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|
MEDISCOR
(PTY) LTD |
NOTIFICATION 40OF2011 |
19
December 2011
|
|
Medical Scheme |
Hosmed Medical Scheme |
|
Administrator |
Allcare
Administrators |
|
Information Relevant to |
Benefits
and Options for 2012 |
|
Effective Date |
1
January 2012 |
With effect 1 January 2012, Mediscor will be
applying the scheme rules for Hosmed Medical Scheme as outlined below.
Herewith the detail for submitting
medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0021 |
|
2. |
Switch Destination Code |
2. |
THHM0000 |
|
3. |
EDI Activation Code (Dispensing Doctors) |
3. |
523P |
|
4. |
Reference
Pricing |
4. |
Yes |
|
5. |
Maximum supply of medicine |
5. |
30 Days |
|
6. |
Days supply of the dispensed medicine |
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 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 Diagnosis code |
13. |
Yes / Compulsory |
|
14. |
9 digit NAPPI code of medicine dispensed |
14. |
Yes / Compulsory |
|
15. |
Membership number requirements |
15. |
8 Numerical digits |
|
16. |
Payments to Providers |
16. |
Allcare Administrators |
|
17. |
Chronic/PMB pre-authorisation |
17. |
Mediscor ChroniLine™ |
|
18. |
Reimbursement structure – Dispensing Doctors |
18. |
SEP + 30%/R23.40 |
|
19. |
Reimbursement
structure – Pharmacies |
19. |
SEP
+ 28%/R28 |
|
20. |
Over the counter (OTC) |
20. |
SEP
+ 28%/R28 |
·
SEP
(VAT Incl.) and dispensing fee (VAT Excl.)
·
Reimbursement
structure will be applied on scheduled medicines (0 – 8) and unscheduled products.
·
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 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 Hosmed Medical Scheme
effective from 1 January 2012:
|
OPTIONS |
BENEFIT STRUCTURE |
LEVY / |
MRP® |
EXCLUSIONS |
|
PLUSPLAN VALUEPLAN STEPPLAN |
Acute Benefit |
No Levy |
Yes |
1-5, 7-9, 11, 14, 15, 19-25, 27, 30-32, 35, 40, 41, 43-45,47,48, 51,
53, 55, 57, 56, 61, 62 |
|
Chronic Benefit |
PLUSPLAN: Mediscor Standard Formulary: Non-formulary
products: 20% co-payment VALUEPLAN: Mediscor Basic Formulary: Non-formulary
products: 20% co-payment STEPPLAN: Mediscor Core Formulary: Non-formulary
products: Reject |
|||
|
Prescribed Minimum Benefits (PMBs) |
PLUSPLAN: Mediscor Standard Formulary: Non-formulary
products: 20% co-payment VALUEPLAN: Mediscor Basic Formulary: Non-formulary
products: 20% co-payment STEPPLAN: Mediscor Core Formulary: Non-formulary
products: Reject |
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Appliances |
No Levy |
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Oncology |
No Levy |
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OTC/PAT (STEPPLAN – no benefit) |
No
Levy R120 max. per prescription
and 1 script every 3 days PLUSPLAN R170 max. per prescription and 1 script every 3 days |
|||
|
HIV |
No Levy |
Pre-authorised products will allow 1 fill every 26
days.
PRESCRIBED MINIMUM BENEFITS (PMBs):
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
Call Centre |
: |
0860 113 238 or 0860 117 705 |
|
|
Mediscor
ChroniLine™ Mediscor
E-Mail |
: : |
0860 119 553 helpdesk@mediscor.co.za |
|
Kind regards.
JACK PEREL