2013 PPN manual optimum

1 PPN manual 2013 Compiled 24/12/2012CG 1 PPN manual 2013 1. Important 2013 Updates: Price increase & Scheme updates 2. Split Billing 3. PPN network 4. Settlement discount and offering 5. PPN frames 6. PPN Readymade Readers 7. optimum 8. NVS 9. PPN professional indemnity 10. PPN Filters 11. Stale claim procedure 12. RSC 13. PPN Motivations procedure 14. Rate a PPN practice 15. Validate IT and Laboratory Information 16. PPN Invoicing and Payment PPN manual 2013 Compiled 24/12/2012CG 1. IMPORTANT 2013 UPDATES We negotiated the following improvements to the benefit and service deliveries for 2013: A. Consultation & Lens increases for 2013 B. List of 2013 Medical schemes A. Consultation & Lens Increases Consultations We have successfully negotiated an increase of our Comprehensive consultation fee inclusive of dispensing within the benefit design to R 540 for 2013.

2 Code 70005 can be used together with the PPN consultation codes on Capitation PPN 1 schemes only when the total service to the member falls within the benefit design. Description 2013 2012 Code Composite Consultation R400 R380 70001 Consultation only R360 R345 70002 Consultation & Tonometry (OR Visual Fields) R380 R360 70003 Re-Examination R290 R275 70004 Dispensing within the benefit R140 R125 70005 Contact Lens Re-Examination R160 R150 21844 Contact Lens Re-Examination (Bankmed) R200 R190 20844 Lens Pricing We only have the PPN 1 and PPN 2 pricing listed on our tariff grid for 2013 as all our schemes have contracted with these tariffs.

3 The important changes to the tariffs are: PPN 1 Description 2013 2012 Aquity Single Vision Lens R140 R130 Aquity Bifocal Lens R310 R290 Aquity Multifocal Lens R570 R530 PPN 2 Description 2013 2012 Aquity Single Vision Lens R175 R165 Aquity Bifocal Lens

4 R400 R375 Aquity Multifocal Lens R700 R655 Lens Extras The PPN lens extras/additions on the grid for 2013 remains the same as 2012 . PPN manual 2013 Compiled 24/12/2012CG B. List of 2013 Medical Schemes Medical aidOptionBANKMEDCOMPREHENSIVEBANKMEDTRAD ITIONALBESTMEDBEAT 3 BESTMEDPACE 1 BESTMEDPACE 2 BESTMEDPACE 3 BESTMEDPACE 4 BONITASPRIMARY 277 BONITASSTANDARD 020BP SABP SACAMAFFIRST CHOICECAMAFNETWORK CHOICECARECROSS - BANKMEDBANKMED BASICCARECROSS - ESSENTIAL MEDGROUP AND INDIVIDUAL OPTIONSCARECROSS - HORIZONMAJOR MEDICAL PLANCARECROSS - LIBERTY MEDICAL SCHEMEBONA PLUSCARECROSS - MOTOHEALTHCUSTOMCARECROSS - MOTOHEALTHESSENTIALCARECROSS - OCSA CAREOCSACARE SILVERCARECROSS - OCSA CAREOCSACARE GOLDCARECROSS - OCSA CAREGOLD SCORPIONSCARECROSS - OCSA CAREACKERMANSCARECROSS - OCSA CARESILVERCARECROSS - OCSA CAREGOLDCARECROSS - OCSA CAREGOLD 3 CARECROSS - OCSA CAREGOLD MASSMARTCARECROSS - OLD MUTUAL STAFFNETWORK PLANCARECROSS - PLATINUM HEALTHPLAT CAPCARECROSS - REMEDISTANDARD OPTIONCARECROSS - TOPMEDNETWORK OPTIONCARECROSS - WOOLTRUCORE

5 OPTIONHOSMEDPLUSHOSMEDSTEPHOSMEDVALUEMBM EDMBMEDMEDIHELPMY NECESSEMEDIHELPDIMENSION PRIME 2 MEDIHELPDIMENSION PRIME 3 MEDIHELPDIMENSION ELITEMEDIHELPPLUSPROVIDENCE MINEMEDMINEMED MEDICAL CENTREPROVIDENCE MEDIMEDMANAGED CARE ECIPAPROVIDENCE MEDIMEDMEDISAVE STANDARDPG GROUPPG GROUPPOLMEDLOWER PLANPOLMEDHIGHER PLANTHEBEMEDENERGYTHEBEMEDUNIVERSALTOPME DTRADITIONALTRANSMEDSTATE PLUS OWN CHOICETRANSMEDSATS PENSIONERSTRANSMEDPRIVATE NETWORKPPN 1 Medical SchemesPPN manual 2013 Compiled 24/12/2012CG The additional PPN Medical Schemes for 2013 are: Bankmed Plus option Bestmed Pace 1, Pace 2, Pace 3, Pace 4 and Beat 2 options Bonitas BonCap option Motohealth Classic, optimum options Transmed State Plus OwnChoice, SATS pensioners and Private Network options 2. SPLIT BILLING Split billing is not permitted according to a ruling by the Health Professions Council and the Medical Schemes Act of 1998.

6 According to the above ruling medical service providers are not allowed to use split billing when charging for their services. What is split billing? Split billing occurs when the Provider submits more than one account for the same service. The reason why split billing is not allowed is that 1. it makes it impossible to track the healthcare services provided and the costs thereof as well as 2. makes it possible for providers to disguise the fact that they are dispensing alternative products or charging more than the recommended negotiated rates It has come to our attention that some optical providers participate in Split Billing. PPN will be very strict when we identify one of our providers participating in Split Billing. Therefore, please take note that should split billing be identified for your practice, PPN will be left with no alternative but to issue a final notice should any occurrences be reported or identified for your practice.

7 A second incident will result in PPN having no other alternative but to remove your practice with immediate effect from our network listing to all our contracted medical aids and their members. BANKMEDPLUSBESTMEDBEAT 2 BONITASBONCAPBOMAIDSCHEME ABOMAIDSCHEME BBOMAIDSCHEME CLIBERTY MEDICAL SCHEMETITANLIBERTY MEDICAL SCHEMETITAN SELECTMEDIHELPPRIME 1 MOTOHEALTHCLASSICMOTOHEALTHOPTIMUMREMEDI COMPREHENSIVEREMEDICLASSICMEDICAL AIDOPTIONPPN 2 Medical SchemesPPN manual 2013 Compiled 24/12/2012CG 3. PPN NETWORK As at the end of 2012 , the PPN network comprised of OVER 2200 practices. This represents 83% of all registered optometrists in South Africa. We trust that through our continued initiatives, this total will grow. PPN do not charge a monthly management fee from their providers and membership to PPN is therefore FREE. 4. SETTLEMENT DISCOUNT AND OFFERING SETTLEMENT DISCOUNTS PPN1 Schemes - Capitation PPN will continue with the R150 settlement discount on frames.

8 Do not deduct the R 150 prior to invoicing. PPN will merely deduct R 150 off the frame/lens enhancement value up to the frame/lens enhancement benefit on settlement. Example Frame Benefit Invoice ValueSettlement DiscountPaid to practiceDue by MemberPPN FrameR 150R 150R 0R 0R 450R 450R 150R 300R 0R 450R 600R 150R 300R 150 PPN OFFERING PPN has facilitated the recovery of R35 or a PPN frame per Capitated transaction where R150 settlement discount was deducted per frame dispensed. This will be administered via the following OFFERINGS elected for and communicated by the practice to PPN: o PPN Frame offering Every accepted transaction on our capitation medical aids where a frame or extras have been approved and R150 settlement discount has been deducted, PPN will reimburse the practice with a replacement PPN frame. o Cost of a PPN Frame offering Every accepted transaction on our capitation medical aids where a frame or extras have been approved and R150 settlement discount has been deducted, PPN will reimburse the practice with R35 per claim.

9 O A combination of both The practice must then indicate the split between the two that they would prefer. PPN will only transact these re-imbursements/replacements based on written communication received by your practice. The reimbursement will be transacted at the end of the calendar quarter in which we receive written communication. Communication must be emailed to or faxed to 086 6749 700 with a heading: PPN OFFERING. PPN will respond to acknowledge receipt of communication. PPN 2 Fee For Service A 10% settlement discount on materials only will apply. This is in-line with alternative networks in the industry. This settlement discount applies to the higher tariff values of PPN 2 only. PPN manual 2013 Compiled 24/12/2012CG CASH PATIENTS Cash transactions conducted with members of PPN contracted medical aids must be done using the associated PPN tariff.

10 The pricing may not exceed the prescribed tariff amounts. If a member is identified as a PPN contracted member after having been charged SAOA codes, then the claim will need to be reversed and the applicable PPN tariff invoiced. It is therefore crucial that o The practice obtains the medical aid number of the patient wishing to be charged cash prices. o The Practice explains to the member the benefits of the lower PPN tariff as opposed to the SAOA Codes. 5. PPN FRAMES It is COMPULSORY that all PPN practices carry a minimum stock of 20 PPN frames. The PPN frames must be clearly displayed and identifiable by the members of our contracted schemes. What is PPN frames benefit all about? All PPN capitation medical aids benefit structures include a PPN frame benefit at a PPN practice. Therefore, it is compulsory for all the PPN practices to carry a minimum stock of 20 PPN frames.