Discovery Health Medical Scheme

Pricing look-up tool and payment direction update

SAOPA has communicated with you before regarding;

The potential effects of the NAPPI-coded product prices on the direct-payment arrangements associated with the Discovery Network agreement, and

Our talks with Discovery about the differences between the product prices on Discovery’s ‘Medicine Comparator’ facility, the Discovery network rates and the Medprax or equivalent price files

The latest news is that Discovery have acknowledged the problems caused by practitioners not being able to access the DH NAPPI code rates. They have therefore confirmed that, if practitioners should use Medikredit or any other rates on their claims and their rate happens to be higher than the DH rate: 

  • The claim will cut and pay the NAPPI code at the DH rate, as listed by the supplier and approved by Discovery Health. The onus is on the supplier to provide the Scheme with their price files and updates annually.
  • Practitioners will still be directly reimbursed if they are on the OP network, as long as the professional fee that they have charged is in line with the DH OP network rate
  • A Discovery Health Rate and Frequency limits apply to certain categories of NAPPI coded items such as mobility devices 

This means that if a practitioner should unintentionally charge a higher price for NAPPI-coded items, it will not be considered to be a breach of their agreement with Discovery, as long as their professional fees are in line with the Discovery network rate.

Please contact the office on 087 094 3100 or email us at should you require any additional information or for assistance.