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MEDISCOR
(PTY) LTD |
NOTIFICATION 39OF2009 |
15/12/2009
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Medical Scheme |
Gen-Health Medical Scheme |
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Administrator |
Sechaba Medical
Solutions |
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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 Gen-Health Medical Scheme as outlined below.
Herewith the detail for submitting medicine claims to
Mediscor:
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1. |
Scheme Code (PCN) |
1. |
MDS0035
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2. |
Switch Destination Code |
2. |
GHEA0001 |
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3. |
EDI Activation Code
(Dispensing Doctors) |
3. |
517P |
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4. |
MRP® |
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. |
Min 5 Max 9 numerical |
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16. |
Payments to Providers |
16. |
Gen-Health |
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17. |
Chronic pre-authorisation
at Mediscor |
17. |
Yes |
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18. |
Reimbursement Structure –
Dispensing Doctors |
18. |
SEP + 30% / R20 |
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19. |
Reimbursement Structure –
Pharmacies |
19. |
SEP
+ 26% / R26
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20. |
Reimbursement Structure –
Schedule 0 and Unscheduled medicines |
20. |
SEP + max mark-up of 31%
(VAT Excl.) |
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·
MEDISCOR REFERENCE PRICE (MRP®) – information available on
www.mediscor.net
·
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 Gen-Health effective
from 1 January 2010:
|
OPTIONS |
BENEFIT STRUCTURE |
LEVY / |
MRP© |
EXCLUSIONS |
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Basic Cover |
Acute |
No |
Yes |
2-5, 14, 15, 19-25, 27, 28, 30-32, 34, 38, 40, 41, 43, 44, 45, 47, 48,
50, 53, 60, 61 |
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Prescribed Minimum Benefit (PMB) |
Mediscor Basic Formulary Non-formulary
products: 25% co-payment |
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OTC (Pharmacies only) |
No |
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Oncology |
No |
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Appliance |
No |
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Organ Transplant |
No |
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OPTIONS |
BENEFIT STRUCTURE |
LEVY / |
MRP© |
EXCLUSIONS |
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Coverplus |
Acute |
No |
Yes |
2-5, 14, 15, 19-25, 27, 28, 30-32, 34, 38, 40, 41, 43, 44, 45, 47, 48,
50, 53, 60, 61 |
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Prescribed Minimum Benefit (PMB) |
Mediscor Standard Formulary Non-formulary
products: 25% co-payment |
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OTC (Pharmacies only) |
No |
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Oncology |
No |
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Appliance |
No |
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Chronic |
Non-formulary
products: 25% co-payment |
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Organ Transplant |
No |
Additional Customised
EXCLUSIONS:
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1. |
Nootropil™ |
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2. |
Phenolphtalein laxatives |
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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