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MEDISCOR (PTY) LTD |
NOTIFICATION 65
OF
2008 |
18 December 2008
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|
Medical
Scheme |
CompCare Wellness Medical Scheme |
|
Administrator |
Status Medical Aid 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 CompCare Wellness Medical Scheme as outlined below.
Herewith the details for
submitting medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS1406 |
|
2. |
Switch Destination Code |
2. |
SSCC0000
|
|
3. |
EDI Activation Code (Dispensing
Doctors) |
3. |
129P |
|
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 |
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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 |
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15. |
Membership number requirements |
15. |
Minimum 3 digits |
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16. |
Payments to Providers |
16. |
Status |
|
17. |
Chronic pre-authorisation Mediscor ChroniLine™ |
17. |
Yes |
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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.) |
* 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 CompCare
Wellness Medical Scheme effective from 1 January 2009:
|
OPTIONS |
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Accolade Pinnacle Dynamix Mumed Symmetry Axis Networx |
Acute (Axis not
applicable) |
Accolade: 25 % Levy Networx: 25% Levy (out of network) Pinnacle
/ Dynamix / Mumed / Symmetry: No Levy |
Yes |
1-5, 6-9, 11, 19-25, 27, 30,
32, 40-41, 43-45, 47-51, 60-62 |
|
Chronic (Mumed,
Axis and Networx not applicable) |
Accolade
/ Pinnacle / Dynamix: Mediscor
Standard Formulary Non-formulary products: 25% co-payment Symmetry: Mediscor Basic Formulary Non-formulary products: 25% co-payment |
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OTC (Axis not
applicable) |
Accolade
/ Pinnacle / Dynamix : No Levy Max of R150 per prescription Symmetry
/ Mumed: No Levy Max of R125 per prescription Networx: No Levy Max of R100 per prescription |
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Oncology |
No Levy |
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HV/AIDS |
No Levy |
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Prescribed Minimum Benefits (PMB) |
Accolade
/ Pinnacle / Dynamix: Mediscor
Standard Formulary Non-formulary products: 25% co-payment Mumed /
Symmetry: Mediscor Basic Formulary Non-formulary products: 25% co-payment Axis /
Networx: Mediscor Core Formulary Non-formulary products: 25% co-payment |
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 Share Call Centre Helpline |
: |
0860 113 238 or 0860 117 705 |
|
Mediscor ChroniLine™ |
: |
0860 119 553 |
Kind regards.
JACK PEREL