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|
MEDISCOR
(PTY) LTD |
NOTIFICATION 48OF2009 |
18/12/2009
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|
Medical Scheme |
Community Medical Scheme (Commed) |
|
Administrator |
Allcare Administrators |
|
Information Relevant to |
Benefits and Options
for 2010 |
|
Effective Date |
1 January 2010 |
With effect 1 January 2010, Mediscor will
be applying the scheme rules for COMMED Medical Scheme as outlined below.
Herewith the detail for submitting medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0038 |
|
2. |
Switch Destination Code |
2. |
IHCO0000 |
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3. |
EDI Activation Code (Dispensing Doctors) |
3. |
009P |
|
4. |
*MRP® |
4. |
Yes |
|
5. |
Maximum supply of medicine |
5. |
30 Days |
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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 |
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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 |
|
12. |
Practice number of the prescriber |
12. |
Yes / Compulsory |
|
13. |
ICD-10 Diagnostic code |
13. |
Yes / Compulsory |
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14. |
9 digit NAPPI code of medicine dispensed |
14. |
Yes / Compulsory |
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15. |
Membership number requirements |
15. |
Minimum 9 Numerical digits |
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16. |
Payments to Providers |
16. |
Allcare Administrators |
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17. |
Chronic/PMB pre-authorisation at Mediscor |
17. |
Yes |
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18. |
Reimbursement structure – Dispensing Doctors |
18. |
SEP + R20/30% |
|
19. |
Reimbursement structure –
Pharmacies |
19. |
SEP + R26/26% |
|
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 COMMED Medical Scheme effective from 1 January 2010:
|
OPTIONS |
BENEFIT STRUCTURE |
LEVY / |
MRP® |
EXCLUSIONS |
|
Deluxe Standard Core |
Acute Benefit (excluding Core) |
No Levy |
Yes |
1-9,11,14,15, 17,19-25, 27, 30-35, 40,41,43-45, 48,50-51, 53, 55, 56, 58,
60-62 |
|
Chronic Benefit (excluding Core) |
Deluxe:
Mediscor Basic Formulary: Non-formulary products: 20%
co-payment Standard: Mediscor Core Formulary: Non-formulary products: 20% co-payment |
|||
|
Prescribed Minimum Benefits (PMBs) (excluding Core) |
Deluxe:
Mediscor Basic Formulary: Non-formulary products: 20%
co-payment Standard: Mediscor Core Formulary: Non-formulary products: 20% co-payment |
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Appliances (excluding Core) |
No Levy |
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Oncology (excluding Core) |
No Levy |
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OTC/PAT |
Deluxe: No Levy Standard: No Levy R100.00 max. per prescription |
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HIV |
No Levy |
Pre-authorised products will allow 1 fill every 26 days.
PRESCRIBED MINIMUM BENEFITS (PMBs):
Members must apply and register for PMBs and Chronic Medicine Benefits
with Mediscor ChroniLine™ on 0860 119 553.
If you require any assistance, please contact:
|
Mediscor’s Toll-free Call
Centre Helpline |
: |
0860 113 238
or 0860 117 705 |
|
Mediscor ChroniLine™ |
: |
0860 119 553 |
Kind regards.
JACK PEREL