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B
Crated with careto suit your needs
2012 Member Guide
A C
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Crated with care to suit your needs
You shape itIt is amazing how, with the necessary care, a ew tender olds can transorm a
piece o paper into something magnifcent, like this peacock. Its the careul and
thoughtul attention to detail that makes it happen.
In the same way, by paying careul attention to your needs and listening to who you
are as a amily or individual, Liberty Medical Scheme shapes healthcare options as
a perect expression o your lie. Its about doing what we can to help your health
fourish so you can shape the lie you want.
Liberty Medical Scheme We care. For you
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Contents
Introduction 04
2012 Benefit Summary and Contributions 06
Prescribed Minimum Benefits 10
Medication 11
Preventative Care Benefits 15
Day-to-Day Benefits 18
What LMS does not cover 22
Making the most of your cover 30
Membership, Registration of Dependants, Contributions and
Debt Management
34
Additional services offered to Scheme members 42
Glossary
Contact Details
44
47
ER24
EmergencyServices
29
Pre-authorisation
In-hospitalDental
OrthodonticTreatment
Hospital/CasualtyAdmissions
Oncology
HIV/Aids
ChronicMedication
23
Major Medical Benefits
HospitalBenets
DiseaseManagementProgrammes
08
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Caring for your
needs and makinghealthcare easier
Healthcare options
relevant to each stage
of your life
Access to quality
treatment
Affordable
contributions and
real value for money
1
4
3
2
Intro
duction
4
Introduction
Liberty Medical Scheme (LMS) at a glance
Liberty Medical Scheme (LMS) is focused on oering members healthcare options that aretruly relevant to each stage of their life.
LMSshapeshealthcareoptionsthatcareforyourneedsbyprovidingqualitybenetsat
aordable prices.
Access to quality treatment
LMS is dedicated to giving you access to quality treatment and care; everything you may
need to live a full and healthy life. We want your healthcare option to enhance your life
choices and deliver the best healthcare you can aord. Most importantly, to give you
peaceofmindknowingthatcomprehensivebenetsareaccessiblewhenyouneedthem.
We provide meaningful cover according to recognised treatment protocols and constantly
updateourbenetsasnewmedicaltechnologybecomesavailable.
2
Affordable contributions and real value for money
AtLMSwebelievethatrealvalueformoneyisaboutoeringqualitybenetsthatareaordable. So even while an inflationary environment necessitates annual rate increases,
these are always kept competitive.
3
1 Healthcare options relevant to each stage of your life
Peoplehavedierentneedsatdierentlifestages.Thisfacthasveryoftenbeenoverlooked
in the healthcare industry, which is why LMS embarked on a unique market segmentation
study.Theresultsofthisstudyenabledustodevelopoptionstocaterfordierentneeds
and make them relevant to you as your requirements change.
Wealsoreviewourbenetdesigncontinuallytoensurethatwehavewhatyouneedto
make the best decisions for you and your family.
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Intro
duction
5
Caring for your needs and making healthcare easier
LMS takes its customers needs to heart and our service level is of the highest in theindustry. Members receive regular communications aimed at addressing various questions
and concerns. Inaddition, you are able toaccess up-to-date informationonour user-
friendly website www.libmed.co.za.
4
*Note:The LMS rate will indicate what the Scheme is prepared to pay in respect of a particular
service, but is not confirmation of the amount payable as this would be subject to your
entitlement to benefits in terms of the rules at the time the claim is submitted.
How does Liberty Medical Scheme set its rate?
LMS rate
TheLMSratereferstothetariwhichtheSchemewillpayforaparticularhealthcare
service (e.g. consultations, medicines, procedures, examinations, etc)
LMSconsultsandreviewstheinformationissuedbyarangeofexpertstoarriveattheLMS
rate.TheseexpertsincludeLibertyHealth,theDepartmentofHealth,theMedicalScheme
Industry and LMS actuaries. LMS also looks at various economic indicators, e.g. the current
andforecastCPIrate
TheLMSrateforeverysinglehealthcareserviceisdeterminedannually,asmedicalcosts
increase each year
Becauseofthemultitudeofhealthcareservicesitisnotpracticaltopublishalistwithallthe taris. If you or your doctor want to know what the LMS rate is for a particular healthcare
service, please call the LMS Contact Centre on 0860 002 163 and make sure you have the
treatment/taricode(s)onhand*.
Some healthcare providers charge the LMS rate and some dont:
Everyhealthcareproviderisentitledtosethis/herownfees
PleasenotethattheSchemealsonegotiatesdirectlywithcertainprovidergroupse.g.
hospitals, pathologists, radiologists, etc to ensure competitive rates for members
IfyourproviderchargesmorethantheLMSrate,youmustpaythedierencebetween
theLMSrateandthechargedamount.Pleasealsorefertothesectiononpage19
dealingwithco-paymentsrecoveredfromtheMSF. Youhavethepowertonegotiatefees.ManyproviderswillchargetheLMSrate,orat
least lower their fees, if you ask them to or if you pay cash at the time of service.
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PaidfromS
avingsexceptBonaPlus
coveredbyCareCross
Contributions
Liberty Baby Programme
International Travel Benefit Additional
Services**
2012
BenefitSummarya
ndContributions
6
2012 Benefit Summary and Contributions
Network Option Hospital
Bona Plus Gold Focus
A network of care Starting out as a family
Payment Rate 100% LMS rate 100% LMS rateHospitalisation
(sub-limits apply to certain benefits)R980 000 per family Unlimited
Hospital Network Freedom of choice Freedom of choice
Chronic Conditions Covered 27 PMBs 27 PMBs
Additional Chronic Conditions Covered
Disease Management
Casualty Benefit
Preventative Care Benefit
Day Procedures (out-of-hospital)
Crime Trauma Benefit
MRI/CT Scans (0ut-of-hospital)
Dentistry (basic and specialised)
CareCross Network:
GP Consultations
Basic Dentistry Medication
Optometry
Pathology
Radiology
Self-funded
Principal Member R 1 085 R 1 067
Adult Dependant R 831 R 900
Child Dependant*** R 318 R 405
Day-to-DayExtender
paidfromR
isk
MajorMedicalBenefits(MM
B)
*Asavingscomponentisincludedinthecontributionsoftheseoptions.**FormoreinformationontheseadditionalservicesoeredtoLMSmembers,pleaserefertopages42and43.***Childdependantmeansadependentchildundertheageof21,orachildwhoisafull-timestudent,uptoand
includingage26(proofofstudytobesupplied).
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7
ptions. Saver Options Complete Options
Platinum Focus Gold Saver* Platinum Saver* Titan* Platinum Complete*
Excellent risk cover Everything a family needs Meeting your familys needs Perfect cover for the family The ultimate healthcare option
00%/200% LMS rate 100% LMS rate 100%/200% LMS rate 100% LMS rate 100%/200% LMS rate
Unlimited Unlimited Unlimited Unlimited Unlimited
Freedom of choice Freedom of choice Freedom of choice Freedom of choice Freedom of choice
27 PMBs 27 PMBs 27 PMBs 27 PMBs 27 PMBs
37 4 37 37
elf-funded Savings
Member: R 2 496
Adult: R 2 040 Child: R 912
Savings
Member: R 2 160
Adult: R 1 932 Child: R 696
Savings
Member: R 3 084
Adult: R 2 472 Child: R 828
Self Payment Gap
Member: R 700
Adult: R 430
Child: R 160
Threshold Level
Member: R 3 784
Adult: R 2 902
Child: R 988
Threshold Limit
Member: R 3 080 Adult: R 1 820
Child: R 800
Savings Member: R 5 580
Adult: R 4 140 Child: R 1 596
Self Payment Gap Member: R 1 763 Adult: R 1 325 Child: R 514
Threshold Level Member: R 7 343 Adult: R 5 465 Child: R 2 110
Threshold LimitUnlimited:
GP Consultations Specialist Consultations Basic Dentistry Basic Radiology Pathology
Limited: All other benets
1 474 R 1 388 R 1 802 R 1 718 R 3 103
1 326 R 1 138 R 1 618 R 1 375 R 2 305
476 R 510 R 583 R 464 R 892
Please note for a more comprehensive overview of benefits you can
request a Benefit Schedule or view it on www.libmed.co.za
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Hospital BenefitsTheHospitalBenetcoversthecostofadmissionstoanyhospitalincludingprivatehospitals
(subjecttopre-authorisationandtherelevantmanagedhealthcareprogramme).LMSwillpay
the hospital bill and associated costs, e.g. specialist consultations, anaesthetists, blood tests
andx-raysfromthisbenet.Someoftheseservicesaresubjecttofurtherpre-authorisation.
Co-paymentsandsub-limitsareapplicableoncertainbenets.Formoredetailspleasevisit
the website www.libmed.co.za.
Youcanchooseanyhospitalandanyspecialist,ensuringthatyouwillreceivethequalitycare
you require.
Cover for Hospital and associated costs:
BonaPlus,GoldFocus,GoldSaverandTitancoverallcostsuptotheLMSratewhilethePlatinumFocus,PlatinumSaverandPlatinumCompleteoptionscovercostsupto2xtheLMSrate,for
certainbenets.
Sub-limitsmayapplyinrespectofcertainservices.AnycostinexcessoftheLMSrateorasub-
limit will be for the members account.
Co-payments:
Pleasereadthebelowinformationrelatingtoco-payments.
Certainhospitalproceduresaresubjecttoco-payments.Priortoahospitaladmission,please
check the option information or call the Contact Centre to establish which procedures have
co-payments.Youwillberesponsibletopaytheco-paymentdirectlytothehospitalatthe
time of your admission.
Co-paymentsareappliedtospeciedproceduresonalloptions,excludingPlatinumComplete.
Wherespeciedproceduresaredonein-hospital,youwillhavetopaytheco-paymentto
the hospital
LMSwillpayalltheotherapprovedservicesthatarerelatedtotheprocedurefromthe
HospitalBenet
Theco-paymentisnotappliediftheprocedureisdoneinthedoctorsroomsorata
registered day clinic.
Day procedures that do not attract a co-payment:
Certaindiagnosticandminorsurgicalproceduresdonotattractaco-paymentiftheyare
performedinthedoctorsroomsordayclinic.Theseproceduresare:
Diagnosticcystoscopy Proctoscopy/sigmoidoscopy
Lasertonsillectomy Vasectomy
Lumbarpuncture Colonoscopy
Needleaspirationofjoint,bursaorganglion
Majo
rMedicalBenefits
8
Major Medical Benefits
Remember: Some healthcare providers may charge more than the LMS rate, so we encourage
you to negotiate with your chosen healthcare provider and ensure that you are informed
beforehand of the fees that will be charged.
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DiseaseManagementPr
ogrammes
9
Disease Management Programmes
FormoreinformationontheCancerandHIV/Aidsprogrammes,pleaserefertopage27.
Asthma support
Most people with asthma should be able to enjoy a normal lifestyle, including getting a good
nightssleepandparticipatinginsportandothernormaldailyactivities.TheAsthmaSupport
Programmeenablesyoutoachievethisbyfocusingontheappropriateuseofmedication,whileproviding education and counselling to help you understand and manage the disease.
Thisincludes:
Howtomanageyourcondition,includingusinginhalersandpeakowmeters
Howtoreduceasthmasymptomswithoutaectingyourlifestyle
Howtoreducethenumberofhospitalandemergencyroomvisits
Diabetic support
Thisprogrammehelpsyoutocontrolyourbloodsugarandaddressesissuessuchasthe
importanceofscreeningtestsandlifestyleadjustments,whichcanimprovethewell-being
ofdiabeticpatientsvastly.Theprogrammealsoeducatesyouonthecorrectmedicinemanagement and monitoring.
Thisincludes:
Howtoachievegoodglucosecontrol
Addressingriskfactorsforcardiovasculardisease
Discussingscreeningteststhatmayhelppreventlong-termcomplications
Cardio support
If you have had angina or a heart attack, you will know how important it is to manage your
medicationproperlyandtackleanylifestylerisksyoumayhave.TheCardioSupportProgramme
provides the care and guidance you need to do this.
Thisincludes: Bloodpressuremanagementprinciples Stopsmokingprogrammes
Weight-lossprogrammes Exerciseprogrammes
Disease Management ProgrammesOurDiseaseManagementProgrammeshelpprovidethecareyouneedtoliveahealthyand
fulllife.Thereareprogrammesforasthma,diabetes,coronaryheartdiseaseandotherlifestyle
conditions such as epilepsy and bipolar mood disorders.
Case managers identify eligible candidates from members who have one of these conditions,
alsocarefullyconsideringthefollowing:
Doestheconditionseemparticularlysevere?
Isthememberhavingdicultycontrollingthecondition?
Hasthememberbeenhospitalisedasaresultofthecondition?
Youmayalsoapplyforthisbenet.
Allmemberswhoareregisteredontheseprogrammesareprovidedwitheducation,advice
and support from registered healthcare professionals, as well as with a review of the
medication currently being used.
Theprogrammewillkeepyouinformedaboutyourconditionandassistyouinmanagingyour
conditioncondentlysothatyoucanleadabetterqualityoflife.
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PMBswereintroducedintotheMedicalSchemesActtoensurethatmembersofmedical
schemeswouldnotrunoutofbenetsforthetreatmentofcertainconditions.PMBstherefore
ensure continued quality care when you need it most.
TheDepartmentofHealthtookvariousfactorsintoaccountwhendecidingonthediseasesto
becoveredunderPMBs,suchas:thenatureofthediseaseandhowthatdiseasewouldaect
the quality of life of the individual; the most prevalent conditions; the aordability of the
treatmentandthenancialimpactonmedicalschemes.
IntermsoftheMedicalSchemesAct,medicalschemeshavetocovercostsrelatedtothe
diagnosis,treatmentandcareasprescribed(bytheAct).Theseinclude:
Anyemergencymedicalcondition(thisisamedicalconditionwhichisofasuddenand
unexpected onset that requires immediate medical or surgical treatment at a time where
failure to provide this treatment would result in serious impairment of bodily functions,
serious dysfunction of a bodily organ or part, or would place the persons life in serious
jeopardy)
Asetof270medicalconditions,and
27chronicconditions.
PMBsarenotsubjecttoannualbenetlimits.PMBsarepaidfromavailablebenetlimitsand
oncetheselimitsareexceeded,fundingforfurthertreatmentofPMBconditionsiseected
strictlyinaccordancewiththetreatmentprescribedbytheAct.
EachcasewillbeassessedintermsoftheActandinaccordancewiththeSchemesmanaged
healthcare programmes and clinical protocols.
PrescribedMinimum
Be
nefits(PMBs)
10
Prescribed Minimum Benefits (PMBs)
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11
Med
ication
Medication
Generic medication
Astheexpirationdateofthepatentapproaches,anydrugmanufacturer(includingthe
one that produced the brand name version) may apply for permission to produce a
genericversionofthemedication.Companiesmakinggenericversionsdonothaveto:
Dotheresearchthatwasneededtocreatethedrugintherstplace
Putthedrugthroughclinicaltrials;or
Setupmarketingcampaignsforthegenericdrug
Eliminatingthesethreefactorsfromthecostofmanufacturingmeansagenericcanbe
sold at a far lower price than the brand name version.
A generic drug must: Containthesameactiveingredientsastheinnovatordrug(inactiveingredients
may vary)
Beidenticalinstrength,dosageformandrouteofadministration
Havethesameuseindications
Meetthesamebatchrequirementsforidentity,strength,purityandquality
BemanufacturedunderthesamestrictstandardsoftheMedicineControlCouncils
good manufacturing practice regulations required for innovator products
Medicineswithinaspecicgenericgroupareeitheridenticaltoeachother(exceptfortheir appearance or their packaging) or otherwise very similar (for example, only the
inactiveingredientsdierslightly).Thus,agivenillnesscanbetreatedwithanyone
medicine within such a group.
Brand name medication
Brandnamemedicationsaredevelopedunderpatentprotection.Adrugcompany
mayspendyearsonresearchandtestingbeforebringinganewdrugtomarket.A
manufacturers initial price for a new medication includes all the development costs it
incurred for the drug and it is therefore normally very expensive.
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LMS uses a medication formulary which is a list of prescription drugs, both generic and
brandnames,thatitwillfund.Thepurposeoftheformularyistosteeryoutothemost
cost-eectivemedicationsthataresucientlyeectivefortreatingyourhealthcondition.
Thismeansyouwillgetthequalitymedicationyouneedtocareforyourhealthbut
atareasonableandmanagedcost.Youwillpaymoreifyouandyourdoctorchoose
a medication that is not covered on the formulary. Usually, the formulary is updated
annually, although it is subject to change throughout the year.
Theextended formularyappliestoPlatinumComplete,
PlatinumSaverandPlatinumFocusoptions.Thestandard formularyappliestoTitan,GoldSaver
andGoldFocusoptions.
TheCareCross formularyappliestoBonaPlus.
Refer to the diagram below for an example of how the formulary is applied .
What will you pay for medication?
IfamemberonanyoptionbuysTabletAorB,a50%co-paymentwillbeappliedasthe
medication is not on any formulary
IfamemberonanyofthePlatinumoptionsbuysTabletsCGaco-paymentwill not
apply as they are on the extended formulary
IfamemberonanyoftheotheroptionsbuysTabletsCE,a50%co-paymentwill be
applied as the medication is not on the standard formulary, but if a member buys
TabletForGnoco-paymentwillapplyastheyareonthestandardformulary.
Med
ication
12
Medication (cont.)
In- and out-of-formulary medication
Out-of-formulary
Generic TabletR 180for30tablets
B
Brand Name Tablet
R 200for30tablets
A
Generic Tablet
R 160for30tablets
Generic Tablet
R 140for30tablets
D
Generic Tablet
R 120for30tablets
E
Generic Tablet
R 80for30tablets
G
Generic Tablet
R 100for30tablets
FC
Standard formulary(Titan, Gold Saver, Gold Focus)
Extended formulary (Platinum Complete, Platinum Saver, Platinum Focus)
Note:Please refer to
www.libmed.co.za underthe Member section for
the formulary lists.
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Med
ication
13
How does your chronic medicine cover work?
ClinicalprotocolsandguidelineswillapplytothetreatmentofachronicconditionlistedontheChronicConditionsList(CDL)-standardandextendedformularies
Medicationontheformulary,authorisedbyChronicMedicineManagement,willbe
reimbursedsubjecttotheMaximumMedicineReferencePrice(MMRP)
Medication(otherthanforPMBs)notontheformularywillnotbecovered
IfmedicationisforaPMBconditionandvoluntarilyobtainedfromaproviderotherthanan
approvedDSP,thenaco-paymentof50%willapply
IfmedicationisforaPMBconditionandtheformularyincludesanappropriatedrug,but
youvoluntarilychooseanotherdrugoutsideoftheformulary,thenaco-paymentofthe
greaterof50%oftheamountchargedortheamountthatwouldhavebeenpayableinrespect of the formulary drug applies
Theco-paymentinrespectofPMBmedicineistobepaidatthepointofservice,asbylaw
itmaynotbepaidfromyourMSF.
Medicine exclusions
Certainmedicinesareexcludedforpaymentfromtheacuteorchronicmedicationbenetfor
variousreasons.Theseinclude:
Medicationnotproventohaverelevantclinicalvalue
Medicationthatismoreexpensivethanequallyeectiveandsafealternatives
Medicationpronetoabuse
Somecombinationproducts,whereitismoreappropriatetousesingleingredientproducts
Newly-registeredproductsunderreview
Someexpensivechronicmedicationissubjecttostrictclinicalprotocolsandguidelinesand
requires additional authorisation.
Note:LMS has adopted industry-related Maximum Medicine Reference Pricing (MMRP) to help us
manage the costs of prescription medication. The Maximum Medicine Reference Price is a reference
pricing system that uses a benchmark (reference) price for generically similar products.
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Pharmacy Group Retail
pharmacyservices
Courier
pharmacyservices
**Acute
medicines
**Chronic
medicines
Customer Care Line and Website
Clicks
(including
directmedicines)
Yes *Yes Yes Yes 0860254257
www.clicks.co.za
Dis-Chem Yes No Yes Yes 0800201170
www.dischem.co.za
MediRite
(in Checkers &
Shoprite stores)
Yes No No Yes 0219835119
www.medirite.co.za
Pharmacy Direct No Yes No Yes 0860027800
www.pharmacydirect.co.za
Scriptnet Yes No Yes Yes 0105910150
www.scriptnet.co.za
We Care Yes No Yes Yes 0878093122
www.we-care.co.za/store-locator.php
Pharmacy Preferred Provider Network
LMS has negotiated preferred rates with these providers to help you save on dispensing fees.AsanLMSmemberyoucanuseanyserviceprovider,butitisinyourbestintereststousea
PreferredProviderwhereverpossibletoavoidorlimitco-payments.
LMS has contracted with the following pharmacies for chronic and acute medication and will
pay up to the maximum negotiated dispensing fee.
Pharmacy Designated Service Provider Network
TheSchemehasappointedPharmacyDirectastheDSPforallanti-retroviralmedication.
Clicks(includingdirectmedicines)hasbeenappointedastheoncologyDSPtotheScheme.
MembersontheBonaPlusoptionmustcontactCareCrossforthedesignatedpharmacy
serviceprovidersforthisoption.Refertopage47formoreinformation.
Med
ication
14
Pharmacy Service Providers
*Normalcourierordeliveryofpatient-readyparcelatClicksstores.
**Uptothemaximumnegotiateddispensingfeeof26%/R26limit.
Medication (cont.)
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Benets Agelimits Gender Nappi
codes
Description
PapSmear 18-60years Females 4566
4559
Vaginalorcervicalsmears
Note4559paidattheequivalentvalueof4556
Cholesterol From16years All 4027 Cholesterol
BloodGlucose All All 4050
4057
GlucoseStrip-test
Glucose:Quantitative
Immunisation for
Children
Uptoage5 All Seetable2 Seetable2
FluVaccinations All All 700767
702733
732818
732826
812307
813338
836591
838853
711345
711737
HiberixSglDose0.5ml+SalineDiluent
X-uprelled0.5mlsyringe
Inexal0.5mlVac
Inuvac0.5ml
AgrippalS10.5mlprelledSyringe
VaxigripSingleDose0.5mlprelled
VaxigripSingleDose0.25mlprefPaed
MutagripSingleDose0.5mlprefAdult
Fluvax
Fluarix
HIVTest All All 3932
4614
0016
0017
Antibodiestohumanimmunodeciencyvirus(HIV):ELISA
RapidBloodTest
Pre-testcounselling
Post-testandcounselling
TBTest All All 0221
872938
882348
Allergy:Skin-pricktests
Tuberculinppdrt/23-15tests(10x1.5ml)
Biocine
BoneDensityTest
onceevery3years
From50years Females 3604
39173
50120
Bonedensitometry
Bonedensitometry
X-raybonedensitometry
15
Prev
entativeCareBenefi
ts(PCBs)
Thisbenetfocusesontheearlydetectionofseriousmedicalconditions.Earlydetectionwill
help you stay healthy, which is why LMS will cover a variety of screening and diagnostic tests
as well as vaccinations.
LMSwillpayforthersttestorimmunisationperbeneciaryineachofthebelowmentioned
categoriesatthelesserof100%ofcost,MaximumMedicineReferencePriceoruptotheLMS
rate.Specicimmunisationsforbabiesandchildrenarelistedseparately.
Thebenetdoesnotcovertheconsultationcostassociatedwiththetestorotherassociated
costs.Thesecostswillbepaidfromtheavailableday-to-daybenetsorwillbeself-fundedby
the member.
LMS covers you and your family for the annual screening and diagnostic tests and vaccinations
listedbelow:
Preventative Care Benefits (PCBs)
Table 1: Preventative Care Benefits
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16
Prev
entativeCareBenefi
ts(PCBs)
Preventative Care Benefits (PCBs) (cont.)
Benets Agelimits Gender NAPPIcodes
Description
ProstateTest
onceevery3years
From45years Males 4519 Prostate-specicantigen
Mammogram
onceevery2years
From40years Females 3605
34100
39175
Mammography:Unilateralorbilateral,includingultrasound
X-raymammographyincludingultrasound
Mammography:Unilateralorbilateral
ChlamydiaTest From25years Females 3906 Identication:Chlamydia
EyeTest
1peryear
(onlyGoldSaver
option)
Child
Dependant
under the age
of21
All 11001
11081
11021
11041
OptometricExamination
OptometricExamination&VisualFields
OptometricRe-Examinationwithinsixmonthsof
11001/11081
Consultation:15min.withoutperformingOptometricExam
DentalCheck-up
1peryear
(onlyGoldSaver
option)
Child
Dependant
under the age
of21
All 8101
8901
8104
Oralexamination
Consultation at consulting rooms
Limited oral examination
Table 1: Preventative Care Benefits (cont.)
Table 2: Vaccinations available to babies and children
*MeaslesonlyORMeasles,MumpsandRubellavaccinationmaybegiven.
Pleasenotethatconsultationsassociatedwiththeabovetestsandimmunisationsdonotformpartofthisbenet.
Vaccine method
Age of child
At
birth
6
weeks
10
Weeks
18
Weeks
9
Months
12
Months
14
Months
>5
Years
BCG(upperarm);Polio(dropspermouth)
Polio(dropspermouth)Diphtheria;
TetanusandWhoopingCough;HepatitusB;
HaemophilusInuenzaeB(injection
to thigh)
Polio(dropspermouth)Diphtheria;TetanusandWhoopingCough;Measles*(injection
to thigh)
Polio(dropspermouth)Diphtheria;Tetanus
(injection to thigh)
ConjugatedPneumococcalVaccine
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17
Prev
entativeCareBenefi
ts(PCBs)
Nappi Codes are supplied to assist you in the billing process
Note:Please call the LMS Contact Centre on 0860 002 163 to confirm the correct Nappi Code
before your appointment. The list of vaccinations and immunisations is a guideline only and
is subject to change.
Nappi Code Description Immunisation Type
700210
700356
701658
701659
730394
731501
869317
Engerix-b(new)monodose1ml
Engerix-bpaed(new)monodose0.5ml
Heberbiovachbsgldose0.5mlpaediatric
Heberbiovachbsgldose1mladult
H-bvaxvaccine
Hebagamim(HepatitisBigim)
Hebagamim(HepatitisBigim)
HepatitisBVaccine
811165
825522
Moraten berna c syringe
Rouvax sgl dose syr
MeaslesVirusVaccine
700772
792004
879452
Priorixsgldose0.5mlw/pfsyr+dil
Trimovaxsingleprelledsyringe
Morupar single dose
Measles,Mumps&RubellaVirusVaccine(MMR)
888559
812919
804150
832693
832707
Tetagamim2ml
TetagamIm2ml
TetagamIm1ml
Tetavaxsingledosesyringe0.5ml
Tetavaxvial40iu/0.5mlvac
TetanusVaccines
872962
882348
Bcgintradermalinfant20dose
Biocinetest-ppdmultipuncturedevice
TuberculosisVaccines(BCG)
703226
700767834203
Actacel-pasteur0.5ml
Hiberixsgldose0.5ml+salinediluentCombact-hibsingledosesyringe
HaemophilusInuenzaeBVaccines
700773
700768
707522
707285
713229
711258
Infanrixdtpahb1mlprelledsyringe
Tritanrix-hb0.5mlsingledose
Pentaximprelledsyringe0.5ml
InfanrixHexa
AdacelQuadra
Tetraxim
Diphtheria-HepatitisB-Pertussis-Tetanus
Combinations
703335
708854
812331
823678
Tdpolio0.5ml
ImovaxPolio
Polioral10dosetrivalent
Opv-merieux10dose
PoliovirusVaccine
703367
842443
Diftavaxprelledsingledosesyringe
Dtvax0.5mlsingledose
Diptheria-TetanusToxoid(DT)
703994
825158
707285
Infanrixprelledsyringe0.5ml
Dtp-merieuxsingledosesyringe
InfanrixHexa
PertussisVaccines
705032
714999
715858
Prevenar
Synorix0.5mlprelled
Prevenar13
PneumococcalVaccines
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Day-
to-DayBenefits
18
Yourday-to-daybenets(MedicalSavingsFacilityandThresholdBenet)areusedtocover
thecostsofeligibleexpensessuchas:
GPandspecialistconsultations
Routinemedication
Optometry
Pathology
Basicradiology
Alternativetherapies
Mentalhealth
Auxiliaryservices
Basicandspecialiseddentistry(excludingTitan)
Day-to-Day Benefits
1
2
3
Medical
SavingsFac
ility
SelfPayment
Gap
Thresho
ld
Beneft
ThresholdLe
vel
ApplicableonlyonPlatinumComplete,
PlatinumSaver,TitanandGoldSaveroptions.
Yourday-to-dayclaims(e.g.consultations,
optometry and dentistry) are paid fromyour savings.
Medical Savings Facility (MSF)
ApplicableonlyonPlatinumCompleteand
Titanoptions.
When your savings are depleted, you will have to
payyourday-to-dayexpensesoutofyourpocket
untilyoureachtheThresholdLevel.OnlycertaintypesofclaimsaccumulatetotheThresholdLevel.
Ensurethatyousubmitallyoureligibleclaimsto
LMSwhileyouareintheSPG.
Self Payment Gap (SPG)
ApplicableonlyonPlatinumCompleteand
Titanoptions.
Thisisasafety-netthatprovidescoverfor
yourday-to-dayexpensesonceyoursavings
havebeendepletedandyourtotalday-to-dayclaimshavereachedthepre-determined
ThresholdLevel.
Threshold Benefts (THB) paid at 100% LMS rate
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19
Day-
to-DayBenefits
Medical Savings Facility (MSF)
ApplicableonlyonPlatinumComplete,PlatinumSaver,TitanandGoldSaveroptions ThisisaseparatepersonalMSFinwhichfundsareheldforyouandyourdependants
exclusive use.
Availability of annual savings
TheannualMSFismadeavailableinadvanceforimmediateuse
Theamountavailabletopayforbenetsconsistsofpositivesavingsandcreditsavings.
Credit savings (advanced annual savings) may not be utilised to pay for claims arising priortothestartofthenancialyear
TheMSFispro-ratedformembersjoiningLMSafter1Januaryinaccordancewiththe
number of months remaining in the year
Astheyearprogresses,themonthlycontributionstothesavingsfacilityareosetagainst
this advanced credit amount
TheMSFispro-ratedifadependantresignsduringthebenetyear.
Positive savings can be used to pay for: Eligibleday-to-dayexpenseswherebenetlimitshavebeenexhausted
Co-paymentsapplicabletoin-hospitalproceduresmaybeclaimedfromapositive
savings balance
ThesepaymentswillnotaccumulatetotheThresholdLevel(whichappliesonlyto
TitanandPlatinumComplete).
A percentage of the total contribution is allocated to the MSF:
Option MSF Allocation
PlatinumComplete 15%
PlatinumSaver 10%
Titan 15%
GoldSaver 15%
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The Self Payment Gap
WhenthefundsinyourMedicalSavingsFacilityaredepleted,youwillgothroughaperiod
duringwhichyouneedtopayforclaimsforday-to-daytreatmentfromyourownpocket.This
iscalledtheSelfPaymentGap.WhenyouareinyourSelfPaymentGapyoumustcontinueto
submitclaimstotheSchemeeveniftheclaimsarepaidfromyourownpocket.TheSchemewill
keeptrackoftheseout-of-pocketexpensesuntilyoureachapre-determinedThresholdLevel.
The Above Threshold Benefit
OnceyoureachyourThresholdLevel,theSchemewillpayfurtherclaimsforday-to-day
treatmentfromtheAboveThresholdBenet.ClaimsarepaidfromtheAboveThreshold
BenetaccordingtotheSchemerateandsubjecttocertainbenetsub-limits.
Day-
to-DayBenefits
20
Day-to-Day Benefits (cont.)
The funds in the Medical Savings Facility (MSF) remain in your name at all times
Anypositivebalanceleftoverattheendofeachyeariscarriedovertothefollowing
year after four months
Ifyouresignyourmembershipandbecomeamemberofanothermedicalscheme
on a savings option, the positive balance will be transferred to your new scheme
fourmonthsaftertheresignationdate.Youneedtosupplyyournewschemes
information, bank details and your new membership number to LMS to make this
transfer possible
Ifyouresignyourmembershipanddonotbecomeamemberofanothermedical
scheme or if you become a member of a scheme on an option that does not providea medical savings facility, any positive balance will be refunded to you after four
months from the resignation date
Ifyouareonasavingsoptionandyoumovetoanon-savingsoptiononLMS,any
positive balance will be refunded to you four months after the resignation date
Ifyouhaveanegativesavingsbalancewhenyouresignyourmembership,youwill
need to pay this balance back to the Scheme by date of resignation
Ifyouhaveanegativesavingsbalanceattheendoftheyear,youwillneedtopay
thisbalancebacktotheSchemeby31December
Anyamountsduebyamemberwillbeo-setagainstanypositivesavingsbalance
on resignation.
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Day-
to-DayBenefits
21
Note:Ensure that you submit all your eligible claims to LMS while you are in the Self
Payment Gap. This will ensure you reach the Threshold Level so that your Threshold Benefit
becomes available.
There are a few important things you should know about the
Self Payment Gap and the Above Threshold Benefit TheAboveThresholdBenetisonlyavailableonthePlatinumCompleteandTitan
options
TheThresholdLevelyoumustreachtobeabletoclaimfromtheAboveThreshold
BenetisjustthesumofyourMedicalSavingsFacilityandyourSelfPaymentGap.
Theseamountsaredeterminedatthestartoftheyearandarebasedonthenumberof
dependants you have
IfyoujoinedtheSchemeduringtheyear,yourMedicalSavingsFacility,SelfPayment
GapandThresholdLevelwillbepro-ratedbasedonthenumberofmonthsleftinthe
yearatthetimeyoujoinedtheScheme.However,ifyoujoinedafter1Octoberyour
benetswillbepro-ratedasifyoujoinedon1October
CertainexpenseswillnotbetakenintoaccountwhentheSchemedetermineswhether
ornotyouhavereachedyourThresholdLevel.Thisincludesexpensesinexcessofthe
Scheme rate, expenses for medication in excess of the Maximum Medicine Reference
price,expensesformedicationdispensedover-the-counter,expensesinrespectof
Schemeexclusionsandclaimsinexcessofbenetsub-limits.Pleasecontactthe
Schemes Contact Centre for further information.
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Likeothermedicalschemes,therearecertainbenetsthatLMSdoesnotcoveratall.Belowis
alistofthemostcommonexclusions.Forafulllist,pleaserefertotheRulesofLMS.Forfurther
information please call the LMS Contact Centre on 0860 002 163.
Wha
tLMSdoesnotcove
r
22
What LMS does not cover
Summary of most common exclusions
4Dpregnancyscans(unlessauthorisedfor
certain medical conditions)
Abdominoplasties
Allcostsrelatedtowilfully-orself-inicted
injuries
Anabolicsteroids
Anti-addictionandanti-habitagentsAppointmentsnotkept
Aphrodisiacs
Aromatherapy
Arttherapy
Articialdiscreplacements
Autopsies
Ayurvedics
Backrests,chairseats,beds,mattresses,
orthopaedic shoes and boots (unless
specicallyauthorised)
Breastaugmentationandreductions
Bulk-formingandstimulantlaxatives
Circumcisionsfornon-medicalreasonsapart
from newborns
Cochlearimplants
Cosmeticprocedures
Cosmeticpreparations,emollients/
moisturisers
CPAPmachine
Dentalimplants
Drugsforthetreatmentofimpotenceandsexual dysfunction
Depilationtreatment(hairremoval)
Erectiledysfunctionsurgicalprocedures
Erythropoietin
Eveningprimroseoilandsh-liveroil
preparations and combinations
Feeschargedforwritingofmotivations
Food,nutritionalsupplements
Frailcare
GenderrealignmentGrowthhormones
Harvestingoforgansfromadonorwhoisnot
amember/dependantoftheScheme
Humidiers
Hyperbaricoxygentreatment
Immunosuppressivesandimmunostimulants
Infertilitytreatment,reversalofvasectomy
and reversal of tubal ligation
Iridology
Keloidsurgeryandrevisionofscars,exceptfollowing burns or for functional impairment
occurring during the period of cover under
LMS
Massages
Medicatedshampoosandconditioners
Morethanonespouse/common-lawspouse
MRI/CTscansorderedbyaGP
Obesity-relatedsurgicaltreatment
Organdonationstoanypersonotherthana
member or dependant of LMS
Orthodontictreatmentovertheageof21
years
Orthognathicsurgery(tocorrectjaw
misalignment)
Otoplasties
Pain-relievingmachines
Reexology
Repairstodevicesorprosthesis
Rhinoplastiesforcosmeticpurposes
Sleepstudiesandsleeptherapy
SlimmingpreparationsSoaps,scrubsandothercleansers
Sunglasses,readers,repairstospectacle
frames, coloured contact lenses
Sunscreenandsun-tanningpreparations
Surrogatepregnancies
Telephoneconsultations
Topicalandoralacnepreparations
Travellingexpenses
Veterinaryproducts
Vitaminandmineralsupplements
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23
Pre-authorisation
Pre-authorisation
Why do I require pre-authorisation? Thepre-authorisationprocessalertsLMSthatamember/dependantisscheduledfor
hospitalisation
Themember,doctorandhospitalcanbeinformedbeforehandtowhatextentthetreatment
will be covered by LMS
TheprocessenablesLMStocurbever-increasingmedicalcostsasmembersbenetscanbe
managedinsuchamannerthatthemostappropriateandcost-eectivetreatmentisused
Bycomplyingwiththeprocessofobtainingpre-authorisation,youareassistingtheScheme
in managing these costs, ultimately improving LMS reserve levels and containing increases
in monthly contributions
Pre-authorisationisgrantedbasedonmembershipvalidity,clinicalappropriateness,levelof care, length of hospital stay, Scheme Rules, evidence based on clinical guidelines, the
SchemeRulesandeligibilityforbenets.
Anyemergencymedicalconditionisamedicalconditionwhichisofsuddenand
unexpected onset that requires immediate medical or surgical treatment where failure
to provide this treatment would result in serious impairment of bodily functions, seriousdysfunction of a bodily organ or part, or would place the persons life in serious jeopardy.
What is the definition of an emergency?
Additionalinformationmightberequiredpriortotheauthorisationnumberbeinggranted.
Why at least 48 hours in advance?
In an emergency, the hospital will phone, but the responsibility rests ultimately with
you, the member.
What happens if I am admitted in an
emergency situation and cannot phone?
Pre-authorisation is required for:
PlannedHospitalAdmissions
Casualty/MedicalEmergencyAdmissions
MRI/CTScans
OrthodonticProcedures
In-hospitalDentistry
PshychiatricAdmissions
Prosthesis,etc.
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LMS will pay only if you obtain authorisation
TheauthorisationprocessallowsLMStoensurethatyouareprovidedwiththemostappropriate treatment at the most appropriate cost. It also enables us to monitor the quality
of care you receive.
Pre-authorisation
24
Pre-authorisation (cont.)
In-hospital Dental Pre-authorisation
Remember: Youalsohaveaccesstothein-hospitaldentaltrauma
benet,whichprovidescoverfortreatmentrequiredasaresultof:
Facialfractures
Cancers
CongenitalabnormalitiesinthecaseofchildrenbornintoLMS
Orthodontic treatment(Gold Saver, Titan, Platinum Saver and Platinum Complete options)
LMScoversorthodontictreatmentfordependantsyoungerthan21.Theorthodonticquote
andmotivationmustbesenttoobtainpre-authorisation.
ForbeneciariesjoiningLMSaftertreatmenthascommenced,theauthorisationwillbebased
onthetreatmentplanandbenetsapplicablewhentreatmentrstcommenced.
Authorisation (A written quote and motivation must be submitted)
GoldSaver,PlatinumSaverandPlatinum
Complete:contact LMS
Contact Centre 0860002163
Email [email protected]
Titan:contact Dental Risk Company (DRC)
Contact Centre 0861115057
Email [email protected]
Note:Gold Saver and Platinum Saver: Payment is subject to the availability of savings.
Titan: Paid from Day-to-Day Extender, subject to DRC protocol.
Platinum Complete: Payment is subject to MSF and Specialised Dentistry Benefit.
Accountsfromthehospital, dentist and anaesthetist are payable from the hospital
benetsubjecttocertainsub-limits.Thefollowingdentalproceduresarecovered:
Basicdentistryundergeneralanaestheticforchildren8yearsandyounger
Apicectomies
Removalofimpactedwisdomteeth(co-paymentapplicableoncertainoptions)
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Contracted Service Providers:
Optometry Benets: Preferred Provider Negotiators (PPN)(Titan option only)
ThePPNnetworkconsistsofcloseto1900optometrists,givingyouaccesstooptometrists
across the country. Members qualify for substantial cost savings if they use a
PPNprovider.
Pleasevisitwww.ppn.co.za or contact PPN on 086 010 3529tolocateaPPNoptometristin
yourareaortoassistwithinformationonyourbenetavailability.
Dental Benefits: Dental Risk Company (DRC)(Titan option only)
TheschemehascontractedwithDRCtoprovidedentalmanagementservices.Basicdentistry
iscoveredat100%ofLMSrateandbasicdentalconsultationsarelimitedto1perannum
perbeneciary.
PleasecontactDRC on 086 111 5057 or via email at [email protected], to assist with
informationonbenetavailability/authorisationrequirementsforadvanceddentistryprocedures.
Pre-authorisation
25
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Pre-authorisation
26
Pre-authorisation (cont.)
1
Note:While every eort is made to establish member eligibility and availability of funds,
authorisation is not a guarantee of payment. Although benefits are not payable while a waiting
period is still in force, a member needing emergency trauma treatment within the general waiting
period may be covered subject to the Rules of LMS and benefits of the relevant benefit option.
When your request is authorised, you will receive:
Anauthorisation number
Theapprovednumberofdaysinhospital(ifastayisrequired)
ThetariandICD-10code(s)
4
If your hospital stay is extended, the hospital case manager will inform LMS.
Fundingforadditionaldayswillbeapprovedif:
Therequestmeetsclinically-appropriatecriteria
ItiswithintheSchemeRules
Benetsareavailable
5
Planned Procedures
ContactLMSatleast48hourspriortoadmission.
Casualty Medical Emergency
ContactLMSforpost-authorisationwithin48hoursofadmissionor,ifitisa
weekendorpublicholiday,ontherstworkingday.Ifnotauthorised,paymentwill
besubjecttoyourday-to-daybenets.
Tel 0860002163
Email [email protected]
3 The following information MUST be provided:
Membership number
Patient:nameanddateofbirth
Treatingdoctor:name,telephonenumberandpracticenumber
Hospital:nameandpracticenumber
Reasonforadmission/casualtyvisit
Codes:TariandICD-10code(s)
Dateofadmissionandproposeddateoftheprocedure
If the procedure(e.g.MRIordialysis)willbeperformedoutsidethehospital:
the providers name and practice number
How to request Authorisation for hospital admissions
Ifpre-authorisationisnotobtained,claimswillnotbepaid.Thisdoesnotapply to emergencies.
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Pre-authorisation
27
Note:In addition to the authorisation from the LMS Oncology Management team, you will also need to getseparate pre-authorisation from LMS for any hospitalisation, specialised radiology (e.g. MRI/CT scans and
angiography) or private nursing/hospice services which you may need during the course of your oncology treatment.
LMSprovidesanOncologyProgrammetoassistinthecareofmembersreceivingcancertreatment.
Thefollowingprocessneedstobefollowedforoncologyauthorisations(applicabletoall
optionsincludingBonaPluswhichissubjecttotheDSPIconNetwork):
Upon diagnosis, the doctor sends a treatment plan to LMS, by calling 0860 002 163
oremailing:[email protected]
Thetreatmentplanisreviewed.Ifnecessary,LMScontactsyourdoctortodiscuss
alternativesthatmaybemoreappropriateorcost-eectiveforyou.2
Anauthorisationletterwillbesenttoyouandyourdoctorstating:Anauthorisationnumber
Thetreatmentforwhichfundingisapproved
Thequantitiesforwhichfundingisapproved
Theperiodforwhichtheauthorisationisvalid
3
YourdoctormustadviseLMSofanychangeinyourtreatment.Failuretodothis
mayresultinaclaimbeingrejectedoritbeingpaidfromanincorrectbenet(e.g.
yourMSForotherTHB),astherewillnotbeamatchingoncologyauthorisation.
4
Oncology Pre-authorisation
Member and doctor complete the application formSendtheform,prescriptionandbloodtestresultstoAfA.
2
AfA reviews the application
AfAdiscussesthetreatmentplanwithyourdoctor.3
AfA sends a treatment plan to your doctor setting out your treatment plan,medication, monitoring schedule and any other requirementsAdedicatedcasemanagerwillcontactyouonaregularbasistoprovideyou
with assistance, support and advice about your condition and will reinforce the
importance of using your medication correctly and of having the correct blood
testsdonerelatedtoyourdisease.Condentialityisguaranteed.
4
Note:Anti-retroviral medication is to be obtained via Pharmacy Direct, the Designated Service Provider.
HIV/Aids Registration
The member/doctor can contact AfATel 0860100646 Fax 0800600773Email [email protected]
1Website www.aidforaids.co.zasms (call me) 0834109078
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Pre-authorisation
28
Pre-authorisation (cont.)
Chronic Medication Pre-authorisation
ThisprocessisapplicabletoalloptionsexceptBonaPlus.MembersonBonaPlusmustcontact CareCross.
Followthefollowingprocessfor:
First-timeapplicants
Changesandadditionstocurrentauthorisation
Change in your authorised chronic medication
NotifyLMSChronicMedicineManagementofthechange
YourChronicMedicineSpecialistwilladviseyouoftherequirements,ifany,togetthechanges
activated.Additionaldocumentation,dependingonclinicalprotocols,mayberequired
Ifthemedicineisnotcovered,itmaybeduetothefactthatthemedicinesarenot
covered in the formulary or fall outside of the medicine management clinical protocols.
Doctor/Pharmacist contacts LMS Chronic Medicine Management
Tel 0860002163
Fax 0216577681
Email [email protected]
Doctor/Pharmacistsubmitsspecicinformationrelatingtoyourconditionandmedication.
1
The application is reviewed by LMS Chronic Medicine Management
Pharmaceuticalexpertsreviewtherequestand,ifnecessary,yourdoctorwillbe
contacted for additional information.
2
If everything is in order, authorisation is given
Themedicinescanbedispensed,providedyouhaveahand-writtenscriptfrom
your doctor for the medicines listed as per your authorisation.
Youcanviewyourauthorisationonwww.libmed.co.zaorbysendingablankemail
3
Your request is declined e.g. not in formulary or insufficient information
Aletterofexplanationwillbesenttoyouandacopytotheprescribingdoctor.In
the case where a request was declined pending certain information, please ensure
that the doctor provides the requested clinical information (where relevant).
Foronlineclinicaldecisions,yourdoctorshouldcontacttheChronicMedicine
ManagementContactCentre.Yourrequestwillbereconsideredonceallthe
relevant information has been received.
4
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ER24
29
Note:If for some reason a service provider other than ER24 was used for emergency
transportation, you are still required to inform ER24 of the emergency.
ER24 contact details
Medical emergencies in South Africa084124
Medical emergencies in Lesotho and Swaziland+27(0)102053081
Websitewww.er24.co.za
Cover for Emergency Services (RSA, Lesotho and Swaziland)
AsamemberofLMSyouhaveaccesstotheER24EmergencyContactCentreforthemanagement of any medical emergency.
Thisincludes:
24-houremergencyresponseinrapidresponsevehiclesbyroadandwherenecessary,
air ambulance
24-houremergencytelephonicmedicaladvicewhileparamedicsareresponding
Emergencytransportationtotheclosestandmostappropriatehospital
24-hourCrisisCounsellinglinewheretrainedhealthcareprofessionalswillassistwith
issuessuchasHIV/Aids,trauma,bereavement,rape,etc.
24-houractivationofamedicalemergencybycalling084124
Treatmentandstabilisationatthesceneoftheemergencybeforetransporttoan
appropriate hospital.
ER24
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Tips when consulting providers:
Askyourdoctorifhe/shechargesLMSrates.(Thedoctorshoulddiscloseto/informyouupfrontoftheratesthatwillbecharged).Ifhe/shedoesnotchargeLMSrates,thentryto
negotiate a lower fee or oer to pay a discounted fee in cash upfront, which you can then
claim back from LMS
CheckyourmonthlyclaimsstatementtoseeifthedoctoractuallydidchargeLMSrates.If
yes, then the amount charged will be reflected as equal to the tari amount
Ifyourdoctorasksforbloodtests,conrmthatallthetestsaremedicallynecessary.Ifyou
hadasimilartestdonerecently,informyourdoctorandndoutifare-testisstillnecessary.
Selecting a service providerBesidesevaluatingthemedicalcredentials,experienceandreputationofyourmedical
providers,considerthefollowing:
DotheychargeLMSrates,ordotheychargeatahigherfeestructure?
Willtheygiveyouadiscountforimmediateorearlypayment?
Dotheyrequirepaymentatpointofserviceorwilltheysendyouanaccount?
AretheyelectronicallylinkedtoLMS,whichwillensurequickandecientsettlementofclaims?
Remember: Itmaybeworthseekingasecondopinionbeforeincurringsignicantcostsor
consentingtosurgery.Also,consultageneralpractitionerbeforegoingtoaspecialist.
Visits to providers charging/not charging LMS rates
ProviderswhodonotchargeLMSratesusuallyrequireyoutopaytheaccountupfrontandclaim
themoneybackfromyouravailablebenets.Alwaystrytonegotiateadiscountforearlypayment
ProviderswhochargeLMSratesmayprefertobepaiddirectlybyLMS.However,theymaystillrequireyoutopayupfrontandclaimbackfromLMSafterwards
Ifyouarerequiredtopaytheaccountupfrontandclaimthemoneybackfromyour
availablebenets,pleaserefertothesectionHowtoclaimonthefollowingpage.
Third Party Claims
PleaseinformLMSwheneveranotherpartymaybeliableformedicalexpensesincurredasaresult
of injuries. If you are treated for injuries due to an accident at work, these costs should be covered
byworkmanscompensation.PleaseconsultyourHRconsultantforassistanceinthisregard.
Ifyouaretreatedforinjuriesresultingfromamotoraccident,youmustcompleteanAccident
Report form which will be forwarded to you on request.Makingthemostofyourcover
30
Making the most of your cover
Note:When medication is prescribed, always ask if a generic is available.
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When to expect paymentLMShasaweeklypaymentcycletobothmembersandproviders.Thepaymentofyourclaimsis
subjecttothecorrectinformationbeingsuppliedandmeetingsubmissioncut-otimes.
PleasecontactLMSforassistancewhensubmittingyourclaimtotheRoadAccidentFund.LMSwill
liaise directly with the person or institution involved. If LMS has settled the claim on your behalf,
youmustreimbursethisamounttoLMSwhenyoureceivepaymentfromtheRoadAccidentFund.
PleasenotethatyourclaimswillnotbepaiduntilthecompletedAccidentReportForm
issubmittedtoLMS.TheMotorVehicleAccidentRecoveryUnitcanbecontactedon
(011) 669-3166/7 or (011) 669-3169.
How to claim
Wehavemadetheclaimsprocessassimpleaspossibleforyou.Therearehoweversome
rules pertaining to claiming from LMS and vital information is required when claiming that
youneedtobeawareof.Wehavelistedthesebelow:
Makingthemostofyourcover
31
Claiming from the Scheme
Information that must be on
the claimWhat you need to check Sending claims to us
Thecorrectmembership
number
Membernameandinitials
Fullnameofthepatient
Dateofbirthofthepatient
Thecorrectdependantcode
Thedateofservice
Thetari(procedure)code
Theamountcharged
ICD10codeoneveryitem
listed on the claim
Theserviceprovidersname
and practice number
Theclaimmustbelegible
Attachreceiptifyouhavesettled
the account. It needs to be
clearlymarkedasPaid
Makeacopyoftheclaimfor
your own records
Electronically
Post
Most service providers have
the ability to send claims to us
electronically, ensuring a very
short processing time
PrivateBagX35,Claremont,7735
Vital information for claiming:
Ifyourproviderhasclaimedfromuselectronicallyandyoureceiveacopyoftheclaim
(for your information), you do not have to send us the copy
Shouldyourproviderexpectyoutoclaimfromus,pleasesendusafully detailed and
signed claim (not just the receipt). We need the details of what is being claimed to
make sure that we capture and process your claim quickly and correctly
Yourclaimshavetobereceivedbyuswithinfourmonthsfromthedatetheservice
wasprovided,pleaserefertopage32:StaleClaims.
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Whatweneedifyouaddorchangeyourclaimsrefundbankaccountdetails:
Asignedletterfromthememberconrmingthebankdetails
Acopyoftheaccountholdersidentitydocument
Abankstatementoraletterfromthebankconrmingtheaccountnumber.
How will I know what was paid?
Anelectronicmini-statementand/orSMSwillbesenttoyouonceaclaimisprocessed
(Pleaseensurewehaveyourcorrectemailaddressand/orcellphonenumberonourrecords) Youcanalsoviewyourstatementonlineatwww.libmed.co.za
Attheendofeachmonth,astatementissenttoyoucontainingalldetailsofclaimspaid,
savingsbalanceandbenetsavailabletoyou.
Stale claimsClaims received by the Scheme after the end of the fourth month from the last date of the
service rendered, as stated on the claim, are regarded as stale and will not be paid by LMS.
If a claim is submitted within the four month period and is rejected as erroneous or
unacceptableforpayment,itmustbecorrectedandresubmittedwithinaperiodof60days
followingthedateofnoticationofrejection.Ifnot,theclaimwillberegardedasstaleandno
payment will be made.
Managing fraud and abuseFraudcontinuestobeamajorconcerntomostmedicalschemes,costingmillionsofRands
eachyear.Asyouknow,themorefraudthereis,thehighercontributionsbecomeinorderto
counteracttheselosses.Fortunately,LMShasmeasuresinplacetodetectandmanagefraud
andtheabuseofbenets.
Youcancontributetothiseortbycontactingourfraudhotlineanonymouslyifyouare
aware of any provider or patient abusing the system. We urge all members to reconcile theirmonthly claims statements and verify the claims information to ensure that all details are true
and correct and report anything suspicious.
Liberty Health Fraud Hotline: 0800 212 638.
32
Making the most of your cover (cont.)
Note:LMS will not cover any interest or legal fees that are levied on a claim that is
submitted late.
Note:The onus is on the member (and not the provider) to ensure claims are submitted to
LMS for payment.
Makingthemostofyourcover
Note:Please ensure that we have your bank account details to allow for electronic payment.
If we do not have these details (including the documents as set out below) they can be submitted,
via email to [email protected] orfaxed to 021 673 9587.
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Web-based facilities
In these hectic times, isnt it a welcome relief to have access to services that enable you toget the latest information on your medical scheme option according to your schedule and not
ocehours?ThisiswhyLMShasinvestedintechnologytoensurethatyouareabletoaccess
your information when you want it and make your life easier.
33
Makingthemostofyourcover
Note:Please refer to the website for all Scheme forms, formulary lists and much more...
Using the website www.libmed.co.za
No email or Internet access? Just use your cellphone!
Toreceiveyourkeymembershipinformationonyourcellphone,simply SMS the
relevanttwo-lettercodeto39372(SMSsarechargedatstandardSMSrates):
Toconrmyourmembershipdetails:SMSDEto39372
Togetyourbenetbalances:SMSBNto39372 Togetasummaryofyourmostrecentclaims:SMSCLto39372
TorequestyourFinancialAdvisersdetails:SMSBRto39372
Togetalistofself-helpinstructions:SendablankSMSto39372
Torequestacopyofyourcurrenttaxletter:SMSTXto39372(Theletterwillbesent
to your registered postal address)
AnSMSwithalltherequiredinformationwillbesenttoyourcellphone,providedthat
your cellphone number has been registered.
There are other ways to get info quickly just send a blank email
Ouremailserviceisavailable24hoursaday.Allyouhavetodoissendablankemailto
webmail@libertyhealth.co.zaandyouwillgetareturnemailwiththefollowinginformation: Yourmembershipdetails
Aclaimshistory
Benetsusedtodate
Contributionstodate
Acopyofyourlatestclaimsstatement
Acopyofyourcurrenttaxletter
Note:To register your cellphone number call the LMS Contact Centre on 0860 002 163.
Onceyouhaveregisteredonthewebsite,youwillbeableto:
Monitorallthetransactionsonyouraccount
Viewyoursavingsandotherbenetbalances
Viewclaimssubmittedandthepaymentstatusofallclaims Lookupthecontactdetailsandaddressofamedicalprovideryouknow
How to register:Gotowww.libmed.co.za
ClickonRegisteronthetoprightofthepageandfollowthesteps
OryoucancalltheLMSContactCentreon0860002163
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Dependants accepted by LMS and documents required for registration:
Amembercanchoosetoregisteranyofthebelow-listedasdependantstohis/hermembership.
Membership,
RegistrationofD
ependants,
ContributionsandDebtManagement
34
Membership, Registration of Dependants,Contributions and Debt Management
Document(s) Required
Copy of ID/Birth Certificate/hospital confirmation reflecting the babys name
Copy of Marriage Certificate
Copy of Membership Certificate(s)/Affidavit detailing previous membership history*
Affidavit confirming financial dependency of Biological Parent(s)**
Proof of income if employed****
Proof of studies (current proof of registration at a recognised educational institution)
Affidavit confirming financial dependency of Adult Dependant(s)**
Copy of the Doctors disability report
Proof of legal adoption
Membership to LMS is open to anyone who wishes to join, whether as an individual or as part
of an employer group.
Note:
Amembermaynotregistermorethanonespouseand/orpartnerasadependant
Irrespectiveofwhetherbenetsareutilised,contributionsareduemonthly
Newdependants:increasedcontributionswillbeduefromtherstdayoftheregistrationmonth
Newborns:increasedcontributionswillbeduefromtherstofthemonthfollowingthebirth,
although benefits will accrue immediately
Spouses/partnerswillbechargedadultdependantrates,evenifnotyet21yearsold
Financialdependencyisdeterminedaccordingtothedependantsincome,whichshouldnot
exceed the tax threshold per annum for persons below the age of 65 years
Ex-spousesdonotqualifyforregistrationasdependantsunlesstheyqualifyaspartners.
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Membership,
RegistrationofD
ependants,
ContributionsandDebtManagement
35
awful
pouse
Life
Partners
Biological
Parent of
Member
***
Biological
Siblings of
Member
***
Members
Own
Minor
Children
*****
Adult
Children incl.
Stepchildren
***
Permanently
Disabled
Children
Stepchildren
***
Adopted
Children
******
*CopyofMembershipCerticate(s)/Adavitdetailingpreviousmembershiphistory(registrationdate,benet
date,resignationdate,any/allwaitingperiodsandexclusions,allregistereddependants).Membershipcardsor
copiesthereofwillnotbeaccepted.Ifnotattached,theLateJoinerPenaltymayapply.
**LMSAdavittemplatesareavailableonwww.libmed.co.za. ***SubjecttoAnnualReview
BiologicalParentsofMember:Fathers-in-lawandmothers-in-lawarenotaccepted
BiologicalSiblings:Biologicalsiblings>21willbechargedadultrates
AdultChildrenincl.Stepchildren:>21anduptoandincludingtheageof26willbechargedadultratesunlessa
full-timestudentatarecognisedinstitutionordisabled
****Proofofincomemustbeprovidedasfollows:
Copyofdependantsmostrecentpaysliporsalaryadviceorgovernmentgrantcard
Commissionstatementsforthelast12months
CopyofdependantslatestSARSincometaxreturn
Writtenconrmationofincomefromdependantshumanresourcesdepartment,onacompanyletterhead
Ifunemployed,yourUnemploymentInsuranceFund(UIF)bluebookoradischargecerticatefromyour
previousemployeroradavitstatingzeroincome
*****Membersownnewbornchildren:IfregistrationwithLMStakesplacewithin30daysofthebirthnowaiting
periodisimposed.(TheDependantRegistrationformisavailableonthewebsite:www.libmed.co.za)
******AdoptedChildren:NowaitingperiodisimposedifregistrationwithLMSiscompletedwithin30daysofthe
adoption.(TheDependantRegistrationformisavailableonthewebsite:www.libmed.co.za)
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Membership,
RegistrationofD
ependants,
ContributionsandDebtManagement
36
Membership, Registration of Dependants,Contributions and Debt Management (cont.)
Document(s) Required Member deceased
Certiedcopyofdeathcerticateofmember
CopyofIDofoldmember
CopyofIDofnewmember
Letterfromsurvivingspouse/dependantsindicatingnewmember
Bankingdetailsofnewmember
Signeddeclarationofnewmember(Applicationform.Section8)
Continuation in event of death
Termination of membership (deregistration of dependants):
MemberswhoarerequiredtobelongtoLMSintermsoftheirconditionsofemploymentmay not resign their membership while they are employed by the participating employer,
unless they obtain written consent from their employer
MemberswhoseconditionsofemploymentdonotrequirethemtobelongtoLMSmay
resigntheirmembershipbygivingonecalendarmonthsnotice.Employergroupsmay
resigntheirmembershipbygiving3monthsnotice
IfamemberfailstopayamountsduetoLMS,his/hermembershipwillbeterminated
IftheBoardofTrusteesndsamembertobeguiltyofabusingprivileges,makingfalse
claims,misrepresentationornon-disclosureoffactualinformationorofanymedical
condition,his/hermembershipmaybeterminatedandallcontributionspaidmaybeforfeited.TheBoardmayalsorequirethatsuchamemberrefundanymedicalpayments
disbursed as a result of these actions
Whenadependantisnolongereligibleforregistrationasadependanthe/shewillnotbe
entitledtoanybenets,regardlessofwhetherornotLMShasbeeninformed.
Notice period for resignations
MembersarerequiredtogivetheSchemeonecalendarmonthswrittennotice.Amemberis
requiredtoinformLMS,within30days,ofanyeventthatresultsinanydependantnolonger
satisfyingtheconditionsonwhichhe/shewasacceptedasadependantonLMS.Thenoticeof
resignation/deregistrationofdependantmustcomefromthememberonly.
Continuation of membership
AsstipulatedbytheMedicalSchemesAct(ActNo131of1998)allmedicalschemesmust
provide for continuation of membership when a member retires from employment or in the
eventofhis/herdeathtoallowthesurvivingbeneciariestobecomemembers.
Thefollowingdocumentationisrequiredineventofdeath:
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Membership,
RegistrationofD
ependants,
ContributionsandDebtManagement
37
Re-instatement of membership
Ifamembervoluntarilyresignshis/hermembershipandrequeststobere-instatedaftertheterminationdate,themembermustre-applyfornewmembershipandunderwriting
maybeimposed.Ifthememberrequeststobere-instatedbeforetheterminationdate,the
membershipwillbere-instated.
Minor members
TheSchemeallowsforregistrationofmembersyoungerthan18yearsofage.Memberrateswill
beappliedeventhoughthemembermaybeunder21.Thefollowingconditionsareapplicable:
Asignedapplicationformissubmittedbytheguardian(s)indicatingbankingdetailsfor
collection of contributions Aletterisobtainedfromtheguardian(s)statingthefollowing:
Thattheguardian(s)isresponsibleforthemember
Therelationshipoftheguardian(s)tothemember
Allcontactdetailsoftheguardian(s)
Terms and conditions applicable to membership:
Noperson,whetheramemberordependant,maybeabeneciaryofmorethanonemedical
scheme at the same time Amembermaynotcede,transfer,pledgeormakeovertoanythirdpartyanybenet,claim,
orpartthereofthathe/shemayhaveagainstLMS
TherelationshipbetweenLMSanditsmembersisatalltimesdeemedtobeoneofthe
utmostgoodfaith.Thememberthereforeacknowledgesandagreestodisclosealland
anyinformationtoLMSthatmayimpactuponadecisionconcerningthemember,his/her
dependantsorhis/herclaim.
Option changes with effect from 1 January
Individual members:Asanindividualmemberyouwillbeabletoprocessonlineoptionchangesbetween1Novemberand30Novemberannually.Visitwww.libmed.co.zaforfurtherdetails.
Employer group members:SubmityouroptionchangesviayourHRdepartment.Employer
groupoptionchangeswillbeacceptedasfollows:
LetteronocialcompanyletterheadfromHRmanagerordirectorconrmingoption
changes for employees
Excelspreadsheetwiththefollowinginformation:
Employeename
Employeenumber
Membershipnumber
IDnumber
Newoption
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Waiting periods
LMSmayimposebotha3monthgeneralwaitingperiodand/ora12monthcondition-specicwaitingperiodifabeneciaryhasnothadmedicalschemecoverforaperiodofatleast90days
precedingthedateofapplication.TheserestrictionsincludetreatmentforPMBconditions.
12 Month condition-specific waiting periods
LMSreservestherighttoimposeacondition-specicwaitingperiodofnotmorethan12
monthsfromthedateofcommencementofcover.Thiswillapplytoamemberand/orany
dependantinrespectofapre-existingcondition.Apre-existingconditionisoneforwhich
amember/dependantwasdiagnosed,treatedorgivenadviceinthe12monthspriorto
application to LMS.
3 Month general waiting periods
LMS reserves the right to impose a general waiting period of three months from the date of
commencementofmembershipofLMSonamemberand/orhis/herdependants,during
which period contributions will still be payable.
LMS also reserves the right to apply the balance of a valid general waiting period that has
been imposed by a previous scheme, or that was applied on a previous option.
If a member requires emergency trauma treatment within the general waiting period, this willbecovered,subjecttotheRulesofLMSandthebenetsoftheselectedoption.
Membership,
RegistrationofD
ependants,
ContributionsandDebtManagement
38
Membership, Registration of Dependants,Contributions and Debt Management (cont.)
Note:Trauma is defined as an event caused by accidental, violent, external and visible means,
where failure to provide the medical attention would place the members health in serious jeopardy.
Category
3Month
general
waiting period
12Month
conditionspecic
waiting period
AppliedtoPMB
Newbeneciarieswhohavenothadcoverfor90days
or more preceding applicationYes Yes Yes
Applicantswhowerebeneciariesforlessthan2years
andapplywithin90daysofleavingNo* Yes* No*
Applicantswhowerebeneciariesformorethan2
yearsandapplywithin90daysofleavingYes No No
Changeofoptionatthebeginningofthebenetyear No* No* No*
Child dependant born during period of membership
andregisteredwithin30daysNo No No
Involuntary transfers due to change of employment
andapplywithin90daysNo* No* No*
Waiting periods
*Balanceofunexpiredwaitingperiodsmaybeapplied
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Membership,
RegistrationofD
ependants,
ContributionsandDebtManagement
39
LMSalsoreservestherighttoapplythebalanceofacurrentcondition-specicwaitingperiod
that was imposed by a previous scheme, or that was applied on a previous option, and which
has not yet expired.
Remember: Should you have any questions or need to clarify any of these conditions, please
call our Contact Centre on 0860 002 163. We will be happy to assist you in any way we can.
Late-joiner penalties
LMSmayimposelate-joinerpenaltiesonanewmemberorthedependantofamember,if
thepersonis35yearsorolderandwasnotcontinuouslyamemberofamedicalscheme
sincebefore1April2001,orifhe/shehadabreakincoverageofmorethan3consecutivemonthsafterthisdate.Thelate-joinerpenaltyiscalculatedasapercentageofyour
contribution and applies for life, even on transfer to another medical scheme. It is the
members responsibility to provide adequate proof of previous medical scheme coverage
when applying to LMS.
LMS applies its discretion in accordance with its underwriting policy when imposing
late-joinerpenaltieswhichincertaincasesarelessthanthelegislatedguidelinesas
stipulated above.
Removal of late-joiner penalties
Late-joinerpenaltiesmayberemoved,butonlyfromtherstofthemonthfollowingthe
receiptofthenecessaryproofofpriorcoverage.Aswornadavitmaybeprovidedif
proof of cover is not obtainable, clearly stating the name(s) of the medical scheme(s) and
period(s)ofcoverforpreviousschemes.Ifyouareabeneciaryofamedicalschemeatthe
timeofapplicationtoLMS,amembershipcerticateforcurrentcovermustbeprovided.
Number of years applicant was not a member of
a medical scheme after age 35Maximum penalty
04 5%
514 25%
1524 50%
25+years 75%
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Contributions
Contributionsshallbeduemonthlyinadvanceandbepayablenotlaterthanthe 3rddayfollowing the contribution due date each month
WherecontributionsoranyotherdebtowedtotheSchemehavenotbeenpaidbythedue
date,theyshallbeinarrearsandtheSchemeshallhavetherighttosuspendallbenet
paymentswhichhaveaccruedtoyouirrespectiveofwhentheclaimforsuchbenet
aroseduringtheperiodofdefault,andtogiveyouand/oryouremployernoticethatif
contributionsarenotpaiduptodatewithinthirty(30)days,yourmembershipmaybe
terminated
Ifpaymentsarebroughtuptodatebeforetheactualterminationdate,benetsmay
bere-instatedwithoutanybreakincontinuitysubjecttoLMShavingtherighttolevyareasonable fee to cover any expenses associated with the default
Ifyourmembershiphasbeenterminated,re-applicationformembershipwillberequired
and underwriting may apply
AllpayablecontributionsarecalculatedbyLMSbasedonyourchosenoption,the
numberofdependantsandthelate-joinerpenalties(whereapplicable)
Acceptanceofmembershipforanindividualmemberissubjecttoadebitorderinstruction
signed by the member
Whereamemberhassplitbilling(i.e.memberportionandemployer/pensionfundportion),
the member remains liable for the full contribution.
Debts/Amounts owed to the Scheme
PleasebeawarethatanyamountsowedtotheSchemewillberecoveredbytheSchemein
termsoftheSchemesCreditControlPolicy.
Membership,
RegistrationofD
ependants,
ContributionsandDebtManagement
40
Membership, Registration of Dependants,Contributions and Debt Management (cont.)
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Membership,
RegistrationofD
ependants,
ContributionsandDebtManagement
41
Debt process summary
Contributionsaredueontherstofeachmonthandarepayablenolaterthanthe3rddayfollowing the due date each month
AnyotheramountowedbyamemberisadebtduetotheSchemeandrecoverablebyit.
The Debt Process
Action -Nopaymentreceived
If not paid by the due date, the Scheme has the right to suspend the membership.1
Due Date -Suspendmembership/benets
Themembershipshallremainsuspendedforthedurationofthepayment
arrangement until the debt has been settled.
2
30-days - Doublededuction
Ifnotpaidwithin30days,themembershipwillremainsuspendedandadouble
deduction will be lodged via your next debit order.
3
60-days -Terminatemembership
Ifnotpaidwithin60days,themembershipwillbeterminated.4
90-days -Handoverforcollection
Ifthedebtisstilldueafter90days,themembermaybehandedovertodebt
collectorsforcollection.TheSchemeallowspaymentarrangementsforamaximum
ofthreemonthsonly,providedasignedAcknowledgementofDebtformhasbeen
completed by the member.
5
Remember: It is usual for a number of rules, regulations and conditions to apply when
joining a medical scheme. LMS endeavours to help you understand these and know how
they will aect you. If you do have questions or concerns, please call our Contact Centre
on 0860 002 163ordiscussthesewithyourFinancialAdviser.
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ER24-International Travel Benefit
AllactivebeneciariesofLibertyMedicalSchemeontheGoldFocus,GoldSaver,PlatinumFocus,PlatinumSaverandPlatinumCompleteoptionswhotravelinternationally(outsidetheborders
ofSouthAfrica)forleisuremayqualifyforMedicalCover.Thepolicyprovidescoverofuptoa
maximumofR5millionpertripforupto90dayspertrip,irrespectiveofhowmanytripsaremade
during the year.
Additionalinsuranceisrequiredfor
Beneciariesover the age of 80 wanting to travel
Beneciariestravellinginexcess of 90 days per trip
Beneciariespartakinginhazardous pursuits e.g. mountain climbing, scuba diving, any contact
sports, motorcycling, skiing, etc.
Four easy steps to ensure that you are covered when you travel:
AdditionalServices
42
Additional services offered to Scheme members
ObtaindetailsofyourpolicywordingfromER24 on
Local 010 205 3100
International +27 10 205 3100
BusinesshoursMondaytoFriday8:0017:00
1
ObtainadditionalinsuranceifrequiredfromER24on011 319 6500 or via
email [email protected]
Obtainanembassy letter for your visa by phoning Chartis on 0860 100 491
(selectoption6)3
Should you require any medical assistance while travelling, contact the emergency
number +27 10 205 31004
Note:ER24istheserviceproviderfortheInternationalTravelBenetasofJanuary2012.
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AdditionalServices
43
Liberty Baby
Havingchildrenisoneoflifesexcitingadventuresandtoenhancethisexperience,weoerLibertyBabytoexpectantmomsonGoldSaver,Titan,PlatinumSaverandPlatinumCompleteoptions.
LibertyBabyisdesignedtoinformmoms-anddads-to-be,oersupportandgivesoundadvice.
If you are expecting a baby, please call us on 0861 116 019andwewillregisteryouonLibertyBaby.
AsamemberofLibertyBabyyouwillreceiveababybagthatincludes:
Pregnancyandbabybooklets
Productsformomandbaby
Emergencyguide
Somefantasticdiscounts
FormoreinformationonLibertyBabyvisitwww.libmedbaby.co.za
You also have:
Accesstoa24-hourmedicaladviceline,whichismannedbytrainedprofessionals
AccesstotheLibertyBabywebsite
AphonecalleverytrimesterfromLibertyBabytomakesurethatyouandyourbabyare
making healthy progress
Emailsonthestagesofpregnancyformomanddad
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Beneciary Amemberandanyofhis/herregistereddependantswhoisentitledtobenets.
Co-payment When a member is liable for a portion of the costs incurred for
treatmentand/ormedicationreceived.
Cost Theactualamountchargedbytheserviceproviderforservices
rendered.
Credit Savings TheadvancedannualsavingsthatLMSmakesavailableon1Januaryof
everyyear,evenifyouhaventyetmadethefullcontributiontotheMSF.
Day-to-DayExtender
Thisisacollectionofout-of-hospitalbenetswhicharepaidfromScheme risk rather than from savings.
Designated
ServiceProvider
(DSP)
AhealthcareproviderorgroupofprovidersselectedbyLMStoprovide
speciedhealthcareservicestoitsmembers.Ifamembervoluntarily
usesanon-DSP,aco-paymentmayapply.
Eligibleexpenses Medicalexpensesthatarespecicallyincludedinthe2012LMSbenet
schedule;thatarenotlistedunderexclusions;thatareunrelatedto
conditionsforwhichaspecicwaitingperiodisineectandthatare
not incurred during a general waiting period.
Formulary
Medicine
AdenedlistofmedicinesforwhichLMSwillpay.Thelistisbasedon
clinical evidence and protocols.
GenericMedicine Amorecost-eectiveversionofthebrandedmedicinesthatcontain
the same active ingredients and are identical in strength.
ICD10code Thecompulsorydiagnosticcodeusedbyproviderstoindicatewhatthe
medical diagnosis is for treatment received. Claims that do not contain
anICD10codecannotbepaidintermsofcurrentlegislation.
LMS rate TheLibertyMedicalScheme(LMS)rateistherateatwhichtheScheme will pay for a particular health service and which is either the
negotiated rate with providers or in the absence of a negotiated rate,
thelowerofcosts,UPFS(Staterates)orthetariasdeterminedbythe
BoardofTrustees.
Major Medical
Benet(MMB)
Thisisacollectionofhigh-costbenetssuchashospitalisation,certain
day procedures, oncology (cancer) treatment, costs incurred due to
crime trauma, emergency transport and more.
Maximum
Medicine
ReferencePrice
Themaximumreimbursablepriceforamedicineorgroupofmedicines
according to a reference pricing system that allocates a price to a group
ofdrugsthataresimilarinecacy,safetyandquality.Glossary
44
Glossary
Useful definitions
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MedicineExclusions
AlistthatstipulatescategoriesofdrugsNOTcoveredbyLMS.
Medicine
Management
Protocols
Clinical guidelines and protocols formulated for the provision of care
andtreatmentrelatedtospecicdiseases.
Medical Savings
Facility(MSF)
Thisisusedforeligibleday-to-dayexpensesasspeciedinLMSs
Rules. Contributions to a savings facility are set at a percentage of total
contributions.
Negotiated
DispensingFee
AchargeagreedtobetweentheSchemeanddispensersandproviders
in respect of the dispensing of registered medicines.
PositiveSavings ThemonthlysavingscontributionsthatLMShasreceived,buthavenotyet
beenusedbyyou.Thisincludessavingscarriedoverfrompreviousyears.
Pre-authorisation NotifyingtheSchemeatleast48hoursbeforeadmissiontohospital
orreceivingcertainservicesasprovidedforintherulesfornon-
emergencyeventsorwithin2businessdaysafteradmissionor
treatment in an emergency.
Preferred
Providers
TheseareproviderswithwhomtheSchemehasnegotiatedpreferred
rates.Ifamemberusesthem,noco-paymentapplies.
Prescribed
Minimum
Benets
Thebenetscontemplatedinsection29(1)(o)oftheActandwhich
includetheprovisionofthediagnosis,treatmentandcarecostsof:
ThediagnosisandtreatmentpairslistedinAnnexureAofthe
Regulations,subjecttoanylimitationsspeciedtherein;and
Anyemergencymedicalcondition.
Prescribed
MinimumBenet
Condition
Aconditioncontemplatedinthediagnosisandtreatmentpairslistedin
AnnexureAoftheregulationsoranyemergencymedicalcondition.
PreventativeCare
Benet
Cover for certain tests and immunisations that help you to monitor
yourhealthandpreventpossiblefutureillness.Refertopages15to17
of this guide for a list of eligible expenses.
Pro-ratingof
benets
Whenamemberjoinslaterthan1January,benetsfortherstyear
are decreased in accordance with the number of months remaining inthe year. G
lossary
45
Useful definitions
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Glossary
46
Glossary (cont.)
Disclaimer
ThisisamarketingoverviewandsummaryoftheLibertyMedicalScheme,servicesand
complementaryproducts.Everyattempthasbeenmadetoensurecompleteaccuracyofthis
brochure.However,intheeventofaconictbetweenthisbrochureandtheregisteredRules
oftheScheme,theruleswillprevail.E&OE.
RiskBenets Allthebenetsundermajormedicalbenets:Hospitalisation,ChronicCover,DiseaseManagement,Day-to-DayExtenderandThreshold
Benets,aresubjecttotherateandlimitsspeciedintheBenet
Schedule.Unusedbenetscannotbecarriedovertothefollowingyear.
SelfPaymentGap
(SPG)
TheperiodaftertheMSFhasbeendepletedandyoumayhavetopay
forday-to-dayexpensesoutofyourownpocket,untiltheThreshold
Level is reached.
ThresholdBenet
(THB)
Thisprovidesadditionalcoveroncetotaleligibleday-to-dayexpenses
reachaparticularThresholdLevel.Thislevelisbasedonthenumberandtypeofdependantsaprincipalmemberhas.LMSpaysday-to-day
expensesfromtheThresholdBenetattheLMSrate.
Useful definitions (cont.)
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47
Contact Details
Cont
actDetails
Banking Details
Account holder Liberty Medical SchemeBank StandardBankBranch ClaremontBranch code025109Account number 240402235
CareCross Contact Centre (Bona Plus option only)
Contact numbers and support services
Contact Centre 0860103491
Chronic Contact Centre 0860102182Enquiries [email protected] www.carecross.co.za
Dental Risk Company (DRC) (Titan option only)
Contact Centre 0861115057
Authorisations:Fax 0866871285Email [email protected] queries [email protected] enquiries & escalations [email protected]
Chronic Medicines and Disease Management Programmes
Approvalandregistrationofchronicmedicationcoverasperqualifyingconditions.
Tel 0860002163Fax 0216577681Email [email protected]
Claims Submission
Forprocessingofclaims
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Cont
actDetails
48
Contact Details (cont.)
Hospital AuthorisationsAdmissiontohospitalsandregisteredmedicalinstitutions.
Tel 0860002163Fax 0216577711Email [email protected]
Liberty Baby
Applicable only on Gold Saver, Titan, Platinum Saver and Platinum Complete options.
Tel 0861116019
Alternative Tel 0117042151Fax 0117044645Email [email protected] www.libmedbaby.co.za
HIV Management Programme
AdministeredbyAfA.
Tel 0860100646Fax 0800600773Email [email protected] www.aidforaids.co.zasms (call me) 0834109078
Financial Adviser Contact Centre
AdedicatedFinancialAdviserContactCentretoassistwithenquiryresolutionand
information requests (8:00 - 17:00, Monday to Friday).
Tel 0860002168Fax 0216577581Email [email protected] address PrivateBagX35,Claremont,7735
ER24 Emergency transportation
Medical emergencies in South Africa 084124Medical emergencies in Lesotho and Swaziland +27(0)102053081Website www.er24.co.za
ER24 International Travel Insurance (option dependent):
Applicable only on Gold Focus, Gold Saver, Platinum Focus, Platinum Saver andPlatinum Complete 0ptions.
Policy wording detail ER24onLocal:0102053100 International:+27102053100
Medical emergency Local:0102053100
International:+27102053100
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Cont
actDetails
49
Liberty Medical Scheme Contact Centre
AdedicatedContactCentretoassistwithenquiryresolutionandinformationrequestedby current and prospective Liberty Medical Scheme members and healthcare service
providers (8:00 - 17:00, Monday to Friday).
Tel 0860002163
Fax 0216577571
Email [email protected]
Postal address PrivateBagX35,Claremont,7735
Preferred Provider Network (PPN) (optical benefit on Titan option only)Contact Centre 0860103529
Visitwww.ppn.co.zatolocateaPPNoptometristinyourarea
Oncology Management Programme
Requests for the registration and approval of treatment options related to oncology.
Tel 0860002163
Fax 0216577621
Email [email protected]
New BusinessSubmission to the new business team of new membership applications, as well as additions
of dependants and newborns. Send the additional documentation related to a membership
applicationoraddition(optionspecicrequirements,asperSchemesrules)tothene