MEDISCOR (PTY) LTD 1257 South Street, Centurion PO Box 8796, Centurion, 0046 Tel: (012) 674 8000 Fax: (012) 674 8001	NOTIFICATION 54 OF 2011
		23 December 2011

Medical Scheme	TOPMED Medical Scheme
Administrator	Momentum Medical Scheme Administrators (MMSA)
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 TOPMED Medical Scheme as outlined below.

Herewith the detail for submitting medicine claims to Mediscor:

1.	Scheme Code (PCN)	1.	MDS0048
2.	Switch Destination Code	2.	BKTE0001
3.	EDI Activation Code (Dispensing Doctors)	3.	003P
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.	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%/R23.40
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.

· 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 TOPMED Medical Scheme effective from 1 January 2012:

OPTION	BENEFIT STRUCTURE	LEVY/CO-PAYMENT	MMAP©	EXCLUSIONS
TOPMED TRADITIONAL	Acute	20%	Yes	60, 61, 64
	Savings	No
	Chronic	No
	PMB	30% Subject to DSP
	OTC	20%	No
	HIV	No	Yes
	Appliances	20%
	Oncology	No
	Homeopathic	20%
	Maternity	No
	Core
	Wellness
TOPMED PROFESSIONAL TOPMED SAVINGS	Acute	No	Yes	60, 61, 64
	Savings	No
	Chronic	No
	PMB	30% Subject to Formulary & DSP
	OTC	No	No
	HIV		Yes
	Appliances
	Oncology
	Homeopathic
	Maternity
	Core
	Wellness
TOPMED NETWORK	PMB	30% Subject to Formulary & DSP	Yes	3,4,5, 11, 14, 15, 16, 19, 20 - 25, 27, 30, 31, 32, 35, 38, 40, 41, 43, 44, 45, 48, 51, 52, 53, 55, 60, 61, 64
	HIV	No
	Oncology
	Core
	Wellness

OPTION	BENEFIT STRUCTURE	LEVY/CO-PAYMENT	MMAP©	EXCLUSIONS
TOPMED HOSPITAL	Savings	No	Yes	60, 61, 64
	PMB	30% Subject to Formulary & DSP
	HIV	No
	Oncology
	Maternity
	Core
	Wellness

LIMITATIONS AND SPECIAL REQUIREMENTS:

Pre-authorisation for the following is required from MMSA:

• Oncology
• Immunosuppressive
• Anti-retroviral medication
• Medicines for Prescribed Minimum Benefits (PMB)

(Prescription refill once every 24 days)

CLINICAL DUR CHECKS APPLIED TO ALL CLAIMS

(Please check the on-line response)

• Drug to drug interaction (Informational)
• Drug to diagnosis/disease (Reject)
• Dosage range check (Reject)
• Drug to age checking (Reject)
• Drug to gender (Reject)
• Duplicate therapy (Informational)
• Duplicate ingredient (Reject)

 IF YOU REQUIRE ANY ASSISTANCE, PLEASE CONTACT:

Mediscor’s Call Centre : 0860 113 238 / 0860 117 705
Mediscor E-Mail : helpdesk@mediscor.co.za

HIV/ AIDS - TOPMED Your Life : 0860 109 793

TOPMED Medical Scheme Helpline : 0860 002 158

Kind regards.

JACK PEREL