|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 41OF2011 |
20
December 2011
|
|
Medical Scheme |
Community Medical Aid Scheme (COMMED) |
|
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 COMMED as outlined below.
Herewith the detail for submitting medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0038 |
|
2. |
Switch Destination Code |
2. |
IHCO0000 |
|
3. |
EDI Activation Code (Dispensing Doctors) |
3. |
009P |
|
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. |
Minimum 9 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 + 26%/R26 |
|
20. |
Over the counter (OTC) |
20. |
SEP + 16%/R16 |
·
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 COMMED Medical Scheme effective from 1 January 2012:
|
OPTIONS |
BENEFIT STRUCTURE |
LEVY / |
MRP® |
EXCLUSIONS |
|
Deluxe Standard |
Acute Benefit |
No Levy |
Yes |
1-9,11,14,15, 17,19-25, 27, 30-35, 40,41,43-45, 48,50-51, 55, 56, 58,
60-62 |
|
Chronic Benefit (Deluxe only) |
Deluxe:
Mediscor Basic Formulary: Non-formulary products: 30%
co-payment |
|||
|
Prescribed Minimum Benefits (PMBs) |
Deluxe:
Mediscor Basic Formulary: Non-formulary products: 30%
co-payment Standard: Mediscor Core Formulary: Non-formulary products: 30% co-payment |
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|
Appliances |
No Levy |
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Oncology |
No Levy |
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OTC/PAT |
Deluxe: No Levy Standard: No Levy R100.00 max. per prescription and 1 prescription
every 3 days. |
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|
HIV |
No Levy |
Pre-authorised products will allow 1 fill every 26 days.
PRESCRIBED MINIMUM BENEFITS (PMBs):
Members must 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