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MEDISCOR (PTY) LTD |
NOTIFICATION 61
OF
2008 |
18 December 2008
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|
Medical
Scheme |
Umvuzo Health Medical Scheme |
|
Administrator |
Umvuzo Health Medical Scheme (Self Administrated) |
|
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 Umvuzo Health Medical Scheme as outlined below.
Standard and Ultra Affordable Options:
·
GP Prescription claims – Use Mediscor Scheme Codes MDS0331
or MDS0300
·
Specialist Prescription Claims – Use Mediscor Scheme Codes
MDS0059
Supreme Option:
·
All claims – Use Mediscor Scheme Codes MDS0059
Herewith the details for
submitting Acute Medicine claims from Specialists to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0059
|
|
2. |
Switch Destination Code |
2. |
UHMS0001 |
|
3. |
EDI Activation Code (Dispensing
Doctors) |
3. |
No |
|
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. |
9 digit NAPPI code of medicine
dispensed |
13. |
Yes / Compulsory |
|
14. |
ICD-10 Diagnostic code |
14. |
Yes / Compulsory |
|
15. |
Membership number requirements |
15 |
Min. 6 Numerical |
|
16. |
Chronic pre-authorisation at
Mediscor |
16. |
No / Umvuzo Health |
|
17. |
Payments to Providers |
17. |
Umvuzo |
|
18. |
Reimbursement Structure -
Pharmacies |
18. |
SEP + 26% / R26.00 |
|
19. |
Reimbursement Structure – Dispensing Doctors |
19. |
SEP + 16% / R16.00 |
|
20. |
Reimbursement Structure –
Unscheduled and Schedule 0 Medicines |
20. |
SEP + 31% |
·
MEDISCOR
REFERENCE PRICE (MRP®) – 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, Formulary and Exclusion
criteria; SERVICE PROVIDERS MUST refer to our on-line responses
to apply the correct rules.
Herewith the rules for Umvuzo Medical Scheme effective 1 January 2009:
|
OPTION |
BENEFITS
APPLICABLE |
LEVY / |
MRP® |
EXCLUSIONS |
|
Standard & Ultra Affordable |
Savings |
No Levy |
Yes |
1-7, 11, 14, 15, 19, 21-25, 27,
30, 31, 32, 35, 40, 41, 43, 44, 45, 47, 50, 51, 57-59, 61-62 |
|
Acute Benefit |
No Levy Authorised Specialist
consultation and prescription only |
|||
|
Chronic
Benefit |
No Levy Medipost
– Only DSP |
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Prescribed
Minimum Benefits (PMBs) |
No Levy Medipost
– Only DSP |
|||
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Surgical
Benefit |
No levy |
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Oncology
Benefit (excluding
Ultra Affordable) |
No levy |
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High
Cost |
No Levy |
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HIV/AIDS |
No Levy |
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Intermediate |
No Levy |
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Acute Benefit |
No Levy |
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Chronic
Benefit |
No Levy |
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1-7, 11, 14,
15, 19, 21-25, 27, 30, 31, 32, 35, 40, 41, 43, 44, 45, 47, 50, 51, 57-59,
61-62 |
|
|
Prescribed
Minimum Benefits (PMBs) |
No Levy |
Yes |
|
Supreme
|
Surgical
Benefit |
No Levy |
|
|
|
|
Oncology
Benefit |
No Levy |
|
|
|
|
High
Cost |
No Levy |
|
|
|
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HIV/AIDS |
No Levy |
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|
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Intermediate |
No Levy |
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Psychiatric |
No Levy |
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OTC |
No Levy Max of
R150 per prescription |
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ADDITIONAL RULES
- Specialist claims:
Will only pay if Specialist consultation was authorized by Umvuzo
Health. Members to contact Umvuzo
on 086 108 3084. Specialist
Prescribers only.
- Surgical Benefit:
Pre-authorisation obtained from Umvuzo Health on 086 108 3084.
- Chronic/Prescribed Minimum Benefits (PMBs)
(Medipost is the only DSP): Members need to apply for
PMBs and Chronic Medicine Benefits by faxing the Specialist
prescription to Umvuzo Health on 086 670 2623. Umvuzo Formulary will apply.
If you require any assistance, please contact:
|
Mediscor’s Share Call Centre Helpline |
: |
0860 113 238 or 0860 117 705 |
Regards
JACK PEREL