Chronic Medicine Authorisation

Legislation requires that all conditions, and claims submitted to Medical Schemes need to have a condition diagnostic code (ICD-10 code). The World Health Organisation developed ICD-10 codes to classify diseases. A doctor is the only person who can supply the ICD-10 code for acute and chronic medication. Legislation requires record of test results on selected conditions.The Scheme may insist on generic substitution and the use of a medicine formulary where appropriate.

Authorisation of chronic medicine will be limited to the Scheme's Chronic Medicines List (CML), subject to chronic benefits available on your elected plan option. All chronic condition/medicine registration is subject to protocols, facilitated by Medikredit.

The following conditions require a specialist to diagnose and initiate treatment:

HIV - Careworks is the Designated Service Provider (DSP). Register at 0860 10 11 10.
Oncology - Oncologist to fax treatment plan to oncology case manager at (011)-699 0402 or mail oncology@resomed.co.za.

Only electronic claims submitted from the pharmacy or dispensing doctor for chronic medicine will be settled from the Chronic Medication Benefit. Authorised chronic medication submitted on a paper claim to the Scheme will be settled from your Acute Medication Benefit and will be subject to the acute limits available.

Should you have any queries you can contact our Client Services Department at 0861 796 6400

Chronic Conditions (revised January 2006)