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MEDISCOR (PTY) LTD |
NOTIFICATION 63
OF
2008 |
18 December 2008
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Medical
Scheme |
TOPMED Medical Scheme |
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Administrator |
Momentum Medical Scheme Administrators (MMSA) |
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Information
Relevant to |
Benefits and Options for 2009 |
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Effective
Date |
1 January 2009 |
With effect 1 January 2009, Mediscor will be applying the scheme rules
for TOPMED Medical Scheme as outlined below.
Herewith the details for
submitting medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0048 |
|
2. |
Switch Destination Code |
2. |
BKTE0001
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3. |
EDI Activation Code (Dispensing
Doctors) |
3. |
003P |
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4. |
MMAP© |
4. |
Yes
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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 |
|
7. |
Membership number as per
membership card |
7. |
Yes / Compulsory |
|
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. |
ICD-10 diagnostic code |
13. |
Yes / Compulsory |
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14. |
9 digit NAPPI code of medicine
dispensed |
14. |
Yes / Compulsory |
|
15. |
Membership number requirements |
15. |
Minimum 4 numerical including dependant code |
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16. |
Payments to Providers |
16. |
MMSA |
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17. |
Chronic pre-authorisation Mediscor ChroniLine™ |
17. |
MMSA |
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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 TOPMED
Medical Scheme effective from 1 January 2009:
|
OPTION |
BENEFIT STRUCTURE |
LEVY/CO-PAYMENT |
MMAP© |
EXCLUSIONS |
|
TOPMED LIMITED 100% & TOPMED 100% |
Acute |
20% |
Yes |
3,4,5, 11, 14, 15, 16, 19, 20 - 25, 27, 30, 31, 32, 35, 38, 40,
41, 43, 44, 45, 48, 51, 52, 53, 55, 60, 61, 64 |
|
Chronic |
No |
|||
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PMB |
30% Subject to Formulary & DSP |
|||
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OTC |
20% |
No |
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HIV |
No |
Yes |
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Appliances |
||||
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Oncology |
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Homeopathic |
20% |
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Maternity |
No |
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TOPMED 80% |
Acute |
20% |
Yes |
3,4,5, 11, 14, 15, 16, 19, 20 - 25, 27, 30, 31, 32, 35, 38, 40,
41, 43, 44, 45, 48, 51, 52, 53, 55, 60, 61, 64 |
|
Chronic |
20% (calculated by
MMSA) |
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PMB |
30% Subject to Formulary & DSP |
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OTC |
20% |
No |
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HIV |
No |
Yes |
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Appliances |
20% |
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|
Oncology |
No |
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Homeopathic |
20% |
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Maternity |
No |
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TOPMED INCENTIVE COMPREHENSIVE & TOPMED INCENTIVE SAVINGS |
Acute |
No |
Yes |
60, 64, 61 |
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Savings |
|
|||
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Chronic |
25% (Incentive
Comprehensive only) |
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|
PMB |
30% Subject to Formulary & DSP |
|||
|
OTC |
No |
No |
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HIV |
Yes |
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Appliances |
||||
|
Oncology |
||||
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Homeopathic |
||||
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Maternity |
||||
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TOPMED NETWORK
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PMB |
30% Subject to Formulary & DSP |
Yes |
3,4,5, 11, 14, 15, 16, 19, 20 - 25, 27, 30, 31, 32, 35, 38, 40,
41, 43, 44, 45, 48, 51, 52, 53, 55, 60, 61, 64 |
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HIV |
No |
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Oncology |
||||
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TOPMED HOSPITAL PLAN |
PMB |
30% Subject to Formulary & DSP |
Yes |
3,4,5, 11, 14, 15, 16, 19, 20 - 25, 27, 30, 31, 32, 35, 38, 40,
41, 43, 44, 45, 48, 51, 52, 53, 55, 60, 61, 64 |
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HIV |
No |
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Oncology |
||||
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Maternity |
LIMITATIONS AND SPECIAL REQUIREMENTS:
Pre-authorisation for the following is required from MMSA:
- Oncology
- Immunosuppressive
- Anti-retroviral medication
- Medicines for Prescribed Minimum Benefits (PMB)
(Prescription
refill once 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
ANY ASSISTANCE, PLEASE CONTACT:
Mediscor’s Share
Call Centre Helpline : 0860 113 238 or 0860 117 705
TOPMED Medical Scheme Call Centre Helpline &
Medicine
Pre-authorisation : 0860 002 158
Anti-retroviral medication (AfA) : 0860 100 646
MMSA Benefit
Checker (24 Hours) : 0860 104 040
Kind regards.
JACK PEREL