|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 49OF2010 |
15
December 2010
|
|
Medical Scheme |
BESTmed |
|
Administrator |
Sanlam Healthcare Management |
|
Information Relevant to |
Benefits and Options
for 2011 |
|
Effective Date |
1 January 2011 |
With effect 1 January 2011, Mediscor will
be applying the scheme rules for BESTmed as outlined below.
Herewith the detail 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. |
Yes |
|
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
+ R20/30%
|
|
19. |
Reimbursement structure –
Pharmacies |
19. |
SEP + R33/33% |
|
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 2011:
Note: A 10% co-payment on Acute
will be applied by Bestmed if claim is reimbursed from Scheme benefits.
|
OPTIONS |
BENEFIT
STRUCTURE |
LEVY
/ |
MRP® |
EXCLUSIONS |
|
Beat 1 |
Oncology Benefit |
No Levy |
Yes |
As per on-line response |
|
PMB / Prescribed Minimum Benefits |
Formulary: 35% Co-Payment |
|||
|
HIV / AIDS |
No Levy |
|
OPTIONS |
BENEFIT STRUCTURE |
LEVY / |
MRP® |
EXCLUSIONS |
|
Blue Print |
Capitation Benefit Only |
No Levy |
Yes |
According to capitation provider
formulary |
|
HIV / AIDS |
||||
|
Oncology |
|
OPTIONS |
BENEFIT
STRUCTURE |
LEVY
/ |
MRP® |
EXCLUSIONS |
|
Bonus Plus |
Acute / Savings |
No Levy |
Yes |
14, 17, 24, 61 |
|
OTC |
No Levy (No maximum per script) |
|||
|
Oncology Benefit |
No Levy |
|||
|
Chronic Benefit |
Formulary: 35% Co-Payment |
|||
|
PMB / Prescribed Minimum Benefits |
Formulary: 35% Co-Payment |
|||
|
HIV/AIDS |
No Levy |
|||
|
Accountcard |
No Levy |
|
OPTIONS |
BENEFIT
STRUCTURE |
LEVY
/ |
MRP® |
EXCLUSIONS |
|
Beat2 |
Acute/Savings |
No Levy |
No |
14, 24, 61 |
|
OTC |
No Levy (No maximum per script) |
|||
|
Oncology Benefit |
No Levy |
Yes |
||
|
PMB / Prescribed Minimum Benefits |
Formulary: 35% Co-Payment |
|||
|
HIV/AIDS |
No Levy |
|
OPTIONS |
BENEFIT
STRUCTURE |
LEVY
/ |
MRP® |
EXCLUSIONS |
|
Beat3 |
Acute / Savings |
No Levy |
No |
14, 24, 61 |
|
OTC |
No Levy (No maximum per script) |
|||
|
Oncology Benefit |
No Levy |
Yes |
||
|
Chronic Benefit |
Formulary: 35% Co-Payment |
|||
|
PMB / Prescribed Minimum Benefits |
Formulary: 35% Co-Payment |
|||
|
HIV/AIDS |
No Levy |
|
OPTIONS |
BENEFIT
STRUCTURE |
LEVY
/ |
MRP® |
EXCLUSIONS |
|
Millennium Comprehensive |
Acute/Savings |
No Levy (BestMed may apply levy if
patient reaches supplementary benefit) |
No |
14, 24, 61 |
|
OTC |
No Levy (No maximum per script) |
|||
|
Oncology Benefit |
No Levy |
Yes |
||
|
Chronic Benefit |
Formulary: 25% Co-Payment |
|||
|
Life Sustaining Benefit |
Formulary: 25% Co-Payment |
|||
|
PMB / Prescribed Minimum Benefits |
Formulary: 25% Co-Payment |
|||
|
HIV/AIDS |
No Levy |
|
OPTIONS |
BENEFIT
STRUCTURE |
LEVY
/ |
MRP® |
EXCLUSIONS |
|
Topcare |
Acute / Savings |
No Levy |
No |
14, 24, 61 |
|
OTC |
No Levy (No maximum per script) |
|||
|
Oncology Benefit |
No Levy |
Yes |
||
|
Chronic Benefit |
Formulary: 25% Co-Payment |
|||
|
Life Sustaining Benefit |
Formulary: 25% Co-Payment |
|||
|
PMB / Prescribed Minimum Benefits |
Formulary: 25% Co-Payment |
|||
|
HIV/AIDS |
No Levy |
|
OPTIONS |
BENEFIT
STRUCTURE |
LEVY
/ |
MRP® |
EXCLUSIONS |
|
Best Platinum |
Acute Benefit |
No Levy |
Yes |
1-5, 7-9, 11, 14, 15, 19-25, 27, 28, 30-35, 40, 43-45, 47-51, 53, 60, 61, 63 |
|
|
OTC |
R150.00 maximum per script |
||
|
|
Chronic Benefit |
Formulary: 20% Co-Payment |
||
|
|
Life Sustaining Benefit |
Formulary: 20% Co-Payment |
||
|
|
PMB / Prescribed Minimum Benefit |
Formulary: 20% Co-Payment |
||
|
|
HIV/AIDS |
No Levy |
||
|
|
Oncology Benefit |
No Levy |
|
OPTIONS |
BENEFIT
STRUCTURE |
LEVY
/ |
MRP® |
EXCLUSIONS |
|
Best Gold |
Acute Benefit |
No Levy |
Yes |
1-5, 7-9, 11, 14, 15, 19-25, 27, 28, 30-35, 40, 41, 43-45,
47-51, 53, 58, 60, 61, 63 |
|
|
OTC |
R110.00 maximum per script |
||
|
|
Chronic Benefit |
Formulary: 25% Co-Payment |
||
|
|
PMB / Prescribed Minimum Benefits |
Formulary: 25% Co-Payment |
||
|
|
HIV/AIDS |
No Levy |
||
|
|
Oncology Benefit |
No Levy |
|
OPTIONS |
BENEFIT
STRUCTURE |
LEVY
/ |
MRP® |
EXCLUSIONS |
|
Best Gold Select |
Capitation Benefit Only Managed by Onecare |
|
|
|
|
|
HIV/AIDS |
No Levy |
||
|
|
Oncology Benefit |
No Levy |
Additional
Customised Exclusions:
|
1. |
Therapeutic Category 26 – Biologicals |
PRESCRIBED MINIMUM
BENEFITS (PMBs) & CHRONIC MEDICINE APPLICATIONS:
Members must apply
for PMBs and Chronic Medicine Benefits as well as Capitation Benefits with BESTmed – 086 000 2378
or email: medicine@bestmed.co.za
If you require any assistance,
please contact:
|
Mediscor’s Toll-free
Call Centre Helpline |
: |
0860 113 238
or 0860 117 705 |
Kind regards.
JACK PEREL