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MEDISCOR
(PTY) LTD |
NOTIFICATION 43OF2009 |
17/12/2009
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Medical Scheme |
Momentum Health |
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Administrator |
Momentum Medical Scheme
Administrators (MMSA) |
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Information Relevant to |
Benefits and Options
for 2010 |
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Effective Date |
1 January 2010 |
Mediscor will be responsible for the processing of all electronic
medicine claims, materials and consumables dispensed and/or administered during
procedures, while MMSA will be responsible for the authorisation of chronic
medicines, including medicines falling under Prescribed Minimum Benefits
(PMBs).
Herewith the detail for submitting medicine claims to
Mediscor:
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1. |
Scheme Code (PCN) |
1. |
MDS0041 |
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2. |
Switch Destination Code |
2. |
MHEA0007 |
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3. |
EDI Activation Code
(Dispensing Doctors) |
3. |
822P |
|
4. |
*Momentum Health Rate
(MHR) |
4. |
Yes |
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5. |
Maximum supply of medicine |
5. |
30 DAYS |
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6. |
Days of supply of the
dispensed medication |
6. |
Yes /Compulsory |
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7. |
Membership number as per
membership card |
7. |
Yes / Compulsory |
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8. |
Dependant code as per
membership card |
8. |
Yes / Compulsory |
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9. |
Dependant first name as
per the membership card |
9. |
Yes / Compulsory |
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10. |
Dependant date of birth |
10. |
Yes /Compulsory |
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11. |
Dependant’s gender
(male/female) |
11. |
Yes / Compulsory |
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12. |
Practice number of the
prescriber |
12. |
Yes / Compulsory |
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13. |
9 digit NAPPI code of
medicine dispensed |
13. |
Yes / Compulsory |
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14. |
ICD-10 Diagnostic code |
14. |
Yes / Compulsory |
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15. |
Membership number
requirements |
15. |
Minimum 4 Numerical including dependant code |
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16. |
Payments to Providers |
16. |
MMSA |
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17. |
Chronic pre-authorisation |
17. |
MMSA |
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18. |
Reimbursement structure –
Pharmacies |
18. |
S1 to S8: SEP + 26% / R
26.00 unscheduled & S0: SEP + 31% (excl. VAT) |
|
19. |
Reimbursement structure –
Doctors |
19. |
S1 to S8: SEP + 30% / R 20.00
unscheduled & S0: SEP + 31% (excl. VAT) |
|
20. |
Reimbursement structure –
DSP Network |
20. |
Unscheduled to S8: SEP + 24% / R24.00 |
·
MOMENTUM HEALTH RATE (MHR): MHR is the Momentum Health Rate, which is the rate
that Momentum Health sets for the reimbursement of claims and is subject to a
formulary [based on the Mediscor Reference Price (MRP)]. Please refer to the real-time response.
·
Summit Option:
§ Reimbursement structure = MHS 4-Tiered
§ No MHR / MRP applicable
Herewith the Scheme rules for MOMENTUM HEALTH effective
from 1 January 2010:
|
OPTION |
BENEFIT STRUCTURE |
LEVY / CO-PAYMENT |
MRP / MHR |
EXCLUSIONS |
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SUMMIT
|
Acute / Savings |
No
Levy
|
No
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3,5,11,14,15,17,19,20, 22-28,30-35, 38-41, |
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Homeopathic |
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Chronic |
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PMB |
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OTC |
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HIV / AIDS – DSP |
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Surgical |
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Organ Transplant |
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Oncology |
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Stoma Care |
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Health Platform |
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Ex Gratia |
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Biological |
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Health Assessment |
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Health Saver |
Excluded products for the
Summit
option may be obtained from Savings Benefit, if available.
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OPTION |
BENEFIT STRUCTURE |
LEVY / CO-PAYMENT |
MRP / MHR |
EXCLUSIONS |
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EXTENDER |
Acute |
No
Levy |
No |
3,5,11,14,15,17,19,20, 22-28,30-35,
38-41,43-49,50,52-55,56,59, 60,61, 64 |
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Chronic |
Yes |
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PMB |
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OTC |
No |
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HIV / AIDS – DSP |
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Surgical |
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Organ Transplant |
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Oncology |
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Stoma Care |
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Health Platform |
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Health Assessment |
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Health Saver |
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Non accumulate |
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Ex Gratia |
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OPTION |
BENEFIT STRUCTURE |
LEVY / CO-PAYMENT |
MRP / MHR |
EXCLUSIONS |
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EXTENDER GP OPTIONS |
Acute |
If the provider is a non-DSP, for GP options, the claim will pay from
savings / acute. |
No |
3,5,11,14,15,17,19,20, 22-28,30-35,
38-41,43-49,50,52-55,56,59, 60,61, 64 |
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Chronic |
Yes |
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PMB |
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OTC |
No |
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HIV / AIDS – DSP |
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Surgical |
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Organ Transplant |
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Oncology |
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Stoma Care |
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Health Platform |
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Health Assessment |
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Health Saver |
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Non accumulate |
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Ex Gratia |
OPTION |
BENEFIT STRUCTURE |
LEVY / CO-PAYMENT |
MRP / MHR |
EXCLUSIONS |
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INCENTIVE
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Acute |
No
Levy |
No |
3,5,11,14,15,17,19,20, 22-28,30-35,
38-41,43-49,50,52-55,56,59, 60,61, 64 |
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Chronic |
Yes |
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PMB |
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OTC |
No |
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HIV/AIDS – DSP |
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Oncology |
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Stoma Care |
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Health Platform |
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|
Health Assessment |
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Health Saver |
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Ex Gratia |
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OPTION |
BENEFIT STRUCTURE |
LEVY / CO-PAYMENT |
MRP / MHR |
EXCLUSIONS |
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INCENTIVE
GP OPTIONS |
Acute |
If the provider is a non-DSP, for GP options, the claim will pay from
savings / acute. |
No |
3,5,11,14,15,17,19,20, 22-28,30-35,
38-41,43-49,50,52-55,56,59, 60,61, 64 |
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Chronic |
Yes |
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PMB |
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OTC |
No |
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HIV/AIDS – DSP |
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Oncology |
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Stoma Care |
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Health Platform |
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Health Assessment |
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Health Saver |
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Ex Gratia |
OPTION |
BENEFIT STRUCTURE |
LEVY / CO-PAYMENT |
MRP / MHR |
EXCLUSIONS |
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CUSTOM
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Acute |
NO
LEVY |
No |
3,5,11,14,15,17,19, 20, 22-28,30-35,
38-41,43-49,50,52-55,56,59, 60,61, 64 |
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PMB |
Yes |
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OTC |
No |
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HIV / AIDS – DSP |
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Oncology |
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Stoma Care |
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Health Platform |
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Health Assessment |
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Health Saver |
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Ex Gratia |
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OPTION |
BENEFIT STRUCTURE |
LEVY / CO-PAYMENT |
MRP / MHR |
EXCLUSIONS |
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CUSTOM
GP OPTIONS |
Acute |
If the provider is a non-DSP, for GP options, the claim will pay from
savings / acute. |
No |
3,5,11,14,15,17,19,20, 22-28,30-35,
38-41,43-49,50,52-55,56,59, 60,61, 64 |
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PMB |
Yes |
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OTC |
No |
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HIV / AIDS – DSP |
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Oncology |
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Stoma Care |
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Health Platform |
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Health Assessment |
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Health Saver |
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Ex Gratia |
CAPITATION OPTIONS:
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OPTION |
BENEFIT
STRUCTURE |
LEVY /
CO-PAYMENT |
MRP / MHR |
EXCLUSIONS |
ACCESS
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Savings* |
No Levy
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No
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3,5,11,14,15,17,19,20,
22-28,30-35,38-41,43-49,50,52-55,56,59,
60,61, 64
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OTC |
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HIV / Aids - DSP |
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Organ Transplant – State only |
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Oncology – State only |
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Stoma Care |
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Health Assessment |
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Health Saver |
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Ex Gratia |
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OPTION |
BENEFIT
STRUCTURE |
LEVY /
CO-PAYMENT |
MRP / MHR |
EXCLUSIONS |
BASE
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Savings* |
No Levy
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No
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3,5,11,14,15,17,19,20,
22-28,30-35,38-41,43-49,50,52-55,56,59,
60,61, 64
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OTC |
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HIV / Aids - DSP |
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Organ Transplant – State only |
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Oncology – State only |
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Stoma Care |
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Health Assessment |
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Ex Gratia |
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OPTION |
BENEFIT
STRUCTURE |
LEVY /
CO-PAYMENT |
MRP / MHR |
EXCLUSIONS |
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Base Carecross Option |
HIV / Aids - DSP |
No Levy |
No |
3,5,11,14,15,17,19,20,
22-28,30-35,38-41,43-49,50,52-55,56,59,
60,61, 64
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Organ Transplant – State only |
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Oncology – State only |
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Exceptions |
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Stoma Care |
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Health Assessment |
*The capitation
formulary is excluded from the Savings Benefit.
Additional scheme rules
for 2010:
·
PMBs
to pay from savings if not authorized
·
If
the provider is a non-DSP, for GP options, the claim will pay from savings /
acute.
If you require any assistance, please contact:
|
Mediscor’s Share Call Centre Helpline |
: |
0860 113 238
or 0860 117 705 |
Kind regards.
JACK PEREL