|
|
MEDISCOR (PTY) LTD |
NOTIFICATION
59
OF
2008 |
15 December 2008
|
|
Medical Scheme |
Community Medical Scheme (Commed) |
|
Administrator |
Allcare Administrators |
|
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 COMMED
Medical Scheme as outlined below.
Herewith
the details for submitting medicine claims to Mediscor:
|
1. |
Scheme
Code (PCN) |
1. |
MDS0038 |
|
2. |
Switch
Destination Code |
2. |
IHCO0000 |
|
3. |
EDI
Activation Code (Dispensing Doctors) |
3. |
009P |
|
4. |
*MRP® |
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 9
Numerical digits |
|
16. |
Payments
to Providers |
16. |
Allcare
Administrators |
|
17. |
Chronic/PMB
pre-authorisation at Mediscor |
17. |
Yes |
|
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.) |
* MEDISCOR
REFERENCE PRICE (MRP®) – information available on www.mediscor.net
* 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 COMMED Medical Scheme
effective from 1 January 2009:
|
OPTIONS |
BENEFIT STRUCTURE |
LEVY / |
MRP® |
EXCLUSIONS |
|
Deluxe Standard Core |
Acute Benefit (excluding Core) |
No Levy |
Yes |
1-9,11,14,15,
17,19-25, 27, 30-35, 40,41,43-45,
48,50-51, 53, 58, 60-62 |
|
Chronic
Benefit (excluding
Core) |
Deluxe: Mediscor Standard Formulary: Non-formulary products: 20%
co-payment Standard: Mediscor Standard Formulary: Non-formulary products: 20% co-payment |
|||
|
Prescribed
Minimum Benefits (PMBs) (excluding
Core) |
Deluxe: Mediscor Standard Formulary: Non-formulary products: 20%
co-payment Standard: Mediscor Standard Formulary: Non-formulary products: 20% co-payment |
|||
|
Appliances (excluding
Core) |
No Levy |
|||
|
Oncology (excluding
Core) |
No Levy |
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|
OTC/PAT |
No Levy R111 max. per prescription (Standard) |
|||
|
HIV |
No Levy |
Pre-authorised products will
allow 1 fill every 26 days.
PRESCRIBED
MINIMUM BENEFITS (PMBs):
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