dental practitioners provider manual 2020
TRANSCRIPT
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
Page1of16Dental 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)
SECTION 1 (continued)
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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
SECTION 1 (continued)
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SECTION 1 (continued)
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
Page6of16Dental Provider Manual - Prime Cure Health 2020
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SECTION 1 (continued)
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
Page7of16Dental Provider Manual - Prime Cure Health 2020
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SECTION 1 (continued)
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.
Page8of16Dental Provider Manual - Prime Cure Health 2020
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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
Page10of16Dental Provider Manual - Prime Cure Health 2020
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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Page12of16
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0000
0Unit
IMSU
SRA
Consum
ables-Clin
icuseonly
PenicillinVPo
tassiumForSoln12
5MG/
5ML
OR
SOLR
AMax4fills/ann
um
PenicillinVPo
tassiumTab
250
MG
OR
TABS
AMax4fills/ann
um
SEC
TIO
N 3
- Pr
ime
Cure
Den
tal F
orm
ular
y 20
20 (c
ontin
ued)
Page13of16
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)
18.1B
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
)
Page14of16
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:
Postal Address: Code:
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:
Postal Address: Code:
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