Treatment baskets for the Prescribed Minimum Benefit Chronic Disease List conditions

Transcription

1 Treatment baskets for the Prescribed Minimum Benefit Chronic Disease List conditions 08

2 Treatment baskets for the Prescribed Minimum Benefit Chronic Disease List conditions Overview The Prescribed Minimum Benefit Chronic Disease List is a list conditions which all registered medical schemes in South Africa need to on all the plans they fer to their members. This includes funding for the diagnosis, treatment and ongoing care for the listed conditions. Read further to understand what procedures, investigations and are ed for both the diagnosis and ongoing management for condition. Disy Health Medical Scheme plans are structured in such a way as to maximise no matter which plan members choose. Some plans cost more but fer more comprehensive benefits while others have lor contributions with fer benefits. Regardless this, all our plans more than just the minimum benefits required by law. About some the terms use in this document Terminology Description Designated service provider (DSP) A healthcare provider (for example doctor,, pharmacist or hospital) who have an agreement with to provide treatment or services at a contracted rate. You may view the full list DSPs on Disy Health Rate (DHR) This is a rate set by us at which pay for healthcare services from hospitals, pharmacies and healthcare pressionals. Day-to-day benefits These are the funds available in the Medical Savings Account and Above Threshold Benefit, where applicable. ICD-0 A clinical code that describes diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes injury or diseases, as classified by the World Health Organisation (WHO). In terms the Medical Schemes Act 998 and its Regulations, all medical schemes have to the costs related to the diagnosis, treatment and care : An emergency medical condition A defined list 70 diagnoses Prescribed Minimum Benefits (PMB) A defined list 7 chronic conditions To access Prescribed Minimum Benefits, there are rules that apply: Your medical condition must qualify for and be part the defined list Prescribed Minimum Benefit conditions. The treatment needed must match the treatments in the defined benefits. You must use designated service providers (DSPs) in our network. This does not apply in emergencies. Hover, even in these cases, where appropriate and CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE OF V

3 Terminology Description according to the rules the Scheme, you may be transferred to a hospital or other service providers in our network once your condition has stabilised. If your treatment doesn t meet the above criteria, will pay up to 80% the Disy Health Rate (DHR). You will be responsible for the difference beten what pay and the actual cost your treatment. Emergency medical condition An emergency medical condition, also referred to as an emergency, is the sudden and, at the time unexpected onset a health condition that requires immediate medical and surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction a bodily organ or part or would place the person s life in serious jeopardy. An emergency does not necessarily require a hospital admission. We may ask you for additional information to confirm the emergency. MaPS Advisor MaPS Advisor is a medical and provider search tool which is available on You can use the tool to search for doctors and other healthcare providers like hospitals and pharmacies that have a payment arrangement with. MaPS Advisor is brought to you by Disy Health (Pty) Ltd; registration number 997/0480/07, an authorised financial services provider and administrator medical schemes. Waiting period A waiting period can be general (up to months) or condition-specific (up to months) and means that the member has to wait for a set time before he or she can claim from their chosen plan s. We pay Prescribed Minimum Benefit Chronic Disease List claims if your condition has been approved on the Chronic Illness Benefit Claims for procedures and listed in the Prescribed Minimum Benefit (PMB) treatment baskets will be paid from the Chronic Illness Benefit. The number s and allod for the ongoing management a condition are pro-rated based on the date approval your chronic condition. Refer to to find out how to register for the benefit. We will pay your treatment in full when you use a designated service provider for your approved condition A designated service provider (DSP) is a healthcare provider (for example doctor,, pharmacist or hospital) who have an agreement with to provide treatment or services at a contracted rate. You may view the full list DSPs on Please use the MaPS Advisor tool on to find a GP who is a designated service provider. How pay s and procedures related to your condition We pay certain s like blood s and x-rays according to the PMB treatment baskets up to a maximum the Disy Health Rate. This includes s and procedures for both the diagnosis and ongoing management for the PMB Chronic Disease List conditions. CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE OF V

4 How pay GP related to your condition Executive, Comprehensive, Priority & Saver Plans Smart Plans Core Plans KeyCare Plus and KeyCare Access Plans KeyCare Core Plans We pay for four (4) a that are related to your approved condition at a GP who is a designated service provider. If you choose to use a GP who is not a designated service provider, will pay up to a maximum 80% the Disy Health Rate. You must pay any difference beten what is charged and what pay. We pay for four (4) a that are related to your approved condition at a GP in the Smart Network. If you choose to use any other GP, will pay up to 80% the Disy Health Rate. You must pay any difference beten what is charged and what pay. We pay for four (4) that are related to your approved condition a at a GP who is a designated service provider. If you use any other GP, will pay up to a maximum 80% the Disy Health Rate. You must pay any difference beten what is charged and what pay. We pay for four (4) a that are related to your approved condition at your chosen primary or secondary GP in the KeyCare GP Network. If you use any other GP, will pay up to a maximum 80% the Disy Health Rate. You must pay any difference beten what is charged and what pay. We pay for four (4) a that are related to your approved condition at a GP in the KeyCare GP Network. If you choose to use any other GP, will pay up to a maximum 80% the Disy Health Rate. You must pay any difference beten what is charged and what pay. How pay related to your condition Executive, Comprehensive, Priority & Saver Plans Smart Plans Core Plans KeyCare Plans Depending on your condition, pay for a specific number with a, as listed in the treatment baskets. We will pay the consultation at a who is a designated service provider up to the agreed rate. We pay up to a maximum 80% the Disy Health Rate for with a who is not a designated service provider. You must pay any difference beten what is charged and what pay. Depending on your condition, pay for a specific number with a, as listed in the treatment baskets. We will pay the consultation at a who is a designated service provider up to the agreed rate. We pay up to a maximum 80% the Disy Health Rate for with a who is not a designated service provider. You must pay any difference beten what is charged and what pay. Depending on your condition, pay for a specific number with a, as listed in the treatment baskets. We will pay the consultation at a who is a designated service provider up to the agreed rate. We pay up to a maximum 80% the Disy Health Rate for with a who is not a designated service provider. You must pay any difference beten what is charged and what pay. Depending on your condition, pay for a specific number with a in the KeyCare Specialist Network. We pay up to a maximum 80% the Disy Health Rate for with any other. You must pay any difference beten what is charged and what pay. Please use the MaPS Advisor tool on to find a who is a designated service provider. The value-added service MaPS Advisor - is owned by Disy Health (Pty) Ltd. CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE 4 OF V

5 Please make sure your claims have the appropriate ICD-0 code All claims must have the appropriate ICD-0 ( ) so can identify them and pay them from the Chronic Illness Benefit. We may pay claims from your day-to-day benefits if these requirements are not met We will pay claims from your available day-to-day benefits if: The claims are submitted without the relevant ICD-0. You have exceeded the frequency limit on or s. CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE 5 OF V

6 Treatment Baskets for Chronic Disease List conditions Condition Addison s disease s Follow-up s U & E only 47 U & E only 47 4 or Cortisol level 4499 ACTH stimulation ing Asthma Flow volume 88 or 86 Bipolar mood disorder 45 4 or Flow volume 88 or 86 Peak flow 9 Peak flow 9 AST Aspartate ALT Alanine Bronchiectasis Sputum MC&S sputum analysis for infection 40 AST Aspartate 4 ALT Alanine 40 4 Thyrotropin (TSH) 4507 Thyrotropin (TSH) 4507 U & E only 47 U & E only 47 Flow volume 867 & 88 & 885 & 887 & 895 & 9 & or 86 Lithium flame ionisation Drug level in biological fluid Sputum MC&S sputum analysis for infection or 470 or or 867 & 88 & 885 & 887 & 895 & 9 & 94 Flow volume 86 Peak flow 9 Peak flow 9 X-ray the chest Cardiac failure ECG 00 or or 4 or 5 or 6 ECG 4 or or 4 or 5 or 6 CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE 6 OF V

7 Condition Cardiac failure Echocardiography 6 & 6 & 6 & 60 & 65 s Follow-up Echocardiography 6 & 6 & 6 & 60 & 65 s U & E only 47 U & E only 47 4 Urine analysis B-Type natriuretic peptide 488 Urine analysis 4488 B-Type natriuretic peptide X-ray the chest Cardiomyopathy ECG 4 or 4 or 00 X-ray the chest Troponin isorms 46 Drug level in Glucose random/ 4057 biological fluid fasting C-reactive protein 947 Full blood count 755 Thyrotropin (TSH) 4507 Total cholesterol 407 Echocardiography or or 4 or 5 or 6 6 & 6 & 6 & 60 & 65 ECG or 470 or 449 or or 4 or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 U & E only 47 U & E only 47 4 Urine analysis 488 Urine analysis B-Type natriuretic peptide X-ray the chest 4488 B-Type natriuretic peptide 4 or 4 or 00 X-ray the chest CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE 7 OF V

8 Condition Cardiomyopathy Glucose random/fasting s Follow-up 4057 Prothrombin index (PI) s C-reactive protein 947 Therapeutic drug level: Dosage Chronic obstructive pulmonary disease (COPD) Chronic renal disease Full blood count 755 Drug level in Thyrotropin (TSH) 4507 biological fluid Total cholesterol 407 Flow volume X-ray the chest 88 or or 470 or 449 Flow volume Peak flow 9 Alpha--antitrypsin 4005 Drug level in biological fluid ECG or or 6 ECG 408 or 470 or 449 or or 6 Full blood count 755 Full blood count U & E only 47 U & E only 47 4 Serum calcium Serum phosphates Serum parathyroid hormone (PTH) 4 or 406 or 407 or 475 or or 4 4 or Serum calcium 406 or 407 or 475 or 476 Serum phosphates 409 or 4 45 Serum parathyroid hormone (PTH) Protein: Quantitative 4 Protein: Quantitative 4 Platelet count 797 Urine analysis Iron 407 Transferrin 444 Ferritin 458 Coronary artery disease ECG or or 4 or 5 or 6 ECG or or 4 or 5 or 6 CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE 8 OF V

9 Condition Coronary artery disease Echocardiography 6 & 6 & 6 & 60 & 65 4 or s Follow-up Echocardiography 6 & 6 & 6 & 60 & 65 4 or s U & E only 47 U & E only 47 Glucose random/fasting 4057 Glucose random/fasting 4057 Total cholesterol 407 Total cholesterol 407 LDL cholesterol 406 LDL cholesterol 406 HDL cholesterol 408 HDL cholesterol 408 Triglycerides 447 Triglycerides 447 C-reactive protein 947 Urine analysis 488 Full blood count 755 Thyrotropin (TSH) 4507 X-ray the chest 00 Platelet count 797 Crohn s disease Colonoscopy 65 or 656 Diabetes insipidus Erythrocyte sedimentation rate or C-reactive protein 74 or 947 Colonoscopy 65 or 656 C-reactive protein 947 Full blood count 755 Full blood count 755 Histology 4567 & 457 or 458 & 4584 U & E only 47 U & E only 47 Osmolality: Serum or urine Diabetes type ECG Microalbuminuria 4 or 4 or 409 Osmolality: Serum or urine or or 6 46 or 46 ECG 409 or or 6 Microalbuminuria 46 or 46 (Ophthalmologist) 4 (Other Specialist) CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE 9 OF V

10 Condition Diabetes type Urine analysis s Follow-up 488 Urine analysis s Total cholesterol 407 Total cholesterol 407 LDL cholesterol 406 LDL cholesterol 406 HDL cholesterol 408 HDL cholesterol 408 Triglycerides 447 Triglycerides 447 U & E only 47 U & E only 47 Serum creatinine Serum creatinine Urine creatinine 4 Urine creatinine 4 Glucose random/fasting Two-hour glucose- OGTT 4057 HBAc Tonometry 04 Basic capital equipped in own rooms by ophthalmologists 009 Diabetes type ECG Microalbuminuria Urine analysis or or 6 46 or 46 Fundus examination Podiatrist Dietician ECG 00 or 004 or or 680 or or 840 or 840 or 840 or 8404 or 8405 or or 6 Microalbuminuria 46 or Urine analysis (Ophthalmologist) Total cholesterol 407 Total cholesterol 407 LDL cholesterol 406 LDL cholesterol 406 HDL cholesterol 408 HDL cholesterol 408 Triglycerides 447 Triglycerides 447 U & E only 47 U & E only 47 Serum creatinine Serum creatinine Urine creatinine 4 Urine creatinine 4 (Other Specialist) CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE 0 OF V

11 Condition Diabetes type Glucose random/fasting Two-hour glucose- OGTT Dysrhythmia ECG Echocardiography s Follow-up s 4057 HBAc Tonometry 04 or or 4 or 5 or 6 6 & 6 & 6 & 60 & 65 Basic capital equipped in own rooms by ophthalmologists Fundus examination Podiatrist Dietician ECG or 004 or or 680 or or 840 or 840 or 840 or 8404 or 8405 or or 4 or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 U & E only 47 U & E only 47 Magnesium: Spectrophotometric 4094 Magnesium: Spectrophotometric 4 or 4 or C-reactive protein 947 Prothrombin index (PI) Thyrotropin (TSH) 4507 Therapeutic drug level: Dosage Hour ambulatory ECG monitoring (holter) 8 & 9 Drug level in biological fluid 408 or 470 or 449 Serum calcium 406 or 407 or 475 or 476 Epilepsy EEG Electroencephalography 7 & 7 EEG Electroencephalography 7 & 7 CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE OF V

12 Condition EEG with special activation s Follow-up 75 Drug level in biological fluid 408 or 470 or 449 s Glaucoma Tonometry 04 Tonometry 04 Fundus examination 00 or 004 Fundus examination 00 or 004 Gonioscopy 00 Gonioscopy 00 Basic capital equipped in own rooms by ophthalmologists 009 Basic capital equipped in own rooms by ophthalmologists 009 Haemophilia Visual fields Disc and nerve fibre layer analysis or Disc photography or Optical Coherent Tomography (OCT) Optic nerve or macula Central corneal thickness measurement Factor VIII or Factor IX antigen or Coagulation factors 06 or or 07 or ( per eye) 758 or 757 Visual fields 06 or 07 Disc and nerve fibre layer analysis or Disc photography or Optical Coherent Tomography (OCT) Optic nerve or macula Retinal threshold trend evaluation Factor VIII or Factor IX inhibitors 06 or 07 or Full blood count 755 Full blood count 755 Platelet count 797 Platelet count 797 Fibrinogen titre 85 PTT - Partial thromboplastin time 87 Prothrombin index (PI) Therapeutic drug level: Dosage Hyperlipidaemia Hyperlipideamia Bleeding time 7 Thrombin time 84 Total cholesterol 407 Total cholesterol LDL cholesterol 406 LDL cholesterol 406 HDL cholesterol 408 HDL cholesterol 408 Triglycerides 447 Triglycerides 447 Thyrotropin (TSH) 4507 AST Aspartate ALT Alanine 40 4 CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE OF V

13 Condition Hypertension ECG Urine analysis Glucose random / fasting or s Follow-up ECG 488 Urine analysis 4057 Glucose random/fasting or s Total cholesterol 407 Total cholesterol Hour ambulatory blood pressure 4 or U & E only 47 4 or 7 Potassium 4 Hypothyroidism Thyrotropin (TSH) 4507 Thyrotropin (TSH) Multiple sclerosis Parkinson s disease Rheumatoid arthritis Free thyroxine (FT4) 448 Free thyroxine (FT4) 448 Total cholesterol 407 MR the brain pre and post contrast or uncontrasted MR the cervical spine and craniocervical junction pre and post contrast or uncontrasted MR the thoracic spine pre and post contrast or uncontrasted MR the lumbar spine pre and post contrast or uncontrasted Visual evoked potentials (VEP): Uni Visual evoked potentials (VEP): Bi 040 or or 540 or or 540 or or 540 or 5400 MR the brain pre and post contrast or uncontrasted MR the cervical spine and craniocervical junction pre and post contrast or uncontrasted MR the thoracic spine pre and post contrast or uncontrasted MR the lumbar spine pre and post contrast or uncontrasted 68 AST Aspartate 68 ALT Alanine 040 or or 540 or or 540 or or 540 or No or monitoring s apply as the diagnosis this condition remains a clinical one Erythrocyte sedimentation rate or C-reactive protein 74 or 947 Erythrocyte sedimentation rate or C-reactive protein 74 or Rheumatoid arthritis Full blood count 755 Full blood count 755 Platelet count 797 Platelet count 797 Urine analysis 488 Urine analysis CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE OF V

14 Condition s Follow-up s AST Aspartate ALT Alanine 40 AST Aspartate 4 ALT Alanine Anti-CCP 4600 Anti-CCP 4600 X-ray the right hand 6505 X-ray the right hand X-ray the left hand 6500 X-ray the left hand X-ray the right foot 745 X-ray the right foot X-ray the left foot 740 X-ray the left foot 740 X-ray the chest Rheumatoid factor X-ray the chest 00 ANF 94 Schizophrenia AST Aspartate 40 4 ALT Alanine 4 U & E only 47 Drug level in biological fluid 4 or 408 or 470 or 449 Systemic lupus erythematosus Full blood count 755 Full blood count Urine analysis 488 Urine analysis U & E only 47 U & E only 47 4 Platelet count 797 Platelet count 797 X-ray the chest 00 X-ray the chest 00 Complement fixation 96 or 48 Complement fixation 96 or 48 Systemic lupus erythematosus Erythrocyte sedimentation rate or C-reactive protein 74 or or Erythrocyte sedimentation rate or C-reactive protein 74 or or 4 4 CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE 4 OF V

15 Condition Skin biopsy 4567 & 0 & 04 & 05 & 07 s Follow-up s Total cholesterol 407 Kidney biopsy 84 kinase 45 or 45 Extractable nuclear antigens 94 or 948 Antiglobulin (Coombs) Urine microscopy 867 AST Aspartate ANF 94 ALT Alanine DNA antibodies 459 or 948 Histology 4567 & 457 or 458 & 4584 Ulcerative colitis Colonoscopy 65 or 656 Colonoscopy 65 or C-reactive protein 947 C-reactive protein 947 Full blood count 755 Full blood count 755 Histology 4567 & 457 or 458 & 4584 Histology 4567 & 457 or 458 & 4584 Flexible sigmoidoscopy 676 CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE 5 OF V

16 Contact us You can call us on or visit for more information. Complaints process The following channels are available for your complaints and encourage you to follow the process: Step To take your query further: If you have already contacted the Disy Health Medical Scheme and feel that your query has still not been resolved, please complete our online complaints form on We would also love to hear from you if have exceeded your expectations. Step To contact the Principal Officer: If you are still not satisfied with the resolution your complaint after following the process in Step you are able to escalate your complaint to the Principal Officer the Disy Health Medical Scheme. You may lodge a query or complaint with Disy Health Medical Scheme by completing the online form on or by ing principalficer@disy.co.za. Step To lodge a dispute: If you have received a final decision from Disy Health Medical Scheme and want to challenge it, you may lodge a formal dispute. You can find more information the Scheme s dispute process on the bsite. Step 4 To contact the Council for Medical Schemes: Disy Health Medical Scheme is regulated by the Council for Medical Schemes. You may contact the Council at any stage the complaints process, but encourage you to first follow the steps above to resolve your complaint before contacting the Council. Contact details for the Council for Medical Schemes: Council for Medical Schemes Complaints Unit, Block A, Eco Glades Office Park, 40 Witch-Hazel Avenue, Eco Park, Centurion 057 complaints@medicalschemes.com CONTACT US TEL PO BOX 7846 SANDTON 46 Disy Health Medical Scheme, registration number 5, is regulated by the Council for Medical Schemes and administered by Disy Health (Pty) Ltd, registration number 997/0480/07, an authorised financial PAGE 6 OF V