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MEDISCOR (PTY) LTD |
NOTIFICATION
58
OF
2008 |
15 December 2008
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Medical Scheme |
MOTO Health Care |
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Administrator |
Momentum
Medical Scheme Administrators (MMSA)
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Information Relevant to |
New
Contract – MOTO Health Care |
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Effective Date |
1 January 2009 |
MOTO Health Care administered
by Momentum Medical Scheme Administrators (MMSA) has exclusively appointed
Mediscor PBM for the processing of all medicine claims as well as material
& consumable claims from service providers (pharmacies, dispensing
providers and all discipline types) with service date 1 January 2009.
Mediscor
will be responsible for the processing of all electronic claims while MMSA will
be responsible for the authorisation of Chronic, HIV and Oncology medicines,
including medicines falling under Prescribed Minimum Benefits (PMB’s).
Herewith the details
for submitting medicine claims to Mediscor:
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1. |
Scheme Code (PCN) |
1. |
MDS0049 |
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2. |
Switch Destination Code |
2. |
MHCA0001
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3. |
EDI Activation Code (Dispensing Doctors) |
3. |
940P
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4. |
MMAP / MRP |
4. |
MRP |
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5. |
Maximum supply of medicine |
5. |
30 Days |
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6. |
Days of supply of the dispensed medication |
6. |
Yes /Compulsory |
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7. |
Membership number as per membership card |
7. |
Yes / Compulsory |
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8. |
Dependant code as per membership card |
8. |
Yes / Compulsory |
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9. |
Dependant first name as per the membership card |
9. |
Yes / Compulsory |
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10. |
Dependant date of birth |
10. |
Yes /Compulsory |
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11. |
Dependant’s gender (male/female) |
11. |
Yes / Compulsory |
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12. |
Practice number of the prescriber |
12. |
Yes / Compulsory |
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13. |
9 digit NAPPI code of medicine dispensed |
13. |
Yes / Compulsory |
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14. |
ICD-10 Diagnostic code |
14. |
Yes / Compulsory |
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15. |
Membership number requirements |
15. |
Minimum 4 Numerical including
dependant code |
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16. |
Payments
to Providers |
16. |
MMSA |
|
17. |
Chronic pre-authorisation |
17. |
MMSA |
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18. |
Reimbursement structure – Pharmacies |
18. |
S1 to
S8: SEP + 26% / R 26, unscheduled & S0: SEP + 31% (excl. VAT) |
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19. |
Reimbursement structure – Doctors |
19. |
S1 to S8: SEP + 16% / R 16, unscheduled & S0: SEP +
31% (excl. VAT) |
VERY IMPORTANT
There is no need to submit
various claiming codes to distinguish between benefit types. Simply enter the Scheme Code and we will
access the appropriate benefit depending on the medicines being claimed. Please refer to our electronic response
message on the processed claim.
The Scheme Limitations,
Requirements and Clinical Checks mentioned below, have been included in this
Communiqué to inform
Providers of the Managed Care initiatives that will be implemented. These Rules
and Checks will be managed and monitored by our PBM System and the results will
be communicated to Providers via the real-time response on the processed claim.
Herewith
the Scheme rules for MOTO Health Care:
|
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 |
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Chronic |
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PMB |
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HIV/AIDS |
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Appliance |
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Organ Transplant |
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Oncology |
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Homeopathic |
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Renal |
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Maternity |
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OTC (Max R120 per script) |
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Hospicare |
Chronic |
No Levy |
Yes |
No Acute
benefit. Only authorised products permitted |
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PMB |
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HIV/AIDS |
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Appliance |
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Organ Transplant |
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Oncology |
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Homeopathic |
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Renal |
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Maternity |
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Custom
& Essential (Network provider options) |
Acute (restricted to network provider formulary) |
No Levy |
Yes |
Restricted
to network provider formularies |
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Chronic (restricted to network provider formulary) |
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PMB (restricted to network provider formulary) |
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HIV/AIDS (restricted to network provider formulary) |
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Appliance |
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Organ Transplant |
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Oncology |
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Renal |
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Maternity |
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/Due Checks
Applied to all Claims:
(Please check the on-line
response)
|
Drug to diagnosis/disease |
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Dosage range checking |
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Drug to age checking |
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Drug to gender |
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Duplicate therapy |
IF
YOU REQUIRE ANY ASSISTANCE, PLEASE CONTACT:
Mediscor’s Toll-free Call Centre Helpline : 0860 113 238 or 0860 117 705
MOTO Health Care
Call Centre Helpline &
Medicine Pre-authorisation : 0860 101 047
MMSA Benefit Checker (24 Hours) : 0860 104 040
Kind
regards.
JACK
PEREL