Transcription

Discovery Health video callpharmacy-clinic network handbook2020OverviewWe recognise the contribution that pharmacy clinics make across South Africa. To improve access to primaryhealthcare for members on certain plans, we established a video call pharmacy-clinic network in January2020 to cover pharmacy-clinic consultations in the network.Discovery Health Wellness Network pharmacies can now offer video call consultations to members onqualifying Discovery Health Medical Scheme plans and policyholders of Primary Care benefit options. Thepurpose of this document is to support clinic healthcare professionals with a better understanding ofapplicable rules, procedures and processes in dealing with pharmacy-clinic consultations and claims.

ContentsOverview . 1Contents . 2Terminology used in this document . 3Overview of the video call pharmacy-clinic network . 4How to apply for the video call pharmacy-clinic network. 4Who can claim for video call consultations? . 4What does the consultation fee cover? . 5Consultation procedure and submitting the claim . 5Detailed Discovery Health Medical Scheme plan rules . 8How to refer a Discovery Health Medical Scheme member to a general practitioner . 10Referrals for virtual consultations with a panel GP . 10Referrals for face-to-face consultations with a network GP. 10Detailed Primary Care benefit rules . 11How to refer a Primary Care policyholder to a general practitioner . 11Referrals for virtual consultations with a GP . 11Referrals for face-to-face consultations with a GP . 12How to register on the Healthcare Professional Zone . 12Contact details . 13Discovery Ltd. registration number: 1999/007789/06. Companies in the Group are authorised financial services providers.Discovery Health pharmacy-clinic network virtualconsultation handbook11 September 2020Page 2 of 13Confidential

Terminology used in this documentTerminologyDescriptionAbove Threshold Benefit(ATB)Available on the Executive, Comprehensive and Priority plansOnce the day-to-day claims that have been sent to us add up to theAnnual Threshold, we pay the rest of the day-to-day claims from theAbove Threshold Benefit (ATB), at the Discovery Health Rate or aportion of it. The Executive and Comprehensive plans have anunlimited ATB, and the Priority plans have a limited ATB.Day-to-day benefitsThese are the available funds allocated to the Medical Savings Account(MSA) and Above Threshold Benefit (ATB). Depending on themember's plan, they have cover for a defined set of day-to-daybenefits. The level of day-to-day benefits depends on the member’schosen plan.Day-to-day ExtenderBenefit (DEB)The Day-to-day Extender Benefit (DEB) extends a member’s day-to-daycover for essential healthcare services in our network if they havespent their annual Medical Savings Account (MSA) allocation andhaven’t reached the Annual Threshold.Medical Savings Account(MSA)Available on the Executive, Comprehensive, Priority andSaver plansWe pay the day-to-day medical expenses such as GP and specialistconsultations, acute medicine, radiology and pathology from theavailable funds allocated to the MSA. Any unused funds will carry overto the next year.Self-payment Gap (SPG)The Self-payment Gap (SPG) occurs when members on the Executive,Comprehensive and Priority Plans run out of funds in the MSA beforereaching the Annual Threshold.During this period, the member is personally responsible for thepayment of all day-to-day medical expenses.Discovery Health Rate(DHR)This is a rate we pay for healthcare services from hospitals,pharmacies, healthcare professionals and other providers of relevanthealth services.MemberThe reference to members in this document also includes dependants,where applicable.Annual ThresholdAt the beginning of each year, Discovery Health sets predeterminedRand values, called Annual Thresholds. All members on Executive,Comprehensive and Priority Plans are given Annual Thresholds. TheseAnnual Thresholds vary according to the number of people that are onthe plan.Discovery Ltd. registration number: 1999/007789/06. Companies in the Group are authorised financial services providers.Discovery Health pharmacy-clinic network virtualconsultation handbook11 September 2020Page 3 of 13Confidential

Annual Thresholds are based on the sum of the different planparticipants. This makes sure the Annual Thresholds are fair.Overview of the video call pharmacy-clinic networkHOW TO APPLY FOR THE VIDEO CALL PHARMACY-CLINIC NETWORKWellness Network pharmacies that have an existing agreement in place with a Discovery Health-integratedtelemedicine enabler are eligible to apply to become part of the video call pharmacy-clinic network and toclaim for video call consultations.Individual pharmaciesYour telemedicine enabler that provides you with the software for video call consultations will give you aDiscovery Health video call pharmacy-clinic network agreement once the software is fully installed. Completethe agreement with details, practice number and nurse permits, and email it toprovider [email protected] Please allow us three working days to process these requests.Group pharmaciesFor group pharmacies with an existing Discovery Health network agreement, please request that yourpharmacy head office emails the completed Discovery Health video call pharmacy-clinic network registrationform with the details, practice number and nurse permits to provider [email protected] allow us three working days to process these requests.WHO CAN CLAIM FOR VIDEO CALL CONSULTATIONS?Discovery Health Medical Scheme members on certain plansDiscovery Health Medical Scheme members who have spent their annual Medical Savings Account (MSA)allocation can claim for video call consultations in our wellness network through the Day-to-day ExtenderBenefit (DEB). This benefit covers pharmacy-clinic consultations with a registered nurse in our definedwellness network, supported virtually by a general practitioner. The number of available consultations is setout in the plan rules.This benefit is available to members only on plans with a Medical Savings Account including theExecutive, Comprehensive, Priority and Saver Plans, and is not available on Classic Smart Comprehensive,Smart, Core or KeyCare plans.Claims are covered from the member’s available day-to-day benefits. If the member is in their Self-paymentGap (SPG), claims are paid from the Day-to-Day Extender Benefit subject to the limits set out in the planrules. (See detailed plan rules section in this document).Discovery Ltd. registration number: 1999/007789/06. Companies in the Group are authorised financial services providers.Discovery Health pharmacy-clinic network virtualconsultation handbook11 September 2020Page 4 of 13Confidential

Primary Care policyholdersPrimary Care policyholders have access to unlimited nurse consultations and virtual GP consultations at apharmacy in the nurse network, which their Primary Care benefits pay for. Primary Care Drug Therapists(PCDT) have not been introduced yet.WHAT DOES THE CONSULTATION FEE COVER?The pharmacy-clinic consultation fee covers a registered nurse in the wellness network at a fixed rate forservices that fall in the nurse’s scope of practice. Only pharmacies with a Discovery Health video callpharmacy-clinic network agreement in place can claim for pharmacy-clinic consultations. We cover thefollowing services: Discovery Health Medical Scheme member consultations with a pharmacy nurse Primary Care policyholder consultations with a pharmacy nurse Discovery Health Medical Scheme member virtual video call consultations with a network generalpractitioner, facilitated by the pharmacy nurse Primary Care policyholder virtual video call consultations with a network general practitioner,facilitated by the pharmacy nurse.When the service needs of the member do not fall within the nurse’s scope of practice, the pharmacy clinicnurse may, when warranted and clinically appropriate, do one of the following: Refer the member to the pharmacist for schedule 0 – 2 medicines, which are then covered by themember’s available benefits or paid for by the member where they do not have benefits available. Facilitate a video call with a general practitioner (GP) on the video call panel. The panel GP willdetermine if a prescription is necessary during the video consultation.The panel GP may refer the member for a face-to-face consultation with a network GP, where required.To find a provider in our network, members can visit www.discovery.co.za or click on Find a healthcareprovider on the Discovery app.Claims are subject to a pharmacy-clinic verification process, and pharmacies need to adhere to all applicablerules of participation for pharmacy clinic consultations to be covered. For more information, please see theDetailed Discovery Health Medical Scheme plan rules section of this guide.Consultation procedure and submitting the claimFollow steps 1 to 11 during your consultation procedure. It is important to follow this sequence of steps tohelp you with the claims procedure.Discovery Ltd. registration number: 1999/007789/06. Companies in the Group are authorised financial services providers.Discovery Health pharmacy-clinic network virtualconsultation handbook11 September 2020Page 5 of 13Confidential

1. Confirm the member’s available benefits with us before the consultation takes place. Go to www.discovery.co.za and click on Healthcare Professionals (bottom right of the home page).Enter your username and password to log in to the Healthcare Professional Zone. Click on Member validation and Virtual quote. Use the patient’s details (member number or ID number, name and surname) to validate theirmembership and to check if the membership is active. Once you have validated the membership, use the virtual quote tool to complete a virtual quote. If the particular plan does not cover the consultation, discuss the self-payment options withthe patient. For information about registering on the Healthcare Professional Zone, please refer to the ‘How toregister on the Healthcare Professional Zone’ section in this document.2. Get appropriate consent from the patient in each of the following steps: To conduct the physical examination, if appropriate To use the GP video consultation To get a prescription from the GP To fill their prescription at the pharmacy, or tell the member where they must go to collecttheir medicine.3. Start your discussion with the patient to determine the reason for the consultation, then do anappropriate examination where needed to come to a conclusion.4. Complete the SOAP note and submit it on the telemedicine system. It is important to do this first,before submitting the claim, because we will reject the claim if we get the claim before the SOAP note issubmitted.5. Determine whether the patient may need extra medicine or care. If they need schedule 0 – 2medicine, refer the patient to the pharmacist for any over-the-counter medicine covered by the relevantplans. If they need schedule 3 and higher medicine, ask the patient for their consent to have a video callwith a panel GP. Have the video call consultation with the panel GP on the Discovery-integratedtelemedicine system.6. Referral for a face-to-face GP consultation. Only the panel GP who performed the virtual consultationcan refer a patient for a face-to-face consultation at a network GP. Please help the panel GP to do thereferral according to the steps on the telemedicine system.7. We will consider paying for extra material, tests or vaccines based on the relevant plan rules. Wemay pay from the member’s available day-to-day benefits or their other benefits, but they might alsohave to pay for it from their own pocket. We cover claims under the Day-to-day Extender Benefit, butthese claims will not accumulate to the member’s Annual Threshold.Discovery Ltd. registration number: 1999/007789/06. Companies in the Group are authorised financial services providers.Discovery Health pharmacy-clinic network virtualconsultation handbook11 September 2020Page 6 of 13Confidential

8. Submit the consultation claim to us on your pharmacy’s dispensing system using the appropriate codefor the agreed rate and the relevant plan. The service description and submission codes should beavailable on your claims software. If not, contact your contracted software provider to load it. Thefollowing codes will apply:NAPPI codeServiceProcedure codeFee004 204 001Primary Care registered nurse consultationIndividual consultation with referral to video call GP880051R70.00004 205 001Discovery Health Medical Scheme registered nurseconsultationIndividual consultation with referral to video call GP880053R90.009. The relevant telemedicine provider will send the GP’s claim on behalf of the panel GP. The followingcodes will apply:NAPPI codeServiceProcedure codeFee004 206 001Discovery Health Medical Scheme virtualconsultation GP Can refer member to a face-toface GP consultation.7503R249.50004 207 001Primary Care virtual consultation GPCan refer policyholder for a face-to-faceGP consultation.7503R230.00We have built verification rules into the Discovery Health system to make sure we cover the claim when youfollow all the requirements. If something is missing or incorrectly submitted, we will reject the claim and youmay have to fix it before submitting the same claim again.10. If your claim is rejected, investigate the reason code on the screen to understand the reason forthe rejection. Correct the claim and resubmit where necessary.Here are some examples of reasons for claim rejections:Reason codeDescriptionReason for rejection of the claim274No money in MSA. Membermust pay the claim.Member must pay the claim.322Screening limit reached. Notpaid.Investigate the procedure submitted and resubmit:code 880051 versus 880053.Discovery Ltd. registration number: 1999/007789/06. Companies in the Group are authorised financial services providers.Discovery Health pharmacy-clinic network virtualconsultation handbook11 September 2020Page 7 of 13Confidential

332Plan does not cover thistreatment or test355Did not use network providerThis pharmacy does not currently take part in thepharmacy-clinic network for video calls. We need acontract.400Provider may not refer,member must pay the claim.Follow correct referral procedures. Only the video callGP can refer a patient for a face-to-face GPconsultation. Not all healthcare disciplines mayprescribe or refer for certain services.1002We do not cover this service.Primary Care does not cover this healthcare service.Patient must pay for this service from their own pocket.1004Non-network provider.Member to pay.We have not paid this claim, because you (thehealthcare provider) are not part of the Primary Carenetwork. The member must pay this amount.Not paid. Need virtualconsultation noteFirst submit the SOAP note before submitting the claim.1245Note: not submitted. Claim notpaidWe have not paid this code, because you have notsubmitted the consultation note to us.9848Invalid claim option. Submit on: Resubmit on the submission code given in response – inthis case, DISCKD20.DISCKD2010436Provider cannot prescribe thismedicine.1040Member must pay the claim.We have not paid the amount on this claim line,because you may not prescribe this medicine.11. If the rejected result is relevant, explain to the patient why they must pay for the consultationthemselves.Detailed Discovery Health Medical Scheme plan rules Consultations from the Day-to-day Extender Benefit will be funded at the Discovery Health Rate. Materials, procedures or any other healthcare services will be paid from the member’s available day-today benefits or paid by the member themselves. Claims paid from the Day-to-day Extender Benefit will not accumulate to the Annual Threshold, whereapplicable.Discovery Ltd. registration number: 1999/007789/06. Companies in the Group are authorised financial services providers.Discovery Health pharmacy-clinic network virtualconsultation handbook11 September 2020Page 8 of 13Confidential

Cover limits for Discovery Health Medical Scheme members through the Day-to-dayExtender BenefitPlanBenefitCoverExecutive,Comprehensiveand PriorityClassic andCoastal SaverUnlimited visits with a nurse at a networkpharmacyPharmacy nurse visitsEssential SaverExecutive,Comprehensiveand PriorityLimited to 3 consultationsper single memberLimited to6 consultations perfamilyLimited to 2 consultationsper single memberLimited to4 consultations perfamilyUnlimited virtual GP consultations if referred bya nurseVirtual video callconsultationsLimited toClassic andCoastal Saver*Limited to 3 consultations6 consultations perper single memberfamilyEssential Saver*Limited to 2 consultationsper single memberLimited to4 consultations perfamilyExecutive,Comprehensiveand PriorityUnlimited consultations if referred by a virtual GPFace-to-face consultationswith a network GPClassic andCoastal Saver**EssentialSaver**Limited toLimited to 3 consultations6 consultations perper single memberfamilyLimited toLimited to 2 consultations4 consultations perper single memberfamily*Nurse consultation virtual consultation will only accumulate to one Day-to-day Extender Benefit consultation.**Nurse consultation virtual consultation face-to-face consultation will accumulate to one Day-to-day Extender Benefit consultation.How we fund pharmacy-clinic claims for Discovery Health Medical Scheme membersThe following table indicates how we will fund claims for members with available funds in their MedicalSavings Account and members in their Self-payment Gap or Above Threshold Benefit.Discovery Ltd. registration number: 1999/007789/06. Companies in the Group are authorised financial services providers.Discovery Health pharmacy-clinic network virtualconsultation handbook11 September 2020Page 9 of 13Confidential

ScenarioHow the consultationwill be fundedOther services (egmedicine blood tests)Member still has funds in theirMedical Savings Account andvisits a pharmacy-clinic networkfor a consultation with a nurseWe will pay from availablefunds in the Medical SavingsAccount.We will pay from available fundsin the Medical Savings Account.Member has run out of funds intheir Medical Savings Account oris in their Self-payment Gap andvisits a pharmacy-clinic networkfor a consultation with a nurseWe will pay from the Day-today Extender Benefit.Member to pay for theconsultation themselvesMember on Saver plan has usedup all of their DEB consultationsand visits a pharmacy-clinicnetwork for a consultation with anurseMember to pay for theconsultation themselves.Member to pay for theconsultation themselvesWe will fund from the AboveThreshold Benefit.We will pay from AboveThreshold Benefit subject tospecific benefit limits.Member is in their AboveThreshold Benefit and visits apharmacy-clinic network for aconsultation with a nurseNote: The Above ThresholdBenefit on the Priority Plan islimited.Note: The Above ThresholdBenefit on the Priority Plan islimited.* Members on other schemes administered by Discovery Health do not have access to the Day-to-day Extender Benefit.How to refer a Discovery Health Medical Scheme member to ageneral practitionerREFERRALS FOR VIRTUAL CONSULTATIONS WITH A PANEL GPWhere necessary, the pharmacy nurse can refer a member for a virtual consultation with a panel generalpractitioner (GP) through Healthforce to dial in the GP. The Healthforce GP consultation portion will beclaimed separately from the nurse consultation.REFERRALS FOR FACE-TO-FACE CONSULTATIONS WITH A NETWORK GPOnly the panel GP can refer a member for a face-to-face network GP visit. To find a GP in the network,members can use the Discovery app or log into www.discovery.co.za and search for a provider by selectingMedical Aid Find a doctor Find a doctor close to you.Discovery Ltd. registration number: 1999/007789/06. Companies in the Group are authorised financial services providers.Discovery Health pharmacy-clinic network virtualconsultation handbook11 September 2020Page 10 of 13Confidential

Detailed Primary Care benefit rulesDiscovery Primary Care is a unique healthcare product that enables employers to provide their employeesand their families with affordable quality private healthcare and wellness management. There are twobenefit options: Primary Care Advanced Primary Care ActivateThe following table indicates how we will fund claims for Discovery Primary Care policyholders.How we fund pharmacy clinic claims for Discovery Primary Care policyholdersBenefitDiscovery Primary Care ActivateDiscovery Primary Care AdvancedWithout nursereferralWithout nursereferralWith nursereferralWith nurse referralNurse visitsUnlimited visits at a pharmacy inthe nurse networkUnlimited visits at a pharmacy in the nursenetworkVirtual GPconsultationsUnlimited virtual GP consultationsif referred by a nurseUnlimited virtual GP consultations if referredby a nurseUnlimited visitsat Primary Carenetwork GPsUnlimited visitsat Primary Carenetwork GPsGP visitsUnlimited visitsat Primary Carenetwork GPs ifreferred byvirtual GP.2 upfront GPvisits withoutreferralUnlimited visits atPrimary Care networkGPs if referred by virtualGP.2 upfront GP visitswithout referral*Nurse consultation virtual consultation will only accumulate to one Day-to-day Extender Benefit consultation.How to refer a Primary Care policyholder to a general practitionerREFERRALS FOR VIRTUAL CONSULTATIONS WITH A GPWhere necessary, the pharmacy nurse can refer a policyholder for a virtual consultation with a generalpractitioner (GP) through Healthforce to dial in the GP. The Healthforce GP consultation portion will beclaimed separately from the nurse consultation.Discovery Ltd. registration number: 1999/007789/06. Companies in the Group are authorised financial services providers.Discovery Health pharmacy-clinic network virtualconsultation handbook11 September 2020Page 11 of 13Confidential

REFERRALS FOR FACE-TO-FACE CONSULTATIONS WITH A GPOnly the network GP can refer a policyholder for a face-to-face GP visit. If you think a referral for a face-toface consultation with a GP is necessary, please consult with the network GP virtually for the referral. Youmust refer patients on a plan without a nurse referral to their allocated GP. If they do not have an allocatedGP, you can refer the patient to the network list on www.discovery.co.za. The same list of providers appliesfor policyholders on a plan with nurse referral. Please direct them to the closest network GP.The Discovery Primary Care network provider lists are available on our website at www.discovery.co.za.Follow these steps to find a network provider: Go to www.discovery.co.za. Select For business. Click on Primary Care. Scroll down and select Find a Discovery Network Provider. Select the appropriate network list, eg Discovery Primary Care GP Network List 2020.How to register on the Healthcare Professional Zone1.Go to www.discovery.co.za2.Click on the blue REGISTER button on the top right-hand side of the screen.3.You will need to give verification information by selecting one of the identification types from thedropdown list and then giving the relevant number.4.On the same page, select the channel that would be most appropriate to receive the PIN (personalidentification number) notification from the drop-down list. The choices are SMS or email. Please notethat if you choose SMS, the respective cellphone must be within reach and if you choose email, theemail system must be connected and open to receive the temporary PIN code that we will email. ThePIN code is a unique temporary code and expires within seven days after you received it. This code isnecessary to continue with the registration process.5.Once you have chosen the relevant notification method and confirmed the email address orcellphone number, tick the box I agree to the terms of consent then click on Send to continue withthe registration process.6.The next page will ask for the PIN code you received by SMS or email, depending on the notificationmethod that you selected in the previous step. Once you have entered the PIN code, click onContinue.7.You must select the login details on the next screen. Select a username from the suggested list orcreate one. Note that the username is a permanent feature that you cannot change. It is also casesensitive. The username must be between 6 and 15 characters. Confirm a personal password, whichmust contain at least six characters and it must be an alphanumeric combination (a combination ofletters and numbers). Please read and accept the terms and conditions erms-and-conditions.Discovery Ltd. registration number: 1999/007789/06. Companies in the Group are authorised financial services providers.Discovery Health pharmacy-clinic network virtualconsultation handbook11 September 2020Page 12 of 13Confidential

8.Once you have given all the details, simply click on the Register Now button to confirm theregistration.9.Click on Enter website. Otherwise, the system will automatically log in.If you need help with the registration, call 0860 10 06 96.Contact detailsGeneral enquiries from healthcare professionals: Primary Care enquiries: 0860 44 47 79 Discovery Health Medical Scheme enquiries: Call us on 0860 44 55 66 or [email protected] Hospital preauthorisation: 0860 44 47 79 HIV-related enquiries: [email protected] To find out who Discovery’s health partners are, visit the Discovery website at www.discovery.co.zaDiscovery Ltd. registration number: 1999/007789/06. Companies in the Group are authorised financial services providers.Discovery Health pharmacy-clinic network virtualconsultation handbook11 September 2020Page 13 of 13Confidential

Discovery Ltd. registration number: 1999/007789/06. Companies in the Group are authorised financial services providers. Discovery Health pharmacy-clinic network virtual consultation handbook 11 September 2020 Page 3 of 13 Confidential Terminology used in this document Terminology Description Above Threshold Benefit (ATB)