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Circular

Circular 64 of 2022: Administrators and Managed Care Organisations accredited by the CMS

The Council for Medical Schemes (CMS) hereby confirms that the Executive Committee (EXCO) of Council considered and resolved not to grant accreditation in respect of the following new managed care accreditation application, at its meeting held on 22 November 2022 (via MS Teams).

  1. I W Dymond Inc t/a Jointcare: Council Exco considered the application and resolved not to grant accreditation as a managed care organisation due to the fact that the services provided do not constitute managed care services, as defined in Regulation 15 of the Medical Schemes Act and the organisation therefore need not be accredited.

The Council for Medical Schemes (CMS) hereby confirms that the Executive Committee (EXCO) of Council considered and resolved to approve the following renewal of accreditation/compliance certificate applications of the organisations listed below at its meeting held on 22 November 2022 (via MS Teams).

Managed Care Organisations:

Renewal Applications

  1. CareWorks (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 31 December 2022 with the conditions as stipulated on the CMS website , in respect of the following services:
  2. Active Disease Risk Management Services
  • Asthma / COPD / Bronchiectasis
  • Cardiac Failure / Cardiomyopathy / Dysrhythmias / Coronary Artery Disease
  • Diabetes (Type 1 and 2)
  • Hypertension
  • Mental Health Services
  • HIV
  1. Health Calibrate (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 31 December 2022 with the conditions as stipulated on the CMS website , in respect of the following services:
    1. Hospital Benefit Management Services
  • Pre-Authorisation services
  • Case Management
  • Clinical Audit
  1. Pharmacy Benefit Management Services
  • Drug utilisation review (DUR)
  • Pharmacy benefit management: Disease risk management support services
  1. Active Disease Risk Management Services
  • Asthma / COPD/ Bronchiectasis
  • Hyperlipidaemia
  • Hypertension
  • HIV
  • Oncology
  • Mental Health Services (Depression / Bipolar)
  • Diabetes Mellitus Type 1 and Type 2
  1. Managed Care Network Management Services and Risk Management
  • Pharmacy Network
  1. Discovery Administration Services (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 31 December 2022 with no conditions as stipulated on the CMS website , in respect of the following services:
    1. Hospital Benefit Management Services
  • Pre-Authorisation
  • Case Management
  • Clinical Audit
    1. Pharmacy Benefit Management Services
  • Pre-authorisation
  • Drug utilisation review.
    1. Active Disease Risk Management Services
  • Asthma / COPD / Bronchiectasis
  • Cardiac Failure /Cardiomyopathy / Dysrhythmias / Coronary Artery Disease
  • Diabetes (Types1 and 2)
  • Hyperlipidemia
  • Hypertension
  • Depression / Bipolar mood disorder
  • Oncology
  • HIV
  • Epilepsy
    1. Dental Benefit Management Services
  • Basic dentistry
  • Specialised dentistry
  1. Kaelo Prime Cure (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 31 December 2022 with no conditions as stipulated on the CMS website , in respect of the following services:
    1. Hospital Benefit Management Services
  • Pre-authorisation services
  • Case Management
  • Clinical Audit
    1. Active Disease Risk Management Services
  • HIV
    1. Dental Benefit Management Services
  • Basic Dentistry
  • Specialised Dentistry
    1. Managed Care Network Management Services and Risk Management
  • Specialist Network
    1. Health Care Services (Risk transfer)
  • Out-of-hospital and limited in-hospital services (as per the scheme’s benefit rules)
  • Out-of-hospital and full in-hospital services (limited services in accordance with the scheme’s benefit rules)
  1. LifeSense Disease Management (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 31 December 2022 with no conditions as stipulated on the CMS website , in respect of the following services:
    1. Active Disease Risk Management Services
  • Diabetes (Type 1 and 2)
  • HIV
  1. National Health Group (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 1 December 2022 with the conditions as stipulated on the CMS website , in respect of the following services:
    1. Managed care network management services and risk management.
    2. Health Care Services (Risk Transfer).
  1. Mediscor PBM (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 31 December 2022 with no the conditions as stipulated on the CMS website , in respect of the following services:
    1. Pharmacy Benefit Management Services
  • Pre-authorisation
  • Drug Utilisation Review (DUR)
  • Pharmacy Benefit Management: Disease Risk Management Support Services
  1. Performance Health (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 31 December 2022 with the conditions as stipulated on the CMS website , in respect of the following services:
    1. Pharmacy Benefit Management Services;
  • Pre-authorisation
  • Drug Utilisation Review (DUR)
  • Pharmacy Benefit Management: Disease Risk Management Support Services
  1. Professional Provident Society Healthcare Administrators (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 31 December 2022 with no the conditions as stipulated on the CMS website , in respect of the following services:
    1. Hospital Benefit Management Services
  • Pre-Authorisation
  • Case Management
  • Clinical Audit
    1. Active Disease Risk Management Services:
  • Asthma / COPD / Bronchiectasis
  • Cardiac Failure / Cardiomyopathy / Dysrhythmias / Coronary Artery Disease
  • Diabetes (Type 1 and 2)
  • HIV
  • Hyperlipidemia
  • Hypertension
  • Mental Health Services
  • Chronic Renal Disease
  • Oncology
  • Maternity Program
    1. Dental Benefit Management Services
  • Basic Dentistry
  • Specialised Dentistry
    1. Managed Care Network Management Services and Risk Management
  • General Practitioner Network
  • Specialist Network
    1. Disease Risk Management Support Services
  1. RX Health (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 31 December 2022 with no conditions as stipulated on the CMS website , in respect of the following services:
    1. Hospital Benefit Management Services
  • Pre-Authorisation
  • Case Management
  • Clinical Audit
    1. Pharmacy Benefit Management Services
  • Pre-authorisation
  • Drug-utilisation Review (DUR)
  • Pharmaceutical Benefit Management: Disease Risk Management Support Services
    1. Active Disease Risk Management Services
  • Asthma / COPD / Bronchiectasis
  • Cardiac Failure /Cardiomyopathy/ Dysrhythmias/ Coronary Artery Disease
  • Diabetes (Type 1 and 2)
  • HIV
  • Hyperlipidemia
  • Hypertension
  • Chronic Renal Disease
  • Oncology
  • Musculo-skeletal Program
  • Mental Health Services
  • Maternity Program
  1. Scriptpharm Risk Management (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 31 December 2022 with the conditions as stipulated on the CMS website , in respect of the following services:
    1. Pharmacy Benefit Management Services
  • Pre-authorisation services
  • Drug Utilisation Review
    1. Managed Care Network Management Services and Risk Management
  • Pharmacy Network
  1. South African Oncology Consotium (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 2 December 2022 with the conditions as stipulated on the CMS website , in respect of the following services:
    1. Active Disease Risk Management Services
  • Oncology
  1. Agility Health (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 31 December 2022 with the conditions as stipulated on the CMS website , in respect of the following services:
    1. Hospital Benefit Management Services
  • Pre-Authorisation
  • Case Management
  • Clinical Audit
    1. Pharmacy Benefit Management Services
  • Pre-authorisation
  • Drug Utilisation Review (DUR)
    1. Active Disease Risk Management Services
  • Asthma / COPD / Bronchiectasis
  • Cardiac Failure / Cardiomyopathy / Dysrhythmias / Coronary Artery Disease
  • Diabetes (Type 1 and 2)
  • Oncology
  • HIV
  • Hypothyroidism
    1. Dental Benefit Management Services
  • Basic Dentistry
  • Specialised Dentistry
    1. Managed Care Network Management Services and Risk Management
  • General Practitioner
  • Specialist Network
  • Hospital Network
  • Pharmacy Network
  • Dental Network
  • Auxiliary Network
    1. Disease Risk Management Support Services
  1. Momentum Health Solutions (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 31 December 2022 with no the conditions as stipulated on the CMS website , in respect of the following services:
    1. Hospital Benefit Management Services
  • Pre-Authorisation
  • Case Management
  • Clinical Audit
    1. Pharmacy Benefit Management Services
  • Pre-authorisation
  • Drug Utilisation Review (DUR)
  • Pharmacy Benefit Management: Disease Risk Management Support Services
    1. Active Disease Risk Management Services
  • Asthma / COPD / Bronchiectasis
  • Cardiac Failure / Cardiomyopathy / Dysrhythmias / Coronary Artery Disease
  • Diabetes (Type 1 and 2)
  • Hyperlipidaemia
  • Hypertension
  • Mental Health Services
  • Oncology
  • HIV
  • Chronic Renal Disease
    1. Dental Benefit Management Services
  • Basic dentistry
  • Specialist dentistry
    1. Managed Care Network Management Services and Risk Management
  • General Practitioner Network;
  • Specialist Network;
  • Hospital Network;
  • Dental Network
    1. Health Care Services (Risk Transfer)
  • Out-of-hospital and full in-hospital services (limited services in accordance with the scheme’s benefit rules)
    1. Disease Risk Management Support Services
  1. Discovery Health (Pty) Ltd : Renewal of accreditation was granted for a period of two years from 31 December 2022 with no the conditions as stipulated on the CMS website , in respect of the following services:
    1. Hospital Benefit Management Services
  • Pre-Authorisation
  • Case Management
  • Clinical Audit
    1. Pharmacy Benefit Management Services
    2. Active Disease Risk Management Services
  • HIV
  • Oncology
  • Diabetes (Type 1 and 2)
  • Chronic Renal Disease
  • Depression / Bipolar
    1. Dental Benefit Management Services
  1. Managed Care Network Management Services and Risk Management
  • General Practitioner Network
  • Specialist Network
  • Hospital Network
  • Pharmacy Network
  • Dental Network
  • Auxillary Network
    1. Health Care Services (Risk Transfer)

Administrators:

Renewal applications

  1. SEDMED (Self-administered): Renewal of the compliance certificate was granted for a period of three years from 5 December 2022 with no conditions.
  2. AfroCentric Integrated Healthcare Administrators (Pty) Ltd: Renewal of accreditation was granted for a period of two years from 14 February 2023, subject to compliance with the condition stipulated on the CMS website.
  3. Momentum Health Solutions (Pty) Ltd: Renewal of accreditation was granted for a period of two years from 25 January 2023, subject to compliance with the condition stipulated on the CMS website.

The above-mentioned Managed Care Organisation and Administrators’ conditions and status are available here.

Download the Circular here.

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