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MEDISCOR
(PTY) LTD |
NOTIFICATION 34OF2009 |
14/12/2009
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Medical Scheme |
TOPMED Medical Scheme |
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Administrator |
Momentum Medical Scheme
Administrators (MMSA) |
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Information Relevant to |
Benefits and Options
for 2010 |
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Effective Date |
1 January 2010 |
With effect 1 January 2010, Mediscor will
be applying the scheme rules for TOPMED Medical Scheme as outlined below.
Herewith the detail for submitting medicine claims to
Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0048 |
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2. |
Switch Destination Code |
2. |
BKTE0001
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3. |
EDI Activation Code
(Dispensing Doctors) |
3. |
003P |
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4. |
MMAP© |
4. |
Yes
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5. |
Maximum supply of medicine |
5. |
30 Days |
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6. |
Days of supply of the
dispensed medication |
6. |
Yes /Compulsory |
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7. |
Membership number as per
membership card |
7. |
Yes / Compulsory |
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8. |
Dependant code as per
membership card |
8. |
Yes / Compulsory |
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9. |
Dependant first name as
per the membership card |
9. |
Yes / Compulsory |
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10. |
Dependant date of birth |
10. |
Yes /Compulsory |
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11. |
Dependant’s gender
(male/female) |
11. |
Yes / Compulsory |
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12. |
Practice number of the
prescriber |
12. |
Yes / Compulsory |
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13. |
ICD-10 diagnostic code |
13. |
Yes / Compulsory |
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14. |
9 digit NAPPI code of
medicine dispensed |
14. |
Yes / Compulsory |
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15. |
Membership number
requirements |
15. |
Minimum 4 numerical
including dependant code |
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16. |
Payments to Providers |
16. |
MMSA |
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17. |
Chronic pre-authorisation Mediscor ChroniLine™ |
17. |
MMSA |
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18. |
Reimbursement structure –
Dispensing Doctors |
18. |
SEP + 30% / R20.00 |
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19. |
Reimbursement structure –
Pharmacies |
19. |
SEP + 26% / R26.00 |
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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 TOPMED Medical Scheme effective from 1 January 2010:
|
OPTION |
BENEFIT STRUCTURE |
LEVY/CO-PAYMENT |
MMAP© |
EXCLUSIONS |
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TOPMED 80% |
Acute |
20% |
Yes |
3,4,5, 11, 14, 15, 16, 19, 20 - 25, 27, 30, 31, 32, 35,
38, 40, 41, 43, 44, 45, 48, 51, 52, 53, 55, 60, 61, 64 |
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Chronic |
20% |
|||
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PMB |
30% Subject to Formulary & DSP |
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OTC |
20% |
No |
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HIV |
No |
Yes |
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Appliances |
20% |
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Oncology |
No |
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Homeopathic |
20% |
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Maternity |
No |
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Core |
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Wellness |
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Health assessment |
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TOPMED INCENTIVE COMPREHENSIVE &
TOPMED INCENTIVE SAVINGS |
Acute |
No |
Yes |
60, 64, 61 |
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Savings |
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Chronic |
25% (Incentive Comprehensive only) |
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PMB |
30% Subject to Formulary & DSP |
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OTC |
No |
No |
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HIV |
Yes |
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Appliances |
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Oncology |
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Homeopathic |
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Maternity |
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Core |
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Wellness |
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Health assessment |
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TOPMED NETWORK
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PMB |
30% Subject to Formulary & DSP |
Yes |
3,4,5, 11, 14, 15, 16, 19, 20 - 25, 27, 30, 31, 32, 35,
38, 40, 41, 43, 44, 45, 48, 51, 52, 53, 55, 60, 61, 64 |
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HIV |
No |
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Oncology |
||||
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Core |
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Wellness |
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Health assessment |
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TOPMED HOSPITAL PLAN |
PMB |
30% Subject to Formulary & DSP |
Yes |
3,4,5, 11, 14, 15, 16, 19, 20 - 25, 27, 30, 31, 32, 35,
38, 40, 41, 43, 44, 45, 48, 51, 52, 53, 55, 60, 61, 64 |
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HIV |
No |
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Oncology |
||||
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Maternity |
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Core |
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Wellness |
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Health assessment |
LIMITATIONS AND
SPECIAL REQUIREMENTS:
Pre-authorisation for the following is required
from MMSA:
- Oncology
- Immunosuppressive
- Anti-retroviral
medication
- Medicines for
Prescribed Minimum Benefits (PMB)
(Prescription refill once every 24
days)
IF YOU REQUIRE
ANY ASSISTANCE, PLEASE CONTACT:
Mediscor’s Share Call Centre Helpline : 0860 113 238 or 0860 117 705
TOPMED Medical Scheme Call Centre Helpline &
Medicine Pre-authorisation : 0860 002 158
Anti-retroviral medication (AfA) : 0860 100 646
MMSA Benefit Checker (24 Hours) : 0860 104 040
Kind regards.
JACK PEREL