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|
MEDISCOR
(PTY) LTD |
NOTIFICATION 55OF2011 |
23
December 2011
|
|
Medical Scheme |
MOTO Health Care |
|
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 MOTO Health Care as outlined below.
Herewith the
detail for submitting medicine claims to Mediscor:
|
1. |
Scheme Code
(PCN) |
1. |
MDS0049 |
|
2. |
Switch
Destination Code |
2. |
MHCA0001
|
|
3. |
EDI Activation
Code (Dispensing Doctors) |
3. |
940P
|
|
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. |
9 digit NAPPI code of
medicine dispensed |
13. |
Yes / Compulsory |
|
14. |
ICD-10 Diagnostic code |
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.
·
Mediscor Reference Price (MRP®) – information available on www.mediscor.net
·
ICD-10
codes – information available on www.medicalschemes.com
·
HOSPICARE: Subject to a closed DSP
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 MOTO Health Care
effective from 1 January 2012:
|
OPTION |
BENEFIT STRUCTURE |
LEVY / CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Optimum & Classic |
Acute |
No Levy |
Yes |
1-5; 7-9; 11; 14-16; 19-22; 24; 25;
27; 30-35; 37; 38; 40; 41; 43-49; 52; 53; 56; 57; 59; 60; 62-64 |
|
Chronic |
Yes |
|||
|
PMB |
Optimum: Mediscor Extended Formulary: No co-pay Out of formulary products: 10% co-pay Classic: Mediscor Standard Formulary: No Levy Non-Preferred Formulary as well as Out of formulary
products: 10% co-pay |
Yes |
||
|
HIV/AIDS |
No Levy |
Yes |
||
|
Appliance |
N/A |
|||
|
Organ Transplant |
||||
|
Oncology |
||||
|
Homeopathic |
||||
|
Renal |
||||
|
Maternity |
||||
|
OTC (Max R120 per script) |
Yes |
|||
|
HIV PEP |
|
OPTION |
BENEFIT STRUCTURE |
LEVY / CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Hospicare |
Chronic |
No Levy |
Yes |
No Acute benefit. Only authorised products
permitted |
|
PMB |
Mediscor Basic Formulary: No Levy Non-Preferred Formulary as well as Out of formulary
products: 10% co-pay |
Yes |
||
|
HIV/AIDS |
No Levy |
Yes |
||
|
Appliance |
N/A |
|||
|
Organ Transplant |
||||
|
Oncology |
||||
|
Homeopathic |
||||
|
Renal |
||||
|
Maternity |
||||
|
HIV PEP |
Yes |
|||
|
Custom & Essential (Network provider options) |
Acute (restricted to network provider formulary) |
No Levy |
Yes |
Restricted to network provider formularies |
|
Chronic (restricted to network provider
formulary) |
Yes |
|||
|
PMB (restricted to network provider formulary) |
Yes |
|||
|
HIV/AIDS (restricted to network provider
formulary) |
Yes |
|||
|
Appliance |
N/A |
|||
|
Organ Transplant |
||||
|
Oncology |
||||
|
Renal |
||||
|
Maternity |
||||
|
HIV PEP |
Yes |
Limitations and
Special Requirements:
Pre-authorisation for the following is required from MMSA:
- Oncology
- Immunosuppressive
- Anti-retroviral
medication
- Oxygen and
delivery systems
- Stomacare
- Prenatal
vitamins
- Coal tar
shampoos
- 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 or 0860 117 705
Mediscor E-Mail : helpdesk@mediscor.co.za
MOTO Health Care : 0860
000 300
HIV/ AIDS - Your Life
: 0860 109 793
Kind
regards
JACK PEREL