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MEDISCOR (PTY) LTD |
NOTIFICATION 70
OF
2008 |
19 December 2008
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|
Medical Scheme |
Gen-Health Medical Scheme |
|
Administrator |
Sechaba
Medical Solutions |
|
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 Gen-Health Medical Scheme as outlined below.
Herewith the details for
submitting medicine claims to Mediscor:
|
1. |
Scheme Code (PCN) |
1. |
MDS0035
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|
2. |
Switch Destination Code |
2. |
GHEA0001 |
|
3. |
EDI Activation Code (Dispensing
Doctors) |
3. |
517P |
|
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. |
Min 5 Max 9 numerical |
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16. |
Payments to Providers |
16. |
Gen-Health |
|
17. |
Chronic pre-authorisation at
Mediscor |
17. |
Yes |
|
18. |
Reimbursement Structure –
Dispensing Doctors |
18. |
SEP + 16% / R16 |
|
19. |
Reimbursement Structure –
Pharmacies |
19. |
SEP + 26% / R26 |
|
20. |
Reimbursement Structure –
Schedule 0 and Unscheduled medicines |
20. |
SEP + max mark-up of 31% (VAT Excl.) |
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*
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 Gen-health effective
from 1 January 2009:
|
OPTIONS |
BENEFIT
STRUCTURE |
LEVY / |
MRP© |
EXCLUSIONS |
|
Basic
Cover |
Acute |
No |
No |
2-5, 14,
15, 19-25, 27, 28, 30-32, 34, 38, 40, 41, 43, 44, 45, 47, 48, 50, 53, 60, 61 |
|
Prescribed Minimum Benefit (PMB) |
Mediscor
Basic Formulary Non-formulary products:
20% co-payment |
Yes |
||
|
OTC (Pharmacies only) |
No |
No |
||
|
Oncology |
No |
Yes |
||
|
Appliance |
No |
Yes |
|
OPTIONS |
BENEFIT
STRUCTURE |
LEVY / |
MRP© |
EXCLUSIONS |
|
Coverplus |
Acute |
No |
No |
2-5, 14,
15, 19-25, 27, 28, 30-32, 34, 38, 40, 41, 43, 44, 45, 47, 48, 50, 53, 60, 61 |
|
Prescribed Minimum Benefit (PMB) |
Mediscor
Standard Formulary Non-formulary products:
15% co-payment |
Yes |
||
|
OTC (Pharmacies only) |
No |
No |
||
|
Oncology |
No |
Yes |
||
|
Appliance |
No |
Yes |
||
|
Chronic |
No |
Yes |
Additional Customised EXCLUSIONS:
|
1. |
Nootropil™ |
|
2. |
Phenolphtalein laxatives |
|
|
|
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