme effective from 1 January 2010:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MMAP© |
EXCLUSIONS |
|
PG Group |
Acute |
No Levy |
Yes |
3-5, 14-15, 24-25, 27,
30-32, 35, 45, 53, 61 |
|
Chronic |
No Levy |
Yes |
||
|
PMB |
No Levy |
Yes |
||
|
OTC |
No Levy Maximum of R140.00 per prescription |
No |
||
|
HIV/Aids |
No Levy |
No |
||
|
Appliance |
No Levy |
Yes |
||
|
Organ Transplant |
No Levy |
No |
||
|
Oncology |
No Levy |
No |
||
|
Homeopathic |
No Levy |
Yes |
||
|
Flu Vaccines |
No Levy |
Yes |
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)
HIV/AIDS medicines require pre-authorisation
from Calibre Clinical Consultant:
Tel (012)
673-8901, and may only be obtained through a DSP.
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 any assistance, please contact:
|
Mediscor’s Share Call
Centre Helpline |
: |
0860 113 238
or 0860 117 705 |
|
MMSA |
: |
0860 005 037 |
Kind regards.
JACK PEREL