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MEDISCOR
(PTY) LTD |
NOTIFICATION 38OF2009 |
15/12/2009
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|
Medical Scheme |
Umvuzo Health Medical Scheme |
|
Administrator |
Umvuzo
Health Managedcare |
|
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 Umvuzo Health
Medical Scheme as outlined below.
Standard and Ultra Affordable
Options:
·
GP Prescription claims – Use
Mediscor Scheme Codes MDS0331 or MDS0300
·
Specialist Prescription Claims – Use
Mediscor Scheme Codes MDS0059
Supreme Option:
·
All claims – Use Mediscor
Scheme Codes MDS0059
Herewith the
detail for submitting Acute Medicine claims from Specialists to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0059
|
|
2. |
Switch Destination Code |
2. |
UHMS0001 |
|
3. |
EDI Activation Code
(Dispensing Doctors) |
3. |
No |
|
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. |
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. |
9 digit NAPPI code of
medicine dispensed |
13. |
Yes / Compulsory |
|
14. |
ICD-10 Diagnostic code |
14. |
Yes / Compulsory |
|
15. |
Membership number
requirements |
15 |
Min. 6 Numerical |
|
16. |
Chronic pre-authorisation
at Mediscor |
16. |
Mediscor ChroniLineTM |
|
17. |
Payments to Providers |
17. |
Umvuzo |
|
18. |
Reimbursement Structure
- Pharmacies |
18. |
SEP + R26/26% |
|
19. |
Reimbursement Structure –
Dispensing Doctors |
19. |
SEP + R20/30% |
|
20. |
Reimbursement Structure –
Unscheduled and Schedule 0 Medicines |
20. |
SEP + 31% |
·
MEDISCOR REFERENCE PRICE (MRP®) – 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, Formulary and Exclusion criteria;
SERVICE PROVIDERS MUST refer to our on-line responses to apply the
correct rules.
Herewith the rules for Umvuzo
Medical Scheme effective 1 January 2010:
|
OPTION |
BENEFITS APPLICABLE |
LEVY / |
MRP® |
EXCLUSIONS |
|
Standard & Ultra
Affordable |
Savings |
No
Levy |
Yes |
1-7,
11, 14, 15, 16, 19, 21-25, 27, 30-32, 35, 38, 40, 41, 43-45, 47-53, 57-62 |
|
Acute Benefit |
No
Levy Authorised
Specialist consultation and prescription only |
|||
|
Prescribed Minimum Benefits (PMBs) |
No Levy DSP applicable |
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Surgical Benefit |
No levy |
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Oncology Benefit (excluding Ultra Affordable) |
No levy |
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High Cost |
No Levy |
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HIV/AIDS |
No Levy |
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|
|
|
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Supreme
|
Acute Benefit |
No Levy |
Yes |
1-7, 11, 14, 15, 16, 19, 21-25, 27, 30-32, 35, 38, 40, 41, 43-45,
47-53, 57-62 |
|
Chronic Benefit |
No Levy |
|||
|
Prescribed Minimum Benefits (PMBs) |
No Levy DSP applicable |
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|
Surgical Benefit |
No Levy |
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|
Oncology Benefit |
No Levy |
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|
High Cost |
No Levy |
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|
HIV/AIDS |
No Levy |
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|
OTC |
No Levy Max of R150 per prescription |
ADDITIONAL RULES
- Specialist claims: Will only pay if Specialist consultation was authorized by
Umvuzo Health. Members to
contact Umvuzo on 086 108 3084.
Specialist Prescribers only.
- Surgical Benefit: Pre-authorisation obtained from Umvuzo Health on 086 108 3084.
- Chronic/Prescribed Minimum Benefits (PMBs) (DSP applicable): Members need to apply and register with Mediscor
ChroniLineTM on 0860 119 553
If you require any assistance, please contact:
|
Mediscor’s Toll-free Call
Centre Helpline |
: |
0860 113 238
or 0860 117 705 |
Regards
JACK PEREL