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MEDISCOR (PTY) LTD |
NOTIFICATION
43
OF
2008 |
12 December 2008
|
Medical Scheme
|
Telemed
Medical Scheme |
|
Administrator |
Telemed
Medical Scheme |
|
Information
Relevant to |
Benefits
and Options 2009 |
|
Effective
Date |
1
January 2009 |
With effect 1 January 2009,
Mediscor will be applying the scheme rules for TELEMED Medical Scheme as
outlined below.
Herewith the details for
submitting medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0009 |
|
2. |
Switch Destination Code |
2. |
TETE0000 |
|
3. |
EDI Activation Code (Dispensing
Doctors) |
3. |
273P |
|
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. |
First 7 Numerical |
|
16. |
Payments to Providers |
16. |
Telemed |
|
17. |
Chronic pre-authorisation at
Mediscor |
17. |
No - MHS |
|
18. |
Reimbursement structure –
Pharmacies |
18. |
SEP + 26%/ R 26
|
|
19. |
Reimbursement structure – Dispensing
Doctors |
19. |
SEP + 16%/ R 16
|
|
20. |
Reimbursement structure –
Unscheduled and Schedule 0 Medicine |
20. |
SEP + 31% (Excl.
VAT)
|
* MEDISCOR REFERENCE PRICE
(MRP®) – information available on www.mediscor.net
* ICD-10 CODES – information available on www.medicalschemes.com
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 TELEMED effective from 1 January 2009:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / |
MRP® |
EXCLUSIONS |
|
|
Platinum Gold Silver |
Acute Benefit |
No
levy |
Yes |
Platinum and Gold
3-5, 11, 14-17, 19, 21-25, 27, 30-32, 40-41, 43-45, 47-48,
50-51, 53, 61,63 Silver Option 3, 5, 21, 24, 25, 27, 53, 61 |
|
|
Chronic Benefit |
Preferred Products
R10/item – Max R30 per script Non-formulary Products: 30% co-pay |
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Chronic Benefit |
Preferred Products: No Levy – restricted to DSP Non-formulary Products:
30% co-pay |
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Prescribed Minimum Benefit (PMB) |
Formulary Products:
R10/item – Max R30 per script |
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Prescribed Minimum Benefit (PMB) |
Formulary Products:
No levy –DSP only Non-formulary Products: 30% co-payment - DSP only |
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Prescribed Minimum Benefit (PMB) |
Formulary Products: No levy – DSP only Non-formulary Products: 30% co-payment – DSP only |
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HIV/AIDS Benefit |
No
levy on authorized meds |
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Organ Transplant Benefit |
No
levy – DSP only |
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Organ Transplant Benefit
Gold/Silver |
No
levy – DSP only |
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Oncology Benefit |
No
levy – DSP only |
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Oncology Benefit
Gold/Silver |
No
levy – DSP only |
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Homeopathic Benefit |
No
levy |
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|
OTC Benefit |
Platinum – Script max of R140 Gold – Script
max of R120 Silver – No
script max |
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External Appliance Benefit |
No
levy |
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|
In-hospital Benefit |
No
levy |
|
Additional
Customised Exclusions:
|
1. |
MIMS Cat. 16.3 (Urinary alkalinizers) e.g. Citro Soda™ |
PRESCRIBED
MINIMUM BENEFITS (PMBs):
Members need to apply for Prescribed Minimum
Benefits as well as Chronic Medication Benefits at MHS (Managed Health Systems)
0860 488 200.
If you require any assistance, please contact:
|
Mediscor’s Share Call Centre Helpline |
: |
0860 113 238 or 0860 117 705 |
Kind
regards
JACK
PEREL