MEDISCOR (PTY) LTD
1257 South Street, Centurion,
PO Box 8796, Centurion, 0046
South Africa

Tel:   +27 12 674 8000
Fax:  +27 12 674 8001

 

NOTIFICATION 71

OF

2008

 

19 December 2008

 

 

Medical Scheme

Momentum Health Medical Scheme

Administrator

Momentum Medical Scheme Administrators (MMSA)

Information Relevant to

Benefits and Options for 2009

Effective Date

1 January 2009

 

Mediscor will be responsible for the processing of all electronic medicine claims, materials and consumables dispensed and/or administered during procedures, while MMSA will be responsible for the authorisation of chronic medicines, including medicines falling under Prescribed Minimum Benefits (PMBs).

 

Herewith the details for submitting medicine claims to Mediscor:

 

1.

Scheme Code (PCN)

1.

MDS0041

2.

Switch Destination Code

2.

MHEA0007

3.

EDI Activation Code (Dispensing Doctors)

3.

822P

4.

*Momentum Health Rate (MHR)

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.

9 digit NAPPI code of medicine dispensed

13.

Yes / Compulsory

14.

ICD-10 Diagnostic code

14.

Yes / Compulsory

15.

Membership number requirements

15.

Minimum 4 Numerical including dependant code

16.

Payments to Providers

16.

MMSA

17.

Chronic pre-authorisation

17.

MMSA

18.

Reimbursement structure – Pharmacies

18.

S1 to S8: SEP + 26% / R 26.00 unscheduled & S0: SEP + 31% (excl. VAT)

19.

Reimbursement structure – Doctors

19.

S1 to S8: SEP + 16% / R 16.00 unscheduled & S0: SEP + 31% (excl. VAT)

20.

Reimbursement structure – DSP Network (Authorised Chronic and PMB only)

Scheme Code (PCN): MDS0041DSP

20.

Unscheduled to S8: SEP + 24% / R 24.00

·         MOMENTUM HEALTH RATE (MHR): MHR is the Momentum Health Rate, which is the rate that Momentum Health sets for the reimbursement of claims and is subject to a formulary [based on the Mediscor Reference Price (MRP)].  Please refer to the real-time response.

·         Summit Option:

§         Reimbursement structure = MHS 4-Tiered

§         No MHR / MRP applicable

Herewith the Scheme rules for MOMENTUM HEALTH effective from 1 January 2009:

OPTION

BENEFIT STRUCTURE

LEVY / CO-PAYMENT

MRP

EXCLUSIONS

SUMMIT

Acute / Savings

No

Yes

3,5,11,14,15,17,19,20, 22-28,30-35, 38-41,
43-49,50,52-55,56,59, 60,61, 64

Homeopathic

Chronic

PMB

OTC

HIV / AIDS – DSP

Surgicals

Organ Transplant

Oncology

Stoma Care

Health Platform

 

 

Excluded products for the Summit option may be obtained from Savings Benefit, if available.

 

OPTION

BENEFIT STRUCTURE

LEVY / CO-PAYMENT

MRP

EXCLUSIONS

EXTENDER

Acute / Savings

NO LEVY

Yes

3,5,11,14,15,17,19,20, 22-28,30-35, 38-41,43-49,50,52-55,56,59, 60,61, 64

Chronic

PMB

OTC

HIV / AIDS – DSP

Surgicals

Organ Transplant

Oncology

Stoma Care

Health Platform

OPTION

BENEFIT STRUCTURE

LEVY / CO-PAYMENT

MRP

EXCLUSIONS

EXTENDER /

GP MCC

Acute / Savings

 

Yes

3,5,11,14,15,17,19,20, 22-28,30-35, 38-41,43-49,50,52-55,56,59, 60,61, 64

Chronic

OPEN NETWORK R10 PER ITEM

 

DSP NETWORK – NO

             CO-PAYMENT

 

IF PRESCRIBER OUT OF NETWORK = 30% CO-PAYMENT

PMB

OTC

 

HIV / AIDS – DSP

Surgicals

Organ Transplant

Oncology

Stoma Care

Health Platform

 

OPTION

BENEFIT STRUCTURE

LEVY / CO-PAYMENT

MRP

EXCLUSIONS

INCENTIVE

Acute / Savings

NO LEVY

Yes

3,5,11,14,15,17,19,20, 22-28,30-35, 38-41,43-49,50,52-55,56,59, 60,61, 64

Chronic

PMB

OTC

HIV/AIDS – DSP

Oncology

Stoma Care

Health Platform

OPTION

BENEFIT STRUCTURE

LEVY / CO-PAYMENT

MRP

EXCLUSIONS

INCENTIVE /

GP MCC

Acute / Savings

 

Yes

3,5,11,14,15,17,19,20, 22-28,30-35, 38-41,43-49,50,52-55,56,59, 60,61, 64

Chronic

OPEN NETWORK R10 PER ITEM

 

DSP NETWORK – NO

             CO-PAYMENT

 

IF PRESCRIBER OUT OF NETWORK = 30% CO-PAYMENT

PMB

OTC

 

HIV/AIDS – DSP

Oncology

Stoma Care

Health Platform

 

OPTION

BENEFIT STRUCTURE

LEVY / CO-PAYMENT

MRP

EXCLUSIONS

CUSTOM

Acute / Savings

NO LEVY

Yes

3,5,11,14,15,17,19,20, 22-28,30-35, 38-41,43-49,50,52-55,56,59, 60,61, 64

Chronic

PMB

OTC

HIV / AIDS – DSP

Oncology

Stoma Care

Health Platform

OPTION

BENEFIT STRUCTURE

LEVY / CO-PAYMENT

MRP

EXCLUSIONS

CUSTOM /

GP MCC

Acute / Savings

 

Yes

3,5,11,14,15,17,19,20, 22-28,30-35, 38-41,43-49,50,52-55,56,59, 60,61, 64

Chronic

OPEN NETWORK R10 PER ITEM

 

DSP NETWORK – NO

             CO-PAYMENT

 

IF PRESCRIBER OUT OF NETWORK = 30% CO-PAYMENT

PMB

OTC

 

HIV / AIDS – DSP

Oncology

Stoma Care

Health Platform

 

CAPITATION OPTIONS:

 

OPTION

BENEFIT STRUCTURE

LEVY / CO-PAYMENT

MRP

EXCLUSIONS

ACCESS

Acute – DSP Only

No

Yes

3,5,11,14,15,17,19,20, 22-28,30-35, 38-41,43-49,50,52-55,56,59, 60,61, 64

Savings*

OTC

PMB – DSP Only

HIV / Aids - DSP

Organ Transplant – State only

Oncology – State only

Stoma Care

 

 

OPTION

BENEFIT STRUCTURE

LEVY / CO-PAYMENT

MRP

EXCLUSIONS

BASE

Acute – DSP Only

No

Yes

3,5,11,14,15,17,19,20, 22-28,30-35, 38-41,43-49,50,52-55,56,59, 60,61, 64

Savings*

PMB – DSP / State

OTC

HIV / AIDS - DSP

Organ Transplant – State only

Oncology – State only

 

 

*The capitation formulary is excluded from the Savings Benefit.

 

 

 

Additional scheme rules for 2009:

·         PMBs to pay from savings if not authorized

·         Members on GP Options will have a R10/item co-pay if the Provider is a non-DSP.  Please refer to the real-time response.

If you require any assistance, please contact:

Mediscor’s Share Call Centre Helpline
Momentum Health Call Centre Helpline
Momentum Health Benefit Checker (24 Hours)

:
:
:

0860 113 238 or 0860 117 705   
0860 117 859
0860 104 040

Kind regards.

JACK PEREL