|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 5
OF
2011
|
30 March 2011
|
|
Medical Scheme |
Nampak SA Medical Scheme |
|
Administrator |
Momentum Medical Scheme
Administrators |
|
Information Relevant to |
MMAP© Change on Extended
Option |
|
Effective Date |
1 April 2011 |
With effect 1 April 2011, Mediscor will be
applying the scheme rules for Nampak SA Medical Scheme as outlined below.
Herewith the detail for submitting medicine claims to
Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0043 |
|
2. |
Switch Destination Code |
2. |
NMAK0000
|
|
3. |
EDI Activation Code
(Dispensing Doctors) |
3. |
046P |
|
4. |
MMAP© |
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. |
Minimum 4 numerical
including dependant code |
|
16. |
Payments to Providers |
16. |
MMSA |
|
17. |
Chronic
pre-authorisation |
17. |
MMSA |
|
18. |
Reimbursement structure – Dispensing Doctors |
18. |
SEP + 30%/R20 |
|
19. |
Reimbursement structure –
Pharmacies |
19. |
SEP + 26%/R26 |
|
20. |
Scheduled 0 or Unscheduled |
20. |
SEP + max mark-up of 31%
(VAT Excl.) |
·
ICD-10 CODES – information available on www.medicalschemes.com
*MMAP© change implemented on Extended option from
01/04/2011
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 Nampak SA Medical Scheme effective from 1
April 2011:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MMAP© |
EXCLUSIONS |
|
Extended |
Chronic |
No Levy |
Yes* |
3-5, 14, 15, 24, 25, 27, 30-32, 35, 45, 53, 61 |
|
Acute / Savings |
No Levy |
No |
||
|
PMB |
No Levy |
|||
|
OTC |
No Levy Maximum of R80
per prescription |
|||
|
HIV/Aids |
No Levy |
|||
|
Appliance |
No Levy |
|||
|
Oncology |
No Levy |
|||
|
Homeopathic |
No Levy |
|||
|
Flu Vaccines |
No Levy Maximum of R75
per prescription |
|||
|
|
|
|
|
|
|
Standard |
Acute / Savings |
No Levy |
Yes |
1-5, 7, 11, 14-16, 19, 20, 22-25, 27,
30-32, 35, 40, 41, 43-45, 49-51, 53, 55, 57, 58, 61 |
|
Chronic |
No Levy |
|||
|
PMB |
No Levy |
|||
|
OTC |
No Levy Maximum of R80
per prescription |
|||
|
HIV/Aids |
No Levy |
No |
||
|
Oncology |
No Levy |
|||
|
Appliance |
No Levy |
Yes |
||
|
Homeopathic |
No Levy |
|||
|
Flu Vaccines |
No Levy Maximum of R75
per prescription |
No |
*MMAP© change implemented on Extended option from 01/04/2011
LIMITATIONS AND
SPECIAL REQUIREMENTS:
Pre-authorisation for the following is required
from MMSA:
- Oncology
- Immunosuppressive
- Growth Hormones
- Immunomodulators
- Anti-retroviral medication
- Erythropoietin
- Surgical, medical and orthopaedic appliances
- Diagnostic agents and appliances
- Oxygen and delivery systems
- Stomacare
- Osteoporosis medication (Standard option only)
- Fertility drugs (Standard option only)
- Pre-natal vitamins
- Medicines for Prescribed Minimum Benefits
(PMB)
(Prescription refill every 24 days)
CLINICAL DUR CHECKS
APPLIED TO ALL CLAIMS
(Please check the on-line response)
·
Drug to diagnosis/disease
·
Dosage range check
·
Drug to age checking
·
Drug to gender
·
Duplicate therapy
IF YOU REQUIRE ANY ASSISTANCE, PLEASE
CONTACT:
Mediscor’s Share Call Centre Helpline : 0860 113 238 or 0860 117 705
MMSA Helpline & Medicine Pre-authorisation : 0860 101 047
Anti-retroviral medication – MMSA Your
Life : 0860
109 793
MMSA Benefit Checker (24 Hours) : 0860
104 040
Kind regards.
JACK PEREL