Home | Council for Medical Schemes
Healthcare providers
Can medical schemes prescribe protocols and formularies?
Schemes can most certainly prescribe treatment protocols in terms of PMBs to improve their risk management. However, should medical schemes make use of formularies, these must be developed on the basis of evidence-based medicine, taking cost-effectiveness and affordability into account while also being on par with the gazetted algorithms for chronic diseases and the public sector protocols for the Diagnosis Treatment Pairs.
Is there a process to follow when the formulary is not effective for a specific patient?
An appeals process is in place for a medical scheme member to request his or her scheme to carry the costs for treatment outside the scheme’s formulary. It is very important that complete medical records are submitted in support of the request. As the treating doctor, it is your responsibility to record the patient’s reaction to the formulary treatment, including all efforts that were made to determine correct dosages and/or other possible contributing factors.
If the PMB codes do not always correspond with the ICD-10 codes, what do I do to ensure a correct account?
The Council for Medical Schemes has compiled a guideline on how to reconcile the two sets of codes. However, whenever there are differences between the ICD-10 codes and PMB codes, the latter takes precedence. This guideline is available on the CMS website www.medicalschemes.com under the Regulatory Info menu as “Prescribed minimum benefit ICD-10 coding”.