MEDISCOR (PTY) LTD 1257 South Street, Centurion PO Box 8796, Centurion, 0046 Tel: (012) 674 8000 Fax: (012) 674 8001	NOTIFICATION 48 OF 2011
		21 December 2011

Medical Scheme	Momentum Health
Administrator	Momentum Medical Scheme Administrators (MMSA)
Information Relevant to	Benefits and Options for 2012
Effective Date	1 January 2012

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:

1.	Scheme Code (PCN)	1.	MDS0041
2.	Switch Destination Code	2.	MHEA0007
3.	EDI Activation Code (Dispensing Doctors)	3.	822P
4.	Momentum Health Rate (MHR)	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.	9 digit NAPPI code of medicine dispensed	13.	Yes / Compulsory
14.	ICD-10 Diagnosis code	14.	Yes / Compulsory
15.	Membership number requirements	15.	Minimum 4 Numerical including dependant code
16.	Payments to Providers	16.	MMSA
17.	Chronic pre-authorisation	17.	MMSA
18. 19. 20.	Reimbursement structure – Pharmacies Over the counter (OTC) Reimbursement structure – Doctors	18. 19. 20.	SEP + 26%/R26.00 SEP + 26%/R26.00 SEP + 30%/R23.40

· SEP (VAT Incl.) and dispensing fee (VAT Excl.)

· Reimbursement structure will be applied on scheduled medicines (0 – 8) and unscheduled products.

· ICD-10 codes – information available on www.medicalschemes.com

· 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 = New regulated pharmacy fee

§ No MHR

Herewith the Scheme rules for MOMENTUM HEALTH effective from 1 January 2012:

OPTION	BENEFIT STRUCTURE	LEVY / CO-PAYMENT	MHR	EXCLUSIONS
SUMMIT	Acute / Savings	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
	Homeopathic
	Chronic
	PMB
	OTC
	HIV / AIDS – DSP
	Surgical
	Organ Transplant
	Oncology
	Stoma Care
	Health Platform
	Ex Gratia
	Biological
	Health Assessment
	Health Saver

Excluded products for the Summit option may be obtained from Savings Benefit, if available.

OPTION	BENEFIT STRUCTURE	LEVY / CO-PAYMENT	MHR	EXCLUSIONS
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
	Chronic		Yes
	PMB
	OTC		No
	HIV / AIDS – DSP
	Surgical
	Organ Transplant
	Oncology
	Stoma Care
	Health Platform
	Health Assessment
	Health Saver
	Non accumulate
	Ex Gratia
OPTION	BENEFIT STRUCTURE	LEVY / CO-PAYMENT	Reference Pricing	EXCLUSIONS
EXTENDER GP OPTIONS	Acute	If the provider is a non-DSP, for GP options, the claim will pay with a 50% co-payment	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
	Chronic		Yes
	PMB
	OTC		No
	HIV / AIDS – DSP
	Surgical
	Organ Transplant
	Oncology
	Stoma Care
	Health Platform
	Health Assessment
	Health Saver
	Non accumulate
	Ex Gratia

OPTION	BENEFIT STRUCTURE	LEVY / CO-PAYMENT	MHR	EXCLUSIONS
INCENTIVE	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
	Chronic		Yes
	PMB
	OTC		No
	HIV/AIDS – DSP
	Oncology
	Stoma Care
	Health Platform
	Health Assessment
	Health Saver
	Ex Gratia
OPTION	BENEFIT STRUCTURE	LEVY / CO-PAYMENT	Reference Pricing	EXCLUSIONS
INCENTIVE GP OPTIONS	Acute	If the provider is a non-DSP, for GP options, the claim will pay with a 50% co-payment	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
	Chronic		Yes
	PMB
	OTC		No
	HIV/AIDS – DSP
	Oncology
	Stoma Care
	Health Platform
	Health Assessment
	Health Saver
	Ex Gratia

OPTION	BENEFIT STRUCTURE	LEVY / CO-PAYMENT	MHR	EXCLUSIONS
CUSTOM	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
	PMB		Yes
	OTC		No
	HIV / AIDS – DSP
	Oncology
	Stoma Care
	Health Platform
	Health Assessment
	Health Saver
	Ex Gratia
OPTION	BENEFIT STRUCTURE	LEVY / CO-PAYMENT	Reference Pricing	EXCLUSIONS
CUSTOM GP OPTIONS	Acute	If the provider is a non-DSP, for GP options, the claim will pay with a 50% co-payment	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
	PMB		Yes
	OTC		No
	HIV / AIDS – DSP
	Oncology
	Stoma Care
	Health Platform
	Health Assessment
	Health Saver
	Ex Gratia

CAPITATION OPTIONS:

OPTION	BENEFIT STRUCTURE	LEVY / CO-PAYMENT	MHR	EXCLUSIONS
ACCESS	Savings*	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
	OTC
	HIV / Aids - DSP
	Organ Transplant – State only
	Oncology – State only
	Stoma Care
	Health Assessment
	Health Saver
	Ex Gratia

OPTION	BENEFIT STRUCTURE	LEVY / CO-PAYMENT	MHR	EXCLUSIONS
INGWE	Savings*	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
	OTC
	HIV / Aids - DSP
	Organ Transplant – State only
	Oncology – State only
	Stoma Care
	Health Assessment
	Ex Gratia
	Health Saver
	Additional Benefit
OPTION	BENEFIT STRUCTURE	LEVY / CO-PAYMENT	MHR	EXCLUSIONS
INGWE 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
	Organ Transplant – State only
	Oncology – State only
	Exceptions
	Stoma Care
	Health Assessment
	Health Saver
	Additional Benefit

*The capitation formulary is excluded from the Savings Benefit.

CLINICAL DUR CHECKS APPLIED TO ALL CLAIMS

(Please check the on-line response)

• Drug to drug interaction (Informational)
• Drug to diagnosis/disease (Reject)
• Dosage range check (Reject)
• Drug to age checking (Reject)
• Drug to gender (Reject)
• Duplicate therapy (Informational)
• Duplicate ingredient (Reject)

Additional scheme rules for 2012:

· PMBs to pay from savings if not authorized

· If the provider is a non-DSP, for GP options, the claim will pay with a 50% co-payment.

If you require any assistance, please contact:

Mediscor’s Call Centre Mediscor E-Mail	: :	0860 113 238 or 0860 117 705 helpdesk@mediscor.co.za
Momentum Health	:	0860 117 859
HIV/AIDS – MMSA Your Life	:	0860 109 793

Kind regards.

JACK PEREL