|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 33OF2009 |
08/12/2009
|
|
Medical Scheme |
UMED Medical Scheme |
|
Administrator |
Discovery Health |
|
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 UMED Medical Scheme as outlined below.
Herewith the detail for submitting
medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0008 |
|
2. |
Switch Destination Code |
2. |
UMUM0000 |
|
3. |
MMAP© |
3. |
Yes |
|
4. |
Maximum supply of medicine |
4. |
30 Days |
|
5. |
Days of supply of the dispensed medication |
5. |
Yes /Compulsory |
|
6. |
Membership number as per membership card |
6. |
Yes / Compulsory |
|
7. |
Dependant code as per membership card |
7. |
Yes / Compulsory |
|
8. |
Dependant first name as per the membership card |
8. |
Yes / Compulsory |
|
9. |
Dependant date of birth |
9. |
Yes /Compulsory |
|
10. |
Dependant’s gender (male/female) |
10. |
Yes / Compulsory |
|
11. |
Practice number of the prescriber |
11. |
Yes / Compulsory |
|
12. |
ICD-10 diagnostic code |
12. |
Yes / Compulsory |
|
13. |
9 digit NAPPI code of medicine dispensed |
13. |
Yes / Compulsory |
|
14. |
Membership number requirements |
14. |
9 Numerical digits |
|
15. |
Payments to Providers |
15. |
Discovery |
|
16. |
Chronic pre-authorisation Mediscor ChroniLine™ |
16. |
Yes |
|
17. |
Reimbursement structure – Dispensing Doctors |
17. |
Not Applicable |
|
18. |
Reimbursement structure –
Pharmacies |
18. |
SEP + 36% / to max of
R52.10 (Excl. VAT) |
|
19. |
Scheduled 0 or Unscheduled |
19. |
SEP + 36% / to max of
R52.10 (Excl. VAT) |
- 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 UMED Medical Scheme effective from 1 January 2010:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MMAP© |
EXCLUSIONS |
|
Classic Value |
Acute |
20% per line item |
Yes |
1-5, 7-11, 14-15, 19,
21-25, 27, 30-32, 35, 40-41, 43-45, 50-51, 53, 61-62 |
|
Chronic |
No Levy |
|||
|
Homeopathic |
20% per line item |
|||
|
OTC |
20% per line item |
|||
|
Prescribed Minimum
Benefits (PMB) |
Formulary Products: No Levy Non-Formulary Products: 20% Levy |
|||
|
Oncology |
No Levy |
|||
|
Flu Vaccines |
No Levy |
|||
|
Appliance |
No Levy |
|||
|
Alternative |
No Levy |
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Stoma |
No Levy |
|||
|
High Risk |
No Levy |
PRESCRIBED MINIMUM BENEFITS (PMBs):
- Mediscor Basic Formulary used for Value option
- Mediscor Standard Formulary used for Classic
option
Members need to apply and register for PMBs and Chronic Medicine
Benefits with Mediscor ChroniLine™ on 0860 119 553.
If you require any assistance, please contact:
|
Mediscor’s Share Call
Centre Helpline |
: |
0860 113 238
or 0860 117 705 |
|
Mediscor ChroniLine™ |
: |
0860 119 553 |
Kind regards.
JACK PEREL