FAMILY PRACTITIONER NETWORK GUIDE
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FAMILY PRACTITIONER NETWORK GUIDE
INDEX
INDEX
BONITAS FAMILY PRACTITIONER NETWORK GUIDE BONCAP FAMILY PRACTITIONER NETWORK GUIDE ANNEXURE A
INTRODUCTION PAGE 2 SUMMARY OF PRIMARY CARE BENEFITS PAGE 14 BONCAP RADIOLOGY FORMULARY PAGE 21
USING THIS GUIDE PAGE 2 FAMILY PRACTITIONER TARIFFS AND FEES PAGE 15
FAMILY PRACTITIONER NETWORK FEES PAGE 3 MEDICATION PAGE 16 ANNEXURE B
SPECIALIST NETWORK AND SPECIALIST REFERRAL PAGE 3 THE REFERRAL MANAGEMENT PROCESS PAGE 17 BONCAP RADIOLOGY REQUEST FORM PAGE 24
FAMILY PRACTITIONER NOMINATION PAGE 4 SPECIALIST BENEFIT PAGE 17
IMPROVED CLINICAL PATHWAY SERVICES (ICPS), MATERNITY BENEFIT AND ANTENATAL VISITS PAGE 17 ANNEXURE C
JOINTCARE AND MAJOR JOINTS FOR LIFE PAGE 5
RADIOLOGY PAGE 18 BONCAP PATHOLOGY FORMULARY PAGE 25
INDEPENDENT CLINICAL ONCOLOGY NETWORK (ICON) PAGE 5
PATHOLOGY PAGE 18
DOCUMENTATION BASED CARE (DBC) & WORKABILITY PAGE 6
DAY-TO-DAY BENEFITS PAGE 18 ANNEXURE D
PHARMACY NETWORK PAGE 6
OPTOMETRY PAGE 19 BONCAP PATHOLOGY REQUEST FORM PAGE 28
HOSPITAL NETWORK PAGE 7
HOSPITALISATION PAGE 19
ELECTRONIC MEDICAL RECORD PAGE 8
PRESCRIBED MINIMUM BENEFITS (PMBS) PAGE 19 ANNEXURE E
CARE PATHWAYS PAGE 8
HIV/AIDS MANAGEMENT PAGE 19 BONCAP SPECIALIST REFERRAL FORM PAGE 29
HEALTHCARE FORENSICS PAGE 9
MAJOR MEDICAL BENEFITS PAGE 20
BABYLINE PAGE 9
ANY OTHER ENQUIRIES PAGE 20 FIND A SERVICE PROVIDER PAGE 30
OUT-OF-HOSPITAL TESTS FOR CHRONIC PMB DISEASES PAGE 9
SUBMITTING CLAIMS PAGE 20
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
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 SchemesINTRODUCTION USING THIS GUIDE
Dear Family Practitioner 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
Despite increasing healthcare inflation and economic pressures in the past year, innovative strategic and to you as a family practitioner.
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 If you have any questions or require further information or assistance, please call us on
financial health. 0861 112 666.
BONITAS FP GUIDE 2019
The worldwide increase in chronic disease burden is one of the reasons for escalating healthcare Please note: There will be a 5.0% increase in the Bonitas & BonCap FP tariff rates, with effect
costs. Bonitas has introduced managed care programmes over the past few years to assist in 1 January 2019.
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 regards
Bonitas Medical Fund
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. Page 2FAMILY PRACTITIONER SPECIALIST NETWORK
NETWORK FEES AND SPECIALIST
Bonitas 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.
REFERRAL
1. The Bonitas Specialist Network
BONITAS FP GUIDE 2019
The Bonitas FP network reimbursement model for 2019 will continue to include an enhanced fee in Bonitas has a network of over 3 400 Specialists in place consisting of the following specialities:
accordance with the practice’s REPI² category score as indicated below:
Dermatology Ophthalmology
Enhanced fees automatically added when
Obstetrics and Gynaecology Orthopaedics
FP Consultation Rates consultation is processed
2019
(0190-0192) Pulmonology Otorhinolaryngology
REPI2 Cat 1 REPI2 Cat 2
Physicians Rheumatology
Bonitas Tariff R379,10 R45,90 R23,00
Gastroenterology Paediatrics
Please take note of the following: Neurology Plastic and Reconstructive Surgery
• To protect Bonitas members from unexpected co-payments, it is important that FPs adhere to Cardiology Surgeons
their contract requirement to bill the Bonitas Tariff.
• Note that the enhanced fee will be automatically added when the practice is reimbursed for Psychiatry Cardiothoracic Surgery
consultations. 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 referral
There 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.
Page 3 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.Please note the following: • Hospital network: The BonCap, BonFit, Standard Select, Primary Select and BonEssential
• For all other options, please contact the Healthcare Provider Contact Centre on Select options have a specific hospital network in place. Members on these options need to
0861 112 666 and use the interactive voice recognition (IVR) function to obtain a referral use a hospital in the respective network to avoid a co-payment. Please refer to the Hospital
number. You will need to have the following information ready: Network section in this guide for further information on the network. Please ensure that
- Your practice number, e.g. 1234567 members on these options are referred to a network hospital.
- 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
FAMILY PRACTITIONER
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. NOMINATION
BONITAS FP GUIDE 2019
• 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).
Bonitas supports care coordination and considers the Family Practitioner (FP) to be at the heart of
For patients on BonCap, the FP needs to contact BonCap Beneficiary Management on this process. Fragmented healthcare has resulted in inefficient, costly treatment for our members;
0861 239 333 to obtain a referral. therefore, Bonitas believes that FP care coordination improves the quality of healthcare and lowers
overall healthcare expenditure.
3. Quick reference guide for Specialist practice types requiring a Specialist referral:
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
Specialist Specialist
Specialist Type Description Specialist Type Description Bonitas Call Centre on 0860 002 108. Main members on the Standard Select and Primary Select
Type Type
options have a greater nominated FP limit and will therefore benefit by visiting a nominated FP
12 D e r m a to l o g i st 28 Or t h o p a e d i c S u rg e o n versus visiting a non-nominated FP.
Oto rh i n o l a r y n g o l o g i st
16 Gy n a e co l o g i st 30 Standard Select:
( EN T )
17 P u l m o n o l o g i st 31 Rh e u mato l o g i st Nominated FP Services Non-Nominated FP Services
18 P hy s i c i a n 32 Pa e d i at ri c i a n Benefit limit of R4 170 Sub-limit of R1 350
19 G a s t ro e n te ro l o g i st 33 Ca rd i o l o g y Pa e d i at ri c i a n
P l a st i c a n d Re co n st ru ct i ve
20 N e uro lo g ist 36
S u rg e o n
Primary Select:
21 Ca rd io lo g ist 42 S u rg e o n Nominated FP Services Non-Nominated FP Services
22 Psychiatr ist 44 Ca rd i ot h o ra c i c S u rg e o n Benefit limit of R1 900 Sub-limit of R615
24 N e urosurg e o n 46 U ro l o g i st
The only exception to the Specialist referral rule will be the following:
1. The first gynaecologist visit for female beneficiaries
2. Paediatric consultations for children under the age of two
3. Maternity consultations
4. Consultations with oncologists
5. Consultations with ophthalmologists
6. 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.
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. Page 4IMPROVED CLINICAL INDEPENDENT
PATHWAY SERVICES CLINICAL
(ICPS) & JOINTCARE ONCOLOGY
& MAJOR JOINTS FOR NETWORK (ICON)
BONITAS FP GUIDE 2019
LIFE 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
Bonitas has partnered with ICPS, JointCare and Major Joints for Life who are groups of orthopaedic
appropriately cared for. ICON offers a network of oncologists, who has agreed to utilise the clinical
surgeons who specialise in performing hip and knee replacements according to standardised clinical
protocols approved by the Fund and will bill at the agreed rate, thereby ensuring that members will
care pathways, to ensure that the quality of the hip and/or knee replacement is of the highest
not incur co-payments.
standard as well as to ensure the best health outcomes.
Please refer Bonitas members to an oncologist within the ICON network to ensure that the member
ICPS, JointCare and Major Joints for Life are the preferred providers for Bonitas members on the
does not incur any potential co-payments.
Standard, BonClassic, BonComplete and BonComprehensive options, and the Designated Service
Provider (DSP) for members on the Standard Select option.
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
ICPS, JointCare and Major Joints for Life will ensure payment in full for the procedure, which will
on 021 944 3750.
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
Bonitas will not fund the procedure if a non-ICPS, non- JointCare or
Standard Select
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
Page 5 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.THE BACK & NECK PHARMACY
DOCUMENTATION NETWORK
BASED CARE (DBC) & 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
WORKABILITY well as various independent community pharmacies.
BONITAS FP GUIDE 2019
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,
The goal of DBC and Workability is to reduce the need for unnecessary surgery caused by chronic Preferred Provider Networks and co-payments.
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
Chronic medication Benefit rules
members who would benefit from the programme and ensure that the care provided is coordinated
to ensure optimal outcomes. • The Designated Service Provider (DSP) is Pharmacy Direct for
all options (excluding BonComprehensive) but only acts as the
All Bonitas options (excluding BonCap) have contracted with DBC and Workability. Members that are DSP for the BonClassic and Standard options once the benefit
eligible for the DBC or Workability programme are proactively identified by the Bonitas beneficiary limit is depleted.
risk management team. Eligible beneficiaries can also be identified by their Family Practitioner or • BonComplete, Primary, Primary Select, BonFit, BonCap,
they can self-refer. BonSave, Standard Select, BonEssential, BonEssential Select
and Hospital Standard all have to utilise Pharmacy Direct as
Pharmacy network
The identification of eligible members in all categories is limited to members that reside within a 30 the DSP from onset of the benefit year.
km radius of a DBC clinic or a Workability facility (distance between the member’s residential postal • Pharmacy Direct can be contacted on 0860 027 800.
code and the applicable facility’s postal code). • The Preferred Provider Network (PPN) for chronic medication
includes Clicks, Dis-Chem, MediRite, Pick n Pay, Pharmacy
Should you wish to enrol your patient in the DBC or Workability programme, please call the Direct, Optipharm, Scriptwise, Netcare and Pharmacross and
Healthcare Provider Contact Centre on 0861 112 666 to see whether your patient qualifies to be various independent community pharmacies, and is only
enrolled in the programme. applicable to the BonClassic and Standard options.
• Please call the Bonitas Contact Centre on 0861 100 220 or
There are currently 15 DBC centres located across South African in Cape Town, Bellville, Sasolburg, email chronicmeds@bonitas.co.za.
Secunda, Emalahleni, Sandton, Kempton Park, Durban, Umhlanga, Roodepoort, Centurion, Pretoria How to apply for chronic
• You can also log in to www.medscheme.com > log in as a
East, Pretoria North, Bloemfontein and Port Elizabeth. There are also 2 additional Workability medicine
provider > click chronic application > insert membership
facilities located in Bloemfontein and Port Elizabeth. Plans are in place to expand the network even number.
further. For an updated list of DBC clinics and Workability facilities, please call the Healthcare
Provider Contact Centre on 0861 112 666. • Formularies can be viewed at www.medscheme.com > log
in as a provider > click on clinical information > medicine
Chronic formularies and management.
disease baskets • Disease baskets can be viewed at www.medscheme.com
> log in as a provider > click lookup tool > disease basket
lookup.
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. Page 6Chronic medication Benefit rules
• You DO NOT need to update or call for a change if the:
• medicine is in the basket; or
HOSPITAL NETWORK
• member changes to another medicine in the basket; or
• member’s quantity or dosage of a medicine is listed in Bonitas has a well-established network of hospitals for BonCap, BonFit, Standard Select, Primary
Changes or updates
the basket. Select and BonEssential Select. In order to avoid the co-payments listed below, it is in the
• Changes or updates to chronic medication (if not part of the member’s best interest to use a network facility. To view a list of network hospitals log in to
disease basket) are done telephonically by contacting the www.bonitas.co.za.
Bonitas Contact Centre on 0861 100 220.
Bonitas members have access to all private hospitals; however, a 30% co-payment will apply at the
BONITAS FP GUIDE 2019
Co-payments can be avoided by:
• Ensuring the patient makes use of the DSP. following hospitals.
• Prescribing in-formulary drugs.
Co-payments
• Asking the pharmacist to substitute expensive medications Hospital
with a generic equivalent that will not attract an MPL
co-payment. Life Rosepark Hospital Life Eugene Marais Hospital
Life Bedford Gardens Private Hospital Life Faerie Glen Hospital
Please contact the Bonitas Contact Centre on 0861 100 220 for any other chronic medication
queries. Life Brenthurst Clinic Little Company of Mary/Life Groenkloof Hospital
Life Carstenhof Clinic Life Wilgers Hospital
Acute medication Benefit rules Life Flora Clinic Life Hilton Private Hospital
• The Preferred Provider Network (PPN) for all Bonitas options Genesis Maternity Clinic (Saxonwold) Life Kingsbury Hospital
includes Clicks, Dis-Chem, MediRite, Pick n Pay, Pharmacy
Life Wilgeheuwel Private Hospital Life Vincent Pallotti Hospital
Direct, Optipharm, Scriptwise, Netcare and Pharmacross and
Pharmacy network various independent community pharmacies.
Please note: This applies to all options, with the exception of BonCap, Standard Select and BonFit.
• If your member wishes to query whether their pharmacy is
These options make use of specific network hospitals.
part of the network, they can call 0860 002 108.
Co-payment for late Co-payment for using a
Co-payments can be avoided by: Option
pre-authorisation non-network hospital
• Ensuring the patient makes use of the DSP.
• Prescribing in-formulary drugs. BonCap R6 700 R6 700
Co-payments
• Asking the pharmacist to substitute expensive medications BonFit 100% of hospital account 30% of hospital account
with a generic equivalent that will not attract an MPL
co-payment. Standard Select 100% of hospital account 30% of hospital account
Primary Select 100% of hospital account 30% of hospital account
If you have BonCap acute medication or formulary queries, call BonCap Beneficiary Management
BonEssential Select 100% of hospital account 30% of hospital account
on 0861 239 333.
A hospital procedure can be pre-authorised by contacting the Bonitas Call Centre: 0861 100 220 or
If you have general queries about acute medication, please call the Healthcare Provider Contact
fax: 0860 002 145 or email: hospital@bonitas.co.za.
Centre on 0861 112 666.
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.
Page 7 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.ELECTRONIC CARE PATHWAYS
MEDICAL RECORD 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
The Electronic Medical Record (EMR) is a digital version of a patient’s paper-based chart, to this collaborative effort is to develop care pathways that take into account clinical and financial
make it easier to share Bonitas beneficiaries’ demographic and clinical information with Family implications, while at the same time being aligned to beneficiary benefits and a primary healthcare
Practitioners (FPs) who are on the Bonitas network. approach.
BONITAS FP GUIDE 2019
The Independent Practice Association (IPA) Forum and the Bonitas Clinical Coordination Committee Going forward, care pathways will be shared with healthcare professionals and it will also be
(BCCC) also provided their input with regard to the EMR. The EMR provides FPs with administrative incorporated into the Electronic Medical Record. To date, a hypertension care pathway as
and clinical benefits that could include the following: 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
Administrative benefits Clinical benefits developed.
Decreased paperwork Prescribing medication electronically
Access to up-to-date patient information
Decreased storage costs
including clinical notes and results
BP 140-159 / 90-99 mmHg BP 140-159 / 90-99 mmHg
More efficient billing Diagnosing patients more effectively withHEALTHCARE OUT-OF-HOSPITAL
FORENSICS TESTS FOR CHRONIC
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
PMB DISEASES
minimising the financial impact of fraud, waste and abuse. In previous years, out-of-hospital tests for the management of Prescribed Minimum Benefit
BONITAS FP GUIDE 2019
conditions (PMBs) were paid from Day-to-Day benefits. In 2019, out-of-hospital tests specified in
The claiming process for all healthcare professionals remains as is. Please continue to submit all the PMB care templates will be paid first from risk (overall annual limit) which will allow members to
claims as per the existing process. Valid claims will be assessed and paid. The claims data will then get the maximum value for money and stretch their Day-to-Day benefits as far as possible.
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
BONITAS DIABETES
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
MANAGEMENT
healthcare professional bodies and ensures that we continue to work towards achieving our goal
for holistic patient-centric and affordable care at all times.
PROGRAMME
For any fraud-related queries, please contact the fraud hotline on 0800 112 811 or email
fraud@medscheme.co.za.
BABYLINE
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.
BabyLine is part of PAED-IQ (Pty) Ltd, which has been in existence for 5 years and is a South African- This ensures that disease management is delivered in a holistic fashion accommodating associated
based medical information company, seeking to provide information and services to parents and co-morbidities and focusing interventions on high risk beneficiaries. In addition, our aim is to
caregivers, that will enhance the level of care they are able to provide to their children. 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.
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, Key components of the new programme include:
a database of information on common health conditions in children was developed. This information • Provision of an enhanced care template
is tailored to the needs of South African children and is endorsed by the Paediatric Management • Active monitoring and support of all Bonitas diabetics
Group of South Africa. • Active monitoring of adherence to treatment and clinical results.
• Targeted communication where gaps in care are identified.
Bonitas has partnered with PAED-IQ from 2017 to educate Bonitas parents and ensure their • Active management of identified beneficiaries by a team of health coaches.
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 If you have any questions or require more information on the Bonitas Diabetes Management
and is delivered by skilled personnel (registered nurses). Bonitas members will have access to this Programme, please contact the Healthcare Professional Contact Centre on 0861 112 666 or email
helpline, free of charge and can dial 0860 999 121 to make use of the service. queries@bonitas.co.za.
For more information on PAED-IQ, please visit https://paediq.com/aboutus.html.
Page 9 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.MENTAL HEALTH WELLNESS EXTENDER
PROGRAMME BENEFIT
Bonitas has created an industry first, the Wellness Extender Benefit that supplements the existing
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 health-risk assessment benefit by promoting continuity of care. Therefore, depending on the
practitioners, specialists, and auxiliary caregivers, and the introduction of a care manager to completion of the member’s health risk assessment, members can consult with their Family
help coordinate the process. This, along with family practitioner upskilling, decision support, and 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,
BONITAS FP GUIDE 2019
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. biokineticist or dietician, if necessary and these consultations are also funded. This is available to
beneficiaries on all options excluding BonCap.
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
Option Benefit Limit Range of Services Covered
specialist advice from the Medscheme Psychiatrist Decision Support service.
BonComprehensive R 2 540
Patient activation and support for self-care are promoted through education of patients and
BonClassic
their families, the facilitation of behavioural activation by care managers during telephonic
interventions, “Ask-Your-Doctor” checklists, and accessing community support groups. BonComplete
Standard R1 750 • Family Practitioner
Should you require more information or wish to confirm whether your patient meets the criteria of Consultations
the Bonitas Mental Health Programme, please call 0860 002 108, follow the prompts to select the Standard Select
• Biokineticist Consultations
Mental Health Programme or email Bonitasmentalhealth@medscheme.co.za. Hospital Plus and treatment
• Dietician Consultations and
BonSave
treatment
FP UPSKILLING
BonFit • Physiotherapist Consultations
and treatment
Hospital Standard R1 270
• Smoking Cessation Programme
Primary
Bonitas has well-established relationships with Family Practitioners (FPs), specifically through the Primary Select
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 BonEssential
R 910
was developed. BonEssential Select
The first FP-upskilling seminar took place in 2014 and following the success of the first upskilling The Wellness Extender Benefit can only be accessed if the member has completed a health risk
seminar, a further 18 sessions have been held up to 2018. 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 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 The benefit will be open for one (1) year. An sms will be sent to member to state that access has
burden diseases, as well as the practical medical skills that are likely to be required by FPs in the been granted.
management of these diseases.
Claims will be funded from the Wellness Extender Benefit if accompanied with valid consultation
All FPs who attend these upskilling seminars are awarded with at least 12 CPD points (depending on tariff codes and ICD-10 code Z00.0 (general medical examination). Please ensure that your claims
the lectures) if all lectures are attended. FPs are also awarded 2 ethics points for an ethics lecture have this specific ICD-10 code.
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.
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. Page 10QUICK REFERENCE GUIDE
Service Purpose Telephone Email address for queries
Healthcare Provider Contact Centre (IVR)
including Website Assistance / Bonitas General queries related to Bonitas 0861 112 666 queries@bonitas.co.za
Provider Contact Centre
BONITAS FP GUIDE 2019
All Bonitas BonCap option related queries, remittance, statement
BonCap Beneficiary Management and Medscheme website enquiries, as well as specialist referral 0861 239 333 boncap@bonitas.co.za
number requests
Bonitas: Bonitas Medical Fund:
0861 100 220 chronicmeds@bonitas.co.za
Chronic Medicine Management Chronic submissions and queries
BonCap: BonCap Option Only:
0861 239 333 boncapchronic@bonitas.co.za
Fraud Hotline Fraud-related matters 0800 112 811 fraud@medscheme.co.za
Bonitas Medical Fund:
hospital@bonitas.co.za
Hospital Pre-Authorisation All hospital pre-authorisations for non-emergency events 0861 100 220
BonCap Option Only:
boncapauthorisations@bonitas.co.za
Submission of Claims To submit a claim for a Bonitas patient claims@bonitas.co.za
0861 112 666
Queries of Claims Queries relating to a Bonitas claim queryclaims@bonitas.co.za
Oncology Services Any oncology related queries oncology@bonitas.co.za
0861 100 220
Ambulatory PMB Any Ambulatory PMB queries pmb@bonitas.co.za
Aid for AIDS (Excluding BonCap) Aid for AIDS Management afa@afadm.co.za
0800 227 700
BonCap HIV Management of HIV for BonCap patients afa@afadm.co.za
Motivation for non-formulary drugs diabetesmeds@bonitas.co.za
Motivate for additional benefits above the care template diabetespmb@bonitas.co.za
Chronic Medicine applications diabetesmeds@bonitas.co.za
Diabetes Management Programme 0861 100 220
Bonitas Diabetes queries or requests diabeticcare@bonitas.co.za
www.medscheme.com > login as a provider
To View Diabetic Educators
> click on network > diabetes educators.
Page 11 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.BONCAP FAMILY
PRACTITIONER
NETWORK GUIDE
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. Page 12DEAR DOCTOR
The Bonitas BonCap option is a low contribution option that provides services to industries such as Alternatively, the following numbers can be contacted:
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.
Service Telephone Email address for queries
Bonitas recognises the Family Practitioner’s role as the coordinator of care and would like to thank Family Practitioner, pharmacy,
you for providing excellent healthcare services to our valued BonCap members and their families. 0861 239 333 www.medscheme.com
oncology and hospital networks
BONITAS FP GUIDE 2019
We remain committed to ensuring that BonCap members receive high quality care that is accessible
and cost effective. Dental network 0861 033 647 www.denis.co.za
Optometry network 086 110 3529 www.ppn.co.za
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 • Hospitalisation is subject to a network of hospitals and obtaining pre-authorisation from BonCap
protocols as contained in this guide. Beneficiary Management on 0861 239 333.
• Oncology is subject to the oncology network and obtaining pre-authorisation from BonCap
The following changes have been implemented in 2019: Beneficiary Management on 0861 239 333.
A limit for acute medicines, pathology and radiology as follows: • Specialist visits are limited to three consultations or R3 110 per beneficiary and five consultations
• Main member only: R1 840 or R4 620 per family per annum.
• Main member + 1 dependant: R3 060 • Member access to Specialist visits is subject to the network Family Practitioner obtaining a
• Main member + 2 dependants: R3 660 referral authorisation by contacting BonCap Beneficiary Management on 0861 239 333.
• Main member + 3 dependants: R4 000 • Chronic medication is subject to pre-authorisation on the Chronic Medicine Management
• Main member + 4+ dependants: R4 440 programme managed by Bonitas Chronic Medicine Management (CMM) and is limited to PMBs
and the Designated Service Provider, Pharmacy Direct.
Please note that a list of specified procedures has been excluded (see surgical benefit section). • Preventative care benefit including an annual HIV test and one flu vaccine; one pneumococcal
• A change to the hospital network list for 2019. vaccine for beneficiaries 65 years and older every five years, one faecal occult blood test per
• Beneficiaries have unlimited FP visits, subject to seeing up to two FPs, subject to the BonCap FP beneficiary (ages 50-75) and 1 pap smear every 3 years, for women between ages 21 and 65 ,
Network. From the 8th visit, consultations are subject to pre-authorisation and Managed Care one mammogram for females aged over 40 years every 2 years and 1 PSA test for men between
Protocols. BonCap members need to obtain this pre-authorisation up front by calling BonCap the ages 45 -69 per annum.
Beneficiary Management on 0861 239 333. • Pathology and radiology are subject to a list of investigations - please refer to Annexures A and
C in this guide.
The BonCap model for 2019 continues to use the following principles: • BonCap benefits and limits can be verified via the BonCap IVR functionality or by speaking to an
• Working with Family Practitioners to manage quality and downstream costs. agent on 0861 239 333.
• Finding ways to reduce the administrative burden on Family Practitioners.
• Exploring the potentials of entering into a risk-sharing arrangements with Family Practitioners BonCap Beneficiary Management can be contacted via:
going forward. Tel: 0861 239 333
Fax: 0860 222 210
Summarised benefits offered on BonCap: Email: boncap@bonitas.co.za
• 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.
Page 13 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.1. Summary of primary care benefits for BonCap
Benefit BonCap Benefit BonCap
• Subject to the BonCap Family Practitioner (FP) network • Subject to registration on the Chronic Medicine
and reimbursed at the BonCap network rate. Management Programme and the BonCap chronic
• Beneficiaries have unlimited FP visits, subject to formulary managed by Bonitas Chronic Medicine
seeing up to two FP’s. From the 8th visit, consultations Management (CMM).
are subject to pre-authorisation and Managed Care • Contact the Bonitas CMM Call Centre on 0861 239 333
Protocols. Chronic medication or email at boncapchronic@bonitas.co.za.
• Procedures in the FP’s room are subject to a specified list. • Only on prescription by a network FP or a Specialist
BonCap members need to obtain this pre-authorisation where the Specialist visit has been authorised as per the
up front by calling BonCap Beneficiary Management on referral management process.
0861 239 333. • All chronic medication must be dispensed by Pharmacy
• Pre-authorisation is required for some of these Direct.
BONITAS FP GUIDE 2019
procedures and utilisation of these procedures will be
• Limited to three (3) consultations or R3 110 per
Family Practitioner monitored.
beneficiary and/or five (5) consultations or R4 620 per
consultations • For more information on in-room procedures, please refer
family per annum. Limit includes all acute medication,
to Section 2: Family Practitioner tariffs and fees.
out-of-hospital specialised radiology, radiology and
• Only listed tariff codes will be reimbursed. There will be
Specialist consultations pathology.
no additional benefits for tariff codes not listed in this
• Only on referral from a network FP and subject to
guide.
authorisation.
• BonCap members get a monetary limit per family for FP
• Please refer to the Specialist Referral form included in
referred pathology, radiology and acute medicines as
this guide.
follows:
- Main member only: R1 840 • Antenatal consultations are included in the FP and
- Main member + 1 dependant: R3 060 Specialist consultation benefit.
- Main member + 2 dependants: R3 660 • Related tests are subject to the radiology/pathology
- Main member + 3 dependants: R4 000 formulary.
- Main member + 4+ dependants: R4 440 • BonCap members get a monetary limit per family for FP
referred pathology, radiology and acute medicines as
• One (1) visit per beneficiary and two (2) visits per
follows:
family per annum.
Out-of-network Family - Main member only: R1 840
• Reimbursed at standard Bonitas Rates, limited to
Practitioner consultations - Main member + 1 dependant: R3 060
R1 050 per family and 20% co-payment by the
- Main member + 2 dependants: R3 660
member.
- Main member + 3 dependants: R4 000
• Subject to the BonCap acute medicine formulary. - Main member + 4+ dependants: R4 440
• The cost of acute medication is included in the • All Specialist referrals require the network FP to obtain
consultation fee for FP’s who are contracted as Maternity benefit authorisation.
dispensing doctors. • Please refer to the Specialist Referral form included in
• For FP’s who are contracted as non-dispensing doctors, this guide.
acute medication is to be dispensed by network • Includes four (4) postnatal consultations per pregnancy
pharmacies only. by midwife.
Acute medication • BonCap members get a monetary limit per family for FP • Includes 2 x 2D scans per pregnancy, subject to the
referred pathology, radiology and acute medicines as BonCap radiology formulary and the monetary limit per
follows: family for FP referred pathology, radiology and acute
- Main member only: R1 840 medicines as follows:
- Main member + 1 dependant: R3 060 - Main member only: R1 840
- Main member + 2 dependants: R3 660 - Main member + 1 dependant: R3 060
- Main member + 3 dependants: R4 000 - Main member + 2 dependants: R3 660
- Main member + 4+ dependants: R4 440 - Main member + 3 dependants: R4 000
- Main member + 4+ dependants: R4 440
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. Page 14Benefit BonCap Benefit BonCap
• Subject to the BonCap pathology formulary and the • R1 050 per family when prescribed by a BonCap
Pathology Management Programme. Dispensing or Non-Dispensing Network FP
Contraceptives
• To access the latest, full version of these protocols, go to • 40% co-payment to apply when using a non DSP
www.medscheme.com, register or log in as a Provider pharmacy
and click Clinical Information > Pathology Formulary.
• Only on referral from a network FP or Specialist. The complete 2019 benefit schedule for BonCap can be viewed on the Medscheme website at
• For tests not included in the formulary, please obtain www.medscheme.com.
authorisation. Please note that authorisation is subject
to Managed Care Protocols. 2. Family Practitioner tariffs and fees
Pathology • BonCap members get a monetary limit per family for FP The reimbursement model for BonCap network FPs is encouraged to manage downstream costs
referred pathology, radiology and acute medicines as while still ensuring good quality care. FPs are also reimbursed for doing certain procedures
follows:
BONITAS FP GUIDE 2019
in their rooms where indicated, e.g. intravenous rehydration or circumcision, as opposed to
- Main member only: R1 840 referring patients to hospital for these interventions.
- Main member + 1 dependant: R3 060
- Main member + 2 dependants: R3 660 To ensure the sustainability of the BonCap option, it is imperative that participating FPs adhere
- Main member + 3 dependants: R4 000 to formularies and protocols. Adherence will be monitored and where necessary, Bonitas will
- Main member + 4+ dependants: R4 440 engage with and assist FPs in their understanding of the network requirements on BonCap.
• Please refer to the Pathology Request Form included in
this guide. The FP Network is crucial to driving the sustainability of the BonCap option. Going forward,
• Subject to the BonCap radiology formulary. Bonitas would like BonCap network FPs to do more interventions in their rooms. To this end,
• Only on referral from a network FP or Specialist. Bonitas will be working through the FP leadership initiative to upskill FPs where necessary.
• For tests not included in the formulary, please obtain
authorisation. Please note that authorisation is subject Consultation tariff codes
to Managed Care Protocols. Dispensing
• Please refer to the Radiology Request Form included in Consultation doctor tariff Non-dispensing
this guide. Authorisation mandatory
tariff codes (inclusive of doctor tariff
Radiology • BonCap members get a monetary limit per family for FP medication)
referred pathology, radiology and acute medicines as
Beneficiaries have unlimited FP
follows:
visits, subject to seeing up to two
- Main member only: R1 840
FPs. From the 8th visit, consultations
- Main member + 1 dependant: R3 060
are subject to pre-authorisation and
- Main member + 2 dependants: R3 660
Managed Care Protocols.
- Main member + 3 dependants: R4 000 0190 to 0192 R428.30 R361.20
- Main member + 4+ dependants: R4 440
BonCap members need to obtain this
• Subject to PMBs. pre-authorisation up front by calling
Physiotherapy and
• Only on referral from a network FP and subject to BonCap Beneficiary Management on
occupational therapy
authorisation. 0861 239 333.
• 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
Preventative care
(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
Page 15 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.Procedure codes that can be charged in addition to a consultation tariff code: 3. Medication
Tariff code Tariff code description (including cost of materials) Rate All 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.
Intravenous rehydration therapy with or without
0206 1 R 306.60
administration of intravenous antibiotics 3.1 CHRONIC MEDICINE
0241 Cauterisation of warts/chemocryotherapy of lesions R 119.50 Prescriber Benefit rules
0255 Drainage of abscess and/or avulsion of nail R 363.80
• Subject to authorisation and registration on the BonCap Chronic
0259 Removal of foreign body superficial to deep fascia R 339.90 Dispensing and Medicine Management Programme and the BonCap chronic
0300 Stitching of a wound R 495.90 non-dispensing formulary.
BonCap • Only on prescription by a network FP or Specialist, provided that the
0301 Stitching of an additional wound R 93.00 network Family Specialist, visit has been authorised as per the referral management
0887 Limb cast (including cost of pop and material) R 510.60 Practitioners process.
BONITAS FP GUIDE 2019
• All chronic medicine must be dispensed by Pharmacy Direct.
17 25 Drainage of external thrombosed pile R 226.00
• Contact the Bonitas Chronic Medicine Management (CMM) Call
0307 Excision and repair R 673.70 How to apply for
Centre on 0861 239 333 to obtain telephonic authorisation or email
chronic medicine
0310 Radical excision of nail bed in rooms R 819.90 boncapchronic@bonitas.co.za.
1186 Flow volume test: inspiration/expiration R 225.00 • Following registration in the BonCap Chronic Medicine Management
Changes or
Flow volume test: inspiration / expiration / pre and Programme, all changes or updates are done telephonically by
1188 R 225.00 updates
post-bronchodilator contacting the Bonitas CMM Call Centre on 0861 239 333.
1232 Resting ECG (including electrodes) R 119.50 General
2137 2 Circumcision in rooms (authorisation required) R 1,112.60 Please ensure that all test results and motivations (where applicable) are submitted
electronically to boncapchronic@bonitas.co.za or via fax 0800 223 670 / 80 upon request.
4614 HIV rapid test R 128.80
3.2 ACUTE MEDICINE
1
A maximum of five (5) treatments will be allowed. A consultation must not be billed together
with 0206 from the second day onwards. Prescriber Benefit rules
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. • Acute medication is included in the consultation fee.
The BonCap tariff code 2133 or 2137 or 2139 must be used for the procedure. Please include • Doctors are requested to display the NAPPI codes for medication
the correct ICD-10 code. dispensed. This will be used for analysis purposes. The consultation
Dispensing
fee will be paid irrespective of medication dispensed or not.
network Family
Please note the following: • Acute pharmacy claims will not be covered where the scripting FP is
Practitioners
• Tariff codes not listed above will not be reimbursed, as the fees for these services are contracted as a dispensing FP.
included in the consultation fee. • FPs contracted as dispensing FPs can; however, script chronic
• After-hour and emergency consultations are included in the 0190 to 0192 codes. medication as this is not included in the fee structure.
• Authorisation of additional consultations will be subject to medical necessity and • Subject to the BonCap acute medicine formulary.
Managed Care Protocols. Non-dispensing • Prescribed acute medication must be obtained from the BonCap
• Surgical procedures performed in hospital or in unattached operating theatres are subject network Family pharmacy network.
to pre-authorisation and there is a specific list of surgical procedures that are excluded for Practitioners • The network can be accessed on the Medscheme online secure
BonCap members (please see relevant section below). services website at www.medscheme.com.
3.3 OVER-THE-COUNTER (OTC) MEDICATION
Benefit for BonCap
OTC 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.
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. Page 164. The referral management process for BonCap 6. Maternity benefit and antenatal visits
Network FPs need to obtain authorisation before the event for the following benefit categories:
Maternity Benefit rules
• All Specialist consultations, including antenatal consultations at a gynaecologist.
• Allied health consultations for physiotherapy and occupational therapy. • The antenatal benefit is subject to the FP and Specialist benefit as
• All additional FP consultations above the limit of seven (7) per beneficiary. set out in this guide.
• Radiology and pathology investigations not indicated on the BonCap pathology and • Related tests are subject to the radiology/pathology formulary.
radiology formularies in this guide. • BonCap members get a monetary limit per family for FP referred
pathology, radiology and acute medicines as follows:
5. Specialist benefit - Main member only: R1 840
- Main member + 1 dependant: R3 060
Specialist visits Benefit rules
- Main member + 2 dependants: R3 660
• Reimbursed at the Bonitas Rate. - Main member + 3 dependants: R4 000
• Limited to three (3) consultations and R3 110 per beneficiary and/ Antenatal - Main member + 4+ dependants: R4 440
BONITAS FP GUIDE 2019
or five (5) consultations and R4 620 per family per annum. consultations, • The ultrasound scans must either be done by the doctor who will be
• Limit includes all acute medication, out-of-hospital specialised scans and blood responsible for the confinement or a radiologist or gynaecologist.
Out-of-hospital tests • All Specialist referred radiology and pathology requests limited to
radiology, radiology and pathology.
consultations Specialist benefit limit.
• Only on referral from the network FP and subject to authorisation.
• FPs can obtain authorisation for Specialist consultations by • Includes 2 x 2D scans per pregnancy, subject to the BonCap
contacting BonCap Beneficiary Management on 0861 239 333. radiology formulary and the monetary limit per family for FP
• Please refer to the Specialist Referral form included in this guide. referred pathology, radiology and acute medicines as follows:
- Main member only: R1 840
Unlimited (subject to pre-authorisation and Managed Care Protocols) - Main member + 1 dependant: R3 060
except for the following exclusions: - Main member + 2 dependants: R3 660
• In-hospital dental benefits - Main member + 3 dependants: R4 000
• Back and neck surgery - Main member + 4+ dependants: R4 440
• Joint replacement surgery (including but not limited to hips, knees,
Surgical • All out-of-hospital Specialist consultations must be referred
shoulders and elbows)
procedures In by a BonCap network FP and require the network FP to obtain
• Caesarean sections done for non-medical reasons
hospital and authorisation by contacting BonCap Beneficiary Management on
• Functional nasal and sinus surgery
unattached 0861 239 333.
• Varicose vein surgery Specialist
operating • Reimbursed at the Bonitas Rate.
• Hernia repair consultations
theatres • Limited to three (3) consultations and R3 110 per beneficiary and/
• Endoscopic surgery (including but not limited to arthroscopies,
colonoscopies, sigmoidoscopies and gastroscopies) or five (5) consultations and R4 620 per family per annum.
• Laparoscopic surgery (except for laparoscopic sterilisation) • Limit includes all acute medication, out-of-hospital specialised
• Correction of hallux valgus/bunions radiology, radiology and pathology.
• Refractive surgery • 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
Hospital
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 a midwife in a registered and accredited birthing unit is
Delivery by
included and subject to prior authorisation.
midwife
• Includes four (4) postnatal consultations per pregnancy.
Page 17 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.You can also read
