Glossary

A tariff as agreed upon between the Scheme and certain service providers.

An angiogram is an X-ray examination where a special dye and camera (fluoroscopy) are employed to take pictures of the blood flow in arteries.

A Principal Member of the Scheme or a person registered as a Dependant of a Principal Member.

The application of Rules, clinical protocols and medical procedures for the treatment of specific conditions.

A team, a shared facility or an entity that provides leadership, best practices, research, support and / or training for a focus area. It provides a patient-centred focus that will include the coordination of care across multiple disciplines based on high and severe risk patient management needs, including pathology management.

A list of chronic illness conditions that are covered by the Scheme in terms of applicable legislation.

Prescribed medication continuously used for more than three (3) months for chronic conditions contained in the Scheme’s PMB CDL (Category A, 26 conditions – all options) and/or the Other Conditions (Category B, 29 conditions – Platinum option only).

A healthcare provider or group of providers selected by the Scheme that provides services at a specific negotiated tariff. They are digitally connected to receive home monitoring data, pathology results and a comprehensive view of the member’s health record.

Basic dental services, such as fillings, extractions and Preventative care.

The portion of the amount due that a Member must pay directly to the service provider involved and in accordance with the latest Scheme Rules.

Specialised, high definition external scanning methods for internal bodily examinations.

On the Platinum, Gold, Silver and Equilibrium options – an annual, combined, non-transferable, out-of-hospital limit which may be utilised (with due allowance for certain limitations) by any of the registered Beneficiaries in respect of products and services as stated in the latest version of the different benefit structures.

A cost and quality Dental Management Programme provided and managed by DENIS
(Dental Information Systems).

A healthcare provider or group of providers selected by the Scheme as the preferred provider(s) to supply its Members with diagnosis, treatment and health products at specific negotiated tariffs.

A unique program to assist Members to help manage their chronic conditions effectively and to improve the well-being of affected Members.

Is an initiative that offers the children of KeyHealth Members free, direct access to a hospital’s Emergency Room (ER) for medical treatment in emergency situations.

An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or intervention. If the treatment/intervention is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.

The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient.

Medicine with the same active ingredients and medicinal effect as the original brand name counterpart, but usually lower in price.

An additional benefit for preventive care available to Beneficiaries of the Scheme at no extra cost.

The international classification of diseases. It is used by healthcare providers to classify and code all diagnoses, symptoms and procedures.

Maximum Medical Aid Price – MediKredit’s MMAP® is a guideline to determine the maximum price that medical schemes will reimburse for specific pharmaceutical products.

The maximum tariff the Scheme is willing to pay for services rendered by healthcare service providers.

National Pharmaceutical Product Interface codification used for unique medication identification.

The treatment of cancer.

A cost and quality Optical Management Programme provided by OptiClear.

A Positron Emission Tomography scan – an imaging study using a very small dose of a radioactive tracer that helps to distinguish cancer from benign tissue to assist in assessing the response of cancer to therapy.

A severe bodily injury due to violence or an accident, e.g. a gunshot, stabbing, a fracture or a motor vehicle accident, causing serious and life-threatening physical injury, potentially resulting in secondary complications such as shock, respiratory failure or death. This includes penetrating, perforating and blunt force trauma.

• The day-to-day benefits on the Platinum option comprise of the following:
  
  • Routine medical expenses
  • Self-funding gap
  • Threshold Zone
• When the routine portion has been depleted, the Member is responsible for the payment of day-to-day expenses, and submits proof of cash payments (copy of account and receipt) to the Scheme, as these claims accumulate to the total of the self-funding gap.
• The self-funding gap will accumulate according to MST rates.
• Threshold Zone: Once the self-funding gap has been bridged, the Member will have access to further benefits.
• Over-the-counter medication is included in the self-funding gap and threshold with a sub-limit.

A healthcare provider or group of providers selected by the Scheme that provides services at a specific negotiated tariff.

The maximum price payable by the Scheme for medication and prosthetics / prosthesis, including hearing aids, in accordance with evidence-based practice(s) and cost effectiveness.

Grandchildren, brothers and/or sisters of the Principal Member and/or his/her Spouse/Partner if proof of care and financial dependency is provided.

Stand-in is dependent on the connection between the Scheme and the provider. If the communication lines are down and the transaction takes too long to process (time-out) or there is general system downtime, the claim will not be processed in real time but in stand-in. In stand-in, MediKredit processes the claim on behalf of the Scheme.

Switch-out is the term used to describe a real-time transaction between the Scheme and the provider. The benefit of switch-out is that the response the provider receives is directly from the Scheme and is basically instantaneous. It includes benefit checks; the provider will know at point-of-sale if there are any co-payments.

Used for the electronic information exchange for procedures and consultation claims.