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MEDISCOR (PTY) LTD |
NOTIFICATION 69
OF
2008 |
19 December 2008
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|
Medical Scheme |
ThebeMed Medical Scheme |
|
Administrator |
Thebe
Ya Bophela Healthcare 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 THEBEMED Medical Scheme as outlined below.
Herewith the details for
submitting medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0033
|
|
2. |
Switch Destination Code |
2. |
TBEN0001 |
|
3. |
EDI Activation Code (Dispensing
Doctors) |
3. |
769P |
|
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. |
7 Numerical |
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16. |
Payments to Providers |
16. |
ThebeMed |
|
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 THEBEMED effective from
1 January 2009:
|
OPTION |
BENEFITS
APPLICABLE |
LEVY / |
MRP® |
EXCLUSIONS |
|
Frontier Energy |
Acute Benefit |
No levy |
Yes |
1-9,11,14-15,17,
19-28,30-32,40-41, 45,47-48 |
|
Chronic Benefit |
No levy |
|||
|
Prescribed Minimum
Benefits (PMB) |
Frontier / Energy Mediscor
Standard Formulary: |
|||
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Oncology |
No Levy |
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HIV / AIDS |
No Levy |
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Appliance |
No levy |
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OTC Benefit |
No levy |
Additional Customised Exclusions:
|
1. |
Nootropil™ |
|
2. |
Celebrex™, Mobic™, Coxflam™ |
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3. |
Phensydyl™ and generic
equivalents |
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4. |
Histaglobin™ |
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|
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If you require any assistance, please contact:
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Mediscor’s Share Call Centre Helpline |
: |
0860 113 238 or 0860 117 705 |
Kind regards
JACK PEREL