Prescribed Minimum Benefit treatment guidelines

Transcription

1 Prescribed Minimum Benefit treatment guidelines 05

2 Treatment guidelines 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 on all the plans they offer 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 each condition. Disy Health Medical Scheme plans offer benefits far richer than that of the Prescribed Minimum Benefits. Our plans are structured in such a way as to maximise no matter which plan members choose. Some plans cost more but offer more comprehensive benefits while others have lor contributions with fer benefits. Regardless of this, all our plans more than just the minimum benefits required by law. We will only pay Prescribed Minimum Benefit claims if your condition has been approved on the Chronic Illness Benefit Only claims for procedures and listed in the Prescribed Minimum Benefit (PMB) treatment guidelines will be paid from the Chronic Illness Benefit. These are pro-rated based on the date of approval of your chronic condition. We will pay tests and procedures for your condition according to the guidelines We pay certain tests like blood tests and x-rays according to the PMB treatment guidelines. This 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 Disy Health Rate. How pay GP related to your condition We pay listed in the PMB treatment guidelines related to your condition from the Chronic Illness Benefit. Executive, Comprehensive, Priority and Saver plans Core plans KeyCare Plus and KeyCare Access plans KeyCare Core plans We pay for four () that are related to your approved condition a at a GP who is a designated service provider. We pay up to a maximum of 00% of the Disy Health Rate for with a GP who is not a designated service provider. You must pay any difference beten what is charged and what pay. We pay for four () 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 of 80% of the Disy Health Rate. You must pay any difference beten what is charged and what pay. We pay for four () that are related to your approved condition a with your chosen primary or secondary GP in the KeyCare GP Network. If you use any other GP, will pay up to a maximum of 80% of the Disy Health Rate. You must pay any difference beten what is charged and what pay. We pay for four () a with a GP in the KeyCare GP Network. If you use any other GP, will pay up to a maximum of 80% of the Disy Health Rate. You must pay any difference beten what is charged and what pay.

3 How pay related to your condition We pay for listed in the PMB treatment guidelines related to your condition from the Chronic Illness Benefit. Executive, Comprehensive, Priority and Saver plans Core plans KeyCare Plus, KeyCare Access and KeyCare Core plans Depending on your condition, pay for a specific number of with a, as listed in the treatment guidelines. We will pay the consultation at a who is a designated service provider up to the agreed rate. We pay up to a maximum of 00% of 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 of with a, as listed in the treatment guidelines. We will pay the consultation at a who is a designated service provider up to the agreed rate. We pay up to a maximum of 80% of 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 of with a who have a payment arrangement with and who agrees to charge the KeyCare Specialist Network Rate. We pay up to a maximum of 80% of the Disy Health Rate for with any other. You must pay any difference beten what is charged and what pay. Please make sure your claims have the appropriate ICD-0 code All claims must have the appropriate ICD-0 codes ( codes) so Disy Health 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 day-to-day benefits 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 or tests. To find a doctor who is a designated service provider, please use the MaPS tool on

4 Treatment guidelines for Chronic Disease List conditions Condition Diagnosis Ongoing management test description test description Addison s disease U & E only 7 U & E only 7 Cortisol level 99 ACTH stimulation testing 5 Asthma Flow volume test 88 or 86 Bipolar mood disorder Bronchiectasis Flow volume test 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 & 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

5 test description test description Cardiac failure 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 Troponin isoforms 6 Drug level in biological fluid 08 or Glucose random/fasting or 9 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 & 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 Glucose random/fasting 057 Prothrombin index (PI) 805 C-reactive protein 97 Therapeutic drug level: Dosage 806 Full blood count 755 Drug level in biological fluid 08 or Thyrotropin (TSH) or 9 Total cholesterol 07 Flow volume test 88 or 86 Flow volume test Peak flow 9 Alpha--antitrypsin 005 Drug level in biological fluid 08 or 70 or 9

6 Chronic renal disease Coronary artery disease test description ECG Electrocardiogram or or 6 test description 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) 06 or 07 or 75 or or Serum calcium 06 or 07 or 75 or 76 Serum phosphates 09 or 5 Serum parathyroid hormone (PTH) 5 Protein: Quantitative Protein: Quantitative ECG Electrocardiogram Echocardiography or or or 5 or 6 6 & 6 & 6 & 60 & 65 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 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

7 Coronary artery disease test description 00 Platelet count 797 Crohn s disease Colonoscopy 65 or 656 Diabetes insipidus Erythrocyte sedimentation rate or C-reactive protein 7 or 97 test description Colonoscopy 65 or 656 C-reactive protein 97 Full blood count 755 Full blood count 755 Histology 567 & 57 or 58 & 58 U & E only 7 U & E only 7 Osmolality: Serum or urine 09 Osmolality: Serum or urine 09 Diabetes type ECG Electrocardiogram or or 6 ECG Electrocardiogram or or 6 Microalbuminuria 6 Microalbuminuria 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 Glucose random/fasting 057 HBAc 06 Two-hour glucose-ogtt 09 Tonometry 0 Basic capital equipped in own rooms by ophthalmologists Fundus examination Podiatrist Dietician (Ophthalmologist) or or 680 or or 80 or 80 or 80 or 80 or 805 (Endocrinologist/ Specialist physician/ Paediatrician)

8 test description Diabetes type ECG Electrocardiogram or or 6 test description ECG Electrocardiogram or or 6 Microalbuminuria 6 Microalbuminuria 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 Glucose random/fasting 057 HBAc 06 Two-hour glucose- OGTT 09 Tonometry 0 Dysrhythmias 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 (Ophthalmologist) or or 680 or or 80 or 80 or 80 or 80 or 805 (Endocrinologist/ Specialist physician/ Paediatrician) ECG Electrocardiogram or or or 5 or 6 Echocardiography 6 & 6 & 6 & 60 & 65 U & E only 7 U & E only 7 Magnesium: Spectrophotometric 09 Magnesium: Spectrophotometric 09 C-reactive protein 97 Prothrombin index (PI) 805 Thyrotropin (TSH) 507 Therapeutic drug level: Dosage 806

9 Dysrhythmias test description Hour ambulatory ECG monitoring (holter) Serum calcium Epilepsy EEG Electro-encephalography 8 & 9 06 or 07 or 75 or 76 7 & 7 EEG with special activation 75 test description Drug level in biological fluid 08 or 70 or 9 Drug level in biological fluid 08 or 70 or 9 Glaucoma Tonometry 0 Tonometry 0 Haemophilia 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 / Disc photography Central corneal thickness measurement Factor VIII or Factor IX antigen or Coagulation factors 009 Basic capital equipped in own rooms by ophthalmologists 06 or or ( per eye) 758 or 757 Visual fields 06 or 07 Disc and nerve fibre layer analysis / Disc photography Retinal threshold trend evaluation Factor VIII or Factor IX inhibitors 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) 805 Therapeutic drug level: Dosage 806 Bleeding time 7 Thrombin time 8 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 0

10 test description test description Hypertension Glucose random/fasting 057 Glucose random/fasting 057 Total cholesterol 07 Total cholesterol 07 Hour ambulatory blood pressure U & E only 7 7 Potassium Hypothyroidism Thyrotropin (TSH) 507 Thyrotropin (TSH) 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 Erythrocyte sedimentation rate or C-reactive protein 00 or or or or 50 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 7 or 97 Erythrocyte sedimentation rate or C-reactive protein 00 or or or or or 97 Full blood count 755 Full blood count 755 Platelet count 797 Platelet count 797 Urine analysis (dipstick) 88 Urine analysis (dipstick) 88 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

11 Rheumatoid arthritis Schizophrenia Systemic lupus erythematosus test description Rheumatoid factor 959 ANF 9 test description AST Aspartate ALT Alanine 0 U & E only 7 Drug level in biological fluid 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 or 8 7 or & 0 & 0 & 05 & 07 Complement fixation test 96 or 8 Erythrocyte sedimentation rate or C-reactive protein 00 7 or 97 Total cholesterol 07 Kidney biopsy 8 kinase 5 or 5 Extractable nuclear antigens 9 or 98 Urine microscopy 867 AST Aspartate ANF 9 ALT Alanine DNA antibodies 59 or 98 Histology 567 & 57 or 58 & 58 Antiglobulin test (Coombs) 709 0

12 test description Ulcerative colitis Colonoscopy 65 or 656 test description Colonoscopy 65 or 656 C-reactive protein 97 C-reactive protein 97 Full blood count 755 Full blood count 755 Histology 567 & 57 or 58 & 58 Flexible sigmoidoscopy 676 Disy Health Medical Scheme; registration number 5, administered by Disy Health (Pty) Ltd, registration number 997/080/07, an authorised financial services provider. In this brochure, the value-added service - MaPS Advisor - is owned by Disy Health (Pty) Ltd.