|
|
MEDISCOR (PTY) LTD |
NOTIFICATION 68
OF
2008 |
19 December 2008
|
|
Medical Scheme |
Pharos |
|
Administrator |
Private
Healthcare Administrators |
|
Information Relevant to |
Benefits
and Options 2009 |
|
Effective Date |
1
January 2009 |
With effect 1 January 2009, Mediscor will be applying the scheme rules for PHAROS Medical Scheme as outlined below.
Herewith the details for
submitting medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0016 |
|
2. |
Switch Destination Code |
2. |
PVPH0000 |
|
3. |
EDI Activation Code (Dispensing
Doctors) |
3. |
583P |
|
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. |
ICD-10 Diagnostic code |
13. |
Yes / Compulsory |
|
14. |
9 digit NAPPI code of medicine
dispensed |
14. |
Yes / Compulsory |
|
15. |
Membership number requirements |
15. |
10 Numerical |
|
16. |
Payments to Providers |
16. |
Private Health Administrators |
|
17. |
Chronic pre-authorisation at
Mediscor |
17. |
Yes |
|
18. |
Reimbursement structure –
Dispensing Doctors |
18. |
SEP +
16% / R16.00
|
|
19. |
Reimbursement structure –
Pharmacies |
19. |
SEP +
26% / R26.00
|
|
20. |
Reimbursement structure –
Schedule 0 and Unscheduled medicine |
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 PHAROS effective from 1
January 2008:
PHAROS OPTIONS:
Rainbow Comprehensive
Rainbow Plus
Rainbow Primary
Paladin Comprehensive
Footprint Comprehensive
Footprint Primary
Methcare
|
BENEFITS APPLICABLE |
LEVY / CO-PAYMENT |
MRP® |
EXCLUSIONS |
|
Acute (excluding Rainbow Primary and
Footprint Primary) |
Rainbow
Comprehensive / Rainbow Plus / Paladin Comprehensive / Footprint
Comprehensive No Levy Methcare 20% Levy |
Rainbow
Plus (except
acute and OTC) Rainbow
Primary Paladin
Comprehensive Footprint
Comprehensive Footprint
Primary Methcare |
3-6, 11, 14, 19, 21-25, 27, 30-32, 34, 40, 41, 43-45, 48, 51, 61, 62 |
|
Chronic (excluding Rainbow Plus /
Rainbow Primary / Footprint Comprehensive / Footprint Primary |
Rainbow
Comprehensive No Levy Paladin
Comprehensive and Methcare Formulary
products: No Levy Non-Formulary
products: 30% Levy |
||
|
OTC (excluding Rainbow Primary /
Footprint Primary) |
Rainbow
Comprehensive / Rainbow Plus / Paladin Comprehensive / Footprint
Comprehensive No Levy |
||
|
Prescribed Minimum Benefits (PMB) |
Rainbow
Comprehensive / Rainbow Plus / Rainbow Primary / Footprint Comprehensive /
Footprint Primary No Levy Paladin Comprehensive
/ Methcare Formulary
products: No Levy Non-Formulary
products: 30% co-payment |
||
|
HIV / AIDS |
No Levy |
||
|
Oncology |
Rainbow
Comprehensive / Rainbow Plus / Rainbow Primary / Footprint Comprehensive /
Footprint Primary / Paladin Comprehensive No Levy Methcare 20% Levy |
If you require any assistance, please contact:
|
Mediscor’s Share Call Centre Helpline |
: |
0860 113 238 or 0860 117 705 |
Kind regards
JACK PEREL