DENTAL PRACTITIONERS PROVIDER MANUAL 2020...Interim dentures Also known as provisional, temporary or...

DENTAL PRACTITIONERSPROVIDER MANUAL2020

Dental Provider Manual - Prime Cure Health 2020

Contents

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1. GeneralAdministrationandProcedures1.1 Benefits................................................................................................................... p1-51.2 Medication.............................................................................................................. p51.3 Pre-Authorisation.................................................................................................... p61.4 ClaimProcedures..................................................................................................... p6-71.5 MemberVerification............................................................................................... p7

SECTION 1

SECTION 2

SECTION 3

SECTION 4

2. CodesCoveredbyPrimeCure2.1 DentalCodes........................................................................................................... p8-p92.2 ExcludedX-Ray........................................................................................................ p92.3 Exclusions................................................................................................................ p9

PrimeCureExampleofForms

PrimeCureDentalFormulary2020................................................................................. p10-14

of16Dental Provider Manual - Prime Cure Health 2020

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Note: Benefits may differ from one scheme/option to another - please refer to the Medical Scheme Benefit Matrix for more information regarding the benefits applicable per scheme. Please contact our call centre without fail to query/verify if in any doubt to prevent claim rejections.

1.1 Benefits

1.1.1 The following benefits are allowed WITHOUT authorisation (unless otherwise indicated)

Code Description Frequency8101 Consultationoralexamination Onceperyear

8104 Examinationforaspecificproblemnotrequiringfullmouthexamination

8109 Infectioncontrol Twopervisit

8110 Sterilisedinstrumentation Onepervisit

8145 Localanaesthetic Onepervisit

8107,8112 Intraoralradiographs/BiteWingX-rays,perfilm(maximumof4xX-raysperbeneficiaryperyear)authorisationrequiredafterthe4th.

8155 Polishingonly Onceayearforages3-12yrs

8159 Scalingandpolishing Onceayearovertheage12yrs

8161 Topicalapplicationoffluoride Onceayearforages3to12yrs

8935 Treatmentofsepticsocket Firsttreatmentnoauthorisationisrequired.Forsecondtreatmentandonwardauthorisationisnecessary(historictreatmentof8201/8202).

Non-surgicalextractionsperbeneficiaryperyear-onlyifclinicallyindicated(maximumof4for8201,8202

allowedthereafterX-raysandmotivationrequired-pre-authoriseadditional)

Code Description8201 Singleextraction-forfirstextractioninquadrant

8202 Extractionofeachadditionaltoothinthesamequadrant

SurgicalextractionsonlyforcertainSchemes(pleasecallServiceCentrefordetails).

SECTION 1


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Code Description8937 One(1)surgicalextractionperbeneficiaryperyear.Mustbeauthorisedandrequiresaletterofmotivation

accompaniedbythex-raystakenwiththeauthorisationrequest.Appliestosuturesaswell.

General Pain and Sepsis Covered under certain Codes*

8131* Palliative(emergency)dentalpaintreatment

8132 Grosspulpaldebridement,primary&permanentteeth(emergencyrootcanal)

8307 Pulpamputation(pulpotomy)-Onlyonprimaryteeth-maximumtwoperyearperbeneficiary

Amalgam restorations (fillings) per beneficiary per year * Resin restorations (fillings) per beneficiary per year *

Code Description Code Description8341 Onesurfaceamalgamrestoration(posterior) 8351 Resinrestoration-onesurface(anterior)

8342 Twosurfaceamalgamrestoration(posterior) 8352 Resinrestoration-twosurface(anterior)

8343 Threesurfaceamalgamrestoration(posterior) 8353 Resinrestoration-threesurface(anterior)

8344 Foursurfaceamalgamrestoration(posterior) 8354 Resinrestoration-foursurface(anterior)

* Please note a maximum of 4 amalgam/resin restorations. Additional need to be pre-authorised

Note:Ifpatientrequests/agreestotreatmentnotontheapprovedlistofcodescoveredbybenefitrules,thepatientmustpleasesignthepatientconsentformattachedinthismanual.NOTE 8367, 8368, 8369, 8370 TO BE PAID AT AMALGAM FEES.

1.1.2 General

• Pre-authorisationneededforcertainproceduresandsubjecttoManagedCareProtocolsandProcesses

• PrimeCureapprovedcodesarecoveredat100%ofagreedtariff• One(1)consultation/examinationcode8101peryearperbeneficiary• Treatment–followupconsultations(ifclinicallyindicatedunlimitedbutmanaged)• Preventativetreatments–onetreatmentperbeneficiaryperyear(Includesfluoridetreatment,

cleaning,scaling,polishing)• 8162needstobeauthorised• Fillings-White/Resin(anterioronly)orAmalgamposterior-Note:PosteriorResinfillingswillbe

paidforatAmalgamrates• Painandsepsistreatment• Infectioncontrol• Extractions(Onlyifclinicallyindicated)• Localanaesthetic• IntraOralRadiograph(X-Raysaspertheapproveddentallistofcodesandprotocols)• EmergencyRootCanal–Authorisationnotrequired(8132)• The Dental benefits are limited and managed according to Managed Care Protocols and

processes• Any claims for work performed without pre-authorisation where indicated will be rejected.

SECTION 1 (continued)


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1.1.3 Emergency Dentistry according to protocols entails

• Emergencypainandsepsistreatmentonly• Pulpotomyonprimaryteethonly• AtapprovedPrimeCuredentalserviceprovideronly• Anyadditionaltreatmentrequiresself-fundingbypatient

Tariff codes that will be funded for under Emergency Dentistry

Code Description Code Description8104 Examinationforspecificproblemnot

requiringfullmouthexamination8145 Localanaesthetic

8109 Infectioncontrol 8110 Sterilisedinstrumentation

8107 Intraoralradiographs/bitewingX-rays,perfilm(maximumof1)

8132 Gross pulpal debridement, primary &permanentteeth(Emergencyrootcanal)

8131 Palliative(emergency)dentalpaintreatment

8202 Extractionofeachadditionaltoothinthesamequadrant

8307 Pulp amputation (pulpotomy - only onprimaryteeth)

8201 Singleextraction-forfirstextractioninquadrant(limitedto1)

1.1.4 Dentures (Please refer to Medical Scheme Benefit Matrix for details) • Authorisationrequired

• Aco-paymentispayableonsomeschemes.PleaserefertotheMedicalSchemeBenefitMatrixfordetails

• Theco-paymentequatesto20%oftheLaboratoryFee• Allco-paymentsmustbecollectedbytheapprovedNetworkDentistpriortoplacingtheorder,

directlyfromthemember• Areceiptmustbeissuedtothememberwhenpayingtheco-payment.Balancebillingmustbe

indicatedonaccount• PrimeCurewillreimbursethedentistanamountequaltothetotallesstheco-payment• 1Setofdenturesallowedperfamilyper24-monthcycle• Onlymembersovertheageof21yearsqualifyforthedenturebenefitEXCLUDINGmetalframe

denturesandclasps• Benefitsexcludemetalframedenturesandclasps.

The following codes will not be funded:

Interimdentures

Alsoknownasprovisional, temporaryortransitionaldentures.Provisionaldenturesareusedfora limitedperiodoftime for reasonsofaesthetics, functionorocclusal support,afterwhich it isreplacedbyamoredefinitiveprosthesis.

Code Description8658 Interimcompletedenture

8659 Interimpartialdenture

8661 Diagnosticdentures(includingtissueconditioning)



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The following Denture Codes are limited to pre-authorisation and available funds: Dentures (A 20% co-payment on laboratory fees)

Code Description Code Description8099 Labcodes 8240 PartialDenture-Eightteeth8233 PartialDenture-Onetooth 8241 PartialDenture-Nineteethandmore8234 PartialDenture-Twoteeth 8232 Fullupperorlowerdenture8235 PartialDenture-Threeteeth 8231 Fullupperorlowerdenture8236 PartialDenture-Fourteeth 8255 ClasporRest-stainlesssteel8237 PartialDenture-Fiveteeth 8269 Repairdenture8238 PartialDenture-Sixteeth 8271 Addtoothtopartialdenture8239 PartialDenture-Seventeeth

Approved Denture Codes (Dental Technician)

8233 8234T007 ONE TOOTH T008 TWO TEETH9301 2 Plastermodel 9301 2 Plastermodel9327 2 Infectioncontrol 9327 2 Infectioncontrol9330 1 Delivery 9330 1 Delivery9351 1 Onetooth 9352 1 Twoteeth9700 1 Dentureteeth1X6/8 9700 1 Dentureteeth1X6/89722 1 Acrylic 9722 1 Acrylic

8235 8236T009 THREE TEETH T010 FOUR TEETH9301 2 Plastermodel 9301 2 Plastermodel9327 2 Infectioncontrol 9327 2 Infectioncontrol9330 1 Delivery 9330 1 Delivery9353 1 Threeteeth 9354 1 Fourteeth9700 1 Dentureteeth1X6/8 9700 1 Dentureteeth1X6/89722 1 Acrylic 9722 1 Acrylic

8237 8238T011 FIVE TEETH T012 SIX TEETH9301 3 Plastermodel 9301 3 Plastermodel9321 1 Occlusionblock 9321 1 Occlusionblock9327 4 Infectioncontrol 9327 4 Infectioncontrol9330 1 Delivery 9330 1 Delivery9355 1 Fiveteeth 9356 1 Sixteeth9431 1 Specialtray 9431 1 Specialtray9700 1 Dentureteeth1X6/8 9700 1 Dentureteeth1X6/89702 1 Tooth-odd 9702 1 Tooth-odd9722 1 Acrylic 9722 1 Acrylic



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8239 8240T013 SEVEN TEETH T014 EIGHT TEETH9301 3 Plastermodel 9301 3 Plastermodel9321 1 Occlusionblock 9321 1 Occlusionblock9327 4 Infectioncontrol 9327 4 Infectioncontrol9330 1 Delivery 9330 1 Delivery9357 1 Seventeeth 9358 1 Eightteeth9431 1 Specialtray 9431 1 Specialtray9700 1 Dentureteeth1X6/8 9700 2 Dentureteeth1X6/89702 1 Tooth-odd 9722 1 Acrylic9722 1 Acrylic

8241 8231T015 NINE OR MORE TEETH T003 FULLUPPER&LOWER9301 3 Plastermodel 9301 4 Plastermodel9321 1 Occlusionblock 9321 2 Occlusionblock9327 4 Infectioncontrol 9327 6 Infectioncontrol9330 1 Delivery 9330 2 Delivery9359 1 Nineormoreteeth 9331 1 Fullupper&lower9431 1 Specialtray 9431 2 Specialtray9700 2 Dentureteeth1X6/8 9700 4 Dentureteeth1X6/89722 1 Acrylic 9722 2 Acrylic

8232 8269T004 FULLUPPERORLOWER T028 REPAIR9301 3 Plastermodel 9301 1 Plastermodel9321 1 Occlusionblock 9327 1 Infectioncontrol9327 4 Infectioncontrol 9330 2 Delivery9330 1 Delivery 9391 1 Repairfirst9333 1 Fullupperorlower

9431 1 Specialtray9700 2 Dentureteeth1X6/89722 1 Acrylic

8271 8263T030 ADD TOOTH T025 ACRYLIC RELINE

9301 2 Plastermodel 9301 1 Plastermodel9327 2 Infectioncontrol 9327 1 Infectioncontrol9330 2 Delivery 9330 1 Delivery9391 1 Repairfirst 9413 1 Acrylicreline9702 1 Tooth-odd

1.2 Medication • MedicationmaybeprescribedaccordingtotheDentalMedicineFormulary • PrescribedbyanapprovedDentist • MedicationwillbedispensedbyapprovedNetworkPharmacies • Benefitisunlimitedandmanaged


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1.3 Pre-Authorisation

ForPre-authorisation,pleasecontacttheCallCentreat0861665665.Pre-authorisationisrequiredfor: • 5th(fifth)ormoreamalgamrestorations(fillings)perbeneficiaryperyear• 5th(fifth)ormoreanteriorresinrestorationperbeneficiaryperyear• 5th(fifth)ormorenon-surgicalextractions(8201,8202)perbeneficiaryperyear• Dentures,reline,rebaseandallspecialiseddentistry-Partialdentures-Toothnumbersrequired• Sutures• Code8144(Intravenous/conscioussedation):refertoPrimeCurecasemanagerforpre-authorisation

(Fullriskschemesonly-pre-authorisationrequired)• Surgicalextractionswhereapplicableschemerulesallowforsurgicalextractions• Topicalapplicationoffluorideforpatientsolderthan12years(code8162)• Morethanfourextractionsperannum.

1.3.1 Pre-authorisation procedure verification of membership and benefits is essential prior to treatment

• TheDentalAuthorisationFormmustbecompletedinfull• Faxtheauthorisationformto0866738106oremailto [email protected]• Pleaseensurethattheformcontainsalltherequiredinformation• All requests will be processed and an authorisation number issued for approved dental

procedures• Theauthorisationletter/numberwillbeforwardedbyfax• Incompleteapplicationformswillberejected.

1.4 Claim procedures

• EDI -WhenclaimingEDI,useclaimcode8099forDentalLaboratories,submitthelaboratoryinvoicetoPrimeCureusingcode8099

• Paper-Whensubmittingpaperclaimsuseclaimcode8099fortheDentalLaboratoriesandsubmittheDentalLaboratoryinvoicetogetherwithyourpaperclaim.Code8099willbepaid.

No claim/authorisation will be accepted without the Professional Fee and the Laboratory code (8099) submitted together

• Codesthatrequireauthorisationwillnotbeconsideredforpaymentiftherelevantauthorisationnumberisnotquotedontheclaim.

1.4.1 Claims submission

SubmissionofclaimsviaEDI

System Destinationcode System DestinationcodeQEDI 642P *LenasiaComputers 642PMediswitch 642P *Medilink PCUR0001HealthBridge 642P EMD 642P


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1.4.2 Required information on claims

• Nameandsurnameofpatient/dependantcodeandgender(male/female)• Mainmembersurname,initials,addressandtelephonenumber• IDnumberordateofbirthofthepatient• MedicalSchemename,optionnameandmembershipnumber• Exactdateoftreatment&practicenumber• Specifictariffcodes(statewhatservicewasgiventothepatient)• Toothnumbersormouthpartsthatreceivedtreatment(includingdentures)• Authorisationnumberforoutofscopebenefits• Medicationdispensed:detailtheNappicodes• Pleasenotethatthepaymentoflaboratoryfeesclaimedbyanypracticeonbehalfofadental

laboratorywillonlybeprocessedforpaymentintheeventthatalllaboratoryprocedurecodesandfeesfeatureontheelectronicallysubmittedinvoicebythedentistinaccordancewiththeSADABillingGuideline(andnotonlycode8099),excerptasfollows:- Electronicsubmissionofinvoicesdirectlytoapatientormedicalaidfund- Thetotal feechargedbyadental technician for laboratoryservicesshallbe indicated

on thedentist’s invoiceby submittingcode8099 -Dental laboratory servicewith theappropriatelaboratoryfeeonthelinefollowingtherelevantdentalprocedurecodeonthedateonwhichthedentalprocedurewasrendered.

- Thetechnician’sinvoiceshallbecertifiedbythedentist(orapersonappointedbythedentist) for correctness by means of a signature. The original invoice of the dentaltechnicianshallbefiledbythedentistforrecordpurposes.

- Thelaboratoryfeeshallbesubmittedelectronicallyforpaymentonthedateonwhichtheprocedurecode issubmittedforpayment,andtheappropriatedental laboratoryservicecodesandfeesshallbereportedonthelinesfollowingcode8099.

1.4.3 Rejection of claims

• Ifthedetailsareincompletetheclaimwillberejected• Anyotherproceduresdoneoutsidethescopeofbenefitwithoutpre-authorisationwillnotbe

paid.

1.5 Member verification

• OnlyvalidmemberswithavalidSouthAfricanIDdocumentandmembershipcardmaybeconsulted• Please authorise/verify by calling the PrimeCure Customer Service Centre formember verification/

benefits.

1.5.1 Authorisation or verification of benefits

• OnlyoneconsultationcoveredbyPrimeCurepermemberperday• PrimeCurewillnotberesponsibleforanypaymentofconsultationsoutsidetheservicetimes,

exceptinthecaseofanemergency.


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SECTION 2 - DENTAL CODES

CODES PROCEDURE AUTH REQUIRED8101 Consultation(Onceperyear) No

8104 Examinationforaspecificproblemnotrequiringfullmouthexamination No

8107,8112 Intraoralradiographs,perfilm.(Maximumof4withoutauthorisationperbeneficiaryperyear)

No

8109 Infectioncontrol/barriertechniques.Code8109includestheprovisionbythedentistofnewrubbergloves,masks,etc.foreachpatientoncepervisit

No

8145 Localanaesthetic(1xpervisit)woulditbeasperthetreatment No

8155 Polishingonceperyearovertheage3years No

8159 Scalingandpolishing(Onceayearovertheageof12years) No

8161 Topicalapplicationoffluoride(onceayearbetweentheagesof3-12years) No

8162 Topicalapplicationoffluoride(onceayearovertheageof12years) Yes

8937 Surgicalextraction Yes

8341 Amalgam–onesurface(5THORMORE) Yes

8342 Amalgam–twosurfaces(5THORMORE) Yes

8343 Amalgam–threesurfaces(5THORMORE) Yes

8344 Amalgam–fourandmoresurfaces(5THORMORE) Yes

8351 Resinrestoration–onesurface,anterior(5THORMORE) Yes

8352 Resinrestoration–twosurfaces,anterior(5THORMORE) Yes

8353 Resinrestoration–threesurfaces,anterior(5THORMORE) Yes

8354 Resinrestoration–fourandmoresurfaces(5THORMORE) Yes

8132 Rootcanaltherapy–grosspulpaldebridement No

8307 Pulpamputation(Pulpotomy)onprimaryteethonly No

8220 Sutures Yes

8231 Completedenture–maxilliaryandmandibular Yes

8232 Completedenture–maxilliaryormandibular Yes

8233 Partialdenture(resinbase)–onetooth Yes

8234 Partialdenture(resinbase)–twoteeth Yes

8235 Partialdenture(resinbase)–threeteeth Yes

8236 Partialdenture(resinbase)–fourteeth Yes

8237 Partialdenture(resinbase)–fiveteeth Yes

8238 Partialdenture(resinbase)–sixteeth Yes

8239 Partialdenture(resinbase)–seventeeth Yes

8240 Partialdenture(resinbase)–eightteeth Yes

8241 Partialdenture(resinbase)–nineormoreteeth Yes

8269 Repairof/addtodentureorotherintra-oralappliances Yes


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SECTION 2 - DENTAL CODES (continued)

CODES PROCEDURE AUTH REQUIRED8271 Addtoothtoexistingpartialdenture.Adentistmaynotchargeprofessionalfeesfor

therepairofdenturesifthepatientwasnotpersonallyexamined;laboratoryfees,however,mayberecovered.

Yes

8144 Conscioussedation Yes

8259 Rebasecompleteorpartialdentures(laboratory) Yes

8267 Relinecompleteorpartialdentures(laboratory) Yes

8201,8202 Extraction,singletooth.Code8201ischargedforthefirstextractioninaquadrant.Maximumfor8201&8202isfour(4),thereafterpre-authorisationrequiredforthefirstextractioninaquad-rant.Maximumfor8201&8202isfour(4),thereafterpre-authorisationrequired

No

8110 Sterilisationinstrumentationtray(1pervisit) No

8935 Treatmentofsepticsocket Notforfirstone-butrequiredthereafter

8141 Inhalationsedation:under7yearsofage–first15minutes Yes

8143 Inhalationsedation–afterthe15thminute(refertocode8141) Yes

8131 Palliative(emergency)dentalpaintreatment No

NOTE 8335, 8336, 8338, 8339, 8340 WILL NOT BE FUNDED NOTE 8367, 8368, 8369, 8370 TO BE PAID AT AMALGAM RATE

2.2 Excluded: X-Rays

Panoramicandotherextraoralx-rays(e.g.8115)doesnotformpartofthebenefitschedule

2.3 Exclusions

• DentalextractionsforNon-Medicalpurposes• Theprovisionofgoldinlaysindentures• ThetreatmentofanycomplicationsrelatedtotreatmentnotfundedbyPrimeCure.• PrimeCuredoesnotfunddenturesanddentaltreatmentthatisrelatedtotraumaticinjuryasaresultof

thefollowing: - MVA:thisshouldbereferredtoschemeexceptinthecaseoffullriskclients(referbenefits

matrix) - TreatmentrelatedtoaworkrelatedinjurywillberequiredtobereferredtoCOID


PLEASE NOTE: Provider Trade Names are not listed on formulary, allowing for generic substitution, but applying Reference Pricing

Key to quantities and limitations:

1. “Consumables-Clinicuseonly”meansthemedicationmayonlybeadministratedbyaDSPattherooms.Allinjectablesareconsumables.PatientswillnotbeabletocollectfromDSPpharmacies.

2. “MaxRx/7days &3Rx/annum”meansascriptfilled toamaximumof7days medicationsupplyand3prescriptionsperyearcanbeclaimed.

3. AllitemsaretobedispensedbyacontractedDSPpharmacy.

4. BenefitsformedicinearesubjecttoMediscorReferencePrice(MRP).ShouldthecostoftheitemexceedtheMRP,thepatientwillbeliableforpaymentofthedifferenceincost.Ifthisisthecase,pleaseinformthepatientthatitwillbeforhis/herownpersonalaccount.

SECTION 3 - Prime Cure Dental Formulary 2020 1

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anua

l - P

rime

Cure

Hea

lth 2

020

Prim

e Cu

re D

enta

l For

mul

ator

y - 2

019

MIM

SMim

sDescriptio

nAc

tiveIngred

ient

Routeof

adm

inDo

sage

Fo

rmAc

ute

Qua

ntitie

sand

Lim

itatio

ns

18.A

NTI-M

ICRO

BIAL

S(con

tinue

d)

18.1B

eta-Lactam

s(conti

nued

)

18.1.2

Ceph

alospo

rins

CefotaximeSo

dium

ForIn

j500

MG

IJSO

LRA

Consum

ables-Clin

icuseonly

Cefoxitin

Sod

iumForIn

j1GM

IVSO

LRA

Consum

ables-Clin

icuseonly

Ceftriaxone

Sod

iumForIn

j1GM

IJSO

LRA

Consum

ables-Clin

icuseonly

Ceftriaxone

Sod

iumForIV

Soln2GM

IVSO

LNA

Consum

ables-Clin

icuseonly

CefuroximeSo

dium

ForIn

j250

MG

IJSO

LRA

Consum

ables-Clin

icuseonly

CefuroximeSo

dium

ForIn

j750

MG

IJSO

LRA

Consum

ables-Clin

icuseonly

18.1.3

Others

NO

NE

LIST

ED

18.2Erythromycinand

otherM

acrolid

es

18.2

Erythrom

ycinand

otherM

acrolid

esErythrom

ycinEstolateCa

p25

0MG

OR

CAPS

AMax4fills/ann

um

Erythrom

ycinEstolateSu

sp125

MG/

5ML

OR

SUSP

AMax4fills/ann

um

Erythrom

ycinEstolateSu

sp250

MG/

5ML

OR

SUSP

AMax4fills/ann

um

Erythrom

ycinStearateTab25

0MG

OR

TABS

AMax4fills/ann

um

18.3A

minog

lycosid

es

18.3

Aminog

lycosid

esGe

ntam

icinSulfateIn

j40MG/

ML

IJSO

LNA

Consum

ables-Clin

icuseonly

Streptom

ycinSulfateIn

j100

0MG/

3ML

IJSO

LNA

Consum

ables-Clin

icuseonly

18.4Tetracyclines

18.4

Tetracyclin

esDo

xycyclineHy

clateCa

p10

0MG

OR

CAPS

AMax4fills/ann

um

Oxytetracyclin

eHC

lCap

250

MG

OR

CAPS

AMax4fills/ann

um

18.5C

hloram

phen

icols

18.5

Chloramph

enicols

Chloramph

enicolCap

250

MG

OR

CAPS

AMax4fills/ann

um

Chloramph

enicolSusp12

5MG/

5ML

OR

SUSP

AMax4fills/ann

um

18.6Sulph

onam

idesand

com

bina

tions

18.6

Sulpho

namidesand

com

bina

tions

Sulfa

metho

xazole-Trim

etho

prim

IVSoln40

0-80

MG/

5ML

IVSO

LNA

Consum

ables-Clin

icuseonly

Sulfa

metho

xazole-Trim

etho

prim

Susp20

0-40

MG/

5ML

OR

SUSP

AMax4fills/ann

um

Sulfa

metho

xazole-Trim

etho

prim

Tab

400

-80MG

OR

TABS

AMax4fills/ann

um

SEC

TIO

N 3

- Pr

ime

Cure

Den

tal F

orm

ular

y 20

20 (

conti

nued

)

of16

Dent

al P

rovi

der M

anua

l - P

rime

Cure

Hea

lth 2

020

Prim

e Cu

re D

enta

l For

mul

ator

y - 2

019

MIM

SMim

sDescriptio

nAc

tiveIngred

ient

Routeof

adm

inDo

sage

Fo

rmAc

ute

Qua

ntitie

sand

Lim

itatio

ns

18.A

NTI-M

ICRO

BIAL

S(con

tinue

d)

18.7Q

uino

lone

s

18.7

Quino

lone

sCiprofl

oxacinHClTab

250

MG

OR

TABS

AMax4fills/ann

um

Ciprofl

oxacinHClTab

500

MG

OR

TABS

AMax4fills/ann

um

18.9O

theranti

-bacteria

lagents

18.9

Otheranti

-bacteria

lagents

Clinda

mycinHClCap

150

MG

OR

CAPS

AMax2fills/ann

um

18.10An

ti-Fu

ngalagents

18.10

Anti-Fu

ngalagents

Nystatin

Susp10

0000

Unit/ML

MT

SUSP

AMax2fills/ann

um

18.11An

ti-protozoa

lagents

18.11

Anti-protozoa

lagents

Metronida

zoleSusp20

0MG/

5ML

OR

SUSP

AMax3fills/ann

um

Metronida

zoleTab

200

MG

OR

TABS

AMax3fills/ann

um

Metronida

zoleTab

400

MG

OR

TABS

AMax3fills/ann

um

18.12An

ti-viralagen

ts

18.12.2

OtherAnti

-vira

lAg

ents

AcyclovirC

ream

5%

EXCR

EAA

Max1Rx/an

num

19. E

NDO

CRIN

E SY

STEM

19.5.C

orticosteroids

19.5

Corticosteroids

Pred

nisone

Tab

5M

G

OR

TABS

AMax3fills/ann

um

Disclaim

er:

Plea

se n

ote

that

the

form

ular

y w

ill b

e re

view

ed re

gula

rly b

y cl

inic

al a

nd p

harm

aceu

tical

adv

isors

to e

nsur

e it

com

plie

s with

the

late

st in

dust

ry n

orm

s for

the

trea

tmen

t of d

enta

l co

nditi

ons.

Prim

e Cu

re re

serv

es th

e rig

ht to

chan

ge m

edic

ation

on

the

form

ular

y w

hen

impo

rtan

t inf

orm

ation

com

es to

ligh

t tha

t req

uire

s us t

o do

so, e

.g. n

ew fi

ndin

gs re

gard

ing

safe

ty o

f med

icin

e.

SEC

TIO

N 3

- Pr

ime

Cure

Den

tal F

orm

ular

y 20

20 (

conti

nued

)

1

2

3

4

Prime Cure Form Examples

Email:

Employer: Paypoint No:

Surname:

First Name:

Medical Scheme: Option:Member Number:

Details of Principal MemberB

C

D

A

Dental Pre-Authorisation Request Form

Kaelo Prime Cure (Pty) Ltd is a member of the Kaelo group of companies. Kaelo Risk (Pty) Ltd is an authorised financial services Provider FSP: 36931, underwritten by Centriq Insurance Company Limited FSP 3417.

IMPORTANT NOTE: Application forms are to be completed in full and submitted via fax: 0866 728 106 or email: [email protected]. For any enquiries call the Prime Cure contect centre on 0861 665 665. Should benefits be approved, a letter of authorisation will be faxed to the attending dental practitioner/therapist within three (3) working days of receipt of this form. The following benefits require pre-authorisation: 5th or more amalgam restorations per beneficiary per

annum, 5th or more resin restorations (anterior only) per beneficiary per annum and dentures, full/partial/reline/rebase.

Dental Practitioner or Dental Therapist Details

Counsil No: Practice Number:

Tel: Fax: Cell:

Email:

Dental Practitioner:

Postal Address: Code:

Tel: Fax: Cell:

Gender: Male Female Age:

Surname:

Identity Number/Passport:

First Name:

Dependent Code:

Patient Details

Email:


Essential Dentistry and/or Denture Application (Please tick the relevant Teeth Numbers below with an X and indicate tariff codes)

Proc/Lab Codes Tooth Numbers ICD 10 Codes Proc/Lab Codes Tooth Numbers ICD 10 Codes

Lab Practice No: Lab No:

Co-Payment Value Receipt No:

Practitioner Signature: Date:

Email:

Employer: Paypoint No:

Surname:

First Name:

Medical Scheme: Option:Member Number:

Details of Principal Member

Tel: Fax: Cell:

Email:

Tel: Fax: Cell:

Gender: Male Female Age:

Surname:

Identity Number/Passport:

First Name:

Dependent Code:

Patient Details

Email:


Patient Requested the Following Non-Formulary Medication

Non-Formulary Medication & Benefits FormPatient Consent:

IMPORTANT NOTE: Any procedure not listed requires pre-authorisation: Prime Cure - 0861 665 665 0r Email - [email protected]. Pre-authorisation number should be recorded on the account to be considered for payment. Please submit your account electronically using

the following destination code - 642P, alternatively post claims to: Prime Cure, Private Bag 2108, Houghton, 2041

Nappi Code(eg: 791237)

Medication Name(eg: Ventolin Nebules)

Strength(Eg: 25mg)

Patient Agreed to the Following Services Not Covered Under the BenefitsTariff Code(eg: 791237)

Description(Eg: Ventolin Nebules)

y y y y - m m - d dDate:Signed:

I, (the undersigned) declare that I was informed by my doctor that the medication / investigation /procedure / services fall outside my Prime Cure benefits. I am aware that the medication / investigation / procedure / services will be for my personal account.

A

B

C

D

E

Doctor Details

Kaelo Prime Cure (Pty) Ltd is a member of the Kaelo group of companies. Kaelo Risk (Pty) Ltd is an authorised financial services Provider FSP: 36931, underwritten by Centriq Insurance Company Limited FSP 3417.

Practice Number:Referring Doctor:

* Member verification during office hours is available by calling 0861 665 665 or by registering on the Prime Cure Dashboard

Prime Cure Customer Service Centre

Monday-Friday:08h00-17h00Saturdays:08h00-12h00ClosedonSundaysandPublicHolidaysPhone:0861665665Email:[email protected]

PhysicalAddress2ndFloor,TheOval–EastWingWanderersOfficePark52CorlettDriveIllovo2196

PostalAddressPrimeCurePrivateBag2108Houghton2041

DENTAL PRACTITIONERS PROVIDER MANUAL 2020...Interim dentures Also known as provisional, temporary or...

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Transcript of DENTAL PRACTITIONERS PROVIDER MANUAL 2020...Interim dentures Also known as provisional, temporary or...