A Designated Service Provider (DSP) is a healthcare provider (doctor, pharmacist, hospital, etc) that is Medshield’s first choice when its members need diagnosis, treatment or care for a PMB condition. If you choose not to use the DSP selected by the Scheme, you may have to pay a portion of the account as a co-payment. This could either be a percentage based co-payment or the difference between a DSP’s tariff and that charged by the provider you consulted.
If you choose not to use the DSP selected by Medshield, you may have to pay a portion of the account as a co-payment. Understanding your PMB benefit is key to having your claims paid correctly. One of the types of codes that appear on healthcare providers’ accounts is known as International Classification of Diseases, ICD-10 codes. These codes are used to inform the Scheme about what conditions members were treated for so that claims can be settled correctly. Understanding your PMB benefit is key to having your claims paid correctly.
More details than merely an ICD-10 code is required to claim for a PMB condition and ICD-10 codes are just one example of the deciding factors whether a condition is a PMB. In some instances you will be required to submit additional information to Medshield. In your current Medshield option you pay for a set of particular benefits. Your benefit option contains a basket of services that often has limits on the health services that will be covered by Medshield.
Because ICD-10 codes provide information on the condition you have been diagnosed with, these codes, along with other relevant information required by the Scheme, help Medshield to determine what benefits you are entitled to and how these benefits should be paid./p>
Medshield does not automatically pay PMB claims at cost as there is a possibility of over-servicing members with PMB conditions. Accordingly, it remains the members’ responsibility to contact the Scheme and confirm which PMB treatments were provided.
Final diagnosis determines if a condition is a PMB or not:
- When diagnosing whether a condition is a PMB, the doctor should look at the signs and symptoms at point of consultation. This approach is called a diagnosis-based approach.
- Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms).
Only the final diagnosis will determine if the condition is a PMB or not.