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MEDISCOR (PTY) LTD |
NOTIFICATION
42
OF
2008 |
12 December 08
|
|
Medical
Scheme |
Prosperity Health Medical Scheme (Africa) |
|
Administrator |
Prosperity Health |
|
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
Prosperity Health Medical Scheme as outlined below.
Herewith the details for
submitting medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0057 |
|
2. |
Switch Destination Code |
2. |
STME0001
|
|
3. |
EDI Activation Code (Dispensing
Doctors) |
3. |
814P |
|
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. |
ICD-10 diagnostic code |
13. |
Yes / Compulsory |
|
14. |
9 digit NAPPI code of medicine
dispensed |
14. |
Yes / Compulsory |
|
15. |
Membership number requirements |
15. |
Minimum 7 Numerical – |
|
16. |
Payments to Providers |
16. |
Prosperity |
|
17. |
Chronic
pre-authorisation Mediscor ChroniLine™ |
17. |
Yes |
|
18. |
Reimbursement structure –
Dispensing Doctors |
18. |
SEP
+ 16%/16 |
|
19. |
Reimbursement structure – Pharmacies |
19. |
SEP + 26%/R26 |
|
20. |
Scheduled 0 or Unscheduled |
20. |
SEP + max mark-up of 31% (VAT Excl.) |
* 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 Prosperity Health Medical
Scheme effective from 1 January 2009:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Econo Hospital Status Hospital Prestige Hospital Complimed |
Oncology |
No |
Yes |
2-5,
11, 14-16, 19-28, 30-32, 35, 40, 41, 43-45, 47, 48, 50, 51, 53, 56-58, 60-61 |
|
Organ
Transplant |
No |
|||
|
Kidney |
No |
|||
|
Appliance |
No |
|||
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|
|
|
|
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Econo Standard Status Standard Prestige Standard Student Standard Econo Advanced Status Advanced Prestige Advanced Student Comprehensive |
Acute |
No |
Yes |
|
|
Oncology |
No |
|||
|
Organ
Transplant |
No |
|||
|
Kidney |
No |
|||
|
Psychiatric |
No |
|||
|
Homeopathic |
No |
|||
|
Appliance |
No |
|||
|
HIV |
No |
|||
|
|
|
|
|
|
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Econo Comprehensive Status Comprehensive Prestige Comprehensive |
Acute |
No |
Yes |
|
|
Chronic |
No |
|||
|
Oncology |
No |
|||
|
Organ
Transplant |
No |
|||
|
Kidney |
No |
|||
|
Psyciatric |
No |
|||
|
Homeopathic |
No |
|||
|
Appliance |
No |
|||
|
HIV |
No |
|||
|
|
|
|
|
|
|
American Embassy |
Oncology |
No |
No |
|
|
Organ
Transplant |
No |
|||
|
Kidney |
No |
|||
|
Savings |
20% Levy |
|||
|
|
|
|
|
|
|
Bomaid Student |
Acute
|
No |
Yes |
|
|
Chronic |
No |
|||
|
Oncology |
No |
|||
|
Organ
Transplant |
No |
|||
|
Kidney |
No |
|||
|
HIV |
No |
|||
|
MVA |
No |
|||
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|
|
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NHP Family Care NHP Executive Care NHP VIP Care |
Acute |
No |
Yes |
|
|
Chronic |
No |
|||
|
Oncology |
No |
|||
|
Organ
Transplant |
No |
|||
|
Kidney |
No |
|||
|
Homeopathic |
No |
|||
|
Appliance |
No |
|||
|
HIV |
No |
|||
|
MVA |
No |
Additional
Customised Exclusions:
|
1. |
Phenolphthalein™ laxatives |
|
|
|
2. |
Phensedyl™ and generics |
|
|
|
3. |
Nootropil™ |
|
|
PRESCRIBED
MINIMUM BENEFITS (PMBs):
Not applicable.
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