|
|
MEDISCOR (PTY) LTD |
NOTIFICATION
57
OF
2008 |
15 December 2008
|
|
Medical Scheme |
Netcare Medical Scheme |
|
Administrator |
Momentum Medical Scheme
Administrators (MMSA) |
|
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 Netcare
Medical Scheme as outlined below.
Herewith
the details for submitting medicine claims to Mediscor:
|
1. |
Scheme
Code (PCN) |
1. |
MDS0046 |
|
2. |
Switch
Destination Code |
2. |
NPMS0000
|
|
3. |
EDI
Activation Code (Dispensing Doctors) |
3. |
067P |
|
4. |
MMAP© |
4. |
Yes
|
|
5. |
Maximum
supply of medicine |
5. |
30 Days |
|
6. |
Days of
supply of the dispensed medication |
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 the 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
diagnostic 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 Mediscor ChroniLine™ |
17. |
MMSA |
|
18. |
Reimbursement
structure – Dispensing Doctors |
18. |
SEP
+ 16% / R16.00 |
|
19. |
Reimbursement structure – Pharmacies |
19. |
SEP + 26% / R26.00 |
|
20. |
Scheduled
0 or Unscheduled |
20. |
SEP + max mark-up of 31% (VAT Excl.) |
* 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 Netcare Medical Scheme
effective from 1 January 2009:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MMAP© |
EXCLUSIONS |
|
Netcare |
Acute
|
No
Levy |
No |
3-5,
14-15, 24-25, 27, 30-32, 35, 45, 53, 61 |
|
Chronic |
No
Levy |
Yes |
||
|
PMB |
No Levy |
Yes |
||
|
OTC |
No Levy |
No |
||
|
HIV/Aids |
No Levy |
No |
||
|
Appliance |
No Levy |
No |
||
|
Organ
Transplant |
No Levy |
No |
||
|
Oncology |
No Levy |
No |
||
|
Homeopathic |
No Levy |
No |
||
|
Flu
Vaccines |
No Levy |
Yes |
||
|
Maternity |
No Levy |
No |
LIMITATIONS
AND SPECIAL REQUIREMENTS:
Pre-authorisation for the following is required from
MMSA:
- Oncology
- Immunosuppressive
- Growth Hormones
- Erythropoietin
- Surgical, medical and orthopaedic appliances
- Diagnostic agents and appliances
- Oxygen and delivery systems
- Stomacare
- Medicines for Prescribed Minimum Benefits (PMB)
(Prescription
refill every 24 days)
CLINICAL
DUR CHECKS APPLIED TO ALL CLAIMS
(Please check the on-line
response)
·
Drug to diagnosis/disease
·
Dosage range check
·
Drug to age checking
·
Drug to gender
·
Duplicate therapy
IF YOU REQUIRE ASSISTANCE,
PLEASE CONTACT:
Mediscor’s Share Call Centre
Helpline : 0860 113 238
or 0860 117 705
Netcare Medical Scheme Call Centre Helpline : 0860 103 406
Netcare Pre-authorisation : 0860 103 406
MMSA Health Benefit Checker (24 Hours) : 0860 104 040
Kind
regards.
JACK
PEREL