|
|
MEDISCOR (PTY) LTD |
NOTIFICATION
40
OF
2008 |
11 November 2008
|
|
Medical
Scheme |
PG Group Medical Scheme |
|
Administrator |
Momentum Medical Scheme Administrators (MMSA) |
|
Information
Relevant to |
Benefits and Options for 2009 |
|
Effective
Date |
1 January 2009 |
With
effect 1 January 2009, Mediscor will be applying the scheme rules for PG Group
Medical Scheme as outlined below.
Herewith the details for
submitting medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0045 |
|
2. |
Switch Destination Code |
2. |
NMPS0000
|
|
3. |
EDI Activation Code (Dispensing
Doctors) |
3. |
146P |
|
4. |
MMAP© |
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. |
ICD-10 diagnostic code |
13. |
Yes / Compulsory |
|
14. |
9 digit NAPPI code of medicine dispensed |
14. |
Yes / Compulsory |
|
15. |
Membership number requirements |
15. |
Minimum 4 numerical including dependant code |
|
16. |
Payments to Providers |
16. |
MMSA |
|
17. |
Chronic
pre-authorisation Mediscor ChroniLine™ |
17. |
MMSA |
|
18. |
Reimbursement structure –
Dispensing Doctors |
18. |
SEP
+ R16/16% |
|
19. |
Reimbursement structure – Pharmacies |
19. |
SEP + R26/26% |
|
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 PG Group Medical Scheme
effective from 1 January 2009:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MMAP© |
EXCLUSIONS |
|
PG Group |
Acute |
No
Levy |
Yes |
3-5,
14-15, 24-25, 27, 30-32, 35, 45, 53, 61 |
|
Chronic |
No
Levy |
Yes |
||
|
PMB |
No Levy |
Yes |
||
|
OTC |
No Levy Maximum
of R140.00 per prescription |
No |
||
|
HIV/Aids |
No Levy |
No |
||
|
Appliance |
No Levy |
Yes |
||
|
Organ
Transplant |
No Levy |
No |
||
|
Oncology |
No Levy |
No |
||
|
Homeopathic |
No Levy |
Yes |
||
|
Flu
Vaccines |
No Levy |
Yes |
LIMITATIONS
AND SPECIAL REQUIREMENTS:
Pre-authorisation for the following is required from MMSA:
- Oncology
- Immunosuppressive
- Growth
Hormones
- Erythropoietin
- Surgical,
medical and orthopaedic appliances
- Diagnostic
agents and appliances
- Oxygen
and delivery systems
- Stomacare
- Medicines
for Prescribed Minimum Benefits (PMB)
(Prescription
refill every 24 days)
HIV/AIDS medicines require
pre-authorisation from Calibre Clinical Consultants - Tel (012) 673-8901, and may only be obtained through a DSP.
CLINICAL
DUR CHECKS APPLIED TO ALL CLAIMS
(Please check the on-line
response)
·
Drug to diagnosis/disease
·
Dosage range check
·
Drug to age checking
·
Drug to gender
·
Duplicate therapy
If
you require any assistance, please contact:
|
Mediscor’s Share Call Centre Helpline |
: |
0860 113 238 or 0860 117 705 |
|
MMSA |
: |
0860 005 037 |
Kind
regards.
JACK
PEREL