|
|
MEDISCOR (PTY) LTD |
NOTIFICATION 67
OF
2008 |
19 December 2008
|
|
Medical
Scheme |
SPECTRAMED Medical Scheme |
|
Administrator |
Medscheme (New) |
|
Information
Relevant to |
Benefits and Options for 2009 |
|
Effective
Date |
1 January 2009 |
As from 1 January 2009, SPECTRAMED
Medical Scheme will be administered by Medscheme.
Rowan and Angel will remain
responsible for the administration of all 2008 service dates, until 30 April
2009 under the scheme code (PCN) MDS0012.
It is important to note that
SPECTRAMED members can still use their OLD medical aid numbers (Alpha-numeric)
when claiming for services in 2009. Service providers are urged to not refuse
services to SPECTRAMED members should they present an OLD membership card.
With effect 1 January 2009,
Mediscor will be applying the scheme rules for SPECTRAMED Medical Scheme as
outlined below.
Herewith the details for
submitting medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0062 |
|
2. |
Switch
Destination Code
|
2. |
ROSP0000 |
|
3. |
EDI Activation Code (Dispensing
Doctors) |
3. |
522P |
|
4. |
MRP® / FRP/ FRP Plus |
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. |
New 11-long numeric Medscheme membership number OR Old alpha-numeric Rowan and Angel membership number |
|
16. |
Payments to Pharmacies for 2008
services Payments to other service
providers 2008 Payments
to ALL providers for 2009 services |
16. |
Mediscor Rowan and Angel Medscheme |
|
17. |
Chronic pre-authorisation at
Mediscor |
17. |
Yes |
|
18. |
Reimbursement structure -
Pharmacies |
18. |
SEP + 26%/ R26 |
|
19. |
Reimbursement structure –
Dispensing Doctors |
19. |
SEP + 16%/ R16 |
|
20. |
Reimbursement structure –
Unscheduled and Schedule 0 Medicine |
20. |
SEP + 31% (Excl. VAT) |
·
FORMULARY REFERENCE PRICE (FRP) – information available on www.mediscor.net
·
FORMULARY REFERENCE PRICE PLUS (FRP PLUS) – information
available on www.mediscor.net
·
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
SPECTRAMED Medical Scheme effective from 1 January 2009:
|
OPTIONS |
BENEFITS
APPLICABLE |
LEVY /
CO-PAYMENT |
MRP® /
FRP |
EXCLUSIONS |
|
Spectra Alliance Spectra Elite Spectra Hospital Spectra Plus |
Acute (Spectra Hospital – no benefit) |
20% Levy |
MRP |
2,
3, 4, 5, 7, 8, 9, 10, 11, 14, 15, 16, 19, 20, 21, 22, 23, 24, 25, 26, 27, 30,
31, 32, 35, 40, 41, 43, 44, 45, 47, 48, 50, 51, 53, 60, 61. |
|
Non-CDL Chronic (Spectra Hospital – no benefit) |
Formulary: 20% Levy Non-Formulary: 20% Levy + Reference Price |
Spectra
Alliance: FRP Spectra
Elite / Spectra Plus: FRP Plus |
||
|
OTC (Spectra Hospital – no benefit) |
Spectra Alliance: 20% Levy / Max of R75 per script Spectra Elite: 20% Levy / Max of R100 per script Spectra Plus: 20% Levy / Max of R100 per script |
MRP |
||
|
Oncology PMB |
DSP: No Levy Non-DSP: 20% co-payment |
MRP |
||
|
Oncology Non-PMB |
DSP: No Levy Non-DSP: 20% co-payment |
MRP |
||
|
Organ Transplant PMB |
No Levy |
MRP |
||
|
Organ Transplant Non-PMB |
No Levy |
MRP |
||
|
HIV/AIDS |
All options DSP: No Levy Non-DSP: 20% co-payment |
MRP |
||
|
Prescribed Minimum Benefits (PMB) |
Spectra Alliance /Spectra Elite/ Spectra
Hospital DSP: No Levy Non-DSP: 20% co-payment Spectra Plus Option No DSP |
FRP |
||
|
Ex-Gratia |
Can have one
of the following: No Levy 25% Levy 50% Levy |
MRP |
·
FRP and FRP Plus
Members
will be liable for payment of the difference in price between the product they
selected to use and the formulary reference price on all non-formulary
products. Please refer to the real-time
response for all co-payment details.
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 11 32 38 or 0860 11 77 05
Mediscor ChroniLine™ : 0860 11 95 53
Kind regards.
JACK PEREL