ID number. Bank account number. PIN. Alarm code. Computer access code. Numbers and codes are everywhere we turn. When it comes to your medical aid claims, however, few numbers are as important as ICD10 codes.
Patrick was diagnosed with high blood cholesterol (hyperlipidaemia) by his GP a few months ago. Understanding the rules of his medical scheme, Patrick completed the necessary chronic medicine application forms. His GP completed his section on the form and supplied a copy of the lipogram pathology report that was used to make the diagnosis. The scheme was satisfied that Patrick met all the criteria and he was registered for chronic benefits. Patrick' GP advised him to obtain the treatments standards and list of medicines covered from his scheme. The doctor prescribed medication that appeared on the scheme's formulary, i.e. the list of drugs fully covered by the scheme, and Patrick started with his treatment.
During the course of this process, Patrick learned that high cholesterol is a Prescribed Minimum Benefits (PMB) condition. This, he was told, means that his medical scheme has to provide full cover for his treatments and medication regardless of his chronic benefits limits for the year. The conditions attached to this are that he uses the drugs listed in the scheme's formulary, adheres to the scheme's treatment standards and, where necessary, goes to the scheme's Designated Service Providers for treatment and medication.
The scheme's treatment standards specify that Patrick may undergo one lipogram pathology test per year to monitor the effectiveness of his treatment. After a couple of months, his doctor duly sends him for a test, but he then receives an account from the pathology laboratory indicating that the scheme had failed to settle the account. When Patrick contacts his scheme, he is told that the diagnosis code (ICD 10 code) on the account does not correspond to his diagnosis. This means that the scheme cannot reimburse the laboratory as PMB related service and that Patrick has to reimburse it himself, since he has exhausted his day-to-day pathology benefits.
"Fortunately, I was informed about ICD10 codes and I knew where to start to address the problem", says Patrick. He went to his doctor and discovered that the GP did not provide the correct diagnosis code on the pathology referral note. The laboratory, therefore, could not put the correct code on the account. "The solution was as simple as asking my GP to get the right code and send it to the laboratory. The lab then resubmitted its account to the scheme and it was settled as a PMB related expense."
What to ask your medical scheme about your chronic condition:
- Is my illness a PMB condition?
- Who are the DSPs for my condition listed in your rules?
- What are the treatment standards (protocols) for my condition according to your rules?
- Which medicines are on your formularies list?
- Are there any other requirements I need to be aware of, e.g. joining a managed care programme?
- What do I need to ask or tell my doctor (e.g. ICD 10 codes) to ensure full PMB benefits?
The Council can help
PMBs can be a rather complicated subject and your medical scheme might not be able to answer all your questions.
Do not despair. The Council for Medical Schemes (CMS) was established to supervise medical schemes in South Africa. In this role, its first priority is to protect the rights of consumers and to ensure that they are treated fairly.
Therefore, if you have a problem with your medical scheme, contact them in any of the following ways:
Tel: 012 431-0500 / 0861 123 267
Fax: 012 430-7644
E-mail: support@medicalschemes.com
Mail: Private Bag X34, Hatfield, 0028 |
