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MEDISCOR (PTY) LTD |
NOTIFICATION
49
OF
2008 |
11 December 2008
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Medical Scheme |
BESTmed |
|
Administrator |
BESTmed |
|
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 BESTmed
as outlined below.
Herewith
the details for submitting medicine claims to Mediscor:
|
1. |
Scheme
Code (PCN) |
1. |
MDS0027 |
|
2. |
Switch
Destination Code |
2. |
BEBE0000 |
|
3. |
EDI
Activation Code (Dispensing Doctors) |
3. |
045P |
|
4. |
MRP® |
4. |
Bonus
Plus option only |
|
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 digits |
|
16. |
Payments
to Providers |
16. |
BESTmed |
|
17. |
Chronic/PMB
pre-authorisation at Mediscor |
17. |
No-BESTmed |
|
18. |
Reimbursement
structure – Dispensing Doctors |
18. |
SEP + R16/16%
|
|
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
* 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 BESTmed effective
from 1 January 2009:
|
OPTIONS |
BENEFIT STRUCTURE |
LEVY / |
MRP® |
EXCLUSIONS |
|
Blue Print |
Capitation Benefit
Only |
No Levy |
No |
According to
capitation provider formulary |
|
Bonus Plus |
Acute / Savings |
No Levy |
Yes |
1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 18, 19, 20, 21, 22, 23, 24, 25,
26, 27, 28, 30, 31, 32, 33, 34, 40, 41, 43, 44, 45, 47, 48, 49, 53, 62 Exclusions will pay from Account Card / Reject, subject to
availability of funds. |
|
Special Benefit |
No Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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Oncology Benefit |
No Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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Chronic Benefit |
15% Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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PMB / Prescribed
Minimum Benefits |
Formulary: Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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HIV/AIDS |
Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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Millennium Basic |
Acute/Savings |
No Levy |
No |
Exclusions will pay
from Savings Benefit / Reject, subject to availability of funds Exclusions will pay
from Savings Benefit / Reject, subject to availability of funds |
|
Special Benefit |
No Levy Difference between
cost of approved nappi and claimed nappi co-payment No Levy |
|||
|
Oncology Benefit |
No Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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PMB / Prescribed
Minimum Benefits |
Formulary: Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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Millennium Standard |
Acute / Savings |
No Levy |
No |
|
|
Special Benefit |
No Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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Oncology Benefit |
No Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
|
Chronic Benefit |
15% Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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PMB / Prescribed
Minimum Benefits |
Formulary: Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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HIV/AIDS |
Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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Millennium
Comprehensive |
Acute/Savings |
No Levy (BestMed may
apply levy if patient reaches supplementary benefit) |
No |
|
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Specific Exclusions |
15% Levy |
|||
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Special Benefit |
No Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
|
Oncology Benefit |
No Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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Chronic Benefit |
15% Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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Life Sustaining
Benefit |
15% Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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PMB / Prescribed
Minimum Benefits |
Formulary: Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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HIV/AIDS |
Difference between
cost of approved nappi and claimed nappi co-payment |
|||
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Topcare |
Acute / Savings |
No Levy |
No |
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Specific Exclusions |
15% Levy |
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Special Benefit |
No Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
|
Oncology Benefit |
No Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
|
Chronic Benefit |
15% Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
|
Life Sustaining
Benefit |
15% Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|||
|
PMB / Prescribed
Minimum Benefits |
Formulary: Difference between
cost of approved nappi and claimed nappi co-payment |
|||
|
HIV/AIDS |
Difference between
cost of approved nappi and claimed nappi co-payment |
|||
|
VitalCare |
Special Benefit |
No Levy Difference between
cost of approved nappi and claimed nappi co-payment |
|
|
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Oncology Benefit |
No Levy Difference between
cost of approved nappi and claimed nappi co-payment |
No |
||
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PMB / Prescribed
Minimum Benefits |
Formulary: Difference between cost
of approved nappi and claimed nappi co-payment |
|
||
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HIV/AIDS |
Difference between
cost of approved nappi and claimed nappi co-payment |
|
Additional Customised Exclusions:
|
1. |
Therapeutic Category 26 – Biologicals |
PRESCRIBED MINIMUM BENEFITS (PMBs) & CHRONIC MEDICINE
APPLICATIONS:
Members need to apply for PMBs and Chronic Medicine Benefits as well as
Capitation Benefits with BESTmed
Medical Scheme - 012-339 9845 or 012-339 9846.
If you require any assistance, please contact:
|
Mediscor’s Share Call Centre Helpline |
: |
0860 113 238 or 0860 117 705 |
Kind regards.
JACK PEREL