|
|
MEDISCOR (PTY) LTD |
NOTIFICATION
46
OF
2008 |
15 December 2008
|
|
Medical Scheme |
Medihelp Medical Scheme |
|
Administrator |
Medihelp Medical Scheme |
|
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 Medical
Medical Scheme as outlined below.
Herewith
the details for submitting medicine claims to Mediscor:
|
1. |
Scheme
Code (PCN) |
1. |
MDS0010
|
|
2. |
Switch
Destination Code |
2. |
MGFM0001
|
|
3. |
EDI
Activation Code (Dispensing Doctors) |
3. |
256P |
|
4. |
MMAP© |
4. |
Yes - Acute/Savings/Chronic |
|
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. |
7
Numerical |
|
16. |
Payments
to Providers |
16. |
Medihelp |
|
17. |
Chronic/PMB
pre-authorisation |
17. |
Medichron
|
|
18. |
Reimbursement
structure |
18. |
Medihelp
Reimbursement Rate |
* ICD-10 coding - information available on www.medicalschemes.com
MEDIHELP
REIMBURSEMENT RATE:
Medihelp
will reimburse medicine claims based on the latest 4Tier-pricing model of the
Department of Health.
|
Single Exit Price (incl. VAT) |
Fixed Fee |
% |
|
<R75 |
R 4 |
33% |
|
R75 - <R250 |
R25 |
6% |
|
R250 - <R1000 |
R33 |
3% |
|
>R1000 |
R50 |
1.5% |
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 MEDIHELP effective from 1 January 2009:
MEDIHELP OPTIONS:
Medihelp Plus
Dimension Elite
Dimension Prime 1 – Prescribed Minimum Benefit (PMB) option only
Dimension Prime 2
Dimension Prime 3
|
BENEFITS APPLICABLE |
LEVY / |
MMAP© |
EXCLUSIONS |
|
Acute Benefit |
20% Levy |
Yes (MMAP
only applicable to Savings / Acute / Chronic and OTC Benefit not to PMBs) |
4,5,7-9,17,24-25,27,30-31, 61-62 (Each
benefit has its own complex Exclusion List.
See the real-time response to verify) |
|
Chronic Benefit |
20% Levy |
||
|
Savings Benefit |
No Levy |
||
|
Prescribed Minimum Benefits (PMB) |
Medihelp Formulary Products: No Levy (subject to Medihelp Therapeutic Reference
Price) Medihelp Non-Formulary Products: Medihelp Therapeutic Reference Price Difference |
||
|
Core Benefit |
No
Levy |
||
|
OTC Benefit |
Medihelp Plus
20% Levy Dimension Elite
20% Levy Dimension Prime2
No Levy Dimension Prime3
20% Levy |
MEMBER
CLAIMS:
|
1. |
Surgical
appliances |
3. |
Medical
appliances |
|
2. |
Orthopedic
appliances |
4. |
Oxygen
and delivery systems |
PRESCRIBED
MINIMUM BENEFITS (PMBs):
Members need to apply for PMBs
and Chronic Medicine Benefits with Medichron/Medihelp
0860 100 678
If
you require any assistance, please contact:
Mediscor’s Share Call Centre Helpline : 0860 113 238 or 0860 117 705
Kind regards
JACK
PEREL