|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 50OF2011 |
22
December 2011
|
|
Medical Scheme |
Bestmed Medical Scheme |
|
Administrator |
Sanlam Healthcare
Management |
|
Information Relevant to |
Benefits and Options
for 2012 |
|
Effective Date |
1 January 2012 |
With effect 1 January 2012, 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. |
Reference Pricing |
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. |
ICD-10 Diagnosis code |
13. |
Yes / Compulsory |
|
14. |
9 digit NAPPI code of medicine dispensed |
14. |
Yes / Compulsory |
|
15. |
Membership number requirements |
15. |
Min 7 Numerical digits |
|
16. |
Payments to Providers |
16. |
Bestmed |
|
17. |
Chronic/PMB pre-authorisation |
17. |
Bestmed |
|
18. |
Reimbursement structure – Dispensing Doctors |
18. |
SEP
+ 30%/R23.40
|
|
19. |
Reimbursement structure –
Pharmacies |
19. |
SEP + 33%/R33 |
|
20. |
Over the counter (OTC) |
20. |
SEP + 33%/R33 |
·
SEP
(VAT Incl.) and dispensing fee (VAT Excl.)
·
Reimbursement
structure will be applied on scheduled medicines (0 – 8) and unscheduled products.
·
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 2012:
Please note the
following options and name changes, effective 1 January 2012.
|
OPTIONS
2011 |
OPTIONS
2012 |
|
Blueprint |
Pulse1♥ |
|
Goldselect |
Pulse2♥ |
|
BonusPlus |
Pace1♥ |
|
Millennium Comprehensive and Gold |
Pace2♥ |
|
Topcare |
Pace3♥ |
|
Platinum |
Pace4♥ |
|
OPTIONS |
BENEFIT STRUCTURE |
CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Pulse1♥ |
Capitation Benefit |
No |
Yes |
According to capitation provider formulary |
|
HIV / AIDS |
||||
|
Oncology |
|
OPTIONS |
BENEFIT
STRUCTURE |
CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Pulse2♥ |
Capitation Benefit Managed by Onecare |
No |
Yes |
According to capitation provider formulary |
|
|
HIV/AIDS |
|||
|
|
Oncology |
|
OPTIONS |
BENEFIT
STRUCTURE |
CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Beat1♥ |
Oncology |
No |
Yes |
As per on-line response |
|
PMB Formulary |
No |
|||
|
PMB Non- Formulary |
35% |
|||
|
HIV / AIDS |
No |
|
OPTIONS |
BENEFIT
STRUCTURE |
CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Beat2♥ |
Acute/Savings |
No |
No |
14, 61 |
|
OTC |
No |
|||
|
Oncology |
No |
Yes |
||
|
PMB Formulary |
No |
|||
|
PMB Non-formulary |
35% |
|||
|
HIV/AIDS |
No |
|
OPTIONS |
BENEFIT
STRUCTURE |
CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Beat3♥ |
Acute / Savings |
No |
No |
14, 61 |
|
OTC |
No |
|||
|
Oncology |
No |
Yes |
||
|
Chronic Formulary |
15% |
|||
|
Chronic Non-formulary |
35% |
|||
|
PMB Formulary |
No |
|||
|
PMB Non-formulary |
35% |
|||
|
HIV/AIDS |
No |