|
|
MEDISCOR
(PTY) LTD |
NOTIFICATION 59OF2010 |
14
December 2010
|
|
Medical Scheme |
Protea Medical Aid Society |
|
Administrator |
Universal Healthcare |
|
Information Relevant to |
New Mediscor scheme |
|
Effective Date |
1 January 2011 |
With effect 1 January 2011, Mediscor has been
exclusively contracted by Protea Medical Aid Society
to process all pharmacy and doctor claims as outlined below.
Herewith the detail for submitting medicine claims to
Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0068 |
|
2. |
Switch Destination Code |
2. |
DEAP0000
|
|
3. |
EDI Activation Code
(Dispensing Doctors) |
3. |
156P |
|
4. |
MRP® / FRP |
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 3 digits |
|
16. |
Payments to Providers |
16. |
Universal Healthcare |
|
17. |
Chronic pre-authorisation Mediscor ChroniLine™ |
17. |
Yes |
|
18. |
Reimbursement structure –
Dispensing Doctors |
18. |
SEP + R20/30% |
|
19. |
Reimbursement structure –
Pharmacies |
19. |
SEP + R26/26% |
|
20. |
Scheduled 0 or Unscheduled |
20. |
SEP + max mark-up of 31%
(VAT Excl.) |
·
MEDISCOR REFERENCE PRICE (MRP®) – information available on
www.mediscor.net
·
FORMULARY
REFERENCE PRICE (FRP) – 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 Protea Medical Aid Society effective from 1
January 2011:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MRP® / FRP |
EXCLUSIONS |
|
Essential Hospital |
Acute
|
Essential only Limited
to formulary No
Levy |
MRP |
3-5, 6-9, 11, 19-25, 27, 30, 32, 40-41, 43-45, 47-51,
60-62 |
|
OTC |
Essential only
Limited to
formulary No Levy Max of R140
per prescription |
MRP |
||
|
Prescribe
Minimum Benefits (PMB) |
Essential: Mediscor Core Formulary Non-formulary
products: No co-payments (subject to Formulary Reference Price) |
FRP |
||
|
Hospital: Mediscor Basic Formulary Formulary
products: No co-payment Non-formulary
products: 25% co-payment |
MRP |
|||
|
Oncology |
No
Levy |
MRP |
||
|
HIV
/ AIDS |
No
Levy |
MRP |
ADDITIONAL CUSTOMISED EXCLUSIONS:
1.
Nootropil™
2.
Phenolphthalein
laxatives™
3.
Phensydyl™ and
generic equivalents
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 Toll-free Call
Centre Helpline |
: |
0860 113 238
or 0860 117 705 |
|
Mediscor ChroniLine™ |
: |
0860 119 553 |
Kind regards.
JACK PEREL