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Managed Care Service Level

 

GetMed is a Managed Care Organisation that conducts its services in full compliance with International medical risk

management standards and the principles of sound corporate governance.

 

GetMed provides clinical and financial risk assessment and management to facilitate appropriate and cost-effective

access to the relevant health services by members of a Fund, in accordance with the Fund rules.

 

GetMed renders its services by way of rules-based and clinical management-based programmes, which utilise

documented clinical review criteria that are based upon internationally accepted evidence-based medicine.  

GetMed undertakes to:

 

  1. Ensure the confidentiality of all clinical and member information.
  2. Employ suitably qualified health care professionals to administer the managed health care programmes and oversee funding decisions, and that the appropriateness of such decisions is evaluated periodically by their clinical peers.  
  3. Ensure that treatment is rendered to all members for the Defined Minimum Benefits.  
  4. Have in place appropriate mechanisms to ensure the consistent application of clinical review criteria and compatible decisions.  
  5. Produce a list of certain conditions for which cover is limited on the basis of evidence-based medicine, cost effectiveness and affordability.  
  6. Ensure that all protocols and formularies used in the programmes are based on evidence-based medicine; are evaluated periodically to ensure relevance for funding decisions; consider both cost-effectiveness and affordability; and ensure that provision is made for appropriate exceptions where a protocol and/or formulary has been ineffective or causes or would cause harm to a beneficiary, without penalty to that beneficiary.  
  7. Provide access to protocols, formularies and exclusion lists to health care providers, beneficiaries and members of the public, upon request.
  8. To use systems and procedures for the early detection and mitigation of irregularities and illegal acts by employees, members and providers.  
  9. To provide procedures for complaints or appeals that will in no way impact upon the entitlement of a beneficiary to complain to, or lodge a dispute with the Fund.  
  10. To provide access to the Fund to any treatment record held by GetMed and other information pertaining to the diagnosis, treatment and health status of any beneficiary, but such information may not be disclosed to any other person without the express consent of the beneficiary.  
  11. To implement policies to employ sufficient and suitably qualified and trained staff, to implement infrastructure information technology and systems to provide the services and to effect its contractual obligations to the Fund.  
  12. To use comprehensive off-site data storage, backup and disaster recovery process in compliance with accepted industry norms and standards.  
  13. To demonstrate the reporting ability on aspects of service delivery, including service centre, call centres and the recording of pre-authorisations.
  14.  To be bound by an agreement that will provide that all the Fund data remains the property of the Fund and copyright vests in the Fund. In addition to existing security measures, GetMed will take such steps as may be required to protect the confidential nature, integrity and assignment of data as far as it relates to the business of the Fund. The data shall be kept and disclosed as per industry norms and standards and as may be required from time to time.
  15. To be willing and able to constructively engage and participate with all other service providers that are contracted by the Fund.
  16. To undertake that the information will be provided in the required format to the Fund IT provider.
  17. To be bound by a managed care agreement to fulfil all functions at least at the level of the industry standard.

 

The scope of work that will be provided by GetMed in terms of its managed care agreement is presented

below and includes:  

 

 

 

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