Prescribed Minimum Benefit Treatment Baskets 08 Who we are LA Health Medical Scheme (referred to as 'the Scheme ), registration number 5, is a non-profit organisation, registered with the Council for Medical Schemes. Discovery Health (Pty) Ltd (referred to as the administrator ), is a separate company and an authorised financial services provider (registration number 997/080/07). We take care of the administration of your membership of the Scheme. Contact us You can call us on 0860 0 9 or visit www.lahealth.co.za for more information. Treatment baskets for the Prescribed Minimum Benefit Chronic Disease List conditions The Prescribed Minimum Benefit Chronic Disease List is a list of conditions which all medical schemes need to cover on all the plans they offer to their members. This cover includes funding for the diagnosis, treatment and ongoing care for the listed conditions. Read further to understand what procedures, investigations and consultations are covered for both the diagnosis and ongoing management for each condition. We will only pay Prescribed Minimum Benefit claims if your condition has been approved on the Chronic Illness Benefit Only claims for procedures and consultations listed in the Prescribed Minimum Benefit (PMB) treatment baskets will be paid from the Chronic Illness Benefit. These will be pro-rated based on the date of approval of your chronic condition. We will pay tests and procedures for your condition according to the baskets We pay certain tests like blood tests and X-rays according to the PMB treatment baskets. This cover includes tests and procedures for both the diagnosis and ongoing management for each of the PMB Chronic Disease List conditions. We pay listed blood tests, scans and X-rays up to a maximum of the LA Health Rate.
How we pay GP consultations related to your condition We pay consultations listed in the PMB treatment baskets related to your condition from the Chronic Illness Benefit. LA Comprehensive, LA Core, LA Active and LA Focus Benefit Options LA KeyPlus Benefit Option We pay for four () consultations a that are related to your approved condition at a GP who is a designated service provider up to the agreed rate. We pay up to a maximum of 00% of the LA Health Rate for consultations with a GP who is not a designated service provider. You must pay any difference between what is charged and what we pay. We pay for four () consultations a that are related to your approved condition with your chosen primary or secondary GP in the GP Network up to the agreed rate. If you use any other GP, we will pay up to a maximum of 80% of the LA Health Rate You must pay any difference between what is charged and what we pay. How we pay specialist consultations related to your condition We pay for consultations listed in the PMB treatment baskets related to your condition from the Chronic Illness Benefit. LA Comprehensive, LA Core, LA Active and LA Focus Benefit Options LA KeyPlus Benefit Option Depending on your condition, we pay for a specific number of consultations with a specialist as listed in the treatment baskets. We will pay the consultation at a specialist who is a designated service provider up to the agreed rate. We pay up to a maximum of 00% of the LA Health Rate for consultations with a specialist who is not a designated service provider. You must pay any difference between what is charged and what we pay. Depending on your condition, we pay for a specific number of consultations with a specialist who we have a payment arrangement with and who agrees to charge the Specialist Network Rate. We pay up to a maximum of 80% of the LA Health Rate for consultations with any other specialist. You must pay any difference between what is charged and what we pay. Page of 05/08
Please make sure your claims have the appropriate ICD-0 code All claims must have the appropriate ICD-0 codes (diagnostic codes) so we can identify them and pay them from the Chronic Illness Benefit. We will not pay claims from the chronic benefit if these requirements are not met We will not pay claims from the chronic benefit if: The claims are submitted without the relevant ICD-0 codes You are not yet registered on the Chronic Illness Benefit for a PMB condition You have exceeded the frequency limit on consultations or tests. To find a healthcare professional who is a designated service provider, please log in to www.lahealth.co.za Page of 05/08
Treatment baskets for Chronic Disease List conditions Condition Ongoing management cover each Addison s disease U & E only 7 U & E only 7 or Cortisol level 99 ACTH stimulation testing 5 Asthma Flow volume test 88 or 86 Bipolar mood disorder Bronchiectasis or Flow volume test 88 or 86 Peak flow 9 Peak flow 9 AST Aspartate ALT Alanine 0 AST Aspartate ALT Alanine 0 Thyrotropin (TSH) 507 Thyrotropin (TSH) 507 U & E only 7 U & E only 7 Sputum MC&S sputum analysis for infection Flow volume test 867 & 88 & 885 & 887 & 895 & 9 & 9 88 or 86 Lithium flame ionisation 067 Drug level in biological fluid Sputum MC&S sputum analysis for infection 08 or 70 or 9 or 867 & 88 & 885 & 887 & 895 & 9 & 9 Flow volume test 86 Peak flow 9 Peak flow 9 Cardiac failure ECG Electrocardiogram or or or 5 or 6 Echocardiography 00 6 & 6 & 6 & 60 & 65 ECG Electrocardiogram or or or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 U & E only 7 U & E only 7 Page of 05/08
Condition Ongoing management Cardiac failure Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 B-Type natriuretic peptide 88 B-Type natriuretic peptide 88 or or 00 Troponin isoforms 6 Drug level in biological Glucose random/fasting 057 fluid C-reactive protein 97 Full blood count 755 Thyrotropin (TSH) 507 Total cholesterol 07 Cardiomyopathy ECG Electrocardiogram or or or 5 or 6 Chronic obstructive pulmonary disease (COPD) Echocardiography 6 & 6 & 6 & 60 & 65 00 08 or 70 or 9 cover each ECG Electrocardiogram or or or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 U & E only 7 U & E only 7 Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 B-Type natriuretic peptide 88 B-Type natriuretic peptide 88 or or 00 00 Glucose random/fasting 057 Prothrombin index (PI) 805 C-reactive protein 97 Therapeutic drug level: Dosage Full blood count 755 Drug level in biological Thyrotropin (TSH) 507 fluid Total cholesterol 07 Flow volume test 88 or 86 806 08 or 70 or 9 Flow volume test 86 00 Peak flow 9 Alpha--antitrypsin 005 Drug level in biological fluid 08 or 70 or 9 Page 5 of 05/08
Condition Ongoing management Chronic renal disease Coronary artery disease ECG Electrocardiogram or or 6 Follow-up test description Follow-up ECG Electrocardiogram or or 6 Full blood count 755 Full blood count 755 U & E only 7 U & E only 7 Serum calcium Serum phosphates Serum parathyroid hormone (PTH) or 06 or 07 or 75 or 76 09 or or Serum calcium 06 or 07 or 75 or 76 Serum phosphates 09 or 5 Serum parathyroid hormone (PTH) cover each 5 Protein: Quantitative Protein: Quantitative ECG Electrocardiogram Echocardiography or or or 5 or 6 6 & 6 & 6 & 60 & 65 or Platelet count 797 Urine analysis (dipstick) 88 Iron 07 Transferrin Ferritin 58 ECG Electrocardiogram or or or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 or U & E only 7 U & E only 7 Glucose random/fasting 057 Glucose random/fasting 057 Total cholesterol 07 Total cholesterol 07 LDL cholesterol 06 LDL cholesterol 06 HDL cholesterol 08 HDL cholesterol 08 Triglycerides 7 Triglycerides 7 C-reactive protein 97 Urine analysis (dipstick) 88 Full blood count 755 Thyrotropin (TSH) 507 Page 6 of 05/08
Condition Ongoing management Coronary artery disease 00 Platelet count 797 Crohn s disease Colonoscopy 65 or 656 Diabetes insipidus Erythrocyte sedimentation rate or C-reactive protein 7 or 97 Colonoscopy 65 or 656 C-reactive protein 97 Full blood count 755 Full blood count 755 Histology 567 & 57 or 58 & 58 cover each U & E only 7 U & E only 7 or or Osmolality: Serum or urine 09 Osmolality: Serum or urine 09 Diabetes type ECG Electrocardiogram or or 6 Microalbuminuria 6 or 6 ECG Electrocardiogram or or 6 Microalbuminuria 6 or 6 Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 Total cholesterol 07 Total cholesterol 07 LDL cholesterol 06 LDL cholesterol 06 HDL cholesterol 08 HDL cholesterol 08 Triglycerides 7 Triglycerides 7 U & E only 7 U & E only 7 Serum creatinine Serum creatinine Urine creatinine Urine creatinine Glucose random/fasting 057 HBAc 06 Two-hour glucose-ogtt 09 Tonometry 0 Basic capital equipped in own rooms by ophthalmologists Fundus examination Podiatrist (Ophthalmologist) 009 00 or 00 or 07 680 or 680 or 680 (Other Specialist) Page 7 of 05/08
Condition Ongoing management Diabetes type Dietician 800 or 80 or 80 or 80 or 80 or 805 Diabetes type ECG Electrocardiogram or or 6 Microalbuminuria 6 or 6 ECG Electrocardiogram or or 6 Microalbuminuria 6 or 6 Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 Total cholesterol 07 Total cholesterol 07 LDL cholesterol 06 LDL cholesterol 06 HDL cholesterol 08 HDL cholesterol 08 Triglycerides 7 Triglycerides 7 U & E only 7 U & E only 7 Serum creatinine Serum creatinine Urine creatinine Urine creatinine Glucose random/fasting 057 HBAc 06 Two-hour glucose- OGTT 09 Tonometry 0 Dysrhythmia ECG Electrocardiogram or or or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 Basic capital equipped in own rooms by ophthalmologists Fundus examination Podiatrist Dietician cover each (Ophthalmologist) 009 00 or 00 or 07 680 or 680 or 680 800 or 80 or 80 or 80 or 80 or 805 (Other Specialist) ECG Electrocardiogram or or or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 U & E only 7 U & E only 7 Page 8 of 05/08
Condition Ongoing management Dysrhythmia Magnesium: Spectrophotometric Follow-up test description 09 Magnesium: Spectrophotometric or Follow-up or 09 C-reactive protein 97 Prothrombin index (PI) 805 Thyrotropin (TSH) 507 Therapeutic drug level: Dosage Hour ambulatory ECG monitoring (holter) Serum calcium Epilepsy EEG Electro-encephalography 8 & 9 06 or 07 or 75 or 76 7 & 7 Drug level in biological fluid 08 or 70 or 9 EEG Electro-encephalography 806 7 & 7 EEG with special activation 75 Drug level in biological fluid 08 or 70 or 9 cover each Glaucoma Tonometry 0 Tonometry 0 Fundus examination 00 or 00 Fundus examination 00 or 00 Gonioscopy 00 Gonioscopy 00 Basic capital equipped in own rooms by ophthalmologists Visual fields Disc and nerve fibre layer analysis or Disc photography 009 Basic capital equipped in own rooms by ophthalmologists 06 or 07 06 or 07 Visual fields 06 or 07 Disc and nerve fibre layer analysis or Disc photography 009 06 or 07 Haemophilia Optical Coherent Tomography (OCT) of Optic nerve or macula Central corneal thickness measurement Factor VIII or Factor IX antigen or Coagulation factors 08 ( per eye) 00 ( per eye) 758 or 757 Optical Coherent Tomography (OCT) of Optic nerve or macula Retinal threshold trend evaluation Factor VIII or Factor IX inhibitors 08 ( per eye) 08 7 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) 805 Therapeutic drug level: Dosage 806 Bleeding time 7 Thrombin time 8 Page 9 of 05/08
Condition Ongoing management cover each Hyperlipidaemia Total cholesterol 07 Total cholesterol 07 0 LDL cholesterol 06 LDL cholesterol 06 HDL cholesterol 08 HDL cholesterol 08 Triglycerides 7 Triglycerides 7 Thyrotropin (TSH) 507 AST Aspartate Hypertension ECG Electrocardiogram or ALT Alanine ECG Electrocardiogram or 0 Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 Glucose random/fasting 057 Glucose random/fasting 057 Total cholesterol 07 Total cholesterol 07 Hour ambulatory blood pressure or U & E only 7 or 7 Potassium Hypothyroidism Thyrotropin (TSH) 507 Thyrotropin (TSH) 507 0 Free thyroxine (FT) 8 Free thyroxine (FT) 8 Total cholesterol 07 Multiple sclerosis MR of the brain pre and post contrast or uncontrasted Parkinson s disease Rheumatoid arthritis MR of the cervical spine and cranio-cervical junction pre and post contrast or uncontrasted MR of the thoracic spine pre and post contrast or uncontrasted MR of the lumbar spine pre and post contrast or uncontrasted Visual evoked potentials (VEP): Unilateral Visual evoked potentials (VEP): Bilateral 00 or 00 50 or 50 or 500 50 or 50 or 500 50 or 50 or 500 MR of the brain pre and post contrast or uncontrasted MR of the cervical spine and cranio-cervical junction pre and post contrast or uncontrasted MR of the thoracic spine pre and post contrast or uncontrasted MR of the lumbar spine pre and post contrast or uncontrasted 68 AST Aspartate 68 ALT Alanine 00 or 00 50 or 50 or 500 50 or 50 or 500 50 or 50 or 500 0 No diagnostic or monitoring tests apply as the diagnosis of this condition remains a clinical one Erythrocyte sedimentation rate or C-reactive protein 7 or 97 Erythrocyte sedimentation rate or C-reactive protein 7 or 97 Full blood count 755 Full blood count 755 Platelet count 797 Platelet count 797 Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 Page 0 of 05/08
Condition Ongoing management Rheumatoid arthritis Schizophrenia Systemic lupus erythematosus AST Aspartate ALT Alanine 0 AST Aspartate ALT Alanine 0 Anti-CCP 600 Anti-CCP 600 X-ray of the right hand 6505 X-ray of the right hand 6505 X-ray of the left hand 6500 X-ray of the left hand 6500 X-ray of the right foot 75 X-ray of the right foot 75 X-ray of the left foot 70 X-ray of the left foot 70 Rheumatoid factor 959 ANF 9 00 AST Aspartate ALT Alanine 00 cover each 0 U & E only 7 Drug level in biological fluid or 08 or 70 or 9 Full blood count 755 Full blood count 755 Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 U & E only 7 U & E only 7 Platelet count 797 Platelet count 797 Complement fixation test Erythrocyte sedimentation rate or C-reactive protein Skin biopsy 00 96 or 8 7 or 97 or 567 & 0 & 0 & 05 & 07 Complement fixation test 96 or 8 Erythrocyte sedimentation rate or C-reactive protein 00 7 or 97 or Total cholesterol 07 Kidney biopsy 8 kinase 5 or 5 Extractable nuclear antigens 9 or 98 Antiglobulin test (Coombs) 709 Page of 05/08
Condition Ongoing management Systemic lupus erythematosus Urine microscopy 867 AST Aspartate ANF 9 ALT Alanine DNA antibodies 59 or 98 Histology 567 & 57 or 58 & 58 Ulcerative colitis Colonoscopy 65 or 656 Colonoscopy 65 or 656 0 C-reactive protein 97 C-reactive protein 97 Full blood count 755 Full blood count 755 Histology 567 & 57 or 58 & 58 Histology 567 & 57 or 58 & 58 Flexible sigmoidoscopy 676 cover each Complaints process You may lodge a complaint or query with LA Health Medical Scheme directly on 0860 0 9 address a complaint in writing to the Principal Officer at the Scheme s registered address. Should your complaint remain unresolved, you may lodge a formal dispute by following the LA Health Medical Scheme internal disputes process. You may, as a last resort, approach the Council for Medical Schemes for assistance. Council for Medical Schemes Complaints Unit, Block A, Eco Glades Office Park, 0 Witch-Hazel Avenue, Eco Park, Centurion, 057 / 086 67 / complaints@medicalschemes.com / www.medicalschemes.com Page of 05/08