Circular 73 of 2021: Administrators and Managed Care Organisations Accredited by the CMS Council
The Council for Medical Schemes (CMS) hereby confirms that the Executive Committee (EXCO) of Council considered and resolved to approve the following accreditation/compliance certificate applications of the organisations/ medical schemes listed below, at its meeting held on 3 December 2021:
Managed Care Organisation – New Application
- Medshield Medical Scheme (Self-administered): Compliance certificate granted for a period of three years from 3 December 2021 with no conditions, for the following services as stipulated on the CMS website:
a. Active Disease Risk Management Services.
- Diabetes (Type 1 and 2)
- Hyperlipidaemia
- Hypertension
Managed Care Organisations – Renewal Applications
- Dental Information Systems (Pty) Ltd: Renewal of accreditation was granted for a period of two years from 31 December 2021 with no conditions, for the following services as stipulated on the CMS website:
a. Dental Benefit Management Services
- Basic Dentistry
- Specialised Dentistry
b. Managed Care Network Management Services and Risk Management
- Dental Network
- Enablemed (Pty) Ltd: Renewal of accreditation was granted for a period of two years from 31 December 2021 for the following services, with the conditions as stipulated on the CMS website:
a. Managed Care Network Management Services and Risk Management
- General Practitioner Network
- Specialist Network
- Hospital Network
- Pharmacy Network
- Dental Network
- Auxiliary Network
b. Health Care Services (Risk Transfer)
- Out-of-hospital and full in-hospital services (limited services in accordance with scheme’s benefit rules).
- Knowledge Objects Healthcare (Pty) Ltd: Renewal of accreditation was granted for a period of two years from 5 December 2021 for the following services, with the conditions as stipulated on the CMS website:
a. Hospital Benefit Management Services
- In hospital pre-authorisation services
- Case Management
- Clinical Audit
b. Active Disease Risk Management Services
- Asthma/ COPD/ Bronchiectasis
- Cardiac Failure/Cardiomyopathy/Dysrhythmias/Coronary Artery Disease
- Diabetes (Type 1 and 2)
- Oncology
- HIV
c. Dental Benefit Management Services
- Basic Dentistry
- Specialised Dentistry
5. Knowledge Objects Solutions (Pty) Ltd: Renewal of accreditation was granted for a period of two years from 5 December 2021 for the following services, with the conditions as stipulated on the CMS website:
a. Pharmaceutical Benefit Management Services
- Pre-authorisation Services
- Drug Utilisation Review (DUR)
b. Managed Care Network Management Services and Risk Management
- General Practitioner Network
- Specialist Network
- Hospital Network
- Pharmacy Network
- Dental Network
- Auxiliary Network
- Medscheme Holdings (Pty) Ltd: Renewal of accreditation was granted for a period of two years from 31 December 2021 for the following services, with the conditions as stipulated on the CMS website:
a. Hospital benefit management services (HBM)
- Pre-authorisation
- Case management
- Clinical Audit
b. Pharmacy Benefit Management services (PBM)
- Pre-authorisation
- Drug utilisation review (DUR)
c. Active Disease Management services (ADM)
- Asthma/ COPD/ Bronchiectasis
- Cardiac failure/ Cardiomyopathy/ Dysrhythmias/ Coronary Artery Disease
- Diabetes (Type 1 and 2)
- Hyperlipidaemia
- Hypertension
- Depression / Bipolar
- Oncology
- Epilepsy
- Muscular-skeletal Program
- Maternity programme
d. Dental Benefit Management Services (DBM)
- Basic dentistry
- Specialised dentistry
e. Managed Care Network Management Services and Risk Management
- General practitioner network
- Specialist network
- Hospital network
- Pharmacy network
- Metropolitan Health Corporate (Pty) Ltd: Renewal of accreditation was granted for a period of two years from 4 December 2021 for the following services, with the conditions as stipulated on the CMS website:
a. Dental Benefit Management Services
- Basic dentistry
- Specialist dentistry
b. Managed Care Network Management Services and Risk Management
- General Practitioner Network;
- Specialist Network;
- Hospital Network;
- Pharmacy Network
c. Health Care Services (Risk Transfer)
- Out-of-hospital and full in-hospital services (limited services in accordance with the scheme’s benefit rules)
d. Active Disease Risk Management Services
- Asthma / COPD / Bronchiectasis
- Cardiac Failure / Cardiomyopathy / Dysrhythmias / Coronary Artery Disease
- Diabetes (Type 1 and 2)
- Hypertension
- Oncology
- HIV
- Chronic Renal Disease
e. Pharmacy Benefit Management Services
- Pre-authorisation
- Drug Utilisation Review (DUR)
- Pharmacy Benefit Management: Disease Risk Management Support Services
f. Hospital Benefit Management Services
- Pre-authorisation services
- Case Management
- Clinical Audit
- Private Health Administrators (Pty) Ltd: Renewal of accreditation was granted for a period of two years from 31 December 2021 for the following services, with the conditions as stipulated on the CMS website:
a. Hospital Benefit Management Services
- Pre-Authorisation services
- Case Management
- Clinical Audit
b. Active Disease Risk Management Services
- Asthma/COPD/Bronchiectasis
- Cardiac Failure/Cardiomyopathy/Dysrhythmias/Coronary Artery Disease
- Oncology
- Diabetes (Type 1 and 2)
- Hypertension
- Chronic Renal Disease
- Mental health services
- Hyperlipidaemia
- HIV
- Maternity Program
c. Dental Benefit Management Services
- Specialised dentistry
d. Managed Care Network Management Services and Risk Management
- General Practitioner Network
- Specialist Network
- Hospital Network
- Pharmacy Network
- Dental Network; and/or
- Auxiliary Network
e. Health Care Services (Risk Transfer)
- Out-of-hospital and full in-hospital services (limited services in accordance with scheme’s benefit rules).
- Supplementary Health Services (Pty) Ltd: Renewal of accreditation was granted for a period of two years from 4 December 2021 for the following services, with the conditions as stipulated on the CMS website:
a. Dental Benefit Management Services
- Basic dentistry
- Specialised Dentistry
- Thebe Health Risk Management (Pty) Ltd: Renewal of accreditation was granted for a period of two years from 10 December 2021 for the following services, with the conditions as stipulated on the CMS website:
a. Dental Benefit Management Services
- Basic dentistry
- Specialised Dentistry
b. Managed Care Network Management Services and Risk Management
- General Practitioner Network;
- Specialist Network;
- Hospital Network;
- Pharmacy Network
c. Disease Risk Management Support Services
- System Lupus Erythematosus
- Rheumatoid Arthritis
d. Active Disease Risk Management Services
- Asthma / COPD / Bronchiectasis
- Cardiac Failure / Cardiomyopathy / Dysrhythmias / Coronary Artery Disease
- Diabetes (Type 1 and 2)
- Hypertension
- HIV
- Chronic Renal Disease
- Epilepsy
- Maternity program
- Hyperlipidaemia
- Mental Health Services
- Hypothyroidism
e. Pharmacy Benefit Management Services
- Pre-authorisation
- Drug Utilisation Review (DUR)
- Pharmacy Benefit Management: Disease Risk Management Support Services
- Universal Care (Pty) Ltd: Renewal of accreditation was granted for a period of two years from 31 December 2021 with no conditions, for the following services as stipulated on the CMS website:
a. Hospital Benefit Management Services
- Pre-authorisation
- Case management
- Clinical audit
b. Pharmacy Benefit Management Services
- Pre-authorisation
- Drug utilisation review (DUR)
c. Active Disease Risk Management Services
- Asthma/ COPD/ Bronchiectasis
- Cardiac Failure/ Cardiomyopathy/ Dysrhythmias/ Coronary Artery Disease
- Diabetes (Type 1 and 2)
- Hyperlipidaemia
- Hypertension
- Oncology
- HIV
- Chronic Renal Disease
- Hypothyroidism
- Depression / Bipolar mood disorder
d. Disease Risk Management Support Services
e. Dental Benefit Management Services
- Basic dentistry
- Specialised dentistry
f. Managed Care Network Management Services
- General Practitioner Network
- Specialist Network
- Hospital Network
- Pharmacy Network
- Dental Network
- Auxiliary Network
g. Health Care Services (Risk transfer)
- Out-of-hospital and full in-hospital services (limited services in accordance with scheme’s benefit rules).
Administrators – Self-administered medical schemes: Compliance Certificate Renewal Applications
- Umvuzo Health Medical Scheme: Renewal of the compliance certificate was granted for a period of three years from 10 December 2021, with no conditions.
- Bestmed Medical Scheme: Renewal of the compliance certificate was granted for a period of three years from 6 December 2021, with the conditions as stipulated on the CMS website.
- Platinum Health Medical Scheme: Renewal of the compliance certificate was granted for a period of three years from 10 December 2021 with no conditions.
Administrator – Accreditation Renewal Applications
- Metropolitan Health Corporate (Pty) Ltd: Accreditation was granted for a period of two years from 1 January 2022 subject to compliance with the conditions as stipulated on the CMS website.
- Medscheme Holdings (Pty) Ltd: Accreditation was granted for a period of two years from 31 December 2021 subject to compliance with the conditions as stipulated on the CMS website.
- Discovery Health (Pty) Ltd: Accreditation was granted for a period of two years from 31 December 2021 subject to compliance with the conditions as stipulated on the CMS website.
The above-mentioned Managed Care and Administrators conditions and status can be viewed here.
Download the circular here.