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Download Annexure A - AGHS Foundation Option 2016
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ANNEXURE A AGHSA DIRECT CONTRACTS - FOUNDATION OPTION 2016 1. Reimbursement Model 1.1. The Client Scheme contract tariff for 2016 is 2015 rate plus 6%. Procedures not listed will be paid at Scheme tariff 2015+ 6% = 2016. Procedures not listed will not be paid unless preauthorisation was obtained. Option Foundation Global Fee: Dispensing Provider R335.00 Global Fee: Non Dispensing Provider R245.00 Payment Schedule Dispensing Non-Dispensing Consultations Global fee for services listed in Annexure A As per dispensing practitioners. Listed In-Rooms Procedures All procedures as listed in Annexure A are included in the Scheme tariff fee. As per dispensing practitioners. Acute Medicine The supply of Acute Medication should be in accordance with the Scheme Formulary and is included in the Global Fee. Any medicine item that falls outside the formulary needs to be authorized by the Scheme, please advise patient when scripting that items are not on the formulary as patients may incur co-payments. When prescribing: The tariff will immediately revert to the non-Dispensing tariff as claw back will not be done. See notes on prescriptions under “non-Dispensing”. Medication needs to be prescribed in terms of the Scheme formulary. Patient to obtain medication from AGHSA contracted pharmacy. All Acute prescriptions has a Scheme limit of R89.00 per prescription per beneficiary. Note that there is also a limit on the number of prescriptions in any period, and the frequency of prescriptions will be used for monitoring purposes. Additional prescription require preauthorisation. Chronic Medication All chronic medication must be duly authorized and approved by Scheme PMB (CDL) conditions only. Pathology & Radiology As per client scheme benefit guide Page 1 of 11 Your partner in Healthcare delivery: As per dispensing provider Chronic medicine prescriptions should be filled at AGHSA enabled pharmacies. As per dispensing provider Annexure A: GP - Foundation 2016 [email protected] | www.agilityghs.com Tel: 012 673 8600 | Fax: 086 605 9440 Building A, Lakefield Office Park, 272 West Avenue, Centurion, 0157, South Africa 1.2. In Rooms Procedures: Included in Global Fee GP PROCEDURES INCLUDED IN FOUNDATION GLOBAL CONSULTATION FEES 0007 Own equipment 0190/1/2 New and established patient 0132 Writing of repeat scripts 0133 Writing of special motivations 0202 Setting of sterile tray 0206 / 0017 Intravenous treatment, patient over 3 years 0210 Collection of blood specimen 0222 Intralesional injection into areas of pathology – single 0223 Intralesional injection into areas of pathology – multiple 0245 Removal of benign lesion – first lesion 0246 Removal of benign lesion – subsequent lesions 0316 Fine needle aspiration for soft tissue – all areas 0317 Aspiration of cyst or tumour 0661 Aspiration of joint or intra-articular injection 1037 Diathermy to nose or pharynx, uni- or bilateral: under local anaesthetic 1063 Removal of foreign bodies from nose (in rooms) 1136 Nebulisation (in rooms) 1192 Peak expiratory flow 1228 Recording of a resting ECG 1232 ECG without effort including interpretation 2271 Removal of tag or polyp – vulva & introitus 2272 Removal of small superficial benign lesions – vulva & introitus 3004 Peripheral fundus examination with indirect ophthalmoscope 3204 External ear canal: Removal of foreign body (in rooms) 3867 Microscopy miscellaneous (body fluids, urine, exudate, fungi, pus, scrapings, etc.) 4188 Urine dipstick, per stick (irrespective of the number of sticks) 4561 Sputum cytology - body fluids and tumour aspirates: first unit 4563 Sputum cytology - body fluids and tumour aspirates: additional unit Page 2 of 11 Your partner in Healthcare delivery: Annexure A: GP - Foundation 2016 [email protected] | www.agilityghs.com Tel: 012 673 8600 | Fax: 086 605 9440 Building A, Lakefield Office Park, 272 West Avenue, Centurion, 0157, South Africa 1.3. The following procedures are excluded from the consultation fee, and may be charged for as additional to the consultation fee, at negotiated scheme rate (2015 + 5% = 2016): Tariff Code Tariff Description Tariff Code Tariff Description 0205 Intravenous treatment: Intravenous infusions (cutdown or push-in) (patients under three years): Cutdown and/or insertion of cannula - chargeable once per 24 hours. 0233 Biopsy without suturing: First lesion 0208 Venesection: Therapeutic venesection (Not to be used when blood is drawn for the purpose of laboratory investigations). 0235 Biopsy without suturing: Maximum for multiple additional lesions 0234 Biopsy without suturing: Subsequent lesions (each). 0255 Drainage of subcutaneous abscess onychia, paronychia, pulp space or avulsion of nail 0237 Deep skin biopsy by surgical incision with local anaesthetic and suturing. 0300 Stitching of soft-tissue injuries: Stitching of wound (with or without local anaesthesia): Including normal after-care) 0259 Removal of foreign body superficial to deep fascia (except hands). 0302 Stitching of soft-tissue injuries: Deep laceration involving limited muscle damage 0301 Stitching of soft-tissue injuries: Additional wounds stitched at same session (each). 0887 Limb cast (excluding after-care) (modifier 0005 not applicable) 0305 Needle biopsy - soft tissue. 1236 Electrocardiogram without effort: Under 4 years old 0922 Removal of foreign bodies requiring incision: Under local anaesthetic. 5375 Venous Doppler examination (both limbs) 1237 24 Hour ambulatory blood pressure: Hire fee. 2713 Spinal (lumbar) puncture. For diagnosis, for drainage of spinal fluid or for therapeutic indications 2293 Vulva and introitus: Drainage of abscess. 4351 Occult blood: Chemical test 3204 External ear canal: Removal of foreign body: At rooms Page 3 of 11 Your partner in Healthcare delivery: Annexure A: GP - Foundation 2016 [email protected] | www.agilityghs.com Tel: 012 673 8600 | Fax: 086 605 9440 Building A, Lakefield Office Park, 272 West Avenue, Centurion, 0157, South Africa 1.4. Procedures: Approval The following procedures may be charged for as additional to the consultation though requires pre-authorisation obtainable from Agility. If no pre-authorisation found then procedure will be rejected: Tariff Code Tariff Description Tariff Code Tariff Description 0217 Allergy: Patch tests: 0218 Allergy: Skin-prick tests: Skin-prick testing: Insect venom, latex and drugs 0220 Allergy: Skin-prick tests: Immediate hypersensitivity testing (Type I reaction): Per antigen: Inhalant and food allergens First patch 0219 Allergy: Patch tests: Each additional patch 0221 Allergy: Skin-prick tests: Delayed hypersensitivity testing (Type IV reaction): Per antigen 0241 Treatment of benign skin lesion by chemo-cryotherapy: First Lesion 0242 Treatment of benign skin lesion by chemocryotherapy: Subsequent lesions (each) 0243 Treatment of benign skin lesion by chemo-cryotherapy: Maximum for multiple additional lesions 0251 Removal of malignant lesions by curetting under local or general anaesthesia followed by electro cautery: First lesion 0252 Removal of malignant lesions by curetting under local or general anaesthesia followed by electro cautery: Subsequent lesions (each) 0307 Excision and repair by direct suture; excision nail fold or other minor procedures of similar magnitude 0308 Each additional small procedure done at the same time 0310 Radical excision of nailbed 0661 Aspiration of joint or intra-articular injection (not including after-care) (modifier 0005 not applicable) 0663 Multiple intra-articular injections for rheumatoid arthritis (excluding after-care) (modifier 0005 not applicable): First joint 0665 Multiple intra-articular injections for rheumatoid arthritis (excluding after-care) (modifier 0005 not applicable): Additional (each) 1107 Opening of quinsy: At rooms 1139 Pleural needle biopsy (no after-care) (modifier 0005 not applicable) 1143 Paracentesis chest: Diagnostic 1234 Effort electrocardiogram with the aid of a special bicycle ergometer, monitoring apparatus and availability of associated apparatus 1235 Multi-stage treadmill test 1367 Doppler blood tests 5369 Doppler arterial pressures 5371 Doppler arterial pressures with exercise 1485 Local excision of benign lesion of lip 1487 Resection for lip malignancy 1587 Upper gastro-intestinal endoscopy: Hospital equipment 1588 Plus polypectomy: ADD to gastro-intestinal endoscopy (Item 1587) 1681 Proctoscopy with removal of polyps: First time 1683 Proctoscopy with removal of polyps: Subsequent times 1705 Incision and drainage of peri-anal abscess 1725 Drainage of external thrombosed pile 2133 Circumcision: Clamp procedure 2137 Circumcision: Surgical excision other than by clamp or Page 4 of 11 Your partner in Healthcare delivery: Annexure A: GP - Foundation 2016 [email protected] | www.agilityghs.com Tel: 012 673 8600 | Fax: 086 605 9440 Building A, Lakefield Office Park, 272 West Avenue, Centurion, 0157, South Africa dorsal slit, any age 2139 Circumcision: Dorsal slit of prepuce (independent procedure) 2207 Vasectomy: Unilateral or bilateral (no extra fee to be charged if done in combination with prostatectomy) 2281 Excision of inclusion cyst 2957 Individual psychotherapy (specify type): Including play therapy for children: Per short session (20 minutes) 2958 Psychoanalytic therapy: Per 60-minute session 2962 Directive therapy to family, parent(s), spouse: Per 20minute session 2963 Pairs, marriage or sex therapy: Per 20-minute session 2974 Individual psychotherapy (specify type): Including play therapy for children: Per intermediate session (40 minutes) 2975 Individual psychotherapy (specify type): Including play therapy for children: Per extended session (60 minutes or longer) 2976 Intermediate treatment where either items 2962 or 2963 are used: Per 40-minute session 2977 Extended treatment where either items 2962 or 2963 are used: Per 60-minute session 3292 Aspiration of joint or inter-articular injection 3293 Aspiration or injection of bursa or ganglion 1.5. Procedures: Ultrasound The following will be paid from ultra sound obstetric benefit if pregnant; if used for pelvic ultra sound an authorisation is required; if any other condition such as ectopic pregnancy confirmation is required. Note that scheme rules apply and that pregnancy need to be registered on the Maternity programme and only 2 X 2D Sonars will be reimbursed without pre – authorisation. Tariff Code Tariff Description Tariff Code Tariff Description 3615 Routine obstetric ultrasound at 10 to 20 weeks gestational age preferable at 10 to 14 weeks gestational age to include nuchal translucency assessment 3617 Routine obstetric ultrasound at 20 to 24 weeks to include detailed anatomical assessment Page 5 of 11 Your partner in Healthcare delivery: Annexure A: GP - Foundation 2016 [email protected] | www.agilityghs.com Tel: 012 673 8600 | Fax: 086 605 9440 Building A, Lakefield Office Park, 272 West Avenue, Centurion, 0157, South Africa 1.6. Primary Care Radiology - 2016 The following imaging is not included in the global fee and will be reimbursed separately. All other imaging not listed needs preauthorisation. Equipment / Diagnostic Tariff Code Procedure 00110 X-ray skeletal survey under five years Skull and Brain 10100 X-ray of the skull Sella turcica 17100 X-ray of the sella turcica 11100 X-ray of the facial bones 11120 X-ray of the nasal bones 12100 X-ray orbits less than three views 12120 X-ray of the orbits for foreign body 13100 X-ray of the paranasal sinuses, single view 13110 X-ray of the paranasal sinuses, two or more views 16100 X-ray of the mastoids, unilateral 16110 X-ray of the mastoids, bilateral 14100 X-ray of the mandible 15100 X-ray tempero-mandibular joint, left 15110 X-ray of tempero-mandibular joint, right 50100 X-ray of the spine scoliosos view AP only 50105 X-ray of the spine scoliosis view AP and lateral 51110 X-ray of the cervical spine, one or two views 51120 X-ray of the cervical spine, more than two views 51130 X-ray of the cervical spine, more than two views including stress views 52100 X-ray of the thoracic spine, one or two views 52110 X-ray of the thoracic spine, more than two views 52140 X-ray of the thoracic spine, more than two views including stress views 53100 X-ray of the lumbar spine – stress studies only 53110 X-ray of the lumbar spine, one or two views 53120 X-ray of the lumbar spine, more than two views 53130 X-ray of the lumbar spine, more than two views including stress views 54100 X-ray of the sacrum and coccyx 54110 X-ray of the sacro-iliac joints 30100 X-ray of the chest, single view 30110 X-ray of the chest two views , PA and lateral 30155 X-ray of the chest and ribs 30170 X-ray of the of the sterno-clavicular joint Head Facial bones and nasal bones Orbits, lacrimal glands and tear ducts Paranasal sinuses Mastoids and internal auditory canal Mandible, teeth and maxilla TM Joints Spine Cervical Thoracic Lumbar Sacrum Chest Page 6 of 11 Your partner in Healthcare delivery: Annexure A: GP - Foundation 2016 [email protected] | www.agilityghs.com Tel: 012 673 8600 | Fax: 086 605 9440 Building A, Lakefield Office Park, 272 West Avenue, Centurion, 0157, South Africa 30180 X-ray of the sternum 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 40210 Ultrasound study of the whole abdomen including the pelvis 41200 Ultrasound study of the upper abdomen 44200 Ultrasound study of abdominal aorta and branches including Doppler 55100 X-ray of the pelvis 43200 Ultrasound study of the pelvis transabdominal 43250 Ultrasound study of the pregnant uterus, first trimester 43260 Ultrasound study of the pregnant uterus, second trimester 43270 Ultrasound study of the pregnant uterus, third trimester, first visit 43273 Ultrasound study of the pregnant uterus, third trimester, follow-up visit 61100 X-ray of the left clavicle 61105 X-ray of the right clavicle 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 61200 Ultrasound of the left shoulder joint 61210 Ultrasound of the right shoulder joint 62100 X-ray of the of the left humerus 62105 X-ray of the right humerus 63100 X-ray of the left elbow 63105 X-ray of the right elbow 63110 X-ray of the left elbow with stress 63115 X-ray of the right elbow with stress Abdomen/Stomach/Bowel Pelvis Reproductive System Reproductive System Shoulder Upper limbs Humerus Elbow Page 7 of 11 Your partner in Healthcare delivery: Annexure A: GP - Foundation 2016 [email protected] | www.agilityghs.com Tel: 012 673 8600 | Fax: 086 605 9440 Building A, Lakefield Office Park, 272 West Avenue, Centurion, 0157, South Africa Forearm Hand and Wrist 64100 X-ray of the left forearm 64105 X-ray of the right forearm 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 65150 X-ray of the left wrist, scaphoid and stress views 65155 X-ray of the right wrist, scaphoid and stress views 70120 X-ray of the lower limbs full length study 70200 Ultrasound lower limb – soft tissue – any study 73100 X-ray of the left lower leg 73105 X-ray of the right lower leg 56100 X-ray of the left hip 56110 X-ray of the right hip 56120 X-ray of pelvis and hips 56120 X-ray of pelvis and hips 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 72130 X-ray of the right knee with stress views 72135 X-ray of the right knee with stress views 72140 X-ray of left patella 72145 X-ray of right patella 72150 X-ray of both knees standing – single view 74100 X-ray of the left ankle 74105 X-ray of the right ankle 74110 X-ray of the left ankle with stress views 74115 X-ray of the right ankle with stress views 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 Lower limbs Lower Leg Hips Femur Knee Ankle and Foot Page 8 of 11 Your partner in Healthcare delivery: Annexure A: GP - Foundation 2016 [email protected] | www.agilityghs.com Tel: 012 673 8600 | Fax: 086 605 9440 Building A, Lakefield Office Park, 272 West Avenue, Centurion, 0157, South Africa 74145 X-ray of the of a toe 74150 X-ray of the sesamoid bones one or both sides 1.7. Primary Care Pathology – 2016 The following pathology is not included in the global fee and will be reimbursed separately. All other pathology tests not listed needs pre-authorisation. FOUNDATION PLAN PATHOLOGY TESTS Haematology / Coagulation Haematology / Coagulation Haematology / Coagulation Haematology / Coagulation Haematology / Coagulation Haematology / Coagulation Haematology / Coagulation Haematology / Coagulation Haematology / Coagulation Haematology / Coagulation Haematology / Coagulation Haematology / Coagulation Haematology / Coagulation Leucocytes: Total Count Leucocyte differential count Haemoglobin estimation Platelet count Packed cell volume: Haematocrit Full blood count (incl items 3739, 3762, 3783, 3785, 3791) Erythrocyte sedimention rate Prothrombin index Iron Ferritin Transferrin Vitamin B12 Antiglobulin test (Coombs’ or trypsinzied red cells) 3785 3783 3762 3797 3791 3755 3743 3805 4071 4528 4144 4491 3709 Kidney / Electrolytes Kidney / Electrolytes Kidney / Electrolytes Kidney / Electrolytes Kidney / Electrolytes Kidney / Electrolytes Kidney / Electrolytes Kidney / Electrolytes Sodium Potassium Urea Creatinine Sodium+potassium+chloride+CO2+urea Calcium: Spectrophotometric Magnesuim: Spectrophotometric Phosphate 4114 4113 4151 4032 4171 4017 4094 4109 Liver / Pancreas Liver / Pancreas Liver / Pancreas Liver / Pancreas Liver / Pancreas Liver / Pancreas Liver / Pancreas Liver / Pancreas Liver / Pancreas Liver / Pancreas Protein: Total Albumin Alanine aminotransferase (ALT) Aspartate aminitransferase (AST) Lactate dehidrogenase (LD) Gamm aglutamyl transferase (GGT) Alkaline phosphatase Bilirubin: Total Bilirubin: Conjugated Amylase 4117 3999 4131 4130 4133 4134 4001 4009 4010 4006 Endocrine / Metabolic Endocrine / Metabolic Endocrine / Metabolic Endocrine / Metabolic Endocrine / Metabolic Endocrine / Metabolic Endocrine / Metabolic Endocrine / Metabolic Glucose: Quantitative HbA1c Free thyroxine (FT4) Thyrotropin (TSH) Oestriol Progesterone Prolactin Cholestrol total 4057 4064 4482 4507 4505 4521 4537 4027 Page 9 of 11 Your partner in Healthcare delivery: Annexure A: GP - Foundation 2016 [email protected] | www.agilityghs.com Tel: 012 673 8600 | Fax: 086 605 9440 Building A, Lakefield Office Park, 272 West Avenue, Centurion, 0157, South Africa Endocrine / Metabolic Endocrine / Metabolic Endocrine / Metabolic Endocrine / Metabolic HDL Cholestrol Triglyceride Uric Acid Creatine kinase (CK) 4028 4147 4155 4132 HIV / STI HIV / STI HIV / STI Antibodies to human immunodeficiency virus (HIV): ELISA Quantitative Kahn, VDRL or other flocculation Syphilis IgG 3932 3951 3948 Infectious Infectious Infectious Infectious Infectious 4531 3893 3922 3928 3867 Infectious Hepatitis: Per Antigen or Antibody Bacteriological culture: Miscellaneous Variable cell count Antimicrobic substances Miscellaneous (body fluids, urine, exudates, fungi, pus, scrapings etc. Mycobacteria Radiometric Tuberculosis Culture Bilharzia Ag Serum/Urine Faeces (including parasites) Slide Agglutination Test (Malaria) Concentration techniques for parasites Plasmodium falciparum: Monoclonal immunological identification Parasites in blood smear Pregnancy Pregnancy Pregnancy Pregnancy Grouping : A B and O antigens Grouping: Rh antigen Rubella IgG HCG: Monoclonal Immunilogical : Qualitative 3764 3765 3948 4450 Unlisted Urine dipstick, per stick (irrespective of the number of tests on stick) Vaginal or cervical smears, each Prostate specific antigen 4188 Infectious Infectious Infectious Infectious Infectious Infectious Infectious Unlisted Unlisted Page 10 of 11 Your partner in Healthcare delivery: 3881 3916 3980 3869 3961 3883 3792 3865 4566 4519 Annexure A: GP - Foundation 2016 [email protected] | www.agilityghs.com Tel: 012 673 8600 | Fax: 086 605 9440 Building A, Lakefield Office Park, 272 West Avenue, Centurion, 0157, South Africa This Annexure A for Foundation Option 2016 is executed for and on behalf of The Service Provider. On this ___________ day of ________________________________________ 2016 __________________________ __________________________ Medical Provider Witness Practice Number: _______________________ AGHSA by _____________________________________________________ duly authorised by Agility Global Health Solutions Africa Pty (Ltd). On this ___________ day of ________________________________________ 2016 _________________________________ __________________________ Agility Global Health Solutions (Pty) Ltd Witness Page 11 of 11 Your partner in Healthcare delivery: Annexure A: GP - Foundation 2016 [email protected] | www.agilityghs.com Tel: 012 673 8600 | Fax: 086 605 9440 Building A, Lakefield Office Park, 272 West Avenue, Centurion, 0157, South Africa
