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Fedhealth Blue Door Plus optionFedhealth Blue Door Plus offers a value for money option for lower income, previously uncovered employees who have never previously enjoyed any medical scheme cover due to it being unaffordable. This option is not suitable for people already on a medical aid or those with higher benefit requirements.

This manual lists the services and benefits that are covered for the Blue Door Plus option for 2015.

Contents

1. ImportantContactDetails 1

2. GeneralPractitionerBenefitsandFeeStructure 2

3. Specialist 3

4. AcuteMedication 6

5. ChronicMedication 6

6. BlueDoorPluspathologybenefitschedule 7

7. BlueDoorPlusradiologybenefitschedule 10

8. Dentalcodes 12

9. NetworkHospitals 13

Important contact details

Provider Call CentreTel: 0861 112 666

Healthcare Professional Managed Care LineTel: 0861 100 220Monday to Friday 08h30 – 16h00

Hospital Authorisation CentreMonday to Thursday 08h30 – 17h00Friday 09h00 – 17h00Tel: 0861 100 220email: authorisations@fedhealth.co.zaLogin as a provider on: www.medscheme.co.za

Aid for AIDSMonday to Friday 08h00 – 17h00Tel: 0860 100 646Fax: 0800 600 773email: afa@afadm.co.zaWeb: www.aidforaids.co.zaSMS (call me): 083 410 9078

Chronic Medicine ManagementMonday to Friday 08h30 to 17h00Tel: 0861 100 220Fax: 0800 223 670/80email: fedhealthcmm@medscheme.co.zaLogin as a provider on: www.medscheme.co.zaPostal address: P O Box 38632, Pinelands, 7430

Medi-Rite PharmaciesTel: 0800 222 617

1

2

General Practitioner (GP) benefits FedhealthsupportstheGP’sroleasthecoordinatorofcareandwillbeimplementingGPNominationforBlueDoorPlusbeneficiariesin2015.ThismeansthatBlueDoorPlusbeneficiarieswillneedtonominateaprimarytreatingdoctorandvisitthisdoctorforalltheirconsultationsgoingforward.InordertoassistexistingBlueDoorPlusbeneficiarieswithGPnomination,FedhealthwillallocateanetworkGPtothemontheirbehalf.ThiswillbebasedontheGPwhotheymostrecentlyandfrequentlyvisited.BlueDoorPlusbeneficiarieswillbeinformedofthisandgiventheopportunitytochangetheirGPbeforeApril2015bycallingthecustomercontactcentreon0860002153.Thereafter,thenominatedGPmayonlybechangedonceeverysixmonths.Twovisitsperfamilyperannumwillbeavailablefromthe‘outofnomination’benefitifabeneficiaryneedstoseeaGPotherthantheirnominatedGP.Aleniencyperiodwillapplyuntil01April2015.Inaddition,pleasetakenoteofthefollowingfor2015:

• FedhealthBlueDoorPlusbeneficiariesarealloweduptosix(6)GPconsultationsatanominatedBlueDoorPlusnetworkGPwithoutpre-authorisation.

• Afterthesixthconsultation,thenominatedGPisrequiredtoobtainpre-authorisationviatheHealthcareProfessionalCallCentreon0861112666

•The‘outofnominated’GPbenefitconsistsof2visitsperfamilyperyearandisreimbursedattheBlueDoorPlusrate

Fee structure and GP in-room procedures

Schemerate Description FixedFee2015

0190-0192 GPvisit(dispensing) 302.60

0190-0192 GPvisit(non-dispensing) 220.30

0300 Stitchingofwound(additionalcodeforsettingsteriletray) 123.40

0307/0308 Excisionandrepair 237.60

0255 Drainageofabscessandavulsionofnail 176.50

0259 Removalofforeignbody 176.50

0887 Limbcast 116.70

0202 Settingofsteriletray 88.90

0210 Collectionofbloodspecimen 36.10

0206-0207 Intravenoustreatment 54.40

0222-0223 Intralesionalinjectionintoareasofpathology 71.70

0233-0237 Biopsy 54.40

0241-0243 Treatmentofbenignskinlesionbychemo-cryotherapy 54.40

0244 Repairofnailbed 264.00

0245-0246 Removalofbenignlesionbycurretting 94.20

1037 Diathermytonoseorpharynx 71.70

1228-1234 ECG/Multi-stagetreadmilltest 116.70

2129-2131 Electrodesiccation 183.10

2271-2272 Removaloftagorpolyporbenignlesions 54.40

2316-2318 Destructionofcondylomata 94.20

2399-2404 Biopsy/Wedgebiopsy 116.70

3171 ExcisionofMeibomiancyst 180.40

3287 Spinaljointandligamentinjection 176.50

List of procedures included in standard fixed fee consultation rate

Code Description

0201 Costofmaterialintreatment

0316-0317 Fineneedleaspiration/Aspirationofcystortumour

1136 Nebulisation(inrooms)

1186-1192 Flowvolumetest

3304 Allotherphysicaltreatments

3*ICON - Independent Clinical Onocology Network FR - Fedhealth Rate*MPL - Medicine Price List Rate

SpecialistsPleasenotethatFedhealthhaspartneredwithspecialistsacrossalldisciplinestoensurethatourmembershavenoco-paymentswhenvisitingspecialists.ItisimportantthatourBlueDoorPlusmembersareonlyreferredtospecialistswhoarepartoftheFedhealthSpecialistPartnership.TolocateaspecialistontheFedhealthSpecialistpartnershippleasecalltheFedhealthProviderCallCentreon0861112666.

majormedicalbenefitAll costs for hospitalisation are covered from this benefit from the first day of hospitalisation in a public or network

private hospital and must be pre-authorised

BENEFIT COVER LIMIT PER FAMILY PER YEAROverall annual limit (OAL) Unlimited at network hospitals only. 40% co-payment on voluntary use of a non-

network hospital

Healthcare Professional tariff (HPT) Specialists tariff

- Fedhealth Network GPs and Specialists

- Non-Fedhealth Network GPs and Specialists

- Other Healthcare Professionals

Covered at cost

Up to 100% of FR

Up to 100% of FR

Unlimited

Unlimited

Unlimited

Prescribed Minimum Benefits (PMBs) Unlimited in state hospitals

Hospitalisation costs

Accommodation, use of operating theatres and hospital equipment, medicine, pharmaceuticals and surgical items

Negotiated tariff Unlimited at network hospitals only. 40% co-payment on voluntary use of a non-network hospital

Alternatives to hospitalisation

Acute facilities and rehabilitation facilities (Does not include Hospice)

Negotiated tariff Unlimited at PMB level of care

Ambulance services Negotiated tariff Unlimited with Europ Assistance

Appliances, external accessories, orthotics, blood, blood equivalents and blood products

100% of cost Unlimited

Physical TherapyPhysiotherapy and biokinetics

Up to 100% of FR Unlimited

Immune deficiency related to HIV infection

- Hospitalisation

- Anti-retroviral and related medication

- Related pathology

Up to 100% of FR Unlimited at PMB level of care

Maternity Up to 100% of FRR31 200 per maternity event with a limit of R46 200 per family, per year. Elective Caesarean Sections subject to a 40% co-payment

Oncology Up to 100% of FR PMBs only at ICON

Organ, tissue and haemopoietic stem cell transplant including immunosuppression medication

PMBs only in state facilities

Pathology and medical technology Up to 100% of FR Unlimited

Prostheses

- Internal

- External

PMBs only in state facilities

PMBs only in state facilities

Psychiatric services See Healthcare Profes-sional tariff

R7 600

Radiology

- General

- Specialised

Up to 100% of FR

Up to 100% of FR

Unlimited

R11 500 per beneficiary, subject to an overall limit of R23 200 per family per year

Renal dialysis (chronic)

Haemodialysis and peritoneal dialysisPMBs only in state facilities

Take out medicines 7 days medication per hospital event at MPL

Day-to-Day Benefit

day-to-daybenefitDay-to-day benefits provided through the nominated Blue Door Plus GP Network

BENEFIT COVER LIMIT PER FAMILY PER YEARGeneral Practitioners (GP)

- Contracted

- Not contracted

Agreed tariff

Limited to tariff for con-tracted GPs

Limited to six (6) consultations to a nominated GP without pre-authorisation. After the sixth consultation, pre-authorisation is required via the Healthcare Profes-sional Call centre on 0861 112 666. Limited to 2 psychiatric consultations per family per annum

The ‘out of nominated’ GP benefit consists of 2 visits per family per year and is reimbursed at the Blue Door Plus rate

Specialists

- Fedhealth Network Specialists

- Non-Fedhealth Network Specialists

At cost

No benefit

2 x specialist consultations per family per year. Must be referred by the nominated GP

Dentistry (Basic)

Removal of teeth and roots and suturing of trau-matic wounds.Oral medical procedures:diagnosis and treatment of oral and associated conditions, plastic dentures and dental techni-cians fees for all such dentistry

Agreed tariff

Subject to a contracted list of dentists and limited to a list of approved procedures, dental tariff codes and protocols.Plastic dentures limited to one set per beneficiary every two years for beneficiaries 21 years and older

Mental health No benefit See GP benefit

Optometry Agreed tariff

Subject to ISO Leso* network optometrists. Frame to the value of R173 or R173 off any other frame every 2 years1 pair of single vision clear CR39 lenses or 1 pair of bifocal clear CR39 lenses1 comprehensive consultation. This benefit is avail-able in a 2 year benefit cycle

Over-the-counter medication No benefit

Maternity Up to 100% of FR 2 x 2D scans per beneficiary per maternity event

Pathology Up to 100% of FRUnlimited subject to basic protocols and limited list of tests & procedures. Must be referred by contracted Medical Practitioner

Prescribed Medication

- Dispensing GP - Non-Dispensing Medical Practitioner

Unlimited

Up to 100% of MPL

Unlimited at nominated GP

Unlimited subject to acute medicine formulary for all Medical Practitioners

Physiotherapy No benefit

Radiology

- General

- Specialised

Up to 100% of FR

No benefit

Unlimited subject to basic protocols and a limited list of tests and procedures. Must be referred by contract-ed Medical Practitioner

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Agreed Tariff - the service fee as agreed to by the Scheme with the healthcare professional

Chronic Disease Benefi t

Medication for approved chronic diseases is covered from this benefi t

Limit Unlimted

Conditions covered 26ChronicConditionsbelow

Formulary Basicformulary(AlsoknownastheLowOptionChronicFormulary)

Designated Service Provider (DSP) Medi-Ritepharmacy

HIV/ AIDS MEDICINE BENEFIT INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS

Limit Unlimited

Non-compliancewithDSPand/orformularyrequirementswillattractaco-paymentof40%.AllmedicineclaimsaresubjecttotheMedicinePriceList(MPL),agenericreferenceprice,andthemaximumnegotiateddispensingfee.Wherethedispensingfeehasnotbeennegotiated,amaximumdispensingfeeof26%/R26willapply.

26 CHRONIC CONDITIONS

Addison’sDisease,Asthma,BipolarMoodDisorder,Bronchiectasis,CardiacFailure,Cardiomyopathy,COPD/Emphysema/ChronicBronchitis,ChronicRenalDisease,CoronaryArteryDisease,Crohn’sDisease,DiabetesInsipidus,DiabetesMellitustype1,DiabetesMellitustype2,Dysrhythmias,Epilepsy,Glaucoma,Haemophilia,Hyper-lipidaemia,Hypertension,Hypothyroidism,MultipleSclerosis,Parkinson’sDisease,RheumatoidArthritis,Schizophrenia,SystemicLupusErythematosus,UlcerativeColitis

5

Major Medical Benefit Please note the following important points:• Costsforhospitalisationarecoveredunlimitedfromthisbenefit-fromthefirstdayofhospitalisationinpublicornetworkprivate

hospitals• Voluntaryuseofnon-networkorpublichospitalswillresultinthememberhavingtomakeaco-paymentof40%ontheirhospitalbill• OrgantransplantsandrenaldialysisarecoveredasPrescribedMinimumBenefitsatstatefacilitiesonly• OncologyiscoveredunlimitedasaPrescribedMinimumBenefitattheIndependentClinicalOncologyNetwork(ICON),theScheme’s

DesignatedServiceProvider• HospitaladmissionsrequireareferralfromanominatedGPandmustbepre-authorisedbytheHealthcareProfessionalManagedCare

Lineon0861100220• PsychiatricadmissionsarelimitedtoR7600perfamilyperyearandwillrequireareferralfromanominatedGPandissubjecttopre-

authorisation• MaternityhasalimitofR31200perpregnancy,withalimitofR46200perfamilyperyear.ElectiveCaesariansectionsaresubjecttoa

40%co-payment.

Acute medicine• Fordispensingdoctorsacutemedicineformspartofthefixedfeeforconsultationsandnoacutemedicinewillbepaidadditionalto

thisfee• Eventhoughafixedfeeispaid,themedicinebillingcodesmustberecordedontheaccount.Thisensuresproperinformationon

dispensingpatternsandisrequiredforqualitymanagementpurposes• Anacutemedicinesformularyisavailabletonon-dispensingdoctors.Thisformularyrepresentsleastcostlyandyeteffective

genericproductsandcanbeusedasaprescribingguide•Itisimportantfordoctorstoprescribemedicinesontheacuteformularysothatmembersdonothaveanyoutofpocketexpenses. Acutemedicinesthatarenotontheacuteformularywillnotbecovered.

Chronic medication•MedschemeappliesaDiseaseAuthorisationmodelwhichmeansthatonceapatientisapprovedforachronicconditiontheywill

haveaccesstoaselectionofpre-approvedmedicinesforthecondition,referredtoasabasket.ThemedicineinthebasketisstillsubjecttoMPLandoutofformularyco-paymentsandcanbeviewedonwww.medscheme.co.zabyloggingintotheproviderzone.Apatientcanupdateorchangetheirmedicinedirectlywiththepharmacywiththeirnewprescription.Notallconditionsaremanagedthisway;apatientwillneedtocontacttheschemeif:~themedicineisnotinthebasket;or~theyarediagnosedwithanewchroniccondition;or~theyneedaquantityordosageofamedicinethatismorethanthequantitylistedinthebasket.

From 01 January 2015, the Fedhealth Blue Door Plus Option will be applying the Basic Chronic Formulary (also known as the Low Option Chronic Formulary). The following must be kept in mind when prescribing chronic medication to Blue Door Plus members:

• ChronicmedicationmustbeprescribedbyaBlueDoorPluscontractedGP• ChronicmedicationisprovidedthroughaDesignatedServiceProvider,Medi-Ritepharmacies• Aco-paymentof40%willapplytomedicinesoutsideofformularyorprescribedbyanon-designatedserviceprovider• 26PMB(CDL)conditionsonly• MedschemeBasicFormularyapplies(alsoknownastheLowOptionChronicFormulary)• Memberstoregisterforchronicmedication• MedicinePriceList(MPL)ruleapplieswhichensuresthatthemosteffectiveandyetcosteffectivegenericswillbesuppliedtoBlue

DoorPlusmembers.

Telephonic chronic medicine application• CallourChronicMedicineManagementdepartmentbetween08h30and17h00on0861100220andselectoptionnumber3• Yourcallwillberoutedthroughtoaclinicalconsultant.Makesureyouhaveallrelevantdetailsofyourpatientathand• Onapprovalthemedicationwillbepaidfromthechronicmedicinebenefit• Normal0199paymentwillapplyforfirsttimetelephonicregistrations.

Online chronic medicine application• LogintotheMedschemewebsite(www.medscheme.co.za)andclickonChronicApplication• Loginwithyourusernameandpassword.Pleaseregisterifyouareafirsttimeuser• Makesurethatyouhavealltherelevantpatientdetailsathandtocompletetheonlineapplication• Remembertheonlineapplicationcanbeusedformembersapplyingforchronicmedicineforthefirsttimeorforupdatingcurrent authorisations•Normal0199paymentwillapplyforfirsttimeonlinechronicapplications.

Aid for Aids (AfA)• SubjecttoregistrationandmanagementbyAfA• MedicineprovidedbyMedi-Ritepharmacies• PathologytestsarepartofmanagementbyAfA• Benefitincludestreatmentformother-to-childtransmission,rape,andpost-exposure-prophylaxis.

6

Blue Door Plus pathology benefit schedule• ThemembermustbereferredbyaBlueDoorPlusnominatedGP• Pathologyiscoveredat100%oftheBlueDoorPlusschemerate• Unlimitedbutsubjecttothetestslistedbelow.

Pathology codes payable

Tariff Code DESCRIPTION

Chemistry

Cardia/ Muscle

4152 CK-MB:Massdetermination:Quantitative(Automated)

4161 Troponinisoforms:Each

Diabetes

4050 Glucosestriptest

4057 Glucose:Quantitative

4064 HbA1C

Inflammation/ Immune

3947 C-reactiveprotein

Lipids

4027 Cholesteroltotal

4026 LDLcholesterol

4028 HDLcholesterol

4147 Triglyceride

Liver/ Pancreas

3999 Albumin

4001 Alkalinephosphatase

4006 Amylase

4009 Bilirubin:Total

4010 Bilirubin:Conjugated

4117 Protein:Total

4130 Aspartateaminotransferase(AST)

4131 Alanineaminotransferase(ALT)

4133 Lactatedehidrogenase(LD)

4134 Gammaglutamyltransferase(GGT)

Renal/ Electrolytes/ Bone

4017 Calcium:Spectrophotometric

4032 Creatinine

4086 Lactate

4094 Magnesium:Spectrophotometric

4109 Phosphate

4113 Potassium

4114 Sodium

4155 Uricacid

4151 Urea

4171 Soduim+Posassium+Cloride+C02+Urea

Haematology

3709 Antiglobulintest(Coombs’ortrypsinziedredcells)

3716 Meancellvolume

3743 Erythrocytesedimentationrate

3755 Fullbloodcount(includingitems3739,3762,3783,3785,3791)

7

3762 Haemoglobinestimation

3764 Grouping:ABandOantigens

3765 Grouping:Rhantigen

3797 Plateletcount

3805 Prothrombinindex

3809 Reticulocytecount

3865 Parasitesinbloodsmear

4071 Iron

4144 Transferrin

4491 VitaminB12

4528 Ferritin

4533 Folicacid

Endocrine - Reproductive

4450 HCG:Monoclonalimmunological:Qualitative

4537 Prolactin

Endocrine - Thyroid

4482 Freethyroxine(FT4)

4507 Thyrotropin(TSH)

Other Endocrine

4519 Prostatespecificantigen

Serology

Auto immune

3934 Autoantibodiesbylabelledantibodies:FORANFONLY

3939 Agglutinationtestperantigen

4155 Uricacid

4182 Quantitativeproteinestimation:NephelometerorTurbidometericmethod:FORRHEUMATOIDFACTORONLY

Hepatitis tests

4531 Hepatitis:Perantigenorantibody

4531 AcutehepatitisA(IgM)

4531 ChronicHepatitisA(IgG)

4531 AcuteHepatitisB(BsAG)

4531 HepatitisB:carrier/immunity(BsAB)

HIV tests

3816 TandB-cellsEACmarkers(limitedtoONEmarkeronlyforCD4/8counts)

3932 Antibodiestohumanimmunodeficiencyvirus(HIV):ELISA

3974 QualitativePCR(onlyforchildren<age6months)

4429 QuantitativePCR(DNA/RNA)

Infectious Diseases and Others

3946 IgM:Specificantibodytiter:ELISA/EMIT:RUBELLA

3948 IgG:Specificantibodytiter:ELISA/EMIT:RUBELLA

3951 QuantitativeKahn,VDRLorotherflocculation

Cytology

4566 Vaginalorcervicalsmears,each

Histology

4567 Histologypersample

Microbiology

MCS

3909 Anaerobeculture:Limitedprocedure

8

3901 Fungalculture

3918 Mycoplasmaculture:Comprehensive

4401 Cellcount

4188 Urinedipstick,perstick(irrespectiveofthenumberoftestsonstick)

3928 Antimicrobicsubstances

3893 Bacteriologicalculture:Miscellaneous

3867 Miscellaneous(bodyfluids,urine,exudate,fungi,puss,scrapings,etc.)

3922 Viablecellcount

3879 Campylobacterinstool:Fastidiousculture

3895 Bacteriologicalculture:Fastidiousorganisms

3928 Antimicrobicsubstances

3887 Antibioticsusceptibilitytest:Perorganism

3924 Biochemicalidentificationofbacterium:Extended

3869 Faeces(includingparasites)

3868 Fungusidentification

3881 Mycobacteria

3901 Fungalculture

3868 Fungusidentification

AFB fluorochrome auramine (ZN) only

3885 Cytochemicalstain

3881 Antigendetectionwithmonoclonalantibodies

TB culture

3881 Antigendetectionwithmonoclonalantibodies

4433 BacteriologicalDNAidentification(LCR)

3916 Radiometrictuberculosisculture

3867 Miscellaneous(bodyfluids,urine,exudate,fungi,puss,scrapings,etc.)

3895 Bacteriologicalculture:Fastidiousorganisms

TB sensitivity

3887 Antibioticsusceptibilitytest:Perorganism

3974 Polymerasechainreaction

Parasites

3869 Faeces(includingparasites)

3883 Concentrationtechniquesforparasites

3865 Parasitesinbloodsmear

Bilharzia micro

3980 BilharziaAgSerum/Urine

3867 Miscellaneous(bodyfluids,urine,exudate,fungi,puss,scrapings,etc.)

3946 IgM:Specificantibodytiter:ELISA/EMIT:PerAg

3883 Concentrationtechniquesforparasites

9

10

Blue Door Plus radiology benefit schedule• ThemembermustbereferredbyanominatedGP• X-raysarecoveredat100%oftheBlueDoorPlusschemerate• Pregnancyscansarelimitedto2scansperbeneficiaryperpregnancyandcanberequesteddirectlybyaspecialist• Generalradiologyisunlimitedbutsubjecttothelistbelow• Specialisedradiology(inhospital)islimitedtoR11500perbeneficiary,subjecttopre-authorisationandan

overallannuallimitofR23200perfamilyperyear

Radiology codes payable

Skull and Brain

10100 X-ray of the skull

Facial bones and nasal bones

11100 X-ray of the facial bones

11120 X-ray of the nasal bones

Orbits, lachrymal glands and tear ducts

12100 X-ray orbits

Paranasal sinuses

13100 X-ray of the paranasal sinuses, single view

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

Mandible, teeth and maxilla

14100 X-ray of the mandible

14130 X-ray of the teeth single quadrant

14140 X-ray of the teeth more than one quadrant

14150 X-ray of the teeth full mouth

15100 X-ray tempero-mandibular joint, left

15110 X-ray tempero-mandibular joint, right

16100 X-ray of the mastoids, unilateral

16110 X-ray of the mastoids, bilateral

Thorax

30100 X-ray of the chest, single view

30110 X-ray of the chest two views, PA and lateral

30150 X-ray of the ribs

Abdomen and Pelvis

40100 X-ray of the abdomen

40105 X-ray of the abdomen supine and erect, or decubitus

40110 X-ray of the abdomen multiple views including chest Skeleton: Spinal column - Per region, e.g. cervi-cal, sacral, lumbar coccygeal, one region thoracic

50100 X-ray of the spine scoliosis view AP only

Cervical

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

Thoracic

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

Lumbar

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

54100 X-ray of the sacrum and coccyx

54110 X-ray of the sacro-iliac joints

Pelvis

55100 X-ray of the pelvis

56120 X-ray pelvis and hips

Hips

56100 X-ray of the left hip

56110 X-ray of the right hip

Shoulder

61100 X-ray of the left clavicle

61105 X-ray of the right clavicle

11

Shoulder

61110 X-ray of the left scapula

61115 X-ray of the right scapula

61120 X-ray of the left acromio-clavicular joint

61125 X-ray of the right acromio-clavicular joint

61130 X-ray of the left shoulder

61135 X-ray of the right shoulder

Humerus

62100 X-ray of the left humerus

62105 X-ray of the right humerus

Elbow

63100 X-ray of the left elbow

63105 X-ray of the right elbow

Forearm

64100 X-ray of the left forearm

64105 X-ray of the right forearm

Hand and Wrist

65100 X-ray of the left hand

65105 X-ray of the right hand

65120 X-ray of a finger

65130 X-ray of the left wrist

65135 X-ray of the right wrist

65140 X-ray of the left scaphoid

65145 X-ray of the right scaphoid

Lower Leg

73100 X-ray of the left lower leg

73105 X-ray of the right lower leg

Ankle and Foot

74100 X-ray of the left ankle

74105 X-ray of the right ankle

74120 X-ray of the left foot

74125 X-ray of the right foot

74130 X-ray of the left calcaneus

74135 X-ray of the right calcaneus

74140 X-ray of both feet – standing – single view

74145 X-ray of a toe

Femur

71100 X-ray of the left femur

71105 X-ray of the right femur

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

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

72120 X-ray of the left knee including patella

72125 X-ray of the right knee including patella

72140 X-ray of left patella

72145 X-ray of right patella

72150 X-ray both knees standing – single view

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

Ultrasound abdomen and Pelvis

41200 Ultrasound study of the upper abdomen

40210 Ultrasound study of the whole abdomen including the pelvis

43200 Ultrasound study of the pelvis transabdominal

43250 Ultrasound study of the pregnant uterus, first trimester

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

43273 Ultrasound study of the pregnant uterus, third trimester, follow-up visit

43277 Ultrasound study of the pregnant uterus, multiple gestation, second or third trimester, first visit

43260 Routine obstetric ultrasound at 20 to 24 weeks to include detailed anatomical assessment

12

CODE CODE DESCRIPTION LIMITATIONS

8101 Consultation Twice per beneficiary per 12 months; once per 6 month period

8104 Examination for a specific problem not requiring full mouth examination

8107/8112 Intra oral radiographs, per film Maximum of two per beneficiary per year

8159 Scaling and polishing Twice per beneficiary per 12 months; once per 6 month period

8161 Topical application of fluoride Between the ages of 3-12 years Twice per beneficiary per 12 months; once per 6 month period

8163 Fissure sealant, per tooth Patients younger than 14; maximum of 2 per quadrant

8341 Amalgam one surface Any four amalgam fillings per beneficiary per year*

8342 Amalgam two surfaces

8343 Amalgam three surfaces

8344 Amalgam four and more surfaces

8351 Resin restoration, one surface anterior Any four resin fillings per beneficiary per year (anterior)*

8352 Resin restoration, two surface anterior

8353 Resin restoration, three surface anterior

8354 Resin restoration, four and more surfaces

8367 Resin restoration, one surface posterior Any four resin fillings per beneficiary per year

8368 Resin restoration, two surface posterior

8369 Resin restoration, three surface posterior

8370 Resin restoration, four and more surfaces

8307 Amputation of pulp (pulpotomy) Only on primary teeth

8132 Root canal therapy - gross pulpal debridement

8201 Extraction, single tooth. Code 8201 is charged for the first extraction in a quadrant

Any four non-surgical extractions per beneficiary per year – ONLY if clinically indicated.

8202 Extraction, each add tooth. Code 8202 is charged for each additional extraction in the same quadrant

8937 Surgical removal of tooth Quantity limit of 4, restricted to posterior permanent teeth

8935 Treatment of septic socket

8109 Infection control / barrier techniques. Codes 8109 in-cludes the provision by the dentist of new rubber gloves, masks, etc for each patient

Two per visit. Limited to 4 per beneficiary per annum

8110 Sterilized instrumentation One per visit

8145 Local anaesthetic One per visit per annum

8231 Complete dentures – maxillary and mandibular 1 (one) set of dentures allowed per beneficiary per 24 months ONLY members and beneficiaries over the age of 21 years of age. No metal base to complete or partial dentures allowed. Pre- authorisation required.

8232 Complete dentures – maxillary or mandibular

8233 Partial Denture (resin base) - One tooth

8234 Partial Denture (resin base) - Two teeth

8235 Partial Denture (resin base) - Three teeth

8236 Partial Denture (resin base) - Four teeth

8237 Partial Denture (resin base) - Five teeth

8238 Partial Denture (resin base) - Six teeth

8239 Partial Denture (resin base) - Seven teeth

8240 Partial Denture (resin base) - Eight teeth

8241 Partial Denture (resin base) - Nine teeth and more

8259 Rebase complete or partial dentures (Lab)

8269 Repair Denture

8263 Reline complete or partial dentures (chair side)

8271 Add tooth to existing partial dentures

8273 Impression to repair / addition

8140 Fee for treatment at a venue

Dental codes payable (Dentists and Dental Therapists)

13

Inadditiontothelistbelow,theHospitalNetworkforBlueDoorPlusincludesallStatefacilities(56),47,49,55,76and77facilities.

Network hospitalsBLUE DOOR HOSPITAL NETWORK PROVINCE SUBURB

Life Beacon Bay Hospital Eastern Cape East London

Netcare Cuyler Hospital Eastern Cape Uitenhage

Life Mercantile Hospital Eastern Cape Port Elizabeth

Port Elizabeth Provincial Hospital Eastern Cape Port Elizabeth

Life St James Hospital Eastern Cape East London

Uitenhage Hospital Eastern Cape Uitenhage

Horizon Eye Care Centre Free State Bloemfontein

Life Pasteur Hospital Free State Bloemfontein

Life Rosepark Hospital Free State Bloemfontein

Universitas Academic Hospital Free State Bloemfontein

Netcare Vaalpark Hospital Free State Sasolburg

Welkom (Bongani) Provincial Hospital Free State Welkom

Netcare Kroon Free State Kroonstad

Mediclinic Welkom Free State Welkom

Clinix Botshelong-Empilweni Private Hospital Gauteng Vosloorus

Netcare Bougainville Hospital Gauteng Pretoria West

Life Brenthurst Clinic Gauteng Parktown

Life Carstenhof Clinic Gauteng Midrand

Charlotte Maxeke Hospital Gauteng Parktown

Chris Hani Baragwanath Hospital Gauteng Soweto

Netcare Clinton Hospital Gauteng Alberton

Cormed Clinic Gauteng Vanderbijlpark

Life Dalview Clinic Gauteng Brakpan

Daxina Private Hospital Gauteng Lenasia

Lenmed Private Hospital Gauteng Lenasia

Lesedi Private Hospital Gauteng Soweto

Leslie Williams Memorial Hospital Gauteng Carletonville

Netcare Linmed Hospital Gauteng Benoni

Louis Pasteur Hospital Gauteng Pretoria

Midvaal Private Hospital Gauteng Vereeniging

Clinix Naledi-Nkanyezi Private Hospital Gauteng Sebokeng

Life Robinson Private Hospital Gauteng Randfontein

Life Roseacres Clinic Gauteng Primrose

Clinix Selby Park Hospital Gauteng Selby

Steve Biko Academic Hospital (Pretoria Academic) Gauteng Pretoria

TK Maternity Services Hospital Gauteng Katlehong

Clinix Tshepo-Themba Private Hospital Gauteng Soweto

Zamokhule Private Hospital Gauteng Tembisa

Addington Hospital Kwa-Zulu Natal Durban

Life Chatsmed Garden Hospital Kwa-Zulu Natal Chatsworth

City Hospital Kwa-Zulu Natal Durban

Life Empangeni Garden Clinic Kwa-Zulu Natal Empangeni

Isipingo Hospital Kwa-Zulu Natal Isipingo

Netcare Kokstad Private Hospital Kwa-Zulu Natal Kokstad

La Verna Hospital Kwa-Zulu Natal Ladysmith

Life Mount Edgecombe Hospital Kwa-Zulu Natal Phoenix

14

BLUE DOOR HOSPITAL NETWORK PROVINCE SUBURB

Mediclinic Newcastle Hospital Kwa-Zulu Natal Newcastle

Newcastle Provincial Hospital Kwa-Zulu Natal Newcastle

Mediclinic Victoria Private Hospital Kwa-Zulu Natal Tongaat

Mediclinic Limpopo Limpopo Polokwane

Mediclinic Tzaneen Limpopo Tzaneen

Mediclinic Thabazimbi Limpopo Thabazimbi

Life Cosmos Hospital Mpumalanga Witbank

Life Midmed Hospital Mpumalanga Middleburg

Mediclinic Barberton Mpumalanga Barberton

Mediclinic Nelspruit Mpumalanga Nelspruit

Mediclinic Brits North West Brits

Mediclinic Legae North West Rosslyn

Life Anncron Clinic North West Klerksdorp

Mooimed Private Hospital North West Potchefstroom

Life Peglerae Hospital North West Rustenburg

Itokolle-Victoria Private Hospital North West Mafikeng

Mediclinic Kathu Northern Cape Kathu

Mediclinic Kimberley Northern Cape Kimberley

Mediclinic Upington Northern Cape Uitenhage

Life Bay View Private Hospital Western Cape Mossel Bay

Melomed Bellville Medical Centre Western Cape Bellville

Netcare Blaauwberg Hospital Western Cape Blaauwberg

Mediclinic Cape Gate Western Cape Brackenfell

Ceres Private Hospital Western Cape Ceres

Melomed Gatesville Medical Centre Western Cape Athlone

Groote Schuur Hospital Western Cape Cape Town

Mediclinic Hermanus Western Cape Hermanus

Karl Bremmer Hospital Western Cape Bellville

Netcare Kuils River Hospital Western Cape Kuils River

Melomed Mitchells Plain Medical Centre Western Cape Mitchells Plain

Paarl Hospital Western Cape Paarl

Mediclinic Paarl Western Cape Paarl

Red Cross War Memorial Children's Hospital Western Cape Rondebosch

Mediclinic Stellenbosch Western Cape Stellenbosch

Stellenbosch Provincial Hospital Western Cape Stellenbosch

Swartland Hospital Western Cape Malmesbury

Tygerberg Hospital Western Cape Bellville

Victoria Hospital Western Cape Wynberg

Vredenburg Hospital Western Cape Vredenburg

Vredendal Hospital Western Cape Vredendal

Life West Coast Private Hospital Western Cape Vredenburg

Worcester Hospital Western Cape Worcester

Mediclinic Worcester Western Cape Worcester

Netcare Christiaan Barnard Memorial Hospital Western Cape Cape Town