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FAMILY PRACTITIONERNETWORK GUIDE

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Please note: Product rules, limits, terms and conditions apply. Where there is a discrepancy between the content provided in this brochure, the website and the Scheme Rules, the Scheme Rules will prevail. The Scheme Rules are available on request. Benefits are subject to approval from the Council for Medical Schemes

BONITAS FAMILY PRACTITIONER NETWORK GUIDE

INTRODUCTION PAGE 2

USING THIS GUIDE PAGE 2

FAMILY PRACTITIONER NETWORK FEES PAGE 3

SPECIALIST NETWORK AND SPECIALIST REFERRAL PAGE 3

FAMILY PRACTITIONER NOMINATION PAGE 4

IMPROVED CLINICAL PATHWAY SERVICES (ICPS), JOINTCARE AND MAJOR JOINTS FOR LIFE PAGE 5

INDEPENDENT CLINICAL ONCOLOGY NETWORK (ICON) PAGE 5

DOCUMENTATION BASED CARE (DBC) & WORKABILITY PAGE 6

PHARMACY NETWORK PAGE 6

HOSPITAL NETWORK PAGE 7

ELECTRONIC MEDICAL RECORD PAGE 8

CARE PATHWAYS PAGE 8

HEALTHCARE FORENSICS PAGE 9

BABYLINE PAGE 9

OUT-OF-HOSPITAL TESTS FOR CHRONIC PMB DISEASES PAGE 9

BONITAS DIABETES MANAGEMENT PROGRAMME PAGE 9

MENTAL HEALTH PROGRAMME PAGE 10

FP UPSKILLING PAGE 10

WELLNESS EXTENDER BENEFIT PAGE 10

QUICK REFERENCE GUIDE PAGE 11

BONCAP FAMILY PRACTITIONER NETWORK GUIDE

SUMMARY OF PRIMARY CARE BENEFITS PAGE 14

FAMILY PRACTITIONER TARIFFS AND FEES PAGE 15

MEDICATION PAGE 16

THE REFERRAL MANAGEMENT PROCESS PAGE 17

SPECIALIST BENEFIT PAGE 17

MATERNITY BENEFIT AND ANTENATAL VISITS PAGE 17

RADIOLOGY PAGE 18

PATHOLOGY PAGE 18

DAY-TO-DAY BENEFITS PAGE 18

OPTOMETRY PAGE 19

HOSPITALISATION PAGE 19

PRESCRIBED MINIMUM BENEFITS (PMBS) PAGE 19

HIV/AIDS MANAGEMENT PAGE 19

MAJOR MEDICAL BENEFITS PAGE 20

ANY OTHER ENQUIRIES PAGE 20

SUBMITTING CLAIMS PAGE 20

ANNEXURE A

BONCAP RADIOLOGY FORMULARY PAGE 21

ANNEXURE B

BONCAP RADIOLOGY REQUEST FORM PAGE 24

ANNEXURE C

BONCAP PATHOLOGY FORMULARY PAGE 25

ANNEXURE D

BONCAP PATHOLOGY REQUEST FORM PAGE 28

ANNEXURE E

BONCAP SPECIALIST REFERRAL FORM PAGE 29

FIND A SERVICE PROVIDER PAGE 30

All claims are paid at the Bonitas Rate, unless otherwise stated. All benefits and limits are per calendar year, unless otherwise stated. Managed Care protocols apply. Benefits are subject to approval from the Council for Medical Schemes.

INTRODUCTIONDear Family Practitioner Despite increasing healthcare inflation and economic pressures in the past year, innovative strategic measures allowed Bonitas to emerge in a strong financial position, keeping the weighted average contribution increase at 8.9% for 2019. The increase clearly signals that the scheme is in good financial health.

The worldwide increase in chronic disease burden is one of the reasons for escalating healthcare costs. Bonitas has introduced managed care programmes over the past few years to assist in managing chronic diseases, in addition to focusing on preventive care and wellness.

The industry has also experienced an increased prevalence of chronic conditions and diabetes in particular, is one of the key contributors to a rising disease burden and escalating healthcare costs. Such conditions are the leading causes of death and disability globally, putting an enormous burden on most healthcare systems. Prevention and early intervention are a big step towards the ultimate aim of making populations healthier through better lifestyles and increased compliance with their suggested care regimens.

Bonitas’ strategy is focused on affordability and quality of healthcare and the Fund continues to enhance business and product offerings.

Bonitas has two new options for 2019, namely Primary Select and BonEssential Select, both are efficiency discount options (EDOs). The benefit limits for Primary Select are to be the same as the main Primary option and the benefit limits for BonEssential Select are to be the same as the main BonEssential option. However, a hospital network and further measures will be applied to these new options. Also note that the Hospital Plus option is no longer available in 2019.

We look forward to building on the successes of the year and partnering with you in 2019. Thank you for the excellent service you continue to deliver to our members.

Kind regardsBonitas Medical Fund

This guide supplies you with the necessary information to treat our members effectively. It also includes the initiatives that Bonitas has in place and how they apply to the various Bonitas options and to you as a family practitioner.

If you have any questions or require further information or assistance, please call us on 0861 112 666.

Please note: There will be a 5.0% increase in the Bonitas & BonCap FP tariff rates, with effect 1 January 2019.

USING THIS GUIDE

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FAMILY PRACTITIONER NETWORK FEESBonitas recognises the Family Practitioner’s role as the coordinator of care, which is key to ensure the sustainability of the Bonitas options. To this end, Family Practitioners (FPs) are encouraged to manage downstream costs while still ensuring good quality care.

The Bonitas FP network reimbursement model for 2019 will continue to include an enhanced fee in accordance with the practice’s REPI² category score as indicated below:

FP Consultation Rates (0190-0192)

2019

Enhanced fees automatically added when consultation is processed

REPI2 Cat 1 REPI2 Cat 2

Bonitas Tariff R379,10 R45,90 R23,00

Please take note of the following:• To protect Bonitas members from unexpected co-payments, it is important that FPs adhere to

their contract requirement to bill the Bonitas Tariff.• Note that the enhanced fee will be automatically added when the practice is reimbursed for

consultations.

1. The Bonitas Specialist NetworkBonitas has a network of over 3 400 Specialists in place consisting of the following specialities:

Dermatology Ophthalmology

Obstetrics and Gynaecology Orthopaedics

Pulmonology Otorhinolaryngology

Physicians Rheumatology

Gastroenterology Paediatrics

Neurology Plastic and Reconstructive Surgery

Cardiology Surgeons

Psychiatry Cardiothoracic Surgery

Neurosurgery Urology

The network Specialists have all agreed to bill the Bonitas Tariff; therefore, your patient will not incur a co-payment when consulting with these doctors.

Please note:• The Bonitas Specialist network is a Designated Service Provider (DSP) network for

Prescribed Minimum Benefits (PMBs).• To find out if the Specialist you refer to is on the network, you can contact the Healthcare

Provider Contact Centre on 0861 112 666.• Should you need to refer a patient to an orthopaedic surgeon (for hip or knee surgery),

please first read the section on ICPS.

2. Why Bonitas patients need a referral and how to obtain a Specialist referralThere is a growing trend of fragmented care, where a number of our beneficiaries are receiving duplicate treatment from multiple doctors and providers. This leads to poor patient experience and unsatisfactory outcomes in providing safe, appropriate and effective care.

All Specialist visits for members on Bonitas therefore require the FP to obtain a referral authorisation prior to the patient visiting the Specialist.

SPECIALIST NETWORK AND SPECIALIST REFERRAL

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Please note the following:• For all other options, please contact the Healthcare Provider Contact Centre on

0861 112 666 and use the interactive voice recognition (IVR) function to obtain a referral number. You will need to have the following information ready:- Your practice number, e.g. 1234567- Your patient’s membership number, e.g. 24000000001- Your patient’s beneficiary number, e.g. 00- Your patient’s date of birth in the format DDMMYYYY, e.g. 31121954- The practice type, e.g. 18 for a physician- The number of months that you want the patient to visit the Specialist between 1

and 6, e.g. 3. A referral number will automatically be created for the member on the system, from the date that you created the referral and adding the number of months you have chosen to create an end date for the referral.

• Specialist Referral can also be done via the web:- Visit www.medscheme.com > login as a provider > click on Specialist Referral (and

complete all required information).

For patients on BonCap, the FP needs to contact BonCap Beneficiary Management on 0861 239 333 to obtain a referral.

3. Quick reference guide for Specialist practice types requiring a Specialist referral:

Specialist Type Specialist Type Description Specialist

Type Specialist Type Description

12 D e r m ato l o g i st 2 8 Orthopaedic Surgeon

16 Gy n a e co l o g i st 3 0 Otorhinolaryngologist (ENT)

17 P u l m o n o l o g i st 3 1 Rheumatologist

18 P hys i c i a n 3 2 Paediatr ic ian

19 G a st ro e nte ro l o g i st 3 3 Cardiology Paediatr ic ian

20 Neurologist 36 Plastic and Reconstructive Surgeon

21 Cardiologist 42 Surgeon

22 Psychiatr ist 44 Cardiothoracic Surgeon

24 Neurosurgeon 46 Urologist

The only exception to the Specialist referral rule will be the following:1. The first gynaecologist visit for female beneficiaries2. Paediatric consultations for children under the age of two3. Maternity consultations4. Consultations with oncologists 5. Consultations with ophthalmologists6. Specialist to specialist referral

• Hospital exclusions: Please refer to the Hospital Network section for a list of hospitals where a 30% co-payment will be raised (except BonCap, Standard Select, Primary Select, BonEssential Select and BonFit). Where possible, please avoid referring patients to Specialists that work exclusively at these hospitals.

• Hospital network: The BonCap, BonFit, Standard Select, Primary Select and BonEssential Select options have a specific hospital network in place. Members on these options need to use a hospital in the respective network to avoid a co-payment. Please refer to the Hospital Network section in this guide for further information on the network. Please ensure that members on these options are referred to a network hospital.

Bonitas supports care coordination and considers the Family Practitioner (FP) to be at the heart of this process. Fragmented healthcare has resulted in inefficient, costly treatment for our members; therefore, Bonitas believes that FP care coordination improves the quality of healthcare and lowers overall healthcare expenditure.

Bonitas requires beneficiaries on Standard Select, Primary Select and BonEssential Select to nominate their treating network FP to coordinate their care. This can be done by contacting the Bonitas Call Centre on 0860 002 108. Main members on the Standard Select and Primary Select options have a greater nominated FP limit and will therefore benefit by visiting a nominated FP versus visiting a non-nominated FP.

Standard Select:

Nominated FP Services Non-Nominated FP Services

Benefit limit of R4 170 Sub-limit of R1 350

Primary Select:

Nominated FP Services Non-Nominated FP Services

Benefit limit of R1 900 Sub-limit of R615

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IMPROVED CLINICAL PATHWAY SERVICES (ICPS) & JOINTCARE & MAJOR JOINTS FOR LIFE

INDEPENDENT CLINICAL ONCOLOGY NETWORK (ICON)

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Bonitas has partnered with ICPS, JointCare and Major Joints for Life who are groups of orthopaedic surgeons who specialise in performing hip and knee replacements according to standardised clinical care pathways, to ensure that the quality of the hip and/or knee replacement is of the highest standard as well as to ensure the best health outcomes.

ICPS, JointCare and Major Joints for Life are the preferred providers for Bonitas members on the Standard, BonClassic, BonComplete and BonComprehensive options, and the Designated Service Provider (DSP) for members on the Standard Select option.

ICPS, JointCare and Major Joints for Life will ensure payment in full for the procedure, which will include the following:• All hospital costs• Surgeon and anaesthetist fees• Prosthesis (subject to prosthesis benefit)• Physiotherapist (pre-, intra and post-operative)

Please remember to call the Healthcare Provider Contact Centre on 0861 112 666 for a Specialist referral for your patient. By calling the contact centre, you will be given the details of an ICPS, JointCare or Major Joints for Life orthopaedic surgeon closest to you.

Please ensure that members are referred to an ICPS, JointCare or Major Joints for Life orthopaedic surgeon to avoid co-payments as stated below:

Option Use of a Non-ICPS Provider for Hip and Knee Surgery

Standard Select Bonitas will not fund the procedure if a non-ICPS, non- JointCare or non-Major Joints for Life provider is used

Standard R6 000 co-payment

BonClassic R6 000 co-payment

BonComplete R6 000 co-payment

BonComprehensive R6 000 co-payment

Bonitas has partnered with ICON as their Preferred Provider, and as their Designated Service Provider for the provision of oncology services for Prescribed Minimum Benefits (PMBs). ICON is a network of Oncology Specialists utilising standardised protocols to ensure that Bonitas cancer patients are appropriately cared for. ICON offers a network of oncologists, who has agreed to utilise the clinical protocols approved by the Fund and will bill at the agreed rate, thereby ensuring that members will not incur co-payments.

Please refer Bonitas members to an oncologist within the ICON network to ensure that the member does not incur any potential co-payments.

In order to find out which oncologists are on the ICON network, you can either visit the ICON website: www.iconsa.co.za or call the Healthcare Provider Contact Centre on 0861 112 666, or call ICON SA on 021 944 3750.


THE BACK & NECK DOCUMENTATION BASED CARE (DBC) & WORKABILITYThe goal of DBC and Workability is to reduce the need for unnecessary surgery caused by chronic back and neck pain. Conventional treatment often focuses on alleviating the symptoms, whereas DBC and Workability aim to treat the underlying functional problem. DBC and Workability enrol members who would benefit from the programme and ensure that the care provided is coordinated to ensure optimal outcomes.

All Bonitas options (excluding BonCap) have contracted with DBC and Workability. Members that are eligible for the DBC or Workability programme are proactively identified by the Bonitas beneficiary risk management team. Eligible beneficiaries can also be identified by their Family Practitioner or they can self-refer.

The identification of eligible members in all categories is limited to members that reside within a 30 km radius of a DBC clinic or a Workability facility (distance between the member’s residential postal code and the applicable facility’s postal code).

Should you wish to enrol your patient in the DBC or Workability programme, please call the Healthcare Provider Contact Centre on 0861 112 666 to see whether your patient qualifies to be enrolled in the programme.

There are currently 15 DBC centres located across South African in Cape Town, Bellville, Sasolburg, Secunda, Emalahleni, Sandton, Kempton Park, Durban, Umhlanga, Roodepoort, Centurion, Pretoria East, Pretoria North, Bloemfontein and Port Elizabeth. There are also 2 additional Workability facilities located in Bloemfontein and Port Elizabeth. Plans are in place to expand the network even further. For an updated list of DBC clinics and Workability facilities, please call the Healthcare Provider Contact Centre on 0861 112 666.

Bonitas has a large pharmacy network that consists of almost 2 200 pharmacies including Pharmacy Direct, Clicks, Dis-Chem, MediRite, Pick n Pay, Optipharm, Scriptwise, Netcare and Pharmacross as well as various independent community pharmacies.

Network pharmacies agreed to charge contracted dispensing fees, ensuring members will not be liable for co-payments. Please find the below information regarding Designated Service Providers, Preferred Provider Networks and co-payments.

Chronic medication Benefit rules

Pharmacy network

• The Designated Service Provider (DSP) is Pharmacy Direct for all options (excluding BonComprehensive) but only acts as the DSP for the BonClassic and Standard options once the benefit limit is depleted.

• BonComplete, Primary, Primary Select, BonFit, BonCap, BonSave, Standard Select, BonEssential, BonEssential Select and Hospital Standard all have to utilise Pharmacy Direct as the DSP from onset of the benefit year.

• Pharmacy Direct can be contacted on 0860 027 800.• The Preferred Provider Network (PPN) for chronic medication

includes Clicks, Dis-Chem, MediRite, Pick n Pay, Pharmacy Direct, Optipharm, Scriptwise, Netcare and Pharmacross and various independent community pharmacies, and is only applicable to the BonClassic and Standard options.

How to apply for chronic medicine

• Please call the Bonitas Contact Centre on 0861 100 220 or email [email protected].

• You can also log in to www.medscheme.com > log in as a provider > click chronic application > insert membership number.

Chronic formularies and disease baskets

• Formularies can be viewed at www.medscheme.com > log in as a provider > click on clinical information > medicine management.

• Disease baskets can be viewed at www.medscheme.com > log in as a provider > click lookup tool > disease basket lookup.

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Chronic medication Benefit rules

Changes or updates

• You DO NOT need to update or call for a change if the:• medicine is in the basket; or• member changes to another medicine in the basket; or• member’s quantity or dosage of a medicine is listed in

the basket.• Changes or updates to chronic medication (if not part of the

disease basket) are done telephonically by contacting the Bonitas Contact Centre on 0861 100 220.

Co-payments

Co-payments can be avoided by:• Ensuring the patient makes use of the DSP.• Prescribing in-formulary drugs.• Asking the pharmacist to substitute expensive medications

with a generic equivalent that will not attract an MPL co-payment.

Please contact the Bonitas Contact Centre on 0861 100 220 for any other chronic medication queries.

Acute medication Benefit rules

Pharmacy network

• The Preferred Provider Network (PPN) for all Bonitas options includes Clicks, Dis-Chem, MediRite, Pick n Pay, Pharmacy Direct, Optipharm, Scriptwise, Netcare and Pharmacross and various independent community pharmacies.

• If your member wishes to query whether their pharmacy is part of the network, they can call 0860 002 108.

Co-payments

Co-payments can be avoided by:• Ensuring the patient makes use of the DSP.• Prescribing in-formulary drugs.• Asking the pharmacist to substitute expensive medications

with a generic equivalent that will not attract an MPL co-payment.

If you have BonCap acute medication or formulary queries, call BonCap Beneficiary Management on 0861 239 333.

If you have general queries about acute medication, please call the Healthcare Provider Contact Centre on 0861 112 666.

Bonitas has a well-established network of hospitals for BonCap, BonFit, Standard Select, Primary Select and BonEssential Select. In order to avoid the co-payments listed below, it is in the member’s best interest to use a network facility. To view a list of network hospitals log in to www.bonitas.co.za.

Bonitas members have access to all private hospitals; however, a 30% co-payment will apply at the following hospitals.

Hospital

Life Rosepark Hospital Life Eugene Marais Hospital

Life Bedford Gardens Private Hospital Life Faerie Glen Hospital

Life Brenthurst Clinic Little Company of Mary/Life Groenkloof Hospital

Life Carstenhof Clinic Life Wilgers Hospital

Life Flora Clinic Life Hilton Private Hospital

Genesis Maternity Clinic (Saxonwold) Life Kingsbury Hospital

Life Wilgeheuwel Private Hospital Life Vincent Pallotti Hospital

Please note: This applies to all options, with the exception of BonCap, Standard Select and BonFit. These options make use of specific network hospitals.

Option Co-payment for late pre-authorisation

Co-payment for using a non-network hospital

BonCap R6 700 R6 700

BonFit 100% of hospital account 30% of hospital account

Standard Select 100% of hospital account 30% of hospital account

Primary Select 100% of hospital account 30% of hospital account

BonEssential Select 100% of hospital account 30% of hospital account

A hospital procedure can be pre-authorised by contacting the Bonitas Call Centre: 0861 100 220 or fax: 0860 002 145 or email: [email protected].

Please have the following information at hand when requesting an authorisation:• the Bonitas membership number• the date of admission• name of the practitioner and his/her telephone number and practice registration number• the name and practice number of the hospital• all relevant procedure codes and applicable tooth numbers, including diagnostic codes• in certain instances a radiological report, clinical report or additional information will be

requested in order to process the pre-authorisation.

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ELECTRONIC MEDICAL RECORDThe Electronic Medical Record (EMR) is a digital version of a patient’s paper-based chart, to make it easier to share Bonitas beneficiaries’ demographic and clinical information with Family Practitioners (FPs) who are on the Bonitas network.

The Independent Practice Association (IPA) Forum and the Bonitas Clinical Coordination Committee (BCCC) also provided their input with regard to the EMR. The EMR provides FPs with administrative and clinical benefits that could include the following:

Administrative benefits Clinical benefits

Decreased paperwork Prescribing medication electronically

Decreased storage costs Access to up-to-date patient information including clinical notes and results

More efficient billing Diagnosing patients more effectively

Recording of clinical notes Reducing medical errors

Reviewing and setting up appointments for the patient Reducing duplication of care

Tracking patient compliance Providing high quality care

Viewing the patient’s medical history

The EMR was piloted with a group of FPs to ensure that the design meets the needs and expectations of all who are involved in the care of our beneficiaries. Enhancements to the EMR were made based on feedback received from the pilot FPs.

The EMR was rolled out during 2017 and 2018 to a small group of doctors in order to make further enhancement based on their feedback. In future the EMR will be made available to more healthcare professionals. Bonitas will keep you informed on the progress of this exciting initiative.

Ensuring good clinical outcomes for its members is a top priority for Bonitas. Equally important is equipping doctors with the tools needed to achieve this. In consultation with experts in each chronic disease field, practising Family Practitioners and Fund representatives, a process has been started to develop Integrated Care Pathways for the major chronic conditions. The goal of this collaborative effort is to develop care pathways that take into account clinical and financial implications, while at the same time being aligned to beneficiary benefits and a primary healthcare approach.

Going forward, care pathways will be shared with healthcare professionals and it will also be incorporated into the Electronic Medical Record. To date, a hypertension care pathway as well as a diabetes mellitus care pathway have been developed and can be accessed by visting the Medscheme website at www.medscheme.com > Communication library > Communication > General Communication. Below is an extract of the hypertension care pathway that has been developed.

CARE PATHWAYS

BP 140-159 / 90-99 mmHgwith <3 risk factors, no TOD

or complications

Lifestyle modificationfor 3-6 months

Not at goal

BP 140-159 / 90-99 mmHgwith <3 risk factors, no TOD

or complications

Commence monotherapy,review in 4-6 weeks

Not at goal

BP ≥160 / 100 mmHg*

Commence 2 drugspreferably in fixed drug combination,

review in 4-6 weeks

Not at goal

Add third drug / optimisedoses of drugs

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Bonitas uses world-class analytical software, Insurance Fraud Manager (IFM) by FICO, which employs advanced mathematical techniques to detect suspicious and abnormal claiming patterns. This ensures that our members receive the best and appropriate patient care at all times while minimising the financial impact of fraud, waste and abuse.

The claiming process for all healthcare professionals remains as is. Please continue to submit all claims as per the existing process. Valid claims will be assessed and paid. The claims data will then be reviewed to identify abnormal claiming patterns. If found to be inappropriate, the identified healthcare professional will be consulted to address the findings. Corrective measures will then be discussed and agreed upon in addressing the irregular claiming behaviour.

Fraud, waste and abuse will continue to be addressed in a fair and transparent manner, which includes taking into account best practice and clinical necessity, where relevant.

A healthy claims audit and forensic capability enables Bonitas to strengthen our ties with all healthcare professional bodies and ensures that we continue to work towards achieving our goal for holistic patient-centric and affordable care at all times.

For any fraud-related queries, please contact the fraud hotline on 0800 112 811 or [email protected].

BabyLine is part of PAED-IQ (Pty) Ltd, which has been in existence for 5 years and is a South African-based medical information company, seeking to provide information and services to parents and caregivers, that will enhance the level of care they are able to provide to their children.

PAED-IQ partnered with the Paediatric Management Group of South Africa, a body that represents the majority of Paediatric Specialists in private practice in South Africa. Through this collaboration, a database of information on common health conditions in children was developed. This information is tailored to the needs of South African children and is endorsed by the Paediatric Management Group of South Africa.

Bonitas has partnered with PAED-IQ from 2017 to educate Bonitas parents and ensure their benefits last longer. BabyLine offers a paediatric telephone triage service, which is available 24/7, 365 days a year. The service offers healthcare advice to parents with children under 3 years of age and is delivered by skilled personnel (registered nurses). Bonitas members will have access to this helpline, free of charge and can dial 0860 999 121 to make use of the service.

For more information on PAED-IQ, please visit https://paediq.com/aboutus.html.

In previous years, out-of-hospital tests for the management of Prescribed Minimum Benefit conditions (PMBs) were paid from Day-to-Day benefits. In 2019, out-of-hospital tests specified in the PMB care templates will be paid first from risk (overall annual limit) which will allow members to get the maximum value for money and stretch their Day-to-Day benefits as far as possible.

Bonitas, together with Medscheme has an excellent Diabetes Management Programme. This enables all managed care interventions for our diabetic patients to be integrated.

The Bonitas Diabetes Management Programme is based on the principles of patient-centered care. This ensures that disease management is delivered in a holistic fashion accommodating associated co-morbidities and focusing interventions on high risk beneficiaries. In addition, our aim is to increase the number of diabetics who are managed in a coordinated manner and ensure that all Bonitas network doctors have the opportunity to participate in this initiative.

Key components of the new programme include: • Provision of an enhanced care template• Active monitoring and support of all Bonitas diabetics• Active monitoring of adherence to treatment and clinical results. • Targeted communication where gaps in care are identified. • Active management of identified beneficiaries by a team of health coaches.

If you have any questions or require more information on the Bonitas Diabetes Management Programme, please contact the Healthcare Professional Contact Centre on 0861 112 666 or email [email protected].

HEALTHCARE FORENSICS

BABYLINE

OUT-OF-HOSPITAL TESTS FOR CHRONIC PMB DISEASES

BONITAS DIABETES MANAGEMENT PROGRAMME

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The Bonitas Mental Health Programme follows an internationally successful model of integrating mental health care into the primary care setting through effective collaboration between family practitioners, specialists, and auxiliary caregivers, and the introduction of a care manager to help coordinate the process. This, along with family practitioner upskilling, decision support, and benefit review, creates the necessary structure to allow the busy family practitioner to deliver and coordinate good quality, patient-centered care, which includes mental health care.

The Medscheme Care Manager communicates regularly with the FP regarding potential new cases and treatment response as measured by validated symptom scores. This is underpinned by specialist advice from the Medscheme Psychiatrist Decision Support service. Patient activation and support for self-care are promoted through education of patients and their families, the facilitation of behavioural activation by care managers during telephonic interventions, “Ask-Your-Doctor” checklists, and accessing community support groups. Should you require more information or wish to confirm whether your patient meets the criteria of the Bonitas Mental Health Programme, please call 0860 002 108, follow the prompts to select the Mental Health Programme or email [email protected].

Bonitas has well-established relationships with Family Practitioners (FPs), specifically through the IPA Forum and the Bonitas Clinical Coordination Committee (BCCC). As a result of this relationship and the fact that Bonitas views the FP as central to coordination of care, the FP-upskilling initiative was developed.

The first FP-upskilling seminar took place in 2014 and following the success of the first upskilling seminar, a further 18 sessions have been held up to 2018.

The goal of the FP-upskilling initiative is to equip the FP with the skill and knowledge to confidently fulfil the role of care coordinator. Focus at these seminars is placed on the top cost-driving and high burden diseases, as well as the practical medical skills that are likely to be required by FPs in the management of these diseases.

All FPs who attend these upskilling seminars are awarded with at least 12 CPD points (depending on the lectures) if all lectures are attended. FPs are also awarded 2 ethics points for an ethics lecture that is included in each programme. The overwhelming positive response from FPs and the growing demand to attend these upskilling seminars have resulted in Bonitas committing to continue to support upskilling events across the country for 2019.

Look out for FP-upskilling seminars that will be taking place in your area in 2019.

Bonitas has created an industry first, the Wellness Extender Benefit that supplements the existing health-risk assessment benefit by promoting continuity of care. Therefore, depending on the completion of the member’s health risk assessment, members can consult with their Family Practitioner (FP) and these consultations do not deplete their savings or day-to-day benefit. Furthermore, the FP can refer the member to other healthcare practitioners, e.g. physiotherapist, biokineticist or dietician, if necessary and these consultations are also funded. This is available to beneficiaries on all options excluding BonCap.

Option Benefit Limit Range of Services Covered

BonComprehensive R 2 540

• Family Practitioner Consultations

• Biokineticist Consultations and treatment

• Dietician Consultations and treatment

• Physiotherapist Consultations and treatment

• Smoking Cessation Programme

BonClassic

R1 750

BonComplete

Standard

Standard Select

Hospital Plus

BonSave

R1 270

BonFit

Hospital Standard

Primary

Primary Select

BonEssentialR 910

BonEssential Select

The Wellness Extender Benefit can only be accessed if the member has completed a health risk assessment. Please note, children under 21 years of age will have access to the wellness extender benefit once an adult beneficiary has completed a health risk assessment.

The benefit will be open for one (1) year. An sms will be sent to member to state that access has been granted.

Claims will be funded from the Wellness Extender Benefit if accompanied with valid consultation tariff codes and ICD-10 code Z00.0 (general medical examination). Please ensure that your claims have this specific ICD-10 code.

MENTAL HEALTH PROGRAMME

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QUICK REFERENCE GUIDE Service Purpose Telephone Email address for queries

Healthcare Provider Contact Centre (IVR) including Website Assistance / Bonitas Provider Contact Centre

General queries related to Bonitas 0861 112 666 [email protected]

BonCap Beneficiary ManagementAll Bonitas BonCap option related queries, remittance, statement and Medscheme website enquiries, as well as specialist referral number requests

0861 239 333 [email protected]

Chronic Medicine Management Chronic submissions and queries

Bonitas: 0861 100 220

BonCap:0861 239 333

Bonitas Medical Fund:[email protected]

BonCap Option Only:[email protected]

Fraud Hotline Fraud-related matters 0800 112 811 [email protected]

Hospital Pre-Authorisation All hospital pre-authorisations for non-emergency events 0861 100 220

Bonitas Medical Fund:[email protected]

BonCap Option Only:[email protected]

Submission of Claims To submit a claim for a Bonitas patient0861 112 666

[email protected]

Queries of Claims Queries relating to a Bonitas claim [email protected]

Oncology Services Any oncology related queries0861 100 220

[email protected]

Ambulatory PMB Any Ambulatory PMB queries [email protected]

Aid for AIDS (Excluding BonCap) Aid for AIDS Management0800 227 700

[email protected]

BonCap HIV Management of HIV for BonCap patients [email protected]

Diabetes Management Programme

Motivation for non-formulary drugs

0861 100 220

[email protected]

Motivate for additional benefits above the care template [email protected]

Chronic Medicine applications [email protected]

Bonitas Diabetes queries or requests [email protected]

To View Diabetic Educatorswww.medscheme.com > login as a provider > click on network > diabetes educators.

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BONCAP FAMILYPRACTITIONERNETWORK GUIDE


The Bonitas BonCap option is a low contribution option that provides services to industries such as the manufacturing and mining industry. BonCap members have access to a network of over 4 700 Family Practitioners, almost 2 200 pharmacies and over 160 hospitals.

Bonitas recognises the Family Practitioner’s role as the coordinator of care and would like to thank you for providing excellent healthcare services to our valued BonCap members and their families. We remain committed to ensuring that BonCap members receive high quality care that is accessible and cost effective.

To ensure the sustainability of the BonCap option and to protect members from unexpected co-payments, it is imperative that participating Family Practitioners adhere to formularies and protocols as contained in this guide.

The following changes have been implemented in 2019:A limit for acute medicines, pathology and radiology as follows:• Main member only: R1 840• Main member + 1 dependant: R3 060• Main member + 2 dependants: R3 660• Main member + 3 dependants: R4 000• Main member + 4+ dependants: R4 440

Please note that a list of specified procedures has been excluded (see surgical benefit section).• A change to the hospital network list for 2019.• Beneficiaries have unlimited FP visits, subject to seeing up to two FPs, subject to the BonCap FP

Network. From the 8th visit, consultations are subject to pre-authorisation and Managed Care Protocols. BonCap members need to obtain this pre-authorisation up front by calling BonCap Beneficiary Management on 0861 239 333.

The BonCap model for 2019 continues to use the following principles:• Working with Family Practitioners to manage quality and downstream costs.• Finding ways to reduce the administrative burden on Family Practitioners.• Exploring the potentials of entering into a risk-sharing arrangements with Family Practitioners

going forward.

Summarised benefits offered on BonCap:• BonCap members get a monetary limit per family for Family Practitioner referred pathology,

radiology and acute medicines.• Primary care benefits are available through the Bonitas BonCap network of healthcare providers

(Family Practitioners, dentists, optometrists and pharmacies) and are subject to network formularies. The contracted provider networks for BonCap are available on the Medscheme secure online services website at www.medscheme.com.

Alternatively, the following numbers can be contacted:

Service Telephone Email address for queries

Family Practitioner, pharmacy, oncology and hospital networks

0861 239 333 www.medscheme.com

Dental network 0861 033 647 www.denis.co.za

Optometry network 086 110 3529 www.ppn.co.za

• Hospitalisation is subject to a network of hospitals and obtaining pre-authorisation from BonCap Beneficiary Management on 0861 239 333.

• Oncology is subject to the oncology network and obtaining pre-authorisation from BonCap Beneficiary Management on 0861 239 333.

• Specialist visits are limited to three consultations or R3 110 per beneficiary and five consultations or R4 620 per family per annum.

• Member access to Specialist visits is subject to the network Family Practitioner obtaining a referral authorisation by contacting BonCap Beneficiary Management on 0861 239 333.

• Chronic medication is subject to pre-authorisation on the Chronic Medicine Management programme managed by Bonitas Chronic Medicine Management (CMM) and is limited to PMBs and the Designated Service Provider, Pharmacy Direct.

• Preventative care benefit including an annual HIV test and one flu vaccine; one pneumococcal vaccine for beneficiaries 65 years and older every five years, one faecal occult blood test per beneficiary (ages 50-75) and 1 pap smear every 3 years, for women between ages 21 and 65 , one mammogram for females aged over 40 years every 2 years and 1 PSA test for men between the ages 45 -69 per annum.

• Pathology and radiology are subject to a list of investigations - please refer to Annexures A and C in this guide.

• BonCap benefits and limits can be verified via the BonCap IVR functionality or by speaking to an agent on 0861 239 333.

BonCap Beneficiary Management can be contacted via:Tel: 0861 239 333Fax: 0860 222 210Email: [email protected]

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1. Summary of primary care benefits for BonCap

Benefit BonCap

Family Practitioner consultations

• Subject to the BonCap Family Practitioner (FP) network and reimbursed at the BonCap network rate.

• Beneficiaries have unlimited FP visits, subject to seeing up to two FP’s. From the 8th visit, consultations are subject to pre-authorisation and Managed Care Protocols.

• Procedures in the FP’s room are subject to a specified list. BonCap members need to obtain this pre-authorisation up front by calling BonCap Beneficiary Management on 0861 239 333.

• Pre-authorisation is required for some of these procedures and utilisation of these procedures will be monitored.

• For more information on in-room procedures, please refer to Section 2: Family Practitioner tariffs and fees.

• Only listed tariff codes will be reimbursed. There will be no additional benefits for tariff codes not listed in this guide.

• BonCap members get a monetary limit per family for FP referred pathology, radiology and acute medicines as follows:

- Main member only: R1 840- Main member + 1 dependant: R3 060- Main member + 2 dependants: R3 660- Main member + 3 dependants: R4 000- Main member + 4+ dependants: R4 440

Out-of-network Family Practitioner consultations

• One (1) visit per beneficiary and two (2) visits per family per annum.

• Reimbursed at standard Bonitas Rates, limited to R1 050 per family and 20% co-payment by the member.

Acute medication

• Subject to the BonCap acute medicine formulary.• The cost of acute medication is included in the

consultation fee for FP’s who are contracted as dispensing doctors.

• For FP’s who are contracted as non-dispensing doctors, acute medication is to be dispensed by network pharmacies only.



Benefit BonCap

Chronic medication

• Subject to registration on the Chronic Medicine Management Programme and the BonCap chronic formulary managed by Bonitas Chronic Medicine Management (CMM).

• Contact the Bonitas CMM Call Centre on 0861 239 333 or email at [email protected].

• Only on prescription by a network FP or a Specialist where the Specialist visit has been authorised as per the referral management process.

• All chronic medication must be dispensed by Pharmacy Direct.

Specialist consultations

• Limited to three (3) consultations or R3 110 per beneficiary and/or five (5) consultations or R4 620 per family per annum. Limit includes all acute medication, out-of-hospital specialised radiology, radiology and pathology.

• Only on referral from a network FP and subject to authorisation.

• Please refer to the Specialist Referral form included in this guide.

Maternity benefit

• Antenatal consultations are included in the FP and Specialist consultation benefit.

• Related tests are subject to the radiology/pathology formulary.



• All Specialist referrals require the network FP to obtain authorisation.

• Please refer to the Specialist Referral form included in this guide.

• Includes four (4) postnatal consultations per pregnancy by midwife.

• Includes 2 x 2D scans per pregnancy, subject to the BonCap radiology formulary and the monetary limit per family for FP referred pathology, radiology and acute medicines as follows:


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Benefit BonCap

Pathology

• Subject to the BonCap pathology formulary and the Pathology Management Programme.

• 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.

• Only on referral from a network FP or Specialist.• For tests not included in the formulary, please obtain

authorisation. Please note that authorisation is subject to Managed Care Protocols.



• Please refer to the Pathology Request Form included in this guide.

Radiology

• Subject to the BonCap radiology formulary.• Only on referral from a network FP or Specialist.• For tests not included in the formulary, please obtain

authorisation. Please note that authorisation is subject to Managed Care Protocols.

• Please refer to the Radiology Request Form included in this guide.



Physiotherapy and occupational therapy

• Subject to PMBs.• Only on referral from a network FP and subject to

authorisation.

Preventative care

• HIV test annually.• Flu vaccine annually, subject to usage of the DSP

pharmacy.• 1 x pneumococcal vaccine for beneficiaries 65 years and

older every five years.• 1 x faecal occult blood test per elderly beneficiary

(ages 50-75).• 1 pap smear every 3 years, for women between ages

21 and 65.• 1 mammogram for females aged over 40 years every 2

years..• 1 PSA test for men 45 – 69 years per annum

Benefit BonCap

Contraceptives

• R1 050 per family when prescribed by a BonCap Dispensing or Non-Dispensing Network FP

• 40% co-payment to apply when using a non DSP pharmacy

The complete 2019 benefit schedule for BonCap can be viewed on the Medscheme website at www.medscheme.com.

2. Family Practitioner tariffs and feesThe reimbursement model for BonCap network FPs is encouraged to manage downstream costs while still ensuring good quality care. FPs are also reimbursed for doing certain procedures in their rooms where indicated, e.g. intravenous rehydration or circumcision, as opposed to referring patients to hospital for these interventions.

To ensure the sustainability of the BonCap option, it is imperative that participating FPs adhere to formularies and protocols. Adherence will be monitored and where necessary, Bonitas will engage with and assist FPs in their understanding of the network requirements on BonCap.

The FP Network is crucial to driving the sustainability of the BonCap option. Going forward, Bonitas would like BonCap network FPs to do more interventions in their rooms. To this end, Bonitas will be working through the FP leadership initiative to upskill FPs where necessary.

Consultation tariff codes

Consultation tariff codes

Dispensing doctor tariff (inclusive of medication)

Non-dispensing doctor tariff Authorisation mandatory

0190 to 0192 R428.30 R361.20

Beneficiaries have unlimited FP visits, subject to seeing up to two FPs. From the 8th visit, consultations are subject to pre-authorisation and Managed Care Protocols.

BonCap members need to obtain this pre-authorisation up front by calling BonCap Beneficiary Management on 0861 239 333.

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Procedure codes that can be charged in addition to a consultation tariff code:

Tariff code Tariff code description (including cost of materials) Rate

02061 Intravenous rehydration therapy with or without administration of intravenous antibiotics

R 306.60

0241 Cauterisation of warts/chemocryotherapy of lesions R 119.50

0255 Drainage of abscess and/or avulsion of nail R 363.80

0259 Removal of foreign body superficial to deep fascia R 339.90

0300 Stitching of a wound R 495.90

0301 Stitching of an additional wound R 93.00

0887 Limb cast (including cost of pop and material) R 510.60

17 25 Drainage of external thrombosed pile R 226.00

0307 Excision and repair R 673.70

0310 Radical excision of nail bed in rooms R 819.90

1186 Flow volume test: inspiration/expiration R 225.00

1188 Flow volume test: inspiration / expiration / pre and post-bronchodilator

R 225.00

1232 Resting ECG (including electrodes) R 119.50

21372 Circumcision in rooms (authorisation required) R 1,112.60

4614 HIV rapid test R 128.80

1 A maximum of five (5) treatments will be allowed. A consultation must not be billed together with 0206 from the second day onwards.

2 Limited to a global fee that includes all post-procedure care, consultations and medication within a month of the procedure. The global fee is specific to out-of- hospital procedures. The BonCap tariff code 2133 or 2137 or 2139 must be used for the procedure. Please include the correct ICD-10 code.

Please note the following:• Tariff codes not listed above will not be reimbursed, as the fees for these services are

included in the consultation fee.• After-hour and emergency consultations are included in the 0190 to 0192 codes.• Authorisation of additional consultations will be subject to medical necessity and

Managed Care Protocols.• Surgical procedures performed in hospital or in unattached operating theatres are subject

to pre-authorisation and there is a specific list of surgical procedures that are excluded for BonCap members (please see relevant section below).

3. MedicationAll medication for BonCap is subject to the BonCap medicine formularies. Please visit the Medscheme secure online services website at www.medscheme.com to view these formularies.

3.1 CHRONIC MEDICINE

Prescriber Benefit rules

Dispensing and non-dispensing BonCap network Family Practitioners

• Subject to authorisation and registration on the BonCap Chronic Medicine Management Programme and the BonCap chronic formulary.

• Only on prescription by a network FP or Specialist, provided that the Specialist, visit has been authorised as per the referral management process.

• All chronic medicine must be dispensed by Pharmacy Direct.

How to apply for chronic medicine

• Contact the Bonitas Chronic Medicine Management (CMM) Call Centre on 0861 239 333 to obtain telephonic authorisation or email [email protected].

Changes or updates

• Following registration in the BonCap Chronic Medicine Management Programme, all changes or updates are done telephonically by contacting the Bonitas CMM Call Centre on 0861 239 333.

GeneralPlease ensure that all test results and motivations (where applicable) are submitted electronically to [email protected] or via fax 0800 223 670 / 80 upon request.

3.2 ACUTE MEDICINE

Prescriber Benefit rules

Dispensing network Family Practitioners

• Acute medication is included in the consultation fee.• 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 FP is contracted as a dispensing FP.

• FPs contracted as dispensing FPs can; however, script chronic medication as this is not included in the fee structure.

Non-dispensing network Family Practitioners

• Subject to the BonCap acute medicine formulary.• Prescribed acute medication must be obtained from the BonCap

pharmacy network.• The network can be accessed on the Medscheme online secure

services website at www.medscheme.com.

3.3 OVER-THE-COUNTER (OTC) MEDICATIONBenefit for BonCapOTC medication is subject to the BonCap acute formulary at network pharmacies only.• •Limited to R95 per script and a maximum of R265 per beneficiary per annum.

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4. The referral management process for BonCapNetwork FPs need to obtain authorisation before the event for the following benefit categories:• All Specialist consultations, including antenatal consultations at a gynaecologist.• Allied health consultations for physiotherapy and occupational therapy.• All additional FP consultations above the limit of seven (7) per beneficiary.• Radiology and pathology investigations not indicated on the BonCap pathology and

radiology formularies in this guide.

5. Specialist benefit

Specialist visits Benefit rules

Out-of-hospital consultations

• Reimbursed at the Bonitas Rate.• Limited to three (3) consultations and R3 110 per beneficiary and/

or five (5) consultations and R4 620 per family per annum.• Limit includes all acute medication, out-of-hospital specialised

radiology, radiology and pathology.• Only on referral from the network FP and subject to authorisation.• FPs can obtain authorisation for Specialist consultations by

contacting BonCap Beneficiary Management on 0861 239 333.• Please refer to the Specialist Referral form included in this guide.

Surgical procedures In hospital and unattached operating theatres

Unlimited (subject to pre-authorisation and Managed Care Protocols) except for the following exclusions:• In-hospital dental benefits• Back and neck surgery• Joint replacement surgery (including but not limited to hips, knees,

shoulders and elbows)• Caesarean sections done for non-medical reasons• Functional nasal and sinus surgery• Varicose vein surgery• Hernia repair• Endoscopic surgery (including but not limited to arthroscopies,

colonoscopies, sigmoidoscopies and gastroscopies)• Laparoscopic surgery (except for laparoscopic sterilisation)• Correction of hallux valgus/bunions• Refractive surgery

6. Maternity benefit and antenatal visits

Maternity Benefit rules

Antenatal consultations, scans and blood tests

• The antenatal benefit is subject to the FP and Specialist benefit as set out in this guide.

• Related tests are subject to the radiology/pathology formulary.• BonCap members get a monetary limit per family for FP referred

pathology, radiology and acute medicines as follows:- Main member only: R1 840- Main member + 1 dependant: R3 060- Main member + 2 dependants: R3 660- Main member + 3 dependants: R4 000- Main member + 4+ dependants: R4 440

• The ultrasound scans must either be done by the doctor who will be responsible for the confinement or a radiologist or gynaecologist.

• All Specialist referred radiology and pathology requests limited to Specialist benefit limit.

• Includes 2 x 2D scans per pregnancy, subject to the BonCap radiology formulary and the monetary limit per family for FP referred pathology, radiology and acute medicines as follows:



• All out-of-hospital Specialist consultations must be referred by a BonCap network FP and require the network FP to obtain authorisation by contacting BonCap Beneficiary Management on 0861 239 333.

• Reimbursed at the Bonitas Rate.• Limited to three (3) consultations and R3 110 per beneficiary and/

or five (5) consultations and R4 620 per family per annum.• Limit includes all acute medication, out-of-hospital specialised

radiology, radiology and pathology.

Hospital

• Access to hospitals for maternity is subject to the BonCap hospital network and pre-authorisation, which can be obtained by contacting BonCap Beneficiary Management on 0861 239 333.

• The BonCap hospital network can be obtained from www.medscheme.com or by contacting BonCap Beneficiary Management on 0861 239 333.

• Hospital stay will be covered at 100% of the BonCap Rate provided that pre-authorisation is obtained and a network hospital is used.

• Neonatal care is limited to R45 380 per family per annum, except for PMBs.

Delivery by midwife

• Delivery by a midwife in a registered and accredited birthing unit is included and subject to prior authorisation.

• Includes four (4) postnatal consultations per pregnancy.

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7. Radiology

Radiology Benefit rules

Codes that apply

• Out-of-hospital radiology is covered according to the BonCap radiology formulary. See Annexure A in this guide.

• All additional tests not listed in the formulary are subject to Managed Care Protocols and will require pre- authorisation.

• Please refer to the Radiology Request Form included in this guide.• BonCap members get a monetary limit per family for FP referred

pathology, radiology and acute medicines as follows:- Main member only: R1 840- Main member + 1 dependant: R3 060- Main member + 2 dependants: R3 660- Main member + 3 dependants: R4 000- Main member + 4+ dependants: R4 440

• All Specialist referred radiology and pathology requests limited to the Specialist benefit limit.

Who can refer the member?

Only scans and x-rays referred by the network FP or Specialist, subject to authorisation of the Specialist visit, will qualify for payment

Authorisation for out-of-formulary investigations

• All additional investigations are subject to Managed Care Protocols and will require pre-authorisation.

• Authorisation can be obtained from BonCap Beneficiary Management on 0861 239 333.

8. Pathology

Pathology Benefit rules

Codes that apply

• In-hospital pathology is limited to R25 440 per family.• Out-of-hospital pathology is covered according to the BonCap

pathology formulary and the Pathology Management Programme. Please refer to Annexure C 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.

• All additional tests not listed in the formulary are subject to Managed Care Protocols and will require pre-authorisation.

• BonCap members get a monetary limit per family for FP for referred pathology, radiology and acute medicines as follows:



• Please refer to the Pathology Request Form included in this guide.

Who can refer the member?

Members must be referred by the network FP or a Specialist: subject to authorisation of the Specialist visit in order for tests to qualify for payment.

How to obtain authorisation

• Tests not included in the pathology formulary, are subject to authorisation. Please contact BonCap Beneficiary Management on 0861 239 333 to obtain authorisation.

• The authorisation number must be included in the Pathology Request Form. Failure to do so could result in the laboratory being unable to perform the test.

Pathology Preferred Provider Network

• The BonCap preferred pathology network must be used for pathology investigations.

• The network consists of Ampath, Lancet, Pathcare and Vermaak pathologists.

9. Day-to-day benefits

9.1 Allied health services: Occupational and Physiotherapy

Occupational and physiotherapy

Benefit rules

Out of hospital• PMBs only and subject to referral from a network FP.• Subject to a network FP obtaining authorisation from BonCap

Beneficiary Management on 0861 239 333.

9.2 Dentistry

Dentistry Benefit rules

Basic dentistry

Subject to the DENIS Designated Service Provider network, Managed Care Protocols and a list of approved services/tariff codes:• One (1) consultation per beneficiary per annum.• One (1) specific (emergency) consultation per beneficiary per

annum for pain and sepsis treatment.• One (1) polish or one (1) scaling and polishing per beneficiary per

annum.• One (1) fluoride treatment per beneficiary under the age of 16

years per annum.• Fissure sealants: one (1) per tooth in a 3-year period for

beneficiaries younger than 16 years of age.• Extractions (removal of teeth) in dental rooms.• Four (4) fillings and four (4) intra-oral x-rays per beneficiary per

annum.• Emergency root canal treatment. Root canal therapy on wisdom

teeth (3rd molar) is not covered.• Plastic dentures: Pre-authorisation is required; one (1) set per

family in a 2-year period for beneficiaries 21 years and older; 20% co-payment applies.

• The complete list of dental tariff codes on BonCap can be obtained as follows: www.denis.co.za > provider > check-scheme-benefits

Hospitalisation (general anaesthetic)

• Pre-authorisation is required and must be obtained from DENIS.• General anaesthetic benefit is only available for PMB admissions.

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Dentistry Benefit rules

Dental network• The dental network list can be obtained as follows:

- Web: www.denis.co.za- Contact: 0861 033 647

9.3 Optometry

Optometry Benefit rules

Benefit

Subject to the BonCap optometry network managed by Preferred Provider Negotiators (PPN) and a list of approved services, subject to pre-authorisation:• Each beneficiary is entitled to the following benefit over a

24-month cycle from the last date of service:Frames:• R225 per beneficiary in network.• R150 per beneficiary out of networkLenses:• 100% coverage towards the cost of clear lenses at network rates.• Limited to R175 per single vision lens per beneficiary out of

network.• Limited to R410 per bifocal lens per beneficiary out of network.• Limited to R710 per multifocal lens per beneficiary out of network.• Limited to R1 035 per beneficiary out of network for contact lenses.

Optometry network

• The optometry network list can be obtained as follows:- Web: www.ppn.co.za- Contact: 086 110 3529

10. Hospitalisation

Hospitalisation Benefit rules

Benefit

• The hospitalisation benefit is subject to the BonCap hospital network, pre-authorisation and Managed Care Protocols. A R6 700 co-payment applies for admission to a non-network hospital, late request and a non-authorised hospital admission.

• Discharge medication (TTO) is limited to R380 per beneficiary per admission and is subject to the BonCap acute formulary and Managed Care Protocols.

Hospital network

• Access to public and a network of private hospitals can be obtained as follows:

- Web: www.medscheme.com- Contact: 0861 239 333

• To view a list of network hospitals log in to www.bonitas.co.za.

How to obtain pre-authorisation

• Phone: 0861 239 333• Fax: 021 466 1913• Email: [email protected]

11. Prescribed Minimum Benefits (PMBs)Benefits for BonCap are as per the Bonitas PMB treatment protocols. Please contact BonCap Beneficiary Management on 0861 239 333 if more information is required. Registration for chronic diseases is compulsory. Please refer to section 3.1

12. HIV/AIDS management

Benefit Benefit rules

BenefitSubject to registration on the BonCap HIV/AIDS Programme and Managed Care Protocols managed by Aid for AIDS (AfA).

Family Practitioner consultations

Subject to the BonCap FP network and reimbursed at the BonCap network rate.


• Only if clinically indicated.• Limited to three (3) consultations and R3 110 per beneficiary and/

or five (5) consultations or R4 620 per family per annum.• Only on referral from a network FP and subject to authorisation.• Please refer to the Specialist Referral form included in this guide.

Out-of-hospital pathology and radiology

• Out-of-hospital pathology and radiology are covered according to the BonCap radiology or BonCap pathology formulary and the Pathology Management Programme. Please refer to Annexures A and C in this guide.

• All additional tests not listed in the formulary will require pre-authorisation.

• Please refer to the Pathology/Radiology Request Form included in this guide.




Queries, clinical advice and script updates

• Doctors and pharmacist queries:- Phone (toll-free): 0800 227 700

• Members queries:- Phone: 0860 100 646


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13. Major medical benefits

Benefit Benefit rules

Oncology (chemotherapy and radiotherapy)

• Limited to PMBs and subject to the ICON medical Specialist network. Subject to pre-authorisation and Managed Care Protocols.

• Authorisation can be obtained by contacting BonCap Beneficiary Management on 0861 239 333.

• 40% co-payment for services rendered by a non-ICON medical Specialist.

• The oncology network can be obtained as follows:- Web: www.medscheme.com- Contact: 0861 239 333

Organ transplants and renal dialysis

• Limited to PMBs.• Renal dialysis subject to a Designated Service Provider• Subject to pre-authorisation and Managed Care Protocols.• For renal dialysis, a 20% co-payment applies for services rendered

by a non-DSP.• No benefit for corneal grafts unless PMB.• Authorisation can be obtained by contacting BonCap Beneficiary

Management on 0861 239 333 or by fax on 021 466 1913 or by emailing [email protected].

Mental health

• Limited to PMBs. Subject to pre-authorisation and Managed Care Protocols.

• Out-of-hospital Specialist consultations subject to a network FP obtaining a referral authorisation and subject to out-of-hospital Specialist limits of three (3) consultations or R3 110 per beneficiary and/or five (5) consultations and R4 620 per family per annum.

Alcoholism and drug dependency

• Limited to PMBs and subject to pre-authorisation and Managed Care Protocols.

• Authorisation can be obtained by contacting BonCap Beneficiary Management on 0861 239 333 or by fax on 021 466 1913 or by emailing [email protected].

Surgical procedures In hospital and unattached operating theatres

Unlimited (subject to the relevant Managed Care Protocols and pre-authorisation), except for the following exclusions:• In-hospital dental benefit.• Back and neck surgery.• Joint replacement surgery (including but not limited to hips, knees,

shoulders and elbows).• Caesarean sections done for non-medical reasons.• Functional nasal and sinus surgery• Varicose vein surgery• Hernia repair• Laparoscopic surgery (except laparoscopic sterilisation)• Endoscopic surgery (including but not limited to hysteroscopies,

arthroscopies, colonoscopies, sigmoidoscopies, gastroscopies)• Correction of hallux valgus/bunions• Refractive surgery

14. Any other enquiriesFor BonCap dental-related queries, please use the following contact details:• Dental network and dental benefit queries web: www.denis.co.za• Contact for providers: 0861 033 647

For BonCap optometry-related queries, please use the following contact details:• Optometry network and optometry benefit queries web: www.ppn.co.za• Contact for providers: 086 110 3529

For all other BonCap queries (benefit enquiries, claims enquiries, authorisation requests):• Email: [email protected]• Contact: 0861 239 333• Fax: 0860 222 210

15. Submitting claimsSubmit all paper claims to:• Bonitas Medical Fund, PO Box 1101, Florida Glen, 1709

Submit electronic claims using the following codes:• DHS Switch: qedi - 964p MedSwitch: BBON0001

Other clearing houses or hubs:• Please contact your relevant clearing houses or hubs on the respective submission codes

Should you have any queries, kindly contact BonCap Beneficiary Management on 0861 239 333.


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BonCap - 2019 - Radiology formulary

All codes not listed, require authorisation. Please contact BonCap Beneficiary Management on 0861 239 333.

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 39041X-ray of the paranasal sinuses, single view

13110X-ray of the paranasal sinuses, two or more views

Mandible, teeth and maxilla

3355 14100 39045 X-ray of the mandible

3361 14130 39051X-ray of the teeth single quadrant

3363 14140 39053X-ray of the teeth more than one quadrant

3365 14150 39055 X-ray of the teeth full mouth

3361 15100 39059X-ray tempero-mandibular joint, left

3361 15110 39059X-ray tempero-mandibular joint, right

3359 16100 39049X-ray of the mastoids, unilateral - Left

3359 16100 39049X-ray of the mastoids, unilateral - Right

3359 16110 39049X-ray of the mastoids, bilateral

Thorax



3445 30100 39107X-ray of the chest, single view - PA

3445 30100 39107X-ray of the chest, single view - Lateral

30110 39107X-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

40110X-ray of the abdomen multiple views including chest

40105 39125X-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 39025X-ray of the spine scoliosis view AP only

3321 51110 39017X-ray of the cervical spine, one or two views - AP

3321 51110 39017X-ray of the cervical spine, one or two views - Lateral

3321 52100 39017X-ray of the thoracic spine, one or two views - AP

3321 52100 39017X-ray of the thoracic spine, one or two views - Lateral

3321 53110 39017X-ray of the lumbar spine, one or two views - AP

Spine

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3321 53110 39017X-ray of the lumbar spine, one or two views - Lateral

3321 54100 39017X-ray of the sacrum and coccyx

54110 39027 X-ray of the sacro-iliac 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

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 39003X-ray of the left acromio-clavicular joint

6508 61125 39003X-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 39003X-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 39003X-ray of the left knee one or two views - AP

6515 72100 39003X-ray of the left knee one or two views - Lateral

6515 72105 39003X-ray of the right knee one or two views - AP

6515 72105 39003X-ray of the right knee one or two views - Lateral

72120 39003X-ray of the left knee including patella

72125 39003X-ray of the right knee including patella

6516 72140 39003 X-ray of left patella

6516 72145 39003 X-ray of right patella

72150 39003X-ray both knees standing – single view

6519 74150 39003X-ray of the sesamoid bones one or both sides - Left

6519 74150 39003X-ray of the sesamoid bones one or both sides - Right

CT scans

6416 13300CT of the paranasal sinuses single plane, limited study

CT scans

6417 13300CT of the paranasal sinuses single plane, limited study


ANN

EXU

RE A



Ultrasound abdomen and Pelvis

5102 61200Ultrasound of the left shoulder joint

5102 61210Ultrasound of the right shoulder joint

41200Ultrasound study of the upper abdomen

3627 40210Ultrasound study of the whole abdomen including the pelvis

3618 43200 39147Ultrasound study of the pelvis transabdominal

3615 43250 39145Ultrasound study of the pregnant uterus, first trimester

43270 39145Ultrasound study of the pregnant uterus, third trimester, first visit

43273 39145Ultrasound 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


ANN

EXURE B

ANNEXURE BBonCap - 2019 - Radiology Request Form

Version: NO

V 2017 - A 1

P.O. Box 1101, Florida G

len, 1708 Call 0860 002 108

Fax (011) 758 7171 Email m

emberm

[email protected]

BonC

ap Radiology Request Form 2019

InstructionsPlease com

plete the form in full and check that all your inform

ation is correct before submitting it.

Section 1: Referring family practitioner details

Section 2: Patient detail

I certify that the above information is correct and give specifi c consent for selected test(s) to be done. I authorise the disclosure of these results to m

y doctor, medical

aid administrators and/or insurance com

pany. I undertake to pay all outstanding monies not covered by m

edical aid. I fully understand the implication of the test and

have received adequate pre-test counselling.

Section 3: Clinical Inform

ation

Section 4: ICD

-10 Codes

Please choose from the follow

ing investigations below, for certain tests, please the view

and site.

Doctor’s nam

e:

Practice number:

Telephone:Fax:

Email:

Signature:

Title:Surnam

e:

First names:

Identity number:

Date of birth:

Marital status:

Gender:

MF

Medical Schem

e name:

Medical Schem

e Option:

Mem

bership number:

Dependant C

ode:

Signature of Patient: D

ate:

Skull and Brain

SKULL

R 512,40

Facial bones and nasal bones

FACIAL BO

NES

R 522,00

NASAL BO

NES

R 317,20

Orbits and Paranasal sinuses

ORBITS

R 472,60

PARANASAL SIN

USES

R 363,70

PARANASAL SIN

USES: 2 view

s R 485,70

Mandible, teeth and m

axilla

MAN

DIBLE

R 485,70

TEETH: SIN

GLE Q

UAD

RANT

R 265,40

Specify quadrants:

TEETH: M

ORE TH

AN O

NE

QU

ADRAN

TR 336,00

Specify quadrants:

TEETH: FU

LL MO

UTH

R 480,50

TEMPERO

-MAN

DIBU

LAR JOIN

T: LEFT

R 472,60

TEMPERO

-MAN

DIBU

LAR JOIN

T: RIG

HT

R 472,60

MASTO

IDS: LEFT

R 476,80

MASTO

IDS: RIG

HT

R 476,80

MASTO

IDS: RIG

HT AN

D LEFT

R 953,10

ThoraxCH

EST: PAR 403,50

CH

EST: LATERALR 403,50

CH

EST : PA AND

LATERALR 509,60

RIBSR 635,90

Abdom

en and Pelvis

ABDO

MEN

R 440,80

ABDO

MEN

:MU

LTIPLE VIEWS IN

CL

CH

ESTR 1 075,00

Specify views:

ABDO

MEN

: SUPIN

E AND

ERECT O

R D

ECU

BITUS

R 711,40

SpineSPINE SC

OLIO

SIS VIEW: AP O

NLY

R 929,30

CERVIC

AL SPINE: AP

R 399,70

CERVIC

AL SPINE: LATERAL

R 399,70

THO

RACIC

SPINE: AP

R 425,90

THO

RACIC

SPINE: LATERAL

R 425,90

LUM

BAR SPINE: AP

R 472,60

LUM

BAR SPINE: LATERAL

R 472,60

SACC

RUM

AND

CO

CCYX

R 475,10

SACRO

-ILIAC JO

INTS

R 544,10

Pelvis and Hips

PELVISR 485,70

HIP: LEFT

R 422,20

HIP: RIG

HT

R 422,20

PELVIS AND

HIPS

R 799,10

Upper Lim

b

CLAVIC

LE: LEFTR 403,50

CLAVIC

LE: RIGH

TR 403,50

SCAPU

LA: LEFTR 403,50

SCAPU

LA: RIGH

TR 403,50

ACRO

MIO

-CLAVIC

ULAR JO

INT:

LEFTR 416,70

ACRO

MIO

-CLAVIC

ULAR JO

INT:

RIGH

TR 416,70

SHO

ULD

ER: LEFTR 461,90

SHO

ULD

ER: RIGH

TR 461,90

HU

MERU

S: LEFTR 390,10

HU

MERU

S: RIGH

TR 390,10

ELBOW

: LEFTR 416,70

Upper Lim

b

ELBOW

: RIGH

TR 416,70

FOREARM

: LEFTR 390,10

FOREARM

: RIGH

TR 390,10

HAN

D: LEFT

R 409,10

HAN

D: RIG

HT

R 409,10

FING

ER: SPECIFY

R 354,40

WRIST: LEFT

R 422,20

WRIST: RIG

HT

R 422,20

SCAPH

OID

: LEFTR 438,20

SCAPH

OID

: RIGH

TR 438,20

Lower Lim

b

LOW

ER LEG: LEFT

R 390,10

LOW

ER LEG: RIG

HT

R 390,10

ANKLE: LEFT

R 440,80

ANKLE: RIG

HT

R 440,80

FOO

T: LEFTR 371,90

FOO

T: RIGH

TR 371,90

CALC

ANEU

S: LEFTR 363,70

CALC

ANEU

S: RIGH

TR 363,70

BOTH

FEET STAND

ING

: SING

LE VIEW

R 371,90

TOE: SPEC

IFYR 354,40

FEMU

R: LEFTR 390,10

FEMU

R: RIGH

TR 390,10

KNEE: LEFT AP

R 367,80

KNEE: LEFT LATERAL

R 367,80

KNEE: RIG

HT AP

R 367,80

KNEE: RIG

HT LATERAL

R 367,80

KNEE IN

CLU

DIN

G PATELLA: LEFT

R 613,20

Lower Lim

b

KNEE IN

CLU

DIN

G PATELLA: RIG

HT

R 613,20

PATELLA: LEFTR 367,80

PATELLA: RIGH

TR 367,80

BOTH

KNEES STAN

DIN

G: SIN

GLE

VIEWR 371,90

SESAMO

ID BO

NES: LEFT

R 371,90

SESAMO

ID BO

NES: RIG

HT

R 371,90

CT scans

CT O

F THE PARAN

ASAL SINU

SESR 955,80

Ultrasound abdom

en and Pelvis

ULTRASO

UN

D: LEFT SH

OU

LDER

JOIN

TR 862,70

ULTRASO

UN

D: RIG

HT SH

OU

LDER

JOIN

TR 862,70

ULTRASO

UN

D STU

DY: UPPER

ABDO

MEN

R 929,30

ULTRASO

UN

D: ABD

OM

EN AN

D

PELVISR 1 093,80

ULTRASO

UN

D:PELVIS

TRANSABD

OM

INAL

R 756,40

ULTRASO

UN

D:PREG

NAN

T UTERU

SVaries

FOR

TESTS N

OT

INC

LUD

ED

ON

TH

IS FO

RM,

PLEASE C

ON

TACT 0861 239 333 A

ND

REQU

EST AN

AU

THO

RISATION

NU

MBER.

LIST AD

DITIO

NA

L TEST REQU

IRED:

AUTH

ORISATIO

N N

UM

BER:


ANN

EXU

RE C

BonCap - 2019 - Pathology formulary


Medical practitioner

PathologyCode Description

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 Micro Albuminurea (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 dehidrogenase (LD) No

Liver / Pancreas




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

3791 Packed Cell Volume: Haematocrit No

3755Full 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

B. Haematology

3805 Prothrombin index No

ANNEXURE C


ANN

EXURE C




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

4182Quantitative protein estimation: Nephelometer or Turbidometeric method: FOR RHEUMATOID FACTOR ONLY

No

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

3816T 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

G. Miscellaneous

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

4188Urine dipstick, per stick (irrespective of the number of tests on stick)

No

3928 Antimicrobic substances No

3893 Bacteriological culture: Miscellaneous No

3867Miscellaneous (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

MCS

3869 Faeces (including parasites) No

3868 Fungus identification No


ANN

EXU

RE C




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


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


No

3946 IgM: Specific antibody titer:ELISA/EMIT: Per Ag No

3883 Concentration techniques for parasites No


ANN

EXURE D

ANNEXURE DBonCap - 2019 - Pathology Request Form

Version: NO

V 2017 - A 1


len, 1708 Call 0860 002 108

Fax (011) 758 7171 Email m

emberm

[email protected]

Section 1: Referring family practitioner details

Section 2: Patient detail

I certify that the above information is correct and give specifi c consent for selected test(s) to be done. I authorise the disclosure of these results to m

y doctor, medical aid adm

inistrators and/or insurance company. I

undertake to pay all outstanding monies not covered by m

edical aid. I fully understand the implication of the test and have received adequate pre-test counselling.

Section 3: Clinical Inform

ation

Section 4: ICD

-10 Codes

Please choose from the follow

ing investigations below, for certain tests, please the view

and site.

BonC

ap Pathology Request Form 2019

Doctor’s nam

e:

Practice number:

Telephone:Fax:

Email:

Signature:

Title:Surnam

e:

First names:

Identity number:

Date of birth:

Marital status:

Gender:

MF

Medical Schem

e name:

Medical Schem

e Option:

Mem

bership number:

Dependant C

ode:

Signature of Patient: D

ate:

CH

EMISTRY

RENA

L / ELECTRO

LYTES / BON

EC

REATININ

ER 57,80

CALC

IUM

(serum - no cu� )

R 57,80M

AGN

ESIUM

R 57,80PH

OSPH

ATE (serum)

R 57,80SO

DIU

MR 57,80

POTASSIU

MR 57,80

UREA

R 57,80LAC

TATER 254,40

LIVER / PA

NC

REAS

ALBUM

INR 76,30

TOTAL PRO

TEINR 49,50

ALPR 82,30

ALTR 85,80

ASTR 85,80

BILIRUBIN

(total, conjugated) - fee ±R 75,90

GG

TR 85,80

LACTATE D

EHYD

ROG

ENASE

R 85,80AM

YLASER 82,30

CA

RDIAC

/ MU

SCLE

TROPO

NIN

R 317,80

CK-M

B MASS

R 197,00LIPID

S / CA

D RISK

CH

OLESTERO

L R 84,90

HD

L and LDL

R 109,60TRIG

LYCERID

ES (fasting)R 126,10

CREATIN

INE KIN

ASE (CK)

R 85,80H

ISTOLO

GY

HISTO

LOG

Y PER SAMPLE

R 347,00C

linical Data (please supply):

Specimen Type:

CYTOLO

GY

CERVIC

AL /VAGIN

AL SMEAR

R 201,80Specim

en Type:

END

OC

RINO

LOG

YEN

DO

CRIN

E – THYRO

IDTSH

R 311,50FREE T4

R 277,80EN

DO

CRIN

E – REPROD

UC

TIVE

b-HC

G SC

REEN

R 158,90PRO

LACTIN

(rest 15 minutes)

R 197,20D

IABETESG

LUC

OSE fasting

R 57,80G

LUC

OSE random

R 57,80

HBA1C

R 226,50C

REATININ

ER 57,80

MIC

ROALBU

NU

REA (quanititative)R 197,20

AN

TENATA

L SCREEN

HAEM

OG

LOBIN

ESTIMATIO

NR 28,80

PLATELET CO

UN

TR 35,70

BLOO

D G

ROU

P: A B AND

O AN

TIGEN

R 57,30C

OO

MBS TEST

R 58,00G

ROU

PING

: Rh ANTIG

ENR 57,30

HEP B s Ag

R 230,10H

IV 1+2 Ab + P24 AgR 224,10

VDRL

R 57,30RU

BELLA IgG, IgM

- fee ±R 223,60

TUM

OU

R MA

RKERSPSA

R 230,10H

AEM

ATOLO

GY

GRO

UPIN

G: A B AN

D O

ANTIG

ENS

R 57,30G

ROU

PING

: Rh ANTIG

ENR 57,30

FULL BLO

OD

CO

UN

T R 167,00

PLATELET CO

UN

TR 35,70

HAEM

OG

LOBIN

ESTIMATIO

NR 28,80

RETICU

LOCYTE C

OU

NT

R 47,60ESR

R 47,60IRO

NR 107,30

TRANSFERRIN

R 185,90FERRITIN

R 197,20FO

LATE (serum)

R 197,20VIT B12

R 197,20C

OO

MBS TEST

R 58,00PARASITES IN

BLOO

D SM

EARR 89,10

CO

AGU

LATION

INR/PI

R 95,50M

ISCELLA

NEO

US

CO

LOREC

TAL CAN

CER SC

REENIN

GR 35,70

FAECAL O

CC

ULT BLO

OD

TEST (FOB)

R 158,90

INFLA

MM

ATION

/ IMM

UN

OLO

GY

AUTO

-IMM

UN

EC

RPR 172,20

ESRR 47,60

URIC

ACID

R 60,00RH

EUM

ATOID

FACTO

RR 131,60

ANF

R 254,40Agglutination test per antigen

R 87,50IN

FECTIO

US D

ISEASES

VDRL

R 35,70VD

RLR 57,30

RUBELLA IM

MU

NITY (IgG

ON

LY)R 205,80

HEPATITIS TESTS: Specify

ACU

TE HEPATITIS A (IgM

)R 230,10

CH

RON

IC H

EPATITIS A (IgG)

R 230,10AC

UTE H

EPATITIS B (Bs AG)

R 230,10H

EPATITIS B (CARRIER / IM

MU

NITY : BsAB)

R 230,10H

IV TESTSH

IV 1+2 Ab + P24 AgR 224,10

CD

4 CO

UN

TR 335,30

The following H

IV related tests require an authorisation

HIV PC

R VIRAL LOAD

R 1 340,10H

IV PCR Q

UALITATIVE (diagnostic only)

R 1 192,40M

ICRO

BIOLO

GY

MIC

RO SPEC

IMEN

TYPE AND

SITE:

(eg: pus swab, ear):

MC

SAFB fl uorochrom

e auramine (ZN

) onlyPARASITESBILH

ARZIA MIC

ROSC

OPY

The following TB related tests require an authorisation

TB CU

LTURE

TB SENSITIVITY

OTH

ER TESTS: Only investigations included in this request form

w

ill be considered for payment. All other investigations are subject

to pre-authorisation.For tests not m

entioned on this request form, kindly contact

0861 239 333 for a pre-authorisation number.

Other tests requested:

Pre-authorisation number:

Collection date:

Collection tim

e:C

ollected by:

Urgent:

Routine:C

opies to Doctors:

Contat Person:

Test Laboratory:


ANN

EXU

RE E

ANNEXURE EBonCap - 2019 - Specialist Referral Form

Version: NO

V 2018 - A 1


len, 1708 Call 0860 002 108

Fax (011) 758 7171 Email m

emberm

[email protected]

BonC

ap Specialist Referral Form 2019

InstructionsPlease com

plete the form in full and check that all your inform

ation is correct before submitting it.

Section 1: Patient details

Section 2: Referring Doctor detail

Section 3: Specialist details

Section 4: Clinical Report

Referring the patient to another specialist will require an additional referral authorisation.

Title:Surnam

e:

First names:

Identity number:

Mem

bership number:

Dependant code:

Date of appointm

ent:Tim

e:

Authorisation number:

Authorisation date:

Title:Surnam

e:

First names:

Practice number:

Speciality:

Telephone:Fax:

Email:

Title:Surnam

e:

First names:

Practice number:

Speciality:

Telephone:Fax:

Email:

ICD

10 code:External cause code:

Request:

Signature of Doctor:

Date:

Feedback:

Signature of Doctor:

Date:

Return to work:

Sick leave:Review

date:


FIND

A SERVICE PROVID

ER

We’ve partnered with several reputable service providers to ensure that our members receive excellent service and more value for money.

FIND A SERVICE PROVIDER

Babyline

Call: 0860 999 121

Chronic medicine

Call: 0860 027 800Fax: 0866 114 000Email: [email protected]

Optical benefits

Call: 0861 103 529www.ppn.co.za

Emergency assistance

Call: 084 124Email: [email protected]: [email protected]

HIV/AIDS programme

Please call me: 083 410 9078Call: 0860 100 646Fax: 0800 600 773Email: [email protected]

Diabetes programme

Call: 0860 002 108Email: [email protected]

Dental benefits

Call: 0860 336 346Fax: 0866 770 336Email: [email protected]

Cancer programme


Back and neck programme

Call: 0860 105 104

Hip and knee programme


Bonitas Medical Fund

@BonitasMedical

0860 002 108

www.bonitas.co.za

CMS01-V1-01AUG2018

Please note: Product rules, limits, terms and conditions apply. Where there is a discrepancy between the content provided in this brochure, the website and the Fund Rules, the Fund Rules will prevail. The Fund Rules are available on request. Benefits are subject to approval from the Council for Medical Schemes

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