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Problems at EMC?

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URGENT WARNING: ACCREDITATION OF MANAGED CARE ORGANISATION EMERGING MARKET HEALTHCARE SUSPENDED BY CMS: CIRCULAR 25 OF 2011
Dear CPC Shareholders and Members
Your attention is urgently drawn to the fact that The Council for Medical Schemes resolved on 25 May 2011 to suspend the accreditation of the managed care organization, Emerging Market Healthcare for 3 years on the basis of suspected fraud/corrupt payments to certain individuals.
The Medical Aid options with which EMC is involved includes:
• Prosano ProVider & Pro Classic Options
• Resolution Health “Foundation Option”
• Protea Medical Aid: Student and Essential option

It is our duty to caution you that, as a possible provider of service to patients on these schemes, your payment for these options may or may not be affected by this suspension of EMC’s operations. Until further notice, you should carefully consider the position of your practice and whether you should or should not convert patients on these options to cash.

The application of the CPC motto “Cash is King” needs to be carefully considered.
Kind regards
QC Team

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2016 GEMS GP Tariffs (RUBY EMERALD ONYX)

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As per communique from GEMS (RUBY EMERALD ONYX) 2016 Tariffs

  • 3. Tariff changes for 2016

    Please be advised of the following changes for 2016:

  • An increase of 5.5% in professional fees for doctors participating in the GEMS FP network.

    The following fees will be applicable to REO network doctors in 2016:

    GEMS REO FP network consultation fee (Scheme rate) R326.70
    Enhanced consultation fee for REPI2 category 1 FP Network practices R46.60
    Enhanced consultation fee for REPI2 category 2 FP Network practices* R21.10

    *Category 2 practices will be required to achieve the benchmarks indicated in the GEMS quality measures listed above in order to qualify for the enhanced fee.

    Please do not add the enhanced consultation fee to your GEMS REO FP network consultation fee, as we will automatically assign it to qualifying practices upon
    payment of claims.

practice management software review

2017 Polmed GP Tariffs

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Dear Doctor

2017 Polmed GP TARIFFS


It is that time of the year again when the annual review of benefits and contributions are finalised for 2017.

The process of the review of benefits and contributions has been completed, in line with guidelines set by the Council for Medical Schemes. A comprehensive review of benefits was done taking into consideration the claims experience, member experience and the financial performance of the Scheme.

The Scheme is pleased to advise that the GP tariff will increase by 6% for both Network and non-Network doctors for consultation codes, namely 0190, 0191 and 0192, which is R376.00 and R348.00 respectively.

All other GP procedure codes will increase by 6% for both Network and non-Network doctors.

Our benefits are grouped into the following categories:

1. Preventative Care benefit
2. Out-of-hospital benefit
3. In-hospital benefit
4. Chronic medication

I would like to thank all the doctors for their contribution and support during this year of 2016.

Wishing you a happy Christmas and a prosperous 2017.

Yours faithfully

Dr Jaco Makkink
POLMED: Medical Advisor and Acting Chief Operations Officer

 

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How to Submit Claims to Polmed

Submit your claims correctly:

Claims must be submitted within 120 days of the service date. Claims received after this period will be rejected as stale. Copies of accounts will be accepted for processing or payment.

There are various ways of submitting claims to POLMED for processing:
Email: polmedcurrentclaims@medscheme.co.za
Fax: 011 758 7660
Post: POLMED, Private Bag X16, Arcadia 0007



 

Mamoth Health Medical Scheme

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Mamoth Health Medical Scheme

Date: 27 Jan 2012

NEW MAMOTH HEALTH SCHEME INFORMATION

Mamoth Health, a self administered scheme, will be processing medicine claims via MediKredit with effect from 1 February

2012. New acute and chronic option codes as indicated in the summary table have been assigned for the processing of all

plans.

2. HEALTHNET

2.1 Claims:

a) Claims should be submitted via HealthNet

2.2 Validation:

HealthNet will validate:

a) Membership number

b) Date of birth

c) Dependent Code

2.3 Networks:

HealthNet will accommodate all networks as agreed to with the scheme.

2.4 Mark‐up & Dispensing Fee

a) Schedule 0 and non‐scheduled items calculated on published wholesale price : R0 to R78.00: 34.20 %, Max R26.68 (Incl.

VAT)

b) Schedule 1 to 7 calculated on Single Exit Price: R0 to R78.00: 34.20 %, Max R26.68 (Incl. VAT)

2.5 Membership Number

a) Total length: 9 digits

2.6 Stale Claim Period

120 Days

2.7 On‐line Reversal Period

120 Days

3. PAYMENT INFORMATION

MediKredit will be paying providers on behalf of the scheme.

SUMMARY OF SCHEME RULES

PLAN/OPTION OPTION CODE SURCHARGE

MMAP/REF

PRICING or URP

MAMOTH HEALTH DD ACUTE MAHDA 612661 * Check HealthNet ST Response No

MAMOTH HEALTH DD CHRONIC MAHDC 612688 * Check HealthNet ST Response No

∗ The Fam‐ & Auth‐ check functionality will be available on these options.

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Resolution Health Claims

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Resolution Health
“Dear Switch provider,
We have been addressing the last of the data transfer issues. Please be advised that any outstanding claims will be resolved in the cheque run on 1 April 2011 and payment will take place on 4 April 2011.
In addition please take note that should you have received the realtime response from Switch, the Resolution Health remittance advice remains the final outcome of the claims payment.
Please be advised that Agility Global Health Solutions and Resolution Health are committed to provide you with the best service.
Thank you for your support in this regard.
Agility Global Health Solutions – Operations”

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