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MEDISCOR (PTY) LTD
1257 South Street, Centurion
PO Box 8796, Centurion, 0046
Tel:   (012) 674 8000
Fax:  (012) 674 8001

 

NOTIFICATION 53
OF
2011

 

 

23 December 2011

 

 

Medical Scheme

ThebeMed Medical Aid Scheme

Administrator

Thebe Ya Bophelo Healthcare Administrators

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 ThebeMed Medical Aid Scheme as outlined below.  

 

Herewith the detail for submitting medicine claims to Mediscor:

 

1.

Scheme Code (PCN)

1.

MDS0033

2.

Switch Destination Code

2.

TBEN0001

3.

EDI Activation Code (Dispensing Doctors)

3.

769P

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.

7 Numerical

16.

Payments to Providers

16.

ThebeMed 

17.

Chronic pre-authorisation

17.

Mediscor ChroniLine™

18.

Reimbursement structure – Dispensing Doctors

18.

SEP + 30%/R20

19.

Reimbursement structure – Pharmacies

19.

SEP + 28%/R28

20.

Over the counter (OTC)

20.

SEP + 28%/R28

·         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 ThebeMed Medical Aid Scheme effective from 1 January 2012:

 

OPTIONS

BENEFITS APPLICABLE

LEVY /
CO-PAYMENT

MRP®

EXCLUSIONS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Navigator

 

Energy

 

Universal

 

 

 

Acute  (Universal restricted to a Formulary)

No levy

Yes

 

1-9,11,14-15,17, 19-28,30-32,40-41, 45,47-48

Chronic

Navigator

Mediscor Standard Formulary:
No levy
Non-formulary products:
30% Co-payment

Energy

Mediscor Basic Formulary:
No levy
Non-formulary products:
30% Co-payment

Universal

Mediscor Core Formulary:
No levy
Non-formulary products:
Reject

Prescribed Minimum Benefits (PMB)

Navigator

Mediscor Standard Formulary:
No levy
Non-formulary products:
30% Co-payment

Energy

Mediscor Basic Formulary:
No levy
Non-formulary products:
30% Co-payment

Universal

Mediscor Core Formulary:
No levy
Non-formulary products:
Reject

Oncology

No Levy

HIV / AIDS

No Levy

Appliance (except Universal)

No levy

OTC Benefit
(except Universal)

No levy
Navigator: Max. R120 per month

Energy:  Max. R100 per prescription

Flu Vaccine

No levy

 

 

 

 

If you require any assistance, please contact:

 

Mediscor’s Call Centre

:

0860 113 238 or 0860 117 705

Mediscor ChroniLine™

Mediscor E-Mail

:

:

0860 119 553

helpdesk@mediscor.co.za

Kind regards

JACK PEREL