Established Hosmed Essential General Practitioner Network Guide 2019 - IN 1988
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Hosmed Essential
General Practitioner
Network Guide 2019
Established
IN 1988TABLE OF CONTENTS 1. INTRODUCTION.......................................................................................................................................................................................................................1 2. SUMMARY OF PRIMARY CARE BENEFITS FOR HOSMED ESSENTIAL.......................................................................................................2 3. GENERAL PRACTITIONER TARIFFS AND FEES........................................................................................................................................................5 4. MEDICATION.............................................................................................................................................................................................................................6 5. THE REFERRAL MANAGEMENT PROCESS FOR HOSMED ESSENTIAL......................................................................................................7 6. SPECIALIST BENEFIT..............................................................................................................................................................................................................7 7. MATERNITY BENEFIT AND ANTENATAL VISITS......................................................................................................................................................7 8. PATHOLOGY...............................................................................................................................................................................................................................8 9. RADIOLOGY...............................................................................................................................................................................................................................8 10. DAY-TO-DAY BENEFITS........................................................................................................................................................................................................8 11. HOSPITALISATION................................................................................................................................................................................................................10 12. PRESCRIBED MINIMUM BENEFITS (PMB)...............................................................................................................................................................10 13. HIV / AIDS MANAGEMENT.............................................................................................................................................................................................10 14. OTHER MAJOR MEDICAL BENEFITS..........................................................................................................................................................................11 15. ANNEXURE A: PATHOLOGY FORMULARY.............................................................................................................................................................12 16. ANNEXURE B: RADIOLOGY FORMULARY..............................................................................................................................................................15
Hosmed Essential
General Practitioner
Network Guide 2019
INTRODUCTION
Dear Medical Practitioner,
Hosmed Medical Scheme offers an entry level option to their members by means of the Essential Option.
The Scheme recognises the General Practitioner’s role as the coordinator of care and would like to thank you for agreeing to provide
excellent healthcare services to our valued Hosmed Essential members and their families. Hosmed remains committed to ensure
that Hosmed Essential members receive high quality care that is accessible and cost effective.
To ensure the sustainability of the Hosmed Essential Option and to protect members on this option from unexpected co-payments,
it is imperative that participating General Practitioners (GPs) adhere to formularies and protocols as contained in this guide.
Hosmed Essential General Practitioner Network Guide 2019 1Hosmed Essential
General Practitioner
Network Guide 2019
SUMMARY OF PRIMARY CARE BENEFITS FOR HOSMED
ESSENTIAL
Benefit Essential
General Practitioner • Unlimited GP visits, subject to utilisation of the Hosmed GP Network
consultations • Procedures in the Hosmed GP’s room are subject to a specified list
• Only listed tariff codes will be reimbursed
• There will be no additional benefits for tariff codes not listed in this guide
• For more information on in-room procedures, please refer to Section three (3): General Practitioner tariffs
and fees
Out-of-network General No benefit for out of network GP consultations
Practitioner consultations
Specialist consultations • On referral from a Hosmed Network GP only
• The Hosmed Network GP can obtain a referral authorisation by contacting Hosmed on 0860 00 00 48
• Limited to PMB conditions only
• Limited to three (3) visits per family per annum
Pathology • On referral of a Hosmed Network GP only and limited to PMB conditions
• Hosmed’s preferred pathology providers to be used (Ampath, Pathcare and Lancet)
• Limited to R822 per beneficiary per annum
• Subject to the Hosmed pathology formulary as specified in Annexure A
• To access the formulary online visit www.medscheme.com, register or log in as a Provider and click Clinical
Information > Pathology Formulary
Radiology • On referral of a Hosmed Network GP only and limited to PMB conditions
• Limited to R822 per beneficiary per annum
• Subject to the Hosmed radiology formulary as specified in Annexure B
• To access the formulary online visit www.medscheme.com, register or log in as a Provider and click Clinical
Information >Radiology Formulary
Specialised Radiology • On referral of a Hosmed Network GP or Specialist, provided that the Specialist visit has been authorised as
per the referral management process
• MRI/PET/CAT Scans are limited to two (2) per person per annum for in-and-out of Hospital
• Limited to PMB conditions
Acute medication • Can only be prescribed or dispensed by a Hosmed Network GP
(prescribed from formulary) • Unlimited if dispensed by the Hosmed Network GP
• Subject to the acute medicine formulary
• Limited to R1 206 per beneficiary and R3 366 per family for acute scripts per annum if obtained from a DSP
pharmacy
• If PAT, sub-limit of R615 per family per annum and maximum of R90 per script. PAT not chargeable with
acute script on the same day
• Homeopathic medication and contraception are excluded
Chronic medication • Subject to PMBs, pre-authorisations, registration and chronic formulary
• Registration of the chronic medicine to be done by a Hosmed Network GP or a Specialist where the
Specialist visit has been authorised as per the referral management process
• To register, contact 0860 00 00 48 or email hosmedauth@mediscor.co.za
• All chronic medication must be dispensed by a preferred provider network pharmacy
• A list of network pharmacies can be obtained by visiting www.hosmed.co.za
Contraceptives • Limited to R61 per person per month, subject to R732 per family per annum
• Subject to oral and injectable contraceptives only
• Subject to the contraceptive formulary
• Only when using a DSP pharmacy for pharmacy dispensed contraceptives
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Benefit Essential
Optometry Contact lenses:
• Contact lenses at R585 per person every 24 months, obtained from Preferred Provider Negotiators (PPN)
• No benefit for contact lenses if spectacles are purchased
Frames:
• Only frames from Preferred Provider Negotiators (PPN) will be covered
• R300 per beneficiary
Spectacle lenses:
Subject to the Hosmed optometry network managed by Preferred Provider Negotiators (PPN) and a list of
approved services:
Each beneficiary is entitled to the following benefit over a 24-month cycle from the last date of service:
One consultation, and one pair of spectacles per person, and
• R175 per lens for clear single vision; or
• R410 per lens for clear bifocal; or
• R410 per lens for base multifocal
Basic dentistry Subject to the Dental Risk Company’s (DRC) Designated Service Provider network, Managed Care Protocols
and a list of approved services/tariff codes:
• Consultations
• Fillings
• Extractions
• Preventative scale and polish
• Fluoride treatment limited to beneficiaries below the age of 12 years
• X-rays (limited to intra-oral)
Dental protocols apply and pre-authorisation required for extensive treatment plans
• Quantity Limitations Apply
• Contracted Network Provider Only:
▷▷ The complete list of dental tariff codes on Hosmed’s Essential Option can be obtained by visiting
www.dentalrisk.com
▷▷ For pre-authorisations, please email auth@dentalrisk.com
Advanced Dentistry Limited to PMB conditions only
Acrylic (Plastic) Dentures:
• One (1) set of Acrylic/plastic dentures per beneficiary every four (4) years.
• Cover available for realigning and repairing every 12 months
• This includes repairs of dentures
Homeopathy, Naturopathy, Limited to PMBs:
Chiropractor, Podiatry, • Only on referral from a Hosmed Network GP or Specialist, provided that the Specialist visit has been
Audiology, Speech therapy, authorised as per the referral management process
Dieticians, Hearing Aid • Medication obtained from the network pharmacy limit:
Acousticians, Occupational
▷▷ R1 206 per person and
Therapy, Orthotics, Social
Workers and Speech Therapy ▷▷ R3 366 per family per annum as part of the acute benefit
▷▷ Homeopathic Medicine excluded
Maternity benefit • Subject to registration on the Hosmed Bambino Programme
• Limited to R 4 439 per pregnancy
• Related tests are subject to the radiology/pathology formulary as specified in this guide
• All Specialist referrals require the Hosmed Network GP to obtain authorisation by contacting Hosmed on
0860 00 00 48
• Includes two (2) x 2D scans per pregnancy, in-and-out of hospital, subject to the Hosmed radiology
formulary
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Network Guide 2019
Benefit Essential
Physiotherapy and • Subject to PMBs and clinical protocols
Biokinetics • Only on referral from a Hosmed Network GP or Specialist, provided that the Specialist visit has been
authorised as per the referral management process
Cardiac and Respiratory conditions:
• Subject to provision of a treatment plan and therapy goals
• Maximum of six (6) sessions per person, thereafter subject to a progress report and evidence of response
Treatment for Back pain:
• Subject to treatment plan required detailing therapy goals and education programme to transfer self-
management skills
• Maximum of three (3) sessions per week for three (3) weeks. Thereafter, subject to progress reports and
evidence of goals achieved
Appliances • Subject to pre-authorisation and limited to PMBs only
• Limited to R 2 775 per family per annum
Psychology & Psychiatry • Subject to PMB’s
• Only on referral from a Hosmed Network GP or Specialist, provided that the Specialist visit has been
authorised as per the referral management process
• Subject to confirmed diagnosis, treatment plan and managed care protocols
Hospice and private nursing • Limited to PMB conditions only and subject to pre-authorisation
• Call Hosmed on 0860 00 00 48
Maternity benefit (Hosmed • Subject to registration on the Hosmed Bambino Programme
Bambino Programme) • Limited to R 4 439 per pregnancy
• Related tests are subject to the radiology/pathology formulary as specified in this guide
• All Specialist referrals require the Hosmed Network GP to obtain authorisation by contacting Hosmed on
0860 00 00 48
• Includes two (2) x 2D scans per pregnancy in and out of hospital, subject to the Hosmed radiology
formulary
• Immunisation as per the Immunisation schedule by the Department of Health up to twelve (12) months
of age
Preventative care / Wellness • 1 x Pap Smear for females over 18 Years per person per Annum
Programme • 1 x Mammogram for Females over 40 Years per person per Annum
• 1 x PSA for Males over 40 Years per person per Annum
• 1 x Cholesterol Test over 20 Years per person per Annum
• 1 x Flu Vaccine per person per Annum
• 1 x Blood Sugar Test over 15 Years per person per Annum
• 1 x BP check per beneficiary per Annum
• 1 x HIV Test per beneficiary per Annum
• 1 x HPV vaccination per beneficiary between nine (9) and 12 years of age
HIV / AIDS Management • Benefits are subject to PMBs and registration on Hosmed’s programme
Programme • Treatment is subject to the treatment care plan and clinical protocols
• Contact PHA on 0860 00 00 48 (select the HIV option) to register condition on the Chronic Disease
Management Programme
Chronic Disease • Benefits are subject only upon registration on the programme
Management Programme • All treatment is subject to treatment care plans and clinical protocols
• Contact PHA on 0860 00 00 48 to register conditions on the Chronic Disease Management Programme
The complete 2019 benefit schedule for Hosmed’s Essential Option can be viewed on the Hosmed website on www.hosmed.co.za
4 Hosmed Essential General Practitioner Network Guide 2019Hosmed Essential
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GENERAL PRACTITIONER TARIFFS AND FEES
The reimbursement model for the Hosmed Essential Option aims to encourage Network GPs to manage downstream costs and
to ensure good quality care. GPs are also reimbursed for doing certain procedures in their rooms where indicated, e.g. intravenous
rehydration, as opposed to referring patients to hospital for these interventions.
To ensure the sustainability of Hosmed’s Essential Option, it is imperative that participating GPs adhere to formularies and protocols.
Adherence will be monitored and where necessary, Hosmed will engage with and assist GPs in their understanding of the network
requirements.
The support of the GP Network is critical to ensure the sustainability of the Hosmed Essential Option. To this end, Hosmed would
like to encourage Network GPs to perform interventions in their rooms where indicated, in order to prevent unnecessary hospital
admissions. Please see the list of interventions in the table below.
Consultation tariff codes
Consultation Dispensing doctor tariff Non-dispensing doctor
Authorisation mandatory
tariff codes (inclusive of medication) tariff
0190 to 0192 R377.40 R259.90 Beneficiaries have unlimited GP visits, subject to
visiting a Hosmed Network GP
Procedure codes that can be charged in addition to a consultation tariff code:
Tariff Code Tariff Code Description Rate 2019
0300 Stitching of wound (additional code for setting sterile tray) R 199.40
0301 Stitching of an additional wound R 93.00
0307 Excision and repair R 295.80
0255 Drainage of abscess and avulsion of nail R 219.80
0259 Removal of foreign body R 219.80
0887 Limb cast R 185.40
0202 Setting of sterile tray R 142.70
0210 Collection of blood specimen R 45.60
0206 Intravenous treatment R 85.60
0241 Treatment of benign skin lesion by chemo-cryotherapy R 83.90
1232 Resting ECG (including electrodes) R 128.40
2137 Circumcision in rooms (Authorisation required) R 840.10
Authorisation can be obtained by emailing auth@hosmedauth.co.za, or alternatively contact Hosmed on 0860 00 00 48.
Please note:
• Tariff codes not listed above will not be reimbursed, as the fees for these services are included in the consultation fee.
• After-hours and emergency consultations are included in the 0190 to 0192 codes.
• Surgical procedures performed in hospital or in unattached operating theatres are subject to pre-authorisation.
Hosmed Essential General Practitioner Network Guide 2019 5Hosmed Essential
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Network Guide 2019
MEDICATION
All medication for Hosmed Essential members is subject to the Hosmed acute and chronic medicine formularies managed by Mediscor.
Please visit the Mediscor website on www.mediscor.co.za to view these formularies.
Chronic medicine
Prescriber Benefit rules
Dispensing and non- • Only on prescription and chronic registration by a Hosmed Network GP or Specialist provided that the
dispensing Hosmed network Specialist visit has been authorised as per the referral management process
General Practitioners • Subject to PMBs, pre-authorisations, registration and the chronic formulary
• All chronic medicine must be dispensed by a network pharmacy. A list of network pharmacies can be
obtained by visiting www.hosmed.co.za
How to apply for chronic Contact Mediscor on 0860 00 00 48 to obtain telephonic authorisation or
medicine email hosmedauth@mediscor.co.za
Changes or updates Following registration, all changes or updates are done telephonically by
contacting Mediscor on 0860 00 00 48
Please ensure that all test results and motivations (where applicable) are submitted electronically to hosmedauth@mediscor.co.za
or via fax to 0866 151 508/9 upon request.
Acute medicine
Prescriber Benefit rules
Dispensing network General • Can only be prescribed or dispensed by a Hosmed Network GP
Practitioners • Acute medication is included in the consultation fee and subject to the acute medicine formulary
• Dispensing Doctors are requested to display the NAPPI codes for medication dispensed. This will be used
for analysis purposes. The consultation fee will be paid irrespective of medication dispensed or not
• Acute pharmacy claims will not be covered where the scripting GP is contracted as a dispensing GP
Non-dispensing network • Subject to the acute medicine formulary
General Practitioners • Prescribed acute medication must be obtained from the Hosmed preferred pharmacy network. The list of
the preferred providers can be accessed via www.hosmed.co.za
• Limited to R1 206 per beneficiary and R3 366 per family per annum
• If PAT, sub-limit of R615 per family per annum and maximum of R90 per script. PAT not chargeable with
acute script on the same day
• Homeopathic medication is excluded
Contaceptive medicine
Description Benefit rules
Contraceptive benefit • Limited to R61 per person per month, subject to R732 per family per annum
• Subject to oral and injectable contraceptives only
• Subject to the contraceptive formulary
• Only when using a DSP pharmacy for pharmacy dispensed contraceptives
Over-the-counter (Otc) medication
Benefit for Essential
• OTC medication is subject to the Hosmed acute formulary and at network pharmacies only.
• Limited to R90 per script and a maximum of R615 per family per annum.
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THE REFERRAL MANAGEMENT PROCESS FOR HOSMED
ESSENTIAL
Hosmed Network GPs need to obtain authorisation before the event for the following benefit categories:
• All Specialist consultations, including antenatal consultations at a gynaecologist.
• GPs can obtain authorisation for a referral by contacting Hosmed on 0860 00 00 48.
Specialist benefit
Specialist visits Essential
Out-of-hospital • Limited to three (3) visits per family per annum
consultations • Limited to PMB conditions only
• Only on referral from a Hosmed Network GP and subject to authorisation
• Referral authorisation for Specialist consultations can be obtained by contacting Hosmed on 0860 00 00 48
Surgical procedures in Limited to PMBs (subject to pre-authorisation and Managed Care Protocols)
hospital and unattached
operating theatres
Maternity benefit and antenatal visits
Maternity Benefit rules
Antenatal consultations, • Subject to registration on the Hosmed Bambino Programme, which can be done by calling 0860 00 00 48
scans and blood tests or by emailing bambino@hosmedauth.co.za
• Antenatal consultations are included in the GP and Specialist consultation benefit
• Related tests are subject to the radiology/pathology formulary as specified in this guide. Refer to Annexure
A and B
• Includes two (2) x 2D ultrasound scans per pregnancy in-and-out of hospital, subject to the Hosmed
radiology formulary
Specialist consultations • All out-of-hospital Specialist consultations must be referred by a Hosmed Network GP and require the
network GP to obtain authorisation by contacting Hosmed on 0860 00 00 48
• Antenatal consultations are included in the Specialist consultation benefit, these are limited to three (3)
consultations per family per annum
Hospital • Access to hospitals for maternity is subject to the Hosmed hospital network and pre-authorisation, which
can be obtained by contacting Hosmed on 0860 00 00 48
• The Hosmed hospital network can be verified by visiting www.hosmed.co.za or by contacting Hosmed on
0860 00 00 48
• Hospital stay will be covered at 100% of the Hosmed Rate provided that pre-authorisation is obtained and a
network hospital is used
Delivery by midwife • Delivery by a midwife in a registered and accredited birthing unit is included and subject to prior
authorisation
• Authorisation can be obtained by emailing preauth@hosmedauth.co.za or by contacting Hosmed on
0860 00 00 48
• Limited to R 4 439 per pregnancy
Immunisation benefit • Immunisation as per the Immunisation schedule by the Department of Health up to twelve (12) months
of age
• Immunisation is managed by Private Healthcare Administrators (PHA)
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Pathology
Pathology Benefit rules
Codes that apply • In-hospital pathology is limited to R5 883 per beneficiary per annum
• Out-of-hospital pathology is covered according to the pathology formulary in Annexure B in this guide:
▷▷ To access the latest, full version of these protocols, go to www.medscheme.com, register or log in as a
Provider and click Clinical Information > Pathology Formulary
▷▷ On referral of Hosmed Network GP only
▷▷ Limited to PMB conditions only
▷▷ Limited to R822 per beneficiary per annum
Who can refer the member? Members must be referred by a Hosmed Network GP or a Specialist: Subject to authorisation of the Specialist
visit in order for tests to qualify for payment
How to obtain authorisation Contact Hosmed on 0860 00 00 48
Pathology Preferred Provider Hosmed’s preferred pathology providers to be used (Ampath, Pathcare and Lancet)
Network
Radiology
Radiology Benefit rules
Codes that apply • In-hospital radiology is limited to R5 883 per beneficiary per annum
• Out-of-hospital radiology is covered according to the radiology formulary. See Annexure A in this guide:
▷▷ On referral of Hosmed Network GP only
▷▷ To access the latest, full version of these protocols, visit www.medscheme.com, register or log in as a
Provider and click Clinical Information > Radiology Formulary
▷▷ Limited to PMB conditions only
▷▷ Limited to R822 per beneficiary per annum
Who can refer the member? Only scans and x-rays referred by a Hosmed Network GP or a Specialist, subject to authorisation of the
Specialist visit, will qualify for payment
Authorisation for out-of- Authorisation can be obtained from Hosmed by contacting 0860 00 0048
formulary investigations
Specialised Radiology • Limited to PMB conditions only
• MRI/PET/CAT Scans are limited to two (2) per person per annum for in-and-out of Hospital
• Limited to PMB conditions
DAY-TO-DAY BENEFITS
Allied Health Services: Occupational and Physiotherapy
Occupational and Benefit rules
physiotherapy
Biokinetics and • Subject to PMBs and clinical protocols
Physiotherapy • Only on referral from a Hosmed Network GP or Specialist, provided that the Specialist visit has been
authorised as per the referral management process
Cardiac and Respiratory conditions:
• Subject to provision of a treatment plan and therapy goals
• Maximum of six (6) sessions per person, thereafter subject to progress report and evidence of response
Treatment for Back pain:
• Subject to a treatment plan required detailing therapy goals and education programme to transfer self-
management skills
• Maximum of three (3) sessions per week for three (3) weeks. Thereafter, subject to progress reports and
evidence of goals achieved
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Dentistry
Dentistry Benefit rules
Basic dentistry Subject to the Designated Service Provider network, Dental Risk Company (DRC), Managed Care Protocols and a
list of approved services/tariff codes:
• Consultations
• Fillings
• Extractions
• Preventative scale and polish.
• Fluoride treatment limited to beneficiaries below the age of 12 years
• X-rays (limited to intra-oral)
Dental protocols apply and pre-authorisation required for extensive treatment plans:
• Quantity Limitations Apply
• Contracted Network Provider Only
• The complete list of dental tariff codes on the Hosmed Essential Option can be obtained by visiting
www.dentalrisk.com
• For pre-authorisations, please email auth@dentalrisk.com
Advanced Dentistry • Limited to PMB conditions only
• Acrylic (Plastic) Dentures:
▷▷ One (1) set of Acrylic/plastic dentures per beneficiary every four (4) years
▷▷ Cover available for realigning and repairing every 12 months
▷▷ Including repairs of dentures
Hospitalisation (general • Pre-authorisation is required and must be obtained from DRC by emailing auth@dentalrisk.com
anaesthetic • General anaesthetic benefit is only available for PMB admissions
Dental network The dental network list can be obtained by visiting DRC online on www.dentalrisk.com
Optometry
Optometry Essential
Benefit Subject to the Hosmed optometry network managed by Preferred Provider Negotiators (PPN) and a list of
approved services:
Contact lenses:
• Contact lenses at R585 per person every 24 months, obtained from Preferred Provider Negotiators (PPN)
• No benefit for contact lenses if spectacles purchased
Frames:
• Only frames from Preferred Provider Negotiators (PPN) will be covered at R300 per beneficiary
Spectacle lenses:
Each beneficiary is entitled to the following benefit over a 24-month cycle from the last date of service:
• One (1) consultation, and one pair of spectacles per person, and;
• R175 per lens for clear single vision; or
• R410 per lens for clear bifocal; or
• R410 per lens for base multifocal
Optometry network The preferred provider optometry network list can be obtained as follows:
• Web: www.ppn.co.za
• Contact: 0860 103 529
• Claims submissions: claims@ppn.co.za
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HOSPITALISATION
Hospitalisation Benefit rules
Benefit • The hospitalisation benefit is subject to the Hosmed hospital network, pre-authorisation and Managed Care
Protocols
• All admissions to hospitals must be pre-authorised by the Scheme/preferred provider or within 48 hours in the
case of an emergency:
▷▷ Failure to comply with this rule will result in a levy of R1 000 per admission
▷▷ A 10% co-payment applies for admission to a non-network hospital
• Discharge medication (TTO) is subject to the Hosmed acute formulary and limited to PMBs only
Hospital network • Access to public and a network of private hospitals can be obtained from Private Healthcare Administrators
(PHA):
▷▷ Web: www.pha.co.za
▷▷ To view a list of network hospitals, log in to www.hosmed.co.za
How to obtain pre- • Contact Hosmed on 0860 00 00 48
authorisation • Email Hospital Pre-authorisation: preauth@hosmedauth.co.za
PRESCRIBED MINIMUM BENEFITS (pmb)
Benefits for Hosmed’s Essential Option are as per the Hosmed PMB treatment protocols. Please contact Hosmed on 0860 00 00 48 if
more information is required.
HIV/AIDS MANAGEMENT
Benefit Benefit rules
Benefit Subject to registration on the Hosmed HIV/AIDS Programme and Managed Care Protocols managed by
Private Healthcare Administrators (PHA)
General Practitioner Subject to the Hosmed GP network and reimbursed at Hosmed’s GP network rate
consultations
Specialist consultations • Subject to a Hosmed Network GP obtaining a referral authorisation by contacting Hosmed on
0860 00 00 48
• Limited to PMB conditions only
• Consultations are included in the Specialist consultation benefit. Limited to three (3) visits per family per
annum
Out-of-hospital pathology • Out-of-hospital pathology and radiology are covered according to the formularies as specified in Annexures
and radiology A and B in this guide
• All additional tests not listed in the formularies will require pre-authorisation
• Members must be referred by the Hosmed Network GP or a Specialist: Subject to authorisation of the
Specialist visit in order for tests to qualify for payment
• Hosmed Essential members get a monetary limit per beneficiary for pathology and radiology:
▷▷ Limited to PMB conditions only
▷▷ Limited to R822 per beneficiary per annum respectively for pathology and radiology
How to obtain authorisation • Contact Hosmed on 0860 00 00 48
• Email: care@hosmedauth.co.za
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OTHER MAJOR MEDICAL BENEFITS
Benefit Benefit rules
Oncology (chemotherapy • Limited to PMBs and subject to the Designated Service Provider and ICON protocols
and radiotherapy) • Subject to pre-authorisation
• Authorisation can be obtained by contacting Hosmed on 0860 00 00 48
• The oncology network can be verified as follows:
▷▷ Tel: 086 601 5474
▷▷ Email to oncology@hosmedauth.co.za
Organ transplants and renal • Limited to PMBs
dialysis • Subject to pre-authorisation and Managed Care Protocols
• Authorisation can be obtained by contacting Hosmed on 0860 00 0048
Psychiatric Treatment, • Limited to PMBs. Subject to pre-authorisation and Managed Care Protocols
Including Clinical Psychology • Subject to 21 days per beneficiary or up to 15 out-patient contacts per annum
• Authorisation can be obtained by contacting Hosmed on 0860 00 00 48
Drug and Alcohol • Limited to PMBs and subject to pre-authorisation and Managed Care Protocols
Rehabilitation • Authorisation can be obtained by contacting Hosmed on 0860 00 00 48
• Limited to R11 765 per family per annum
Surgical procedures in • Limited to PMBs
hospital and unattached • Subject to pre-authorisation and Managed Care Protocols
operating theatres
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ANNEXURE A: PATHOLOGY FORMULARY
All codes not listed, require authorisation. Please contact Hosmed on 0860 00 00 48
Subject to
Tariff code Description authorisation
A. Chemistry
Cardia/muscle
4152 CK-MB: Mass determination: Quantitative (Automated) No
4161 Troponin isoforms: Each No
Diabetes
4057 Glucose: Quantitative No
4064 HbA1C No
4221 Creatinine No
4261 Microalbuminurea (Quantitative) No
Inflammation/immune
3947 C-reactive protein No
Lipids
4027 Cholesterol total No
4026 LDL cholesterol No
4028 HDL cholesterol No
4147 Triglyceride No
4132 Creatinine Kinase (CK) No
Liver/pancreas
3999 Albumin No
4001 Alkaline phosphatase No
4006 Amylase No
4009 Bilirubin: Total No
4010 Bilirubin: Conjugated No
4117 Protein: Total No
4130 Aspartate aminotransferase (AST) No
4131 Alanine aminotransferase (ALT) No
4133 Lactate dehydrogenase (LD) No
4134 Gamma-glutamyl transferase (GGT) No
Renal/electrolytes/bone
4017 Calcium: Spectrophotometric No
4032 Creatinine No
4086 Lactate No
4094 Magnesium: Spectrophotometric No
4109 Phosphate No
4113 Potassium No
4114 Sodium No
4155 Uric acid No
4151 Urea No
Cerebrospinal fluid
B. Haematology
3709 Antiglobulin test (Coombs' or trypsinzied red cells) No
3716 Mean cell volume No
3743 Erythrocyte sedimentation rate No
3739 Erythrocyte count No
3783 Leucocyte differential count No
3785 Leucocytes – total count No
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All codes not listed, require authorisation. Please contact Hosmed on 0860 00 00 48
Subject to
Tariff code Description authorisation
3791 Packed cell volume: Haematocrit No
3755 Full blood count (including items 3739, 3762, 3783, 3785, 3791) No
3762 Haemoglobin estimation No
3764 Grouping: A, B and O antigens No
3765 Grouping: Rh antigen No
3797 Platelet count No
3805 Prothrombin index No
3809 Reticulocyte count No
3865 Parasites in blood smear No
4071 Iron No
4144 Transferrin No
4491 Vitamin B12 No
4528 Ferritin No
4533 Folic acid No
C. Endocrine – reproductive
4450 HCG: Monoclonal immunological: Qualitative No
4537 Prolactin No
Endocrine – thyroid
4482 Free thyroxine (FT4) No
4507 Thyrotropin (TSH) No
Other endocrine
4519 Prostate specific antigen No
D. Serology
Auto immune
3934 Auto antibodies by labelled antibodies: FOR ANF ONLY No
3939 Agglutination test per antigen No
4155 Uric acid No
4182 Quantitative protein estimation: Nephelometer or Turbidometeric method: FOR RHEUMATOID No
FACTOR ONLY
Hepatitis tests
4531 Hepatitis: Per antigen or antibody No
4531 Acute hepatitis A (IgM) No
4531 Chronic Hepatitis A (IgG) No
4531 Acute Hepatitis B (BsAG) No
4531 Hepatitis B: carrier/immunity (BsAB) No
HIV tests
3816 T and B-cells EAC markers (limited to ONE marker only for CD4/8 counts) No
3932 Antibodies to human immunodeficiency virus (HIV): ELISA No
3974 Qualitative PCR (only for children < age 6 months) Yes
4429 Quantitative PCR (DNA/RNA) Yes
Infectious diseases and others
3946 IgM: Specific antibody titer: ELISA/EMIT: RUBELLA No
3948 IgG: Specific antibody titer: ELISA/EMIT: RUBELLA No
3949 Qualitative Kahn, VDRL or other flocculation No
3951 Quantitative Kahn, VDRL or other flocculation No
E. Cytology
4566 Vaginal or cervical smears, each No
F. Histology
4567 Histology per sample No
Hosmed Essential General Practitioner Network Guide 2019 13Hosmed Essential
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Annexure A: Pathology formulary continued
All codes not listed, require authorisation. Please contact Hosmed on 0860 00 00 48
Subject to
Tariff code Description authorisation
G. Miscellaneous
4351 Colorectal cancer screening No
4352 Faecal occult blood test (FOB) No
H. Microbiology
Mcs
3909 Anaerobe culture: Limited procedure No
3901 Fungal culture No
3918 Mycoplasma culture: Comprehensive No
4401 Cell count No
4188 Urine dipstick, per stick (irrespective of the number of tests on stick) No
3928 Antimicrobic substances No
3893 Bacteriological culture: Miscellaneous No
3867 Miscellaneous (body fluids, urine, exudate, fungi, puss, scrapings, etc.) No
3922 Viable cell count No
3879 Campylobacter in stool: Fastidious culture No
3895 Bacteriological culture: Fastidious organisms No
3928 Antimicrobic substances No
3887 Antibiotic susceptibility test: Per organism No
3924 Biochemical identification of bacterium: Extended No
3869 Faeces (including parasites) No
3868 Fungus identification No
3881 Mycobacteria No
3901 Fungal culture No
3868 Fungus identification No
AFB fluorochrome auramine (zn) only
3885 Cytochemical stain No
3881 Antigen detection with monoclonal antibodies No
TB culture
3881 Antigen detection with monoclonal antibodies No
4433 Bacteriological DNA identification (LCR) No
3916 Radiometric tuberculosis culture No
3867 Miscellaneous (body fluids, urine, exudate, fungi, puss, scrapings, etc.) No
3895 Bacteriological culture: Fastidious organisms No
TB sensitivity
3887 Antibiotic susceptibility test: Per organism No
3974 Polymerase chain reaction Yes
Extrapulmonary TB
4139 Adenosine deaminase (CSF, peritoneal or pleural) No
Parasites
3869 Faeces (including parasites) No
3883 Concentration techniques for parasites No
3865 Parasites in blood smear No
Bilharzia micro
3980 Bilharzia Ag serum/urine No
3867 Miscellaneous (body fluids, urine, exudate, fungi, puss, scrapings, etc.) No
3946 IgM: Specific antibody titer: ELISA/EMIT: Per Ag No
3883 Concentration techniques for parasites No
14 Hosmed Essential General Practitioner Network Guide 2019Hosmed Essential
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ANNEXURE B: RADIOLOGY FORMULARY
All codes not listed, require authorisation. Please contact Hosmed on 0860 00 00 48
Medical practitioner Radiologist Radiography Code description
General
39300 X-ray films
Skull and brain
3349 10100 39039 X-ray of the skull
Facial bones and nasal bones
3353 11100 39043 X-ray of the facial bones
3357 11120 39047 X-ray of the nasal bones
Orbits and paranasal sinuses
3353 12100 39043 X-ray orbits
3351 13100 39041 X-ray of the paranasal sinuses, single view
13110 X-ray of the paranasal sinuses, two or more views
Mandible, teeth and maxilla
3355 14100 39045 X-ray of the mandible
3361 14130 39051 X-ray of the teeth, single quadrant
3363 14140 39053 X-ray of the teeth, more than one quadrant
3365 14150 39055 X-ray of the teeth, full mouth
3361 15100 39059 X-ray temperomandibular joint, left
3361 15110 39059 X-ray temperomandibular joint, right
3359 16100 39049 X-ray of the mastoids, unilateral, Left
3359 16100 39049 X-ray of the mastoids, unilateral, right
3359 16110 39049 X-ray of the mastoids, bilateral
Thorax
3445 30100 39107 X-ray of the chest, single view, PA
3445 30100 39107 X-ray of the chest, single view, lateral
30110 39107 X-ray of the chest two views, PA and lateral
3449 30150 39107 X-ray of the ribs
Abdomen and pelvis
3477 40100 39125 X-ray of the abdomen
40110 X-ray of the abdomen, multiple views including chest
40105 39125 X-ray of the abdomen, supine and erect, or decubitus
Spine
3321 39017 Skeleton: Spinal column
– Per region, e.g. cervical, sacral, lumbar coccygeal, one region
thoracic
50100 39025 X-ray of the spine, scoliosis view, AP only
3321 51110 39017 X-ray of the cervical spine, one or two views, AP
3321 51110 39017 X-ray of the cervical spine, one or two views, lateral
3321 52100 39017 X-ray of the thoracic spine, one or two views, AP
3321 52100 39017 X-ray of the thoracic spine, one or two views, lateral
3321 53110 39017 X-ray of the lumbar spine, one or two views, AP
3321 53110 39017 X-ray of the lumbar spine, one or two views, lateral
3321 54100 39017 X-ray of the sacrum and coccyx
54110 39027 X-ray of the sacroiliac joints
Pelvis and hips
3331 55100 39027 X-ray of the pelvis
6518 56100 39017 X-ray of the left hip
6518 56110 39017 X-ray of the right hip
56120 X-ray pelvis and hips
Hosmed Essential General Practitioner Network Guide 2019 15Hosmed Essential
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Annexure B: Radiology formulary continued
All codes not listed, require authorisation. Please contact Hosmed on 0860 00 00 48
Medical practitioner Radiologist Radiography Code description
Upper limb
6509 61100 39003 X-ray of the left clavicle
6509 61105 39003 X-ray of the right clavicle
6510 61110 39003 X-ray of the left scapula
6510 61115 39003 X-ray of the right scapula
6508 61120 39003 X-ray of the left acromio-clavicular joint
6508 61125 39003 X-ray of the right acromio-clavicular joint
6507 61130 39003 X-ray of the left shoulder
6507 61135 39003 X-ray of the right shoulder
6506 62100 39003 X-ray of the left humerus
6506 62105 39003 X-ray of the right humerus
6505 63100 39003 X-ray of the left elbow
6505 63105 39003 X-ray of the right elbow
6504 64100 39003 X-ray of the left forearm
6504 64105 39003 X-ray of the right forearm
6500 65100 39003 X-ray of the left hand
6500 65105 39003 X-ray of the right hand
3305 65120 39001 X-ray of a finger
6501 65130 39003 X-ray of the left wrist
6501 65135 39003 X-ray of the right wrist
6503 65140 39003 X-ray of the left scaphoid
6503 65145 39003 X-ray of the right scaphoid
Lower limb
6514 73100 39003 X-ray of the left lower leg
6514 73105 39003 X-ray of the right lower leg
6512 74100 39003 X-ray of the left ankle
6512 74105 39003 X-ray of the right ankle
6511 74120 39003 X-ray of the left foot
6511 74125 39003 X-ray of the right foot
6513 74130 39003 X-ray of the left calcaneus
6513 74135 39003 X-ray of the right calcaneus
6511 74140 39003 X-ray of both feet, standing, single view
3305 74145 39001 X-ray of a toe
6517 71100 39003 X-ray of the left femur
6517 71105 39003 X-ray of the right femur
6515 72100 39003 X-ray of the left knee one or two views, AP
6515 72100 39003 X-ray of the left knee, one or two views, lateral
6515 72105 39003 X-ray of the right knee, one or two views, AP
6515 72105 39003 X-ray of the right knee, one or two views, lateral
72120 39003 X-ray of the left knee, including patella
72125 39003 X-ray of the right knee, including patella
6516 72140 39003 X-ray of left patella
6516 72145 39003 X-ray of right patella
72150 39003 X-ray both knees standing, single view
16 Hosmed Essential General Practitioner Network Guide 2019Hosmed Essential
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Annexure B: Radiology formulary continued
All codes not listed, require authorisation. Please contact Hosmed on 0860 00 00 48
Medical practitioner Radiologist Radiography Code description
6519 74150 39003 X-ray of the sesamoid bones, one or both sides, left
6519 74150 39003 X-ray of the sesamoid bones, one or both sides, right
CT scans
6416 13300 CT of the paranasal sinuses, single plane, limited study
6417 13300 CT of the paranasal sinuses, single plane, limited study
Ultrasound abdomen and pelvis
5102 61200 Ultrasound of the left shoulder joint
5102 61210 Ultrasound of the right shoulder joint
41200 Ultrasound study of the upper abdomen
3627 40210 Ultrasound study of the whole abdomen, including the pelvis
3618 43200 39147 Ultrasound study of the pelvis, transabdominal
3615 43250 39145 Ultrasound study of the pregnant uterus, first trimester
3270 39145 Ultrasound study of the pregnant uterus, third trimester, first visit
43273 39145 Ultrasound study of the pregnant uterus, third trimester,
follow‑up visit
3615 43277 39145 Ultrasound study of the pregnant uterus, multiple gestation,
second or third trimester, first visit
3617 43260 39145 Routine obstetric ultrasound at 20 to 24 weeks to include
detailed anatomical assessment
Hosmed Essential General Practitioner Network Guide 2019 17HEAD OFFICE
3 Victoria Link | Route 21 Corporate Park | Irene |0178
PO Box 16148 | Doornfontein 2028 | South Africa | www.hosmed.co.za | Telephone 0861 467 633
Registration Number: 1537
BOARD OF TRUSTEES: Mr SD Langa (Chairperson), Adv. PS Schutte (Vice Chairperson), MS N Netili, Mr NJ Erasmus, Ms TS Kekana,
Ms P Dumelakgosi, Mr MG Henning, Mr N Monyela, Dr A Nhlanhla, Mr AF Mazza, Mr A Greyling | Dr AV Memela (Principal Officer)
Medscheme\Hosmed Branch Networks
Visit a Walk-In-Centre near you to have your queries resolved as follows:
Region Physical Address
Bloemfontein Medical Suites 4 and 5, Middestad Medical Suites,1st Floor, Middestad Centre, c/o Charles & West
Burger Street
Cape Town Icon Building, Ground Floor, c/o Lower Long Street and Hans Strijdom Avenue
Durban 102 Stephen Dlamini Road, Musgrave
Florida Flora Centre – Entrance 2, Shop 21 & 22, Cnr Ontdekkers and Conrad Road, Florida North, Roodepoort
Kathu 6 Rietbok Street, Kathu
Klerksdorp Medicover Building, Shop 11, 22 Knowles street, Wilkoppies
Kimberley Shop no 17, Southey Street
Lephalale Bosveld Boulevard Park, Shop 6, Cnr of Chris Hani and Joe Slovo street, Onverwacht
Mafikeng Mega City, Office 101A, 1st Floor, East Gallery
Nelspruit Union Square Unit G2, 44 Mostert Street
Polokwane Shoprite Checkers Centre, Shop2 Ground Floor, Cnr Hans van Rensburg Street & Grobler Street
Port Elizabeth Block 6, Greenacres, Office Park, 2nd Avenue, Newton Park
Pretoria Nedbank Plaza, Ground Floor, Shop 17, 361 Steve Biko Street, Arcadia
Rustenburg Lifestyle Square, Shop No 23, Beyers Naude Drive
Secunda Grand Palace, Unit A2, 2302 Heunis Street
Vereeniging 36 Merriman Avenue, Ground FloorYou can also read
