|
|
MEDISCOR (PTY) LTD |
NOTIFICATION
53
OF
2008 |
12 December 2008
|
|
Medical Scheme |
UMED Medical Scheme |
|
Administrator |
Discovery Health |
|
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 UMED
Medical Scheme as outlined below.
Herewith
the details for submitting medicine claims to Mediscor:
|
1. |
Scheme
Code (PCN) |
1. |
MDS0008 |
|
2. |
Switch
Destination Code |
2. |
UMUM0000
|
|
3. |
MMAP© |
3. |
Yes
|
|
4. |
Maximum
supply of medicine |
4. |
30 Days |
|
5. |
Days of
supply of the dispensed medication |
5. |
Yes
/Compulsory |
|
6. |
Membership
number as per membership card |
6. |
Yes /
Compulsory |
|
7. |
Dependant
code as per membership card |
7. |
Yes /
Compulsory |
|
8. |
Dependant
first name as per the membership card |
8. |
Yes /
Compulsory |
|
9. |
Dependant
date of birth |
9. |
Yes
/Compulsory |
|
10. |
Dependant’s
gender (male/female) |
10. |
Yes /
Compulsory |
|
11. |
Practice
number of the prescriber |
11. |
Yes /
Compulsory |
|
12. |
ICD-10
diagnostic code |
12. |
Yes /
Compulsory |
|
13. |
9 digit
NAPPI code of medicine dispensed |
13. |
Yes /
Compulsory |
|
14. |
Membership
number requirements |
14. |
9 Numerical digits |
|
15. |
Payments
to Providers |
15. |
Discovery |
|
16. |
Chronic
pre-authorisation Mediscor ChroniLine™ |
16. |
Yes |
|
17. |
Reimbursement
structure – Dispensing Doctors |
17. |
Not
Applicable |
|
18. |
Reimbursement structure – Pharmacies |
18. |
SEP + 36% / to max of R52.10 |
|
19. |
Scheduled
0 or Unscheduled |
19. |
SEP + 36% / to max of R52.10 |
* MEDISCOR FORMULARIES – 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 UMED
Medical Scheme effective from 1 January 2009:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MMAP© |
EXCLUSIONS |
|
Classic Value |
Acute |
20%
per line item |
Yes |
1-5,
7-11, 14-15, 19, 21-25, 27, 30-32, 35, 40-41, 43-45, 50-51, 53, 61-62 |
|
Chronic
|
No
Levy |
|||
|
Homeopathic |
20%
per line item |
|||
|
OTC |
20%
per line item |
|||
|
Prescribed
Minimum Benefits (PMB) |
Formulary Products: No
Levy Non-Formulary
Products: 20%
Levy |
|||
|
Oncology |
No
Levy |
|||
|
Flu
Vaccines |
No
Levy |
|||
|
Appliance |
No
Levy |
|||
|
Alternative |
No
Levy |
|||
|
Stoma |
No
Levy |
|||
|
High
Risk |
No
Levy |
PRESCRIBED
MINIMUM BENEFITS (PMBs):
·
Mediscor Basic Formulary used for Value option
·
Mediscor Standard Formulary used for Classic option
Members
need to apply and register for PMBs and Chronic Medicine Benefits with Mediscor
ChroniLine™ on 0860 119 553.
If
you require any assistance, please contact:
|
Mediscor’s Share Call Centre Helpline |
: |
0860 113 238 or 0860 117 705 |
|
Mediscor ChroniLine™ |
: |
0860 119 553 |
Kind
regards.
JACK
PEREL