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ANNEXURE A

AGHSA DIRECT CONTRACTS - FOUNDATION OPTION 2016

1. Reimbursement Model

1.1. The Client Scheme contract tariff for 2016 is 2015 rate plus 6%.

Procedures not listed will be paid at Scheme tariff 2015+ 6% = 2016. Procedures not listed will not be paid unless pre-

authorisation was obtained.

Option Foundation

Global Fee: Dispensing Provider R335.00

Global Fee: Non Dispensing Provider R245.00

Payment Schedule Dispensing Non-Dispensing

Consultations Global fee for services listed in Annexure A As per dispensing practitioners.

Listed In-Rooms Procedures

All procedures as listed in Annexure A are included in the Scheme tariff fee. As per dispensing practitioners.

Acute Medicine

The supply of Acute Medication should be in accordance with the Scheme Formulary and is included in the Global Fee.

Any medicine item that falls outside the formulary needs to be authorized by the Scheme, please advise patient when scripting that items are not on the formulary as patients may incur co-payments.

When prescribing: The tariff will immediately revert to the non-Dispensing tariff as claw back will not be done. See notes on prescriptions under “non-Dispensing”.

Medication needs to be prescribed in terms of the Scheme formulary.

Patient to obtain medication from AGHSA contracted pharmacy.

All Acute prescriptions has a Scheme limit of R89.00 per prescription per beneficiary. Note that there is also a limit on the number of prescriptions in any period, and the frequency of prescriptions will be used for monitoring purposes. Additional prescription require pre-authorisation.

Chronic Medication All chronic medication must be duly

authorized and approved by Scheme PMB (CDL) conditions only.

As per dispensing provider Chronic medicine prescriptions

should be filled at AGHSA enabled pharmacies.

Pathology & Radiology As per client scheme benefit guide

As per dispensing provider

of 11 Annexure A: GP - Foundation 2016Your partner in Healthcare delivery:

[email protected] | www.agilityghs.comTel: 012 673 8600 | Fax: 086 605 9440

Building A, Lakefield Office Park, 272 West Avenue, Centurion, 0157, South Africa

http://www.agilityghs.com/

mailto:[email protected]

1.2. In Rooms Procedures: Included in Global Fee

GP PROCEDURES INCLUDED IN FOUNDATION GLOBAL CONSULTATION FEES

0007 Own equipment

0190/1/2 New and established patient

0132 Writing of repeat scripts

0133 Writing of special motivations

0202 Setting of sterile tray

0206 / 0017 Intravenous treatment, patient over 3 years

0210 Collection of blood specimen

0222 Intralesional injection into areas of pathology – single

0223 Intralesional injection into areas of pathology – multiple

0245 Removal of benign lesion – first lesion

0246 Removal of benign lesion – subsequent lesions

0316 Fine needle aspiration for soft tissue – all areas

0317 Aspiration of cyst or tumour

0661 Aspiration of joint or intra-articular injection

1037 Diathermy to nose or pharynx, uni- or bilateral: under local anaesthetic

1063 Removal of foreign bodies from nose (in rooms)

1136 Nebulisation (in rooms)

1192 Peak expiratory flow

1228 Recording of a resting ECG

1232 ECG without effort including interpretation

2271 Removal of tag or polyp – vulva & introitus

2272 Removal of small superficial benign lesions – vulva & introitus

3004 Peripheral fundus examination with indirect ophthalmoscope

3204 External ear canal: Removal of foreign body (in rooms)

3867 Microscopy miscellaneous (body fluids, urine, exudate, fungi, pus, scrapings, etc.)

4188 Urine dipstick, per stick (irrespective of the number of sticks)

4561 Sputum cytology - body fluids and tumour aspirates: first unit

4563 Sputum cytology - body fluids and tumour aspirates: additional unit






1.3. The following procedures are excluded from the consultation fee, and may be charged for as additional to the consultation fee, at

negotiated scheme rate (2015 + 5% = 2016):

Tariff Code

Tariff Description Tariff Code

Tariff Description

0205 Intravenous treatment: Intravenous infusions (cut-down or push-in) (patients under three years): Cut-down and/or insertion of cannula - chargeable once per 24 hours.

0233 Biopsy without suturing: First lesion

0208 Venesection: Therapeutic venesection (Not to be used when blood is drawn for the purpose of laboratory investigations).

0235 Biopsy without suturing: Maximum for multiple additional lesions

0234 Biopsy without suturing: Subsequent lesions (each). 0255 Drainage of subcutaneous abscess onychia, paronychia, pulp space or avulsion of nail

0237 Deep skin biopsy by surgical incision with local anaesthetic and suturing.

0300 Stitching of soft-tissue injuries: Stitching of wound (with or without local anaesthesia): Including normal after-care)

0259 Removal of foreign body superficial to deep fascia (except hands).

0302 Stitching of soft-tissue injuries: Deep laceration involving limited muscle damage

0301 Stitching of soft-tissue injuries: Additional wounds stitched at same session (each).

0887 Limb cast (excluding after-care) (modifier 0005 not applicable)

0305 Needle biopsy - soft tissue. 1236 Electrocardiogram without effort: Under 4 years old

0922 Removal of foreign bodies requiring incision: Under local anaesthetic.

5375 Venous Doppler examination (both limbs)

1237 24 Hour ambulatory blood pressure: Hire fee. 2713 Spinal (lumbar) puncture. For diagnosis, for drainage of spinal fluid or for therapeutic indications

2293 Vulva and introitus: Drainage of abscess. 4351 Occult blood: Chemical test

3204 External ear canal: Removal of foreign body: At rooms






1.4. Procedures: Approval

The following procedures may be charged for as additional to the consultation though requires pre-authorisation obtainable from

Agility. If no pre-authorisation found then procedure will be rejected:

Tariff Code

Tariff Description Tariff Code

Tariff Description

0217 Allergy: Patch tests:

First patch

0218 Allergy: Skin-prick tests: Skin-prick testing: Insect venom, latex and drugs

0219 Allergy: Patch tests:

Each additional patch

0220 Allergy: Skin-prick tests: Immediate hypersensitivity testing (Type I reaction): Per antigen: Inhalant and food allergens

0221 Allergy: Skin-prick tests: Delayed hypersensitivity testing (Type IV reaction): Per antigen

0241 Treatment of benign skin lesion by chemo-cryotherapy: First Lesion

0242 Treatment of benign skin lesion by chemo-cryotherapy: Subsequent lesions (each)

0243 Treatment of benign skin lesion by chemo-cryotherapy: Maximum for multiple additional lesions

0251 Removal of malignant lesions by curetting under local or general anaesthesia followed by electro cautery: First lesion

0252 Removal of malignant lesions by curetting under local or general anaesthesia followed by electro cautery: Subsequent lesions (each)

0307 Excision and repair by direct suture; excision nail fold or other minor procedures of similar magnitude

0308 Each additional small procedure done at the same time

0310 Radical excision of nailbed 0661 Aspiration of joint or intra-articular injection (not including after-care) (modifier 0005 not applicable)

0663 Multiple intra-articular injections for rheumatoid arthritis (excluding after-care) (modifier 0005 not applicable): First joint

0665 Multiple intra-articular injections for rheumatoid arthritis (excluding after-care) (modifier 0005 not applicable): Additional (each)

1107 Opening of quinsy: At rooms 1139 Pleural needle biopsy (no after-care) (modifier 0005 not applicable)

1143 Paracentesis chest: Diagnostic 1234 Effort electrocardiogram with the aid of a special bicycle ergometer, monitoring apparatus and availability of associated apparatus

1235 Multi-stage treadmill test 1367 Doppler blood tests

5369 Doppler arterial pressures 5371 Doppler arterial pressures with exercise

1485 Local excision of benign lesion of lip 1487 Resection for lip malignancy

1587 Upper gastro-intestinal endoscopy: Hospital equipment

1588 Plus polypectomy: ADD to gastro-intestinal endoscopy (Item 1587)

1681 Proctoscopy with removal of polyps: First time 1683 Proctoscopy with removal of polyps: Subsequent times

1705 Incision and drainage of peri-anal abscess 1725 Drainage of external thrombosed pile

2133 Circumcision: Clamp procedure 2137 Circumcision: Surgical excision other than by clamp or






dorsal slit, any age

2139 Circumcision: Dorsal slit of prepuce (independent procedure)

2207 Vasectomy: Unilateral or bilateral (no extra fee to be charged if done in combination with prostatectomy)

2281 Excision of inclusion cyst 2957 Individual psychotherapy (specify type): Including play therapy for children: Per short session (20 minutes)

2958 Psychoanalytic therapy: Per 60-minute session 2962 Directive therapy to family, parent(s), spouse: Per 20-minute session

2963 Pairs, marriage or sex therapy: Per 20-minute session

2974 Individual psychotherapy (specify type): Including play therapy for children: Per intermediate session (40 minutes)

2975 Individual psychotherapy (specify type): Including play therapy for children: Per extended session (60 minutes or longer)

2976 Intermediate treatment where either items 2962 or 2963 are used: Per 40-minute session

2977 Extended treatment where either items 2962 or 2963 are used: Per 60-minute session

3292 Aspiration of joint or inter-articular injection

3293 Aspiration or injection of bursa or ganglion

1.5. Procedures: Ultrasound

The following will be paid from ultra sound obstetric benefit if pregnant; if used for pelvic ultra sound an authorisation is required; if

any other condition such as ectopic pregnancy confirmation is required. Note that scheme rules apply and that pregnancy need to be

registered on the Maternity programme and only 2 X 2D Sonars will be reimbursed without pre – authorisation.

Tariff Code Tariff Description Tariff Code Tariff Description

3615 Routine obstetric ultrasound at 10 to 20 weeks gestational age preferable at 10 to 14 weeks gestational age to include nuchal translucency assessment

3617 Routine obstetric ultrasound at 20 to 24 weeks to include detailed anatomical assessment






1.6. Primary Care Radiology - 2016

The following imaging is not included in the global fee and will be reimbursed separately. All other imaging not listed needs pre-

authorisation.

Equipment / Diagnostic Tariff Code Procedure

00110 X-ray skeletal survey under five years

Head

Skull and Brain 10100 X-ray of the skull

Sella turcica 17100 X-ray of the sella turcica

Facial bones and nasal bones11100 X-ray of the facial bones

11120 X-ray of the nasal bones

Orbits, lacrimal glands and tear ducts12100 X-ray orbits less than three views

12120 X-ray of the orbits for foreign body

Paranasal sinuses13100 X-ray of the paranasal sinuses, single view

13110 X-ray of the paranasal sinuses, two or more views

Mastoids and internal auditory canal16100 X-ray of the mastoids, unilateral

16110 X-ray of the mastoids, bilateral

Mandible, teeth and maxilla 14100 X-ray of the mandible

TM Joints15100 X-ray tempero-mandibular joint, left

15110 X-ray of tempero-mandibular joint, right

Spine

50100 X-ray of the spine scoliosos view AP only

50105 X-ray of the spine scoliosis view AP and lateral

Cervical

51110 X-ray of the cervical spine, one or two views

51120 X-ray of the cervical spine, more than two views

51130 X-ray of the cervical spine, more than two views including stress views

Thoracic

52100 X-ray of the thoracic spine, one or two views

52110 X-ray of the thoracic spine, more than two views

52140 X-ray of the thoracic spine, more than two views including stress views

Lumbar

53100 X-ray of the lumbar spine – stress studies only

53110 X-ray of the lumbar spine, one or two views

53120 X-ray of the lumbar spine, more than two views

53130 X-ray of the lumbar spine, more than two views including stress views

Sacrum54100 X-ray of the sacrum and coccyx

54110 X-ray of the sacro-iliac joints

Chest

30100 X-ray of the chest, single view

30110 X-ray of the chest two views , PA and lateral

30155 X-ray of the chest and ribs

30170 X-ray of the of the sterno-clavicular joint

30180 X-ray of the sternum of 11 Annexure A: GP - Foundation 2016Your partner in Healthcare delivery:





Abdomen/Stomach/Bowel

40100 X-ray of the abdomen

40105 X-ray of the abdomen supine and erect, or decubitus

40110 X-ray of the abdomen multiple views including chest

40210 Ultrasound study of the whole abdomen including the pelvis

41200 Ultrasound study of the upper abdomen

44200 Ultrasound study of abdominal aorta and branches including Doppler

Pelvis

55100 X-ray of the pelvis

Reproductive System

43200 Ultrasound study of the pelvis transabdominal

43250 Ultrasound study of the pregnant uterus, first trimester

43260 Ultrasound study of the pregnant uterus, second trimester

Reproductive System

43270 Ultrasound study of the pregnant uterus, third trimester, first visit

43273 Ultrasound study of the pregnant uterus, third trimester, follow-up visit

Shoulder

61100 X-ray of the left clavicle

61105 X-ray of the right clavicle

61110 X-ray of the left scapula

61115 X-ray of the right scapula

61120 X-ray of the left acromio-clavicular joint

61125 X-ray of the right acromio-clavicular joint

61130 X-ray of the left shoulder

61135 X-ray of the right shoulder

61200 Ultrasound of the left shoulder joint

61210 Ultrasound of the right shoulder joint

Upper limbs

Humerus62100 X-ray of the of the left humerus

62105 X-ray of the right humerus

Elbow

63100 X-ray of the left elbow

63105 X-ray of the right elbow

63110 X-ray of the left elbow with stress

63115 X-ray of the right elbow with stress

Forearm 64100 X-ray of the left forearm of 11 Annexure A: GP - Foundation 2016Your partner in Healthcare delivery:





64105 X-ray of the right forearm

Hand and Wrist

65100 X-ray of the left hand

65105 X-ray of the right hand

65120 X-ray of a finger

65130 X-ray of the left wrist

65135 X-ray of the right wrist

65140 X-ray of the left scaphoid

65145 X-ray of the right scaphoid

65150 X-ray of the left wrist, scaphoid and stress views

65155 X-ray of the right wrist, scaphoid and stress views

Lower limbs

70120 X-ray of the lower limbs full length study

70200 Ultrasound lower limb – soft tissue – any study

Lower Leg73100 X-ray of the left lower leg

73105 X-ray of the right lower leg

Hips

56100 X-ray of the left hip

56110 X-ray of the right hip

56120 X-ray of pelvis and hips

56120 X-ray of pelvis and hips

Femur71100 X-ray of the left femur

71105 X-ray of the right femur

Knee

72100 X-ray of the left knee one or two views

72105 X-ray of the right knee one or two views

72120 X-ray of the left knee including patella

72125 X-ray of the right knee including patella

72130 X-ray of the right knee with stress views

72135 X-ray of the right knee with stress views

72140 X-ray of left patella

72145 X-ray of right patella

72150 X-ray of both knees standing – single view

Ankle and Foot 74100 X-ray of the left ankle

74105 X-ray of the right ankle

74110 X-ray of the left ankle with stress views

74115 X-ray of the right ankle with stress views

74120 X-ray of the left foot

74125 X-ray of the right foot

74130 X-ray of the left calcaneus

74135 X-ray of the right calcaneus

74140 X-ray of both feet – standing – single view






74145 X-ray of the of a toe

74150 X-ray of the sesamoid bones one or both sides

1.7. Primary Care Pathology – 2016

The following pathology is not included in the global fee and will be reimbursed separately. All other pathology tests not listed needs

pre-authorisation.

FOUNDATION PLAN PATHOLOGY TESTS

Haematology / Coagulation Leucocytes: Total Count 3785Haematology / Coagulation Leucocyte differential count 3783Haematology / Coagulation Haemoglobin estimation 3762Haematology / Coagulation Platelet count 3797Haematology / Coagulation Packed cell volume: Haematocrit 3791Haematology / Coagulation Full blood count (incl items 3739, 3762, 3783, 3785, 3791) 3755Haematology / Coagulation Erythrocyte sedimention rate 3743Haematology / Coagulation Prothrombin index 3805Haematology / Coagulation Iron 4071Haematology / Coagulation Ferritin 4528Haematology / Coagulation Transferrin 4144Haematology / Coagulation Vitamin B12 4491Haematology / Coagulation Antiglobulin test (Coombs’ or trypsinzied red cells) 3709

Kidney / Electrolytes Sodium 4114Kidney / Electrolytes Potassium 4113Kidney / Electrolytes Urea 4151Kidney / Electrolytes Creatinine 4032Kidney / Electrolytes Sodium+potassium+chloride+CO2+urea 4171Kidney / Electrolytes Calcium: Spectrophotometric 4017Kidney / Electrolytes Magnesuim: Spectrophotometric 4094Kidney / Electrolytes Phosphate 4109

Liver / Pancreas Protein: Total 4117Liver / Pancreas Albumin 3999Liver / Pancreas Alanine aminotransferase (ALT) 4131Liver / Pancreas Aspartate aminitransferase (AST) 4130Liver / Pancreas Lactate dehidrogenase (LD) 4133Liver / Pancreas Gamm aglutamyl transferase (GGT) 4134Liver / Pancreas Alkaline phosphatase 4001Liver / Pancreas Bilirubin: Total 4009Liver / Pancreas Bilirubin: Conjugated 4010Liver / Pancreas Amylase 4006

Endocrine / Metabolic Glucose: Quantitative 4057Endocrine / Metabolic HbA1c 4064Endocrine / Metabolic Free thyroxine (FT4) 4482Endocrine / Metabolic Thyrotropin (TSH) 4507Endocrine / Metabolic Oestriol 4505Endocrine / Metabolic Progesterone 4521Endocrine / Metabolic Prolactin 4537Endocrine / Metabolic Cholestrol total 4027Endocrine / Metabolic HDL Cholestrol 4028Endocrine / Metabolic Triglyceride 4147






Endocrine / Metabolic Uric Acid 4155Endocrine / Metabolic Creatine kinase (CK) 4132

HIV / STI Antibodies to human immunodeficiency virus (HIV): ELISA 3932HIV / STI Quantitative Kahn, VDRL or other flocculation 3951HIV / STI Syphilis IgG 3948

Infectious Hepatitis: Per Antigen or Antibody 4531Infectious Bacteriological culture: Miscellaneous 3893Infectious Variable cell count 3922Infectious Antimicrobic substances 3928Infectious Miscellaneous (body fluids, urine, exudates, fungi, pus,

scrapings etc.3867

Infectious Mycobacteria 3881Infectious Radiometric Tuberculosis Culture 3916Infectious Bilharzia Ag Serum/Urine 3980Infectious Faeces (including parasites) 3869Infectious Slide Agglutination Test (Malaria) 3961Infectious Concentration techniques for parasites 3883Infectious Plasmodium falciparum: Monoclonal immunological

identification3792

Infectious Parasites in blood smear 3865

Pregnancy Grouping : A B and O antigens 3764Pregnancy Grouping: Rh antigen 3765Pregnancy Rubella IgG 3948Pregnancy HCG: Monoclonal Immunilogical : Qualitative 4450

Unlisted Urine dipstick, per stick (irrespective of the number of tests on stick)

4188

Unlisted Vaginal or cervical smears, each 4566Unlisted Prostate specific antigen 4519

This Annexure A for Foundation Option 2016 is executed for and on behalf of The Service Provider.






On this ___________ day of ________________________________________ 2016

__________________________ __________________________

Medical Provider Witness

Practice Number: _______________________

AGHSA by _____________________________________________________ duly authorised by Agility Global Health Solutions Africa

Pty (Ltd).

On this ___________ day of ________________________________________ 2016

_________________________________ __________________________

Agility Global Health Solutions (Pty) Ltd Witness






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