Prescribed Minimum Benefits treatment guidelines 2013

Transcription

1 Prescribed Minimum Benefits treatment guidelines 20

2 Treatment guidelines for the Prescribed Minimum Benefit chronic conditions 20 The Chronic Illness Benefit covers a limited number of tests and each for the chronic conditions listed in the Prescribed Minimum Benefits, according to legislation. This includes tests and that we cover during the for both the diagnosis and ongoing management for each condition, which will be pro-rated based on the date of approval of your chronic condition. This list of conditions is called the Chronic Disease List. Prescribed Minimum Benefit claims Only claims for tests and listed in the Prescribed Minimum Benefits (PMB) treatment guidelines will be paid from the Chronic Illness Benefit. We will only pay claims if you have been approved by the Chronic Illness Benefit for one of the Chronic Disease List conditions. Tests to diagnose your condition We pay tests like blood tests and x-rays according to the PMB treatment guidelines from the Chronic Illness Benefit. We will only pay if the claim for the diagnosis is dated up to 20 days before your application for cover from the Chronic Illness Benefit. If we receive claims that are dated earlier than this, we pay the claims from the available money in your Medical Savings Account and Above Threshold Benefit. We pay listed blood tests and x-rays, up to a maximum of the Scheme Rate. GP related to your condition We pay listed in the treatment guidelines related to your condition from the Chronic Illness Benefit: We pay four (4) per at a GP participating in the Scheme`s GP Network. We`ll pay up to a maximum of 00% of the Scheme Rate if you do not use a GP in these networks. Specialist related to your condition We pay in full if you see a who participates in our payment arrangement. If you see any other, we will pay up to 00% of the Scheme Rate. Please remember that all claims must have the appropriate ICD-0 ( ) so the scheme can identify them and pay them from the Chronic Illness Benefit.

3 We will pay claims from your day-to-day benefits if: the claims are submitted without the relevant ICD-0 you are not yet registered on the Chronic Illness Benefit for a Prescribed Minimum Benefit condition You have exceeded the frequency limit on or tests. For a list of the treatment guidelines go to To find a doctor in our GP network, please visit our website, log in and go to LA Health, MaPS. You can also call us on

4 Treatment guidelines for the Prescribed Minimum Benefit Chronic Disease List Conditions Addison s disease Cortisol level 4499 Serum electrolytes 47 ACTH stimulation testing 452 Creatinine 402 Serum electrolytes 47 Creatinine 402 Asthma Lung function test (FEV) 88 or Lung function test (FEV) Peak flow 92 Peak flow 92 we Bipolar mood disorder Drug monitoring levels for 2 Lithium flame ionisation Bronchiectasis Chest x-ray 00 Sputum MC&S-sputum analysis for infection 867 & 88 & 885 & 895 & 92 & Lung function test (FEV) Sputum MC&S sputum analysis for infection 88 or & 88 & 885 & 895 & 92 & 887 Peak flow 92 Lung functions test (FEV) 86 Peak flow 92 Cardiac failure ECG - Electrocardiogram 22 or Serum electrolytes 47 Chest x-ray 00 Creatinine 402 Serum electrolytes 47 Drug monitoring levels, for Creatinine 402 ECG - Electrocardiogram 22 or Full blood count 755 Chest x-ray 00 Serum glucose 4057 Total cholesterol 4027 Urine analysis (dipstick) 488

5 Cardiac failure Echocardiography 62 or 622 or 62 Echocardiography 62 or 622 or 62 we Thyroid function 4482 or 4484 Cardiomyopathy ECG - Electrocardiogram 22 or Echocardiography 62 or 622 or 62 Serum electrolytes 47 Echocardiography 62 or 622 or 62 Chest x-ray 00 Drug monitoring levels for or 806 Prothrombin index (PI) ECG - Electrocardiogram 22 or Chronic obstructive pulmonary disease (COPD) Chest x-ray 00 Creatinine 402 Chest x-ray 00 Peak flow 92 Alpha antitrypsin deficiency 4005 Drug monitoring levels for (only <20yrs of age) Lung function test (FEV) 88 or Lung function test (FEV) Chronic renal disease Full blood count 755 Full blood count Serum electrolytes 47 Serum electrolytes 47 Creatinine 402 Creatinine 402 Serum calcium 407 Serum calcium 407 Serum phosphates 409 Serum phosphates 409 Serum parathyroid hormone (PTH) 452 Urine analysis (dipstick) 488 Urine-protein/creatinine ratio 422 & 42 Serum parathyroid hormone (PTH) Creatinine clearance 422 ECG - Electrocardiogram 22 or 24

6 Coronary artery disease ECG - Electrocardiogram 22 or ECG - Electrocardiogram 22 or Lipogram 4025 Serum electrolytes 47 Serum electrolytes 47 Creatinine 402 Creatinine 402 Crohn s disease Barium enema Erythrocyte sedimentation 74 Full blood count 755 Biopsy histology 4567 Colonoscopy 65 or 656 Colonoscopy 65 or 656 Diabetes insipidus Serum electrolytes 47 Serum electrolytes 47 Creatinine 402 Creatinine 402 we Water deprivation tests/assessment of relation of plasma to urine osmolality 409 Diabetes type Fasting blood glucose 4057 HBAc 4064 or Two-hour glucose-ogtt 4049 Urinanalysis (dipstick) 488 Random glucose 4057 Microalbuminuria 482 Urine analysis (dipstick) 488 Lipogram 4025 Total cholesterol 4027 ECG - Electrocardiogram 22 or ECG - Electrocardiogram 22 or Fundus examination 00 Microalbuminuria 482 Basic capital equipment ised in own rooms by ophthalmologists 009 Diabetes type 2 Fasting blood glucose 4057 HBAc 4064 or Two-hour glucose-ogtt 4049 Microalbuminuria 482 Random glucose 4057 Lipogram 4025

7 Diabetes type 2 Total cholesterol 4027 ECG - Electrocardiogram 22 or Urine analysis (dipstick)l 488 Urine analysis (dipstick) 488 ECG - Electrocardiogram 22 or Fundus examination 00 Microalbuminuria 482 Basic capital equipment ised in own rooms by ophthalmologists 009 Dysrhythmias ECG - Electrocardiogram 22 or ECG - Electrocardiogram 22 or Drug monitoring levels for approved medicine or 806 Prothrombin index (PI) we Epilepsy EEG 27 & 272 Drug monitoring levels for approved medicine Glaucoma Tonometry 04 Tonometry Basic capital equipment ised in own rooms by ophthalmologists 009 Basic capital equipment ised in own rooms by ophthalmologists Visual fields 05 or Optometrist or 07 Gonioscopy 002 Rentinal threshold trend evaluation 08 Central corneal thickness ( per eye) Visual fields 05 or 06 or 07 Fundus examination 00 or 004 Fundus examination 00 or 004 Haemophilia Factor 8 assay Factor 9 assay 757 VWF antigen 758 PTT 87 INR 805 Bleeding time 7 2

8 Type of test Diagnostic we Haemophilia Full blood count 755 Platelet count 797 Hyperlipidaemia Total cholesterol 4027 Total cholesterol Hypertension LDL 4026 LDL 4026 HDL 4028 HDL 4028 Triglycerides 447 Triglycerides 447 Lipogram 4025 Lipogram 4025 Blood pressure monitoring (incl 24 hour ambulatory BP monitoring) 27 Blood pressure monitoring 0 Urine analysis (dipstick) ECG - Electrocardiogram or Ambulatory blood pressure monitoring Serum electrolytes 47 Creatinine 402 Blood glucose Hypothyroidism Thyroid function (TSH) 4507 Thyroid function (TSH) Multiple sclerosis Free thyroxine (FT4) 4482 Free thyroxine (FT4) TSH + FT TSH + FT MR of the brain pre and post contrast MR of the cervical spine and cranio-cervical junction pre and post contrast MR of the thorasic spine pre and post contrast MR of the spine pre and post contrast Parkinson s disease 2 Rheumatoid arthritis X-ray of the right hand 6505 CRP 947 X-ray of the left hand 6500 X-ray of the right foot 7425 X-ray of the left foot 7420 X-ray of the chest two views, PA and lateral Eythrocyte sedimentation Eythrocyte sedimentation 74 Rheumatoid factor 959 Urine analysis (dipstick) 488 Full blood count 755 AST 40 Platelet count 797 ALT 4

9 Condition Diagnosis Ongoing management Rheumatoid arthritis Urine analysis (dipstick) 488 Drug monitoring levels for we AST 40 Full blood count 755 ALT 4 CRP 974 Schizophrenia Systemic lupus erythematosus Drug monitoring levels for 2 Antinuclear bodies 94 Full blood count Complement fixation test 945 Eythrocyte sedimentation 74 Full blood count 755 Serum electrolytes 47 Urine analysis (dipstick) 488 Creatinine 402 Eythrocyte sedimentation 74 Urine analysis (dipstick) 488 Ulcerative colitis Skin biopsy 4567 & 02 & 024 & 025 & 027 Kidney biopsy 84 Barium enema full blood 409 Colonoscopy 65 or count 656 Eythrocyte sedimentation 74 Full blood count Biopsy histology Colonoscopy 4567 & or 656 LA Health Medical Scheme. Registration number 45. Administered by Discovery Health (Pty) Ltd, registration number 997/0480/07. An authorised financial services provider.