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Circular 14 of 2022: Entry and verification criteria for identifying beneficiaries with risk factors in medical schemes and the SRM Weighting and Count tables for 2021

The Council for Medical Schemes (CMS) has published Version 15.0 of the guidelines for identifying medical schemes beneficiaries with risk factors, in accordance with the entry and verification criteria (E&V Criteria) as well as the SRM Weighting table for 2021.

Schemes are reminded that the guidelines do not translate to PMB requirements but are used to measure schemes risk exposure to chronic conditions. After a review of stakeholders’ comments, the following changes were affected. Please click to access the weighting tables here.

 1. Asthma

Proposed Accepted / Rejected / Amended
R03DX09 – Mepolizumab Request to remove the drug from the document – rejected. Section 21 drugs are included in the counts to ensure that all patients with these conditions are counted.
R03BB04 – Tiotropium Available in SA and applicable to Asthma – request to be added – Accepted

 

2. Cardiac Failure and Cardiomyopathy

Proposed Accepted / Rejected / Amended
O10.1 and O10.3 are not listed under CDL for CF or CMO on the 2013 ICD-10 code list as these are obstetric codes. Both codes are listed as CDLs for Hypertension and O10.3 are also listed as CDL under Chronic renal disease. We recommend that these codes be removed. Accepted – codes deleted. Members already suffered from the disease and would be counted with the correct ICD-10 code, now during pregnancy, it will not change the count as they will still be on be the same treatment
A10BK01 – Dapagliflozin Request to be added

 

3. Multiple Sclerosis (MSS)

Proposed Accepted / Rejected / Amended
L04AA34 – Alemtuzumab Request to be added – Accepted
N07XX07 – Dalfampridine Request to be added – Accepted

 

4. Systemic Lupus Erythematosus (SLE)

Proposed Accepted / Rejected / Amended
L04AA26 -Belimumab Requested to be added – Accepted

 

5. Preparation Data

Proposed Amended
Request that the column containing the applicable E78 codes is moved to the left of the column containing the relevant G- and I-codes and the other alternative entry criteria for Hyperlipidaemia Column moved – Accepted

 

6. Additional changes to the document

The ATC codes indicated in Section 6 and Section 7 have been aligned.

Download the circular here.