PART 2
MEMBERSHIP
PART 2.1
MEMBERSHIP AT THE END OF THE FINANCIAL YEAR
Benefit
Options
Members
Adult
Dependants
Child
Dependants
Beneficiaries
Dependant
Ratio
2.1.1
2.1.2
2.1.2 Consolidated
Total
Please provide the reasons, should the members and/or adult and/or child dependants be zero for
any option:
Please provide the reasons, and action to be taken, should the principal members be less than
6 000 members:
PART 2.2
NUMBER OF REGISTERED MEMBERS AND DEPENDANTS AT THE END OF EACH
MONTH
Month
2.2.1
2.2.2
2.2.3
2.2.4
2.2.5
2.2.6
2.2.7
2.2.8
2.2.9
2.2.10
2.2.11
2.2.12
Members
Adult
Dependants
Child
Dependants
Beneficiaries
Dependant
Ratio
January
February
March
April
May
June
July
August
September
October
November
December
2.2.13 Average
Please provide the reasons if the members and/or adult dependants and/or child dependants are zero
in any month:
PART 2.3.1
AGE ANALYSIS OF BENEFICIARIES AS AT END OF THE FINANCIAL YEAR
Consolidated Total
Male
Female
Per Benefit
Option
Male
2.3.1.1 Less than one
year
2.3.1.2 1-4 years
2.3.1.3 5-9 years
2.3.1.4 10-14 years
2.3.1.5 15-19 years
2.3.1.6 20-24 years
2.3.1.7 25-29 years
2.3.1.8 30-34 years
2.3.1.9 35-39 years
2.3.1.10 40-44 years
2.3.1.11 45-49 years
2.3.1.12 50-54 years
2.3.1.13 55-59 years
2.3.1.14 60-64 years
2.3.1.15 65-69 years
2.3.1.16 70-74 years
2.3.1.17 75-79 years
2.3.1.18 80-84 years
2.3.1.19 85 years +
2.3.1.20 Total
Cumulative Total
65 Years + Ratio
Average Age per
Beneficiary
Please provide the reasons, should the total males or females be zero for any option:
Per Benefit
Option
Female
PART 2.3.2
AGE ANALYSIS OF MEMBERS AS AT END OF THE FINANCIAL YEAR
Consolidated Total
Male
2.3.2.1 Less than one
year
2.3.2.2 1-4 years
2.3.2.3 5-9 years
2.3.2.4 10-14 years
2.3.2.5 15-19 years
2.3.2.6 20-24 years
2.3.2.7 25-29 years
2.3.2.8 30-34 years
2.3.2.9 35-39 years
2.3.1.10 40-44 years
2.3.2.11 45-49 years
2.3.2.12 50-54 years
2.3.2.13 55-59 years
2.3.2.14 60-64 years
2.3.2.15 65-69 years
2.3.2.16 70-74 years
2.3.2.17 75-79 years
2.3.2.18 80-84 years
2.3.2.19 85 years +
2.3.2.20 Total
Cumulative Total
65 Years + Ratio
Average Age per
Member
Female
Per Benefit
Option
Male
Per Benefit
Option
Female
PART 2.4.1
MEMBER MOVEMENT DURING THE FINANCIAL YEAR
Number of New Members Joining the Scheme
Number of
Number of
Members
Members not
Transferring
Transferring
from Other
from Other
Schemes
Schemes
Total
2.4.1.1
Number of
New
Dependants
Joining the
Scheme
Number of
Members
Leaving the
Scheme
Number of
Dependants
Leaving the
Scheme
PART 2.4.2
AGE ANALYSIS OF MEMBER MOVEMENT FOR THE FINANCIAL YEAR
Number of
New
Members
Joining the
Scheme
2.4.2.1
2.4.2.2
2.4.2.3
2.4.2.4
2.4.2.5
2.4.2.6
2.4.2.7
2.4.2.8
2.4.2.9
2.4.2.10
2.4.2.11
2.4.2.12
2.4.2.13
2.4.2.14
2.4.2.15
2.4.2.16
2.4.2.17
2.4.2.18
2.4.2.19
2.4.2.20
Number of
New
Dependants
Joining the
Scheme
Number of
Members
Leaving the
Scheme
Number of
Dependants
Leaving the
Scheme
Less than one year
1-4 years
5-9 years
10-14 years
15-19 years
20-24 years
25-29 years
30-34 years
35-39 years
40-44 years
45-49 years
50-54 years
55-59 years
60-64 years
65-69 years
70-74 years
75-79 years
80-84 years
85 years +
Total
Please provide the reasons for the inclusion of members in the category: Less than one year
PART 2.5
WAITING PERIODS
Number of New Beneficiaries Number of New Beneficiaries Number of New Beneficiaries
to whom General Waiting
to whom Pre-existing
to whom Late Joiner
Periods were Imposed
Condition Exclusions were
Penalties were Imposed
Imposed
New
Transferred
New
Transferred
New
Transferred
Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries Beneficiaries
2.5.1 Less than one
year
2.5.2 1-4 years
2.5.3 5-9 years
2.5.4 10-14 years
2.5.5 15-19 years
2.5.6 20-24 years
2.5.7 25-29 years
2.5.8 30-34 years
2.5.9 35-39 years
2.5.10 40-44 years
2.5.11 45-49 years
2.5.12 50-54 years
2.5.13 55-59 years
2.5.14 60-64 years
2.5.15 65-69 years
2.5.16 70-74 years
2.5.17 75-79 years
2.5.18 80-84 years
2.5.19 85 years +
2.5.20 Total
Please provide reasons why no general waiting periods were imposed
Please provide reasons why no pre-existing condition exclusions were imposed
Please provide reasons why no late joiner penalties were imposed
PART 2.6.1
UTILISATION
Current Year
2.6.1.1
2.6.1.1.1
2.6.1.1.2
2.6.1.1.3
2.6.1.1.4
2.6.1.1.5
2.6.1.1.6
2.6.1.1.7
2.6.1.2
2.6.1.2.1
2.6.1.2.2
2.6.1.2.3
2.6.1.2.4
2.6.1.2.5
2.6.1.2.6
2.6.1.2.7
2.6.1.2.8
2.6.1.2.9
2.6.1.2.10
2.6.1.2.11
2.6.1.2.12
2.6.1.2.13
2.6.1.2.14
2.6.1.2.15
2.6.1.2.16
2.6.1.2.17
2.6.1.2.18
2.6.1.2.19
2.6.1.2.20
2.6.1.2.21
2.6.1.2.22
2.6.1.2.23
2.6.1.2.24
2.6.1.2.25
2.6.1.2.26
2.6.1.2.27
2.6.1.2.28
2.6.1.2.29
2.6.1.2.30
2.6.1.2.31
2.6.1.2.32
Primary and emergency care services
Number of beneficiaries visiting GPs at least once a year
Total number of visits to GPs
Number of beneficiaries visiting dentists at least once a year
Total number of visits to dentists
Number of beneficiaries visiting private nurses at least once a year
Total number of visits to private nurses
Number of beneficiaries admitted at Day clinics/ unattached operating
theatres (disciplines 76 and 77)
Private Hospitals - beneficiaries:
Total number of outpatient visits
Number of inpatient admissions
Total number of beneficiaries admitted as inpatients
Number of beneficiaries admitted for Prescribed Minimum Benefits
Number of beneficiaries receiving MRI scans
Number of MRI scans administered
Number of beneficiaries receiving CT scans
Number of CT scans administered
Number of births
Beneficiaries aged 0 who are active for at least 2 months
Number of caesarean sections performed
Number of births to women under 15 years
Number of births to women between 15 – 19 years
Number of mammograms paid for
Number of pap smears paid for
Number of deaths
Number of beneficiaries receiving PET scans
Number of PET scans administered
Number of beneficiaries receiving angiograms
Number of angiograms administered
Number of beneficiaries receiving bone density scans
Number of bone density scans administered
Number of inpatient days
Number of admissions to ICU
Number of inpatient days in ICU
Number of admissions to High Care
Number of inpatient days in High Care
Number of admissions to General Ward
Number of inpatient days in General Ward
Number of beneficiaries admitted for Renal Dialysis
Number of repeat admissions within 90 days
Number of circumcisions in 15 – 49 year old males
2.6.1.3 Public Hospitals - beneficiaries:
2.6.1.3.1 Total number of outpatient visits
2.6.1.3.2 Number of inpatient admissions
Previous Year
PART 2.6.2
PRIVATE HOSPITAL ADMISSION TYPE CATEGORIES
Admission Type Category
Measures
Number of admissions
Total number of inpatient days
Total hospital amount claimed
Ambulatory (Admissions
where a procedure room is
used but the patient is
discharged directly from that
room as opposed to a ward)
Total hospital amount paid from risk
Total radiologists and pathologists amount claimed
Total radiologists and pathologists amount paid from risk
Total professional fees claimed
Total professional fees paid from risk
Total other fees claimed
Total other fees paid from risk
Number of admissions
Total number of inpatient days
Total hospital amount claimed
Emergency room (Admissions
involving casualty)
Maternity - day case
Total hospital amount paid from risk
Total radiologists and pathologists amount claimed
Total radiologists and pathologists amount paid from risk
Total professional fees claimed
Total professional fees paid from risk
Total other fees claimed
Total other fees paid from risk
Number of admissions
Total number of inpatient days
Total hospital amount claimed
Total hospital amount paid from risk
Total radiologists and pathologists amount claimed
Total radiologists and pathologists amount paid from risk
Total professional fees claimed
Total professional fees paid from risk
Total other fees claimed
Total other fees paid from risk
Number of admissions
Total number of inpatient days
Maternity - inpatient
Total hospital amount claimed
Total hospital amount paid from risk
Total radiologists and pathologists amount claimed
Total radiologists and pathologists amount paid from risk
Total professional fees claimed
Total professional fees paid from risk
Total other fees claimed
Total other fees paid from risk
Surgical - day case
Number of admissions
Current Year
Previous Year
PART 2.6.2
PRIVATE HOSPITAL ADMISSION TYPE CATEGORIES
Admission Type Category
Measures
Total number of inpatient days
Total hospital amount claimed
Total hospital amount paid from risk
Total radiologists and pathologists amount claimed
Total radiologists and pathologists amount paid from risk
Total professional fees claimed
Total professional fees paid from risk
Total other fees claimed
Total other fees paid from risk
Number of admissions
Total number of inpatient days
Total hospital amount claimed
Total hospital amount paid from risk
Surgical – inpatient
Medical - day case
Total radiologists and pathologists amount claimed
Total radiologists and pathologists amount paid from risk
Total professional fees claimed
Total professional fees paid from risk
Total other fees claimed
Total other fees paid from risk
Number of admissions
Total number of inpatient days
Total hospital amount claimed
Total hospital amount paid from risk
Total radiologists and pathologists amount claimed
Total radiologists and pathologists amount paid from risk
Total professional fees claimed
Total professional fees paid from risk
Total other fees claimed
Total other fees paid from risk
Number of admissions
Total number of inpatient days
Total hospital amount claimed
Medical – inpatient
Total hospital amount paid from risk
Total radiologists and pathologists amount claimed
Total radiologists and pathologists amount paid from risk
Total professional fees claimed
Total professional fees paid from risk
Total other fees claimed
Total other fees paid from risk
Current Year
Previous Year
PART 2.7.1
NUMBER OF BENEFICIARIES WITH THE FOLLOWING CHRONIC DISEASES:
PREVALENCE
Name of disease
2.7.1.1
2.7.1.2
2.7.1.3
2.7.1.4
2.7.1.5
2.7.1.6
2.7.1.7
2.7.1.8
2.7.1.9
2.7.1.10
2.7.1.11
2.7.1.12
2.7.1.13
2.7.1.14
2.7.1.15
2.7.1.16
2.7.1.17
2.7.1.18
2.7.1.19
2.7.1.20
2.7.1.21
2.7.1.22
2.7.1.23
2.7.1.24
2.7.1.25
2.7.1.26
2.7.1.27
Consolidated
Current Year Previous Year
Per Benefit Option
Current Year Previous Year
Addison's Disease
Asthma
Bipolar Mood Disorder
Bronchiectasis
Cardiac Failure
Cardiomyopathy
Disease
Chronic Obstructive
Pulmonary Disease
Chronic Renal Disease
Coronary Artery Disease
Crohn's Disease
Diabetes Insipidus
Diabetes Mellitus Type 1
Diabetes Mellitus Type 2
Dysrhythmias
Epilepsy
Glaucoma
Haemophilia
HIV
Hyperlipidaemia
Hypertension
Hypothyroidism
Multiple Sclerosis
Parkinson's Disease
Rheumatoid Arthritis
Schizophrenia
Systemic Lupus
Erythematosus
Ulcerative Colitis
Please provide the reasons for any changes made to the prior year data:
PART 2.7.2
NUMBER OF BENEFICIARIES WITH THE FOLLOWING CHRONIC DISEASES: ENTRY AND
VERIFICATION CRITERIA
Name of disease
2.7.2.1
2.7.2.2
2.7.2.3
2.7.2.4
2.7.2.5
2.7.2.6
2.7.2.7
2.7.2.8
2.7.2.9
2.7.2.10
2.7.2.11
2.7.2.12
2.7.2.13
2.7.2.14
2.7.2.15
2.7.2.16
2.7.2.17
2.7.2.18
2.7.2.19
2.7.2.20
2.7.2.21
2.7.2.22
2.7.2.23
2.7.2.24
2.7.2.25
2.7.2.26
2.7.2.27
Addison's Disease
Asthma
Bipolar Mood Disorder
Bronchiectasis
Cardiac Failure
Cardiomyopathy Disease
Chronic Obstructive
Pulmonary Disease
Chronic Renal Disease
Coronary Artery Disease
Crohn's Disease
Diabetes Insipidus
Diabetes Mellitus Type 1
Diabetes Mellitus Type 2
Dysrhythmias
Epilepsy
Glaucoma
Haemophilia
HIV
Hyperlipidaemia
Hypertension
Hypothyroidism
Multiple Sclerosis
Parkinson's Disease
Rheumatoid Arthritis
Schizophrenia
Systemic Lupus
Erythematosus
Ulcerative Colitis
Consolidated
Per Benefit Option
Current Year Previous Year Current Year Previous Year
PART 2.7.3
NUMBER OF SCREENING TESTS OR PROCEDURES PERFORMED IN RESPECT OF BENEFICIARIES WITH THE FOLLOWING CHRONIC DISEASES
(BASED ON THE ENTRY AND VERIFICATION CRITERIA)
Name of disease
Screening test / Procedure
Consolidated
Per Benefit Option
Current Year Previous Year Current Year Previous Year
2.7.3.1.1
Lung Function Test (FEV1)
2.7.3.1.2
Peak Flow
2.7.3.1.3 Asthma
Nebulisation
2.7.3.1.4
Chest X-ray
2.7.3.1.5
Ige Specific Antibody Titre Elisa/Emit
2.7.3.2.1
2.7.3.2.2
Bipolar Mood Disorder
Lithium –flame ionisation
Drug Monitoring
2.7.3.3.1
Lung Function Test (FEV1)
2.7.3.3.2
Chest X-ray
2.7.3.3.3 Bronchiectasis
Peak Flow
2.7.3.3.4
Sputum MC&S analysis for infection
2.7.3.3.5
Haemoglobin
2.7.3.4.1
ECG (Electrocardiogram)
2.7.3.4.2
2.7.3.4.3
Echo Cardiogram
Chest X-Ray
2.7.3.4.4
Serum Electrolytes
2.7.3.4.5 Cardiac Failure
Creatinine
2.7.3.4.6
Drug Monitoring levels for approved medication
2.7.3.4.7
Prothrombin Index (PI)
2.7.3.4.8
Biopsy
PART 2.7.3
NUMBER OF SCREENING TESTS OR PROCEDURES PERFORMED IN RESPECT OF BENEFICIARIES WITH THE FOLLOWING CHRONIC DISEASES
(BASED ON THE ENTRY AND VERIFICATION CRITERIA)
Name of disease
Screening test / Procedure
Consolidated
Per Benefit Option
Current Year Previous Year Current Year Previous Year
2.7.3.4.9
HB
2.7.3.5.1
ECG (Electrocardiogram)
2.7.3.5.2
2.7.3.5.3
Echo Cardiogram
Chest X-Ray
2.7.3.5.4
Serum Electrolytes
2.7.3.5.5
Cardiomyopathy Disease
Creatinine
2.7.3.5.6
Drug Monitoring levels for approved medication
2.7.3.5.7
Prothrombin Index (PI)
2.7.3.5.8
Biopsy
2.7.3.5.9
HB
2.7.3.6.1
Chest X-ray
2.7.3.6.2
Lung Function Test (FEV1)
2.7.3.6.3
Peak Flow
2.7.3.6.4 Chronic Obstructive Pulmonary Nebulisation
2.7.3.6.5 Disease
Alpha 1 Antitrypsin levels
2.7.3.6.6
Drug Monitoring
2.7.3.6.7
Packed Cells
2.7.3.6.8
Full Blood Count
2.7.3.7.1
2.7.3.7.2
Chronic Renal Disease
Creatinine
Serum Calcium
PART 2.7.3
NUMBER OF SCREENING TESTS OR PROCEDURES PERFORMED IN RESPECT OF BENEFICIARIES WITH THE FOLLOWING CHRONIC DISEASES
(BASED ON THE ENTRY AND VERIFICATION CRITERIA)
Name of disease
Screening test / Procedure
Consolidated
Per Benefit Option
Current Year Previous Year Current Year Previous Year
2.7.3.7.3
Serum Phosphates
2.7.3.7.4
Uric Acid
2.7.3.7.5
Serum Parathyroid Hormone (PTH)
2.7.3.7.6
Serum Electrolytes
2.7.3.7.7
Full Blood Count
2.7.3.7.8
Urine Protein / Creatinine Ratio
2.7.3.8.1
ECG (Electrocardiogram)
2.7.3.8.2
Lipid Profile
2.7.3.8.3 Coronary Artery disease
Serum Electrolytes
2.7.3.8.4
Serum Creatinine
2.7.3.8.5
Glucose
2.7.3.9.1
Fasting Blood Glucose
2.7.3.9.2
Glucose Tolerance Test
2.7.3.9.3
Random Glucose
2.7.3.9.4
Total cholesterol
2.7.3.9.5
2.7.3.9.6
Diabetes Mellitus Type 1
ECG (Electrocardiogram)
Microalbuminuria
2.7.3.9.7
HBA1c
2.7.3.9.8
Lipogram
2.7.3.9.9
Fundus Examination
2.7.3.9.10
Potassium
PART 2.7.3
NUMBER OF SCREENING TESTS OR PROCEDURES PERFORMED IN RESPECT OF BENEFICIARIES WITH THE FOLLOWING CHRONIC DISEASES
(BASED ON THE ENTRY AND VERIFICATION CRITERIA)
Name of disease
Screening test / Procedure
Consolidated
Per Benefit Option
Current Year Previous Year Current Year Previous Year
2.7.3.9.11
Creatinine
2.7.3.10.1
Fasting Blood Glucose
2.7.3.10.2
Glucose Tolerance Test
2.7.3.10.3
Random Glucose
2.7.3.10.4
ECG (Electrocardiogram)
2.7.3.10.5
2.7.3.10.6
Diabetes Mellitus Type 2
Microalbuminuria
HBA1c
2.7.3.10.7
Lipogram
2.7.3.10.8
Fundus Examination
2.7.3.10.9
Creatinine
2.7.3.10.10
Urine Dipstick
2.7.3.11.1
ECG (Electrocardiogram)
2.7.3.11.2
Prothrombin Index (PI)
2.7.3.11.3
2.7.3.11.4
Dysrhythmias
Drug Monitoring Levels
Cardioversion
2.7.3.11.5
Pacemakers
2.7.3.11.6
Electrophysiological Studies
2.7.3.12.1
2.7.3.12.2
2.7.3.13.1
2.7.3.13.2
Epilepsy
Hyperlipidaemia
EEG (Electroencephalography)
Drug Monitoring Levels
Fasting Plasma Total Cholesterol
Lipid Profile
PART 2.7.3
NUMBER OF SCREENING TESTS OR PROCEDURES PERFORMED IN RESPECT OF BENEFICIARIES WITH THE FOLLOWING CHRONIC DISEASES
(BASED ON THE ENTRY AND VERIFICATION CRITERIA)
Name of disease
Screening test / Procedure
Consolidated
Per Benefit Option
Current Year Previous Year Current Year Previous Year
2.7.3.13.3
ECG
2.7.3.13.4
Potassium
2.7.3.13.5
Glucose
2.7.3.14.1
Blood Pressure Monitoring (including 24 hour ambulatory BP
monitoring)
2.7.3.14.2
Urine Analysis (Dipstick)
2.7.3.14.3
Chest X-ray
2.7.3.14.4
ECG (Electrocardiogram)
2.7.3.14.5 Hypertension
Serum Electrolytes
2.7.3.14.6
Serum Creatinine
2.7.3.14.7
Blood Glucose
2.7.3.14.8
Potassium
2.7.3.14.9
Chol/HDL/LDL/Trig
2.7.3.14.10
Lactate dehidrogenase (LD)
2.7.3.15.1
HIV antibodies
2.7.3.15.2
CD4 Count
2.7.3.15.3
Viral Load
2.7.3.15.4 HIV
Full Blood Count
2.7.3.15.5
Liver Function Test
2.7.3.15.6
Fasting Blood Glucose
2.7.3.15.7
Chest X-ray
PART 2.7.3
NUMBER OF SCREENING TESTS OR PROCEDURES PERFORMED IN RESPECT OF BENEFICIARIES WITH THE FOLLOWING CHRONIC DISEASES
(BASED ON THE ENTRY AND VERIFICATION CRITERIA)
Name of disease
Screening test / Procedure
Consolidated
Per Benefit Option
Current Year Previous Year Current Year Previous Year
2.7.3.15.8
Serum Electrolytes
2.7.3.15.9
Serum Creatinine
2.7.3.15.10
Alkaline Phosphatase Test
2.7.3.15.11
TB Screening
2.7.3.15.12
Fasting Cholesterol and Triglycerides
2.7.3.15.13
Glucose (Quantatative)
2.7.3.15.14
Qualtative PCR
2.7.3.15.15
HIV drug resistance test
2.7.3.15.16
Lactate
Please provide the reasons why the following screening tests / procedures were not performed:
PART 2.7.4
REF GRID BENEFICIARY COUNT (AVERAGE OVER THE FINANCIAL YEAR)
No CDL Disease
Female:
2.7.4.1
Less than one year
2.7.4.2
1-4 years
2.7.4.3
5-9 years
2.7.4.4
10-14 years
2.7.4.5
15-19 years
2.7.4.6
20-24 years
2.7.4.7
25-29 years
2.7.4.8
30-34 years
2.7.4.9
35-39 years
2.7.4.10
40-44 years
2.7.4.11
45-49 years
2.7.4.12
50-54 years
2.7.4.13
55-59 years
2.7.4.14
60-64 years
2.7.4.15
65-69 years
2.7.4.16
70-74 years
2.7.4.17
75-79 years
2.7.4.18
80-84 years
2.7.4.19
85 years +
2.7.4.20
Total
A
D
S
A
S
T
B
C
E
B
M
D
C
H
F
C
M
Y
C
O
P
C
R
F
C
S
D
D
B
I
D
M
1
D
M
2
D
Y
S
E
P
L
G
L
C
H
A
E
H
Y
L
H
Y
P
I
B
D
I
H
D
M
S
S
P
A
R
R
H
A
S
C
Z
S
L
E
T
D
H
H
I
V
C
C
2
C C
C C
3 4
Maternity
PART 2.7.4
REF GRID BENEFICIARY COUNT (AVERAGE OVER THE FINANCIAL YEAR)
No CDL Disease
Male:
2.7.4.21
Less than one year
2.7.4.22
1-4 years
2.7.4.23
5-9 years
2.7.4.24
10-14 years
2.7.4.25
15-19 years
2.7.4.26
20-24 years
2.7.4.27
25-29 years
2.7.4.28
30-34 years
2.7.4.29
35-39 years
2.7.4.30
40-44 years
2.7.4.31
45-49 years
2.7.4.32
50-54 years
2.7.4.33
55-59 years
2.7.4.34
60-64 years
2.7.4.35
65-69 years
2.7.4.36
70-74 years
2.7.4.37
75-79 years
2.7.4.38
80-84 years
2.7.4.39
85 years +
2.7.4.40
Total
A
D
S
A
S
T
B
C
E
B
M
D
C
H
F
C
M
Y
C
O
P
C
R
F
C
S
D
D
B
I
D
M
1
D
M
2
D
Y
S
E
P
L
G
L
C
H
A
E
H
Y
L
H
Y
P
I
B
D
I
H
D
M
S
S
P
A
R
R
H
A
S
C
Z
S
L
E
T
D
H
H
I
V
C
C
2
C C
C C
3 4
Maternity
PART 2.7.5
PRIVATE HOSPITAL ADMISSIONS RELATING TO BENEFICIARIES WITH CHRONIC DISEASES FOR
CURRENT YEAR
Name of chronic disease
2.7.5.1.1
Measures
Addison's Disease
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.2
Asthma
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.3
Bipolar Mood Disorder
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.4
Bronchiectasis
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.5
Cardiac Failure
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
Consolidated
Per Benefit
Option
Name of chronic disease
2.7.5.1.6
Measures
Cardiomyopathy Disease
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.7
Chronic Obstructive Pulmonary Disease
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.8
Chronic Renal Disease
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.9
Coronary Artery Disease
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.10 Crohn's Disease
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.11 Diabetes Insipidus
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Consolidated
Per Benefit
Option
Name of chronic disease
Measures
Total amount claimed
2.7.5.1.12 Diabetes Mellitus Type 1
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.13 Diabetes Mellitus Type 2
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.14 Dysrhythmias
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.15 Epilepsy
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.16 Glaucoma
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.17 Haemophilia
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Consolidated
Per Benefit
Option
Name of chronic disease
Measures
Total amount paid from risk
Total amount claimed
2.7.5.1.18 HIV
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.19 Hyperlipidaemia
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.20 Hypertension
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.21 Hypothyroidism
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.22 Multiple Sclerosis
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.23 Parkinson's Disease
Number of admissions
Number of beneficiaries
Consolidated
Per Benefit
Option
Name of chronic disease
Measures
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.24 Rheumatoid Arthritis
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.25 Schizophrenia
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.26 Systemic Lupus Erythematosus
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
2.7.5.1.27 Ulcerative Colitis
Number of admissions
Number of beneficiaries
Total number of inpatient
days
Total amount paid from risk
Total amount claimed
Consolidated
Per Benefit
Option
PART 2.7.6
BENEFICIARY PROFILE AS AT END OF THE FINANCIAL YEAR
Year of
Birth
Per Benefit Option
Chronic
Condition
Members
Beneficiaries Beneficiaries
enrolled for
joining in
> 12 months
the last 12
months
Female:
Before 1930
Before 1930
1930
1930
1931
1931
1932
1932
1933
1933
1934
1934
1935
1935
1936
1936
1937
1937
1938
1938
1939
1939
1940
1940
1941
1941
1942
1942
1943
1943
1944
1944
1945
1945
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Adult Dependants
Child Dependants
Beneficiaries Beneficiaries Beneficiaries Beneficiaries
enrolled for
joining in
enrolled for
joining in
> 12 months
the last 12
> 12 months
the last 12
months
months
PART 2.7.6
BENEFICIARY PROFILE AS AT END OF THE FINANCIAL YEAR
Year of
Birth
Per Benefit Option
Chronic
Condition
Members
Beneficiaries Beneficiaries
enrolled for
joining in
> 12 months
the last 12
months
1946
1946
1947
1947
1948
1948
1949
1949
1950
1950
1951
1951
1952
1952
1953
1953
1954
1954
1955
1955
1956
1956
1957
1957
1958
1958
1959
1959
1960
1960
1961
1961
1962
1962
1963
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Adult Dependants
Child Dependants
Beneficiaries Beneficiaries Beneficiaries Beneficiaries
enrolled for
joining in
enrolled for
joining in
> 12 months
the last 12
> 12 months
the last 12
months
months
PART 2.7.6
BENEFICIARY PROFILE AS AT END OF THE FINANCIAL YEAR
Year of
Birth
Per Benefit Option
Chronic
Condition
Members
Beneficiaries Beneficiaries
enrolled for
joining in
> 12 months
the last 12
months
1963
1964
1964
1965
1965
1966
1966
1967
1967
1968
1968
1969
1969
1970
1970
1971
1971
1972
1972
1973
1973
1974
1974
1975
1975
1976
1976
1977
1977
1978
1978
1979
1979
1980
1980
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Adult Dependants
Child Dependants
Beneficiaries Beneficiaries Beneficiaries Beneficiaries
enrolled for
joining in
enrolled for
joining in
> 12 months
the last 12
> 12 months
the last 12
months
months
PART 2.7.6
BENEFICIARY PROFILE AS AT END OF THE FINANCIAL YEAR
Year of
Birth
Per Benefit Option
Chronic
Condition
Members
Beneficiaries Beneficiaries
enrolled for
joining in
> 12 months
the last 12
months
1981
1981
1982
1982
1983
1983
1984
1984
1985
1985
1986
1986
1987
1987
1988
1988
1989
1989
1990
1990
1991
1991
1992
1992
1993
1993
1994
1994
1995
1995
1996
1996
1997
1997
1998
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Adult Dependants
Child Dependants
Beneficiaries Beneficiaries Beneficiaries Beneficiaries
enrolled for
joining in
enrolled for
joining in
> 12 months
the last 12
> 12 months
the last 12
months
months
PART 2.7.6
BENEFICIARY PROFILE AS AT END OF THE FINANCIAL YEAR
Year of
Birth
Per Benefit Option
Chronic
Condition
Members
Beneficiaries Beneficiaries
enrolled for
joining in
> 12 months
the last 12
months
1998
1999
1999
2000
2000
2001
2001
2002
2002
2003
2003
2004
2004
2005
2005
2006
2006
2007
2007
2008
2008
2009
2009
2010
2010
2011
2011
2012
2012
2013
2013
2014
2014
Male:
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Adult Dependants
Child Dependants
Beneficiaries Beneficiaries Beneficiaries Beneficiaries
enrolled for
joining in
enrolled for
joining in
> 12 months
the last 12
> 12 months
the last 12
months
months
PART 2.7.6
BENEFICIARY PROFILE AS AT END OF THE FINANCIAL YEAR
Year of
Birth
Per Benefit Option
Chronic
Condition
Members
Beneficiaries Beneficiaries
enrolled for
joining in
> 12 months
the last 12
months
Before 1930
Before 1930
1930
1930
1931
1931
1932
1932
1933
1933
1934
1934
1935
1935
1936
1936
1937
1937
1938
1938
1939
1939
1940
1940
1941
1941
1942
1942
1943
1943
1944
1944
1945
1945
1946
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Adult Dependants
Child Dependants
Beneficiaries Beneficiaries Beneficiaries Beneficiaries
enrolled for
joining in
enrolled for
joining in
> 12 months
the last 12
> 12 months
the last 12
months
months
PART 2.7.6
BENEFICIARY PROFILE AS AT END OF THE FINANCIAL YEAR
Year of
Birth
Per Benefit Option
Chronic
Condition
Members
Beneficiaries Beneficiaries
enrolled for
joining in
> 12 months
the last 12
months
1946
1947
1947
1948
1948
1949
1949
1950
1950
1951
1951
1952
1952
1953
1953
1954
1954
1955
1955
1956
1956
1957
1957
1958
1958
1959
1959
1960
1960
1961
1961
1962
1962
1963
1963
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Adult Dependants
Child Dependants
Beneficiaries Beneficiaries Beneficiaries Beneficiaries
enrolled for
joining in
enrolled for
joining in
> 12 months
the last 12
> 12 months
the last 12
months
months
PART 2.7.6
BENEFICIARY PROFILE AS AT END OF THE FINANCIAL YEAR
Year of
Birth
Per Benefit Option
Chronic
Condition
Members
Beneficiaries Beneficiaries
enrolled for
joining in
> 12 months
the last 12
months
1964
1964
1965
1965
1966
1966
1967
1967
1968
1968
1969
1969
1970
1970
1971
1971
1972
1972
1973
1973
1974
1974
1975
1975
1976
1976
1977
1977
1978
1978
1979
1979
1980
1980
1981
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Adult Dependants
Child Dependants
Beneficiaries Beneficiaries Beneficiaries Beneficiaries
enrolled for
joining in
enrolled for
joining in
> 12 months
the last 12
> 12 months
the last 12
months
months
PART 2.7.6
BENEFICIARY PROFILE AS AT END OF THE FINANCIAL YEAR
Year of
Birth
Per Benefit Option
Chronic
Condition
Members
Beneficiaries Beneficiaries
enrolled for
joining in
> 12 months
the last 12
months
1981
1982
1982
1983
1983
1984
1984
1985
1985
1986
1986
1987
1987
1988
1988
1989
1989
1990
1990
1991
1991
1992
1992
1993
1993
1994
1994
1995
1995
1996
1996
1997
1997
1998
1998
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Adult Dependants
Child Dependants
Beneficiaries Beneficiaries Beneficiaries Beneficiaries
enrolled for
joining in
enrolled for
joining in
> 12 months
the last 12
> 12 months
the last 12
months
months
PART 2.7.6
BENEFICIARY PROFILE AS AT END OF THE FINANCIAL YEAR
Year of
Birth
Per Benefit Option
Chronic
Condition
Members
Beneficiaries Beneficiaries
enrolled for
joining in
> 12 months
the last 12
months
1999
1999
2000
2000
2001
2001
2002
2002
2003
2003
2004
2004
2005
2005
2006
2006
2007
2007
2008
2008
2009
2009
2010
2010
2011
2011
2012
2012
2013
2013
2014
2014
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Adult Dependants
Child Dependants
Beneficiaries Beneficiaries Beneficiaries Beneficiaries
enrolled for
joining in
enrolled for
joining in
> 12 months
the last 12
> 12 months
the last 12
months
months
PART 2.8
UTILISATION OF SERVICES BY MEDICAL AND DENTAL SPECIALISTS
Health Professional
(BHF PCNS Discipline code)
2.8.1
2.8.2
2.8.3
2.8.4
2.8.5
2.8.6
2.8.7
2.8.8
2.8.9
2.8.10
2.8.11
2.8.12
2.8.13
2.8.14
2.8.15
2.8.16
2.8.17
2.8.18
2.8.19
2.8.20
2.8.21
2.8.22
2.8.23
2.8.24
2.8.25
2.8.26
2.8.27
2.8.28
2.8.29
2.8.30
2.8.31
2.8.32
2.8.33
2.8.34
2.8.35
Medical Specialists:
Dermatologists (12)
Obstetricians & Gynaecologists (16)
Pulmonologists (17)
Specialist Physicians (18)
Gastroenterologists (19)
Neurologists (20)
Cardiologists (21)
Psychiatrists (22)
Medical Oncologists (23)
Neurosurgeons (24)
Nuclear Medicine Specialists (25)
Ophthalmologists (26)
Clinical Haematologists (27)
Orthopaedic Surgeons (28)
Otorhinolaryngologists (30)
Rheumatologists (31)
Paediatricians (32)
Paediatric Cardiologists (33)
Physical Medicine Specialists (34)
Plastic & Reconstructive Surgeons (36)
Radiation Oncologists (40)
Surgeons (42)
Cardiothoracic Surgeons (44)
Urologists (46)
Clinical Support Specialists:
Anaesthetists (10)
Diagnostic Radiologists (38)
Pathologists (52)
Other Medical or Clinical Support Specialists (specify)
Dental Professionals:
Dental Therapists (95)
Dental Technicians (93)
Maxilla, Facial & Oral Surgeons (62)
Oral Pathologists (98)
Orthodontists (64)
Periodontists (92)
Prosthodontists (94)
Total Number of Visits Number of Beneficiaries
to Specialists
Visiting at Least Once Per
Year
PART 2.9
UTILISATION OF SERVICES BY SUPPLEMENTARY AND ALLIED HEALTH PROFESSIONALS
Health Professional
(BHF PCNS Discipline code)
2.9.1
2.9.2
2.9.3
2.9.4
2.9.5
2.9.6
2.9.7
2.9.8
2.9.9
2.9.10
2.9.11
2.9.12
2.9.13
2.9.14
2.9.15
2.9.16
2.9.17
2.9.18
2.9.19
2.9.20
2.9.21
2.9.22
2.9.23
2.9.24
2.9.25
2.9.26
2.9.27
2.9.28
2.9.29
2.9.30
2.9.31
Art Therapists (67)
Audiologists (82 - 002)
Biokineticists (75-009)
Clinical / Medical / Laboratory Technologists (75)
Dieticians (84)
Hearing Aid Acousticians (83)
Medical Scientists (69)
Occupational Therapists (66)
Optometrists (70)
Orthoptists (74)
Pharmacies (60)
Physiotherapists (72)
Podiatrists / Chiropodists (68)
Psychologists (86)
Radiographers (39)
Registered Nurses (88)
Social Workers (89)
Speech Therapists (82 - 001)
Complementary Medicine Practitioners:
Acupuncturists & Chinese Medicine Practitioners
(105)
Ayurvedic Practitioners (104)
Chiropractors & Osteopaths (04 & 102)
Homeopaths (08)
Naturopaths & Phytotherapists (101 & 103)
Therapeutic Aromatherapists (106) /
Reflexologists (108) / Massage (107)
Community Dentistry (96)
Nurses Institute (80)
Orthotist and Prosthetist (87)
Psychometry (85)
Registered Councellor (81)
Dispensing Optometrists (71)
Other Supplementary & Allied Health
Professionals (specify)
Total Number of Visits
to Supplementary and
Allied Health
Professionals
Number of
Beneficiaries Visiting
at Least Once Per
Year
PART 2.10
UTILISATION OF OTHER BENEFIT SERVICES
Benefit Service
(BHF PCNS Discipline Code)
2.10.1
2.10.2
2.10.3
2.10.4
2.10.5
2.10.6
2.10.7
2.10.8
2.10.9
2.10.10
2.10.11
2.10.12
2.10.13
2.10.14
2.10.15
2.10.16
2.10.17
Ambulance Services - Basic Life Support (13)
Ambulance Services - Intermediate Life Support (11)
Ambulance Services - Advanced Life Support (09)
Blood and Blood Product Couriers (03)
Blood Transfusion Services (78)
Clinical Services - Oxygen Supplier (90-001)
Clinical Services - Appliance Supplier (90002/007/013/014)
Clinical Services - Prosthetic Supplier (90003/004/005/006)
Clinical Services - Other (90-008/009/010/011/012)
Community Health Services (97)
Drug and Alcohol Rehabilitation (47)
Group Practice (50)
Hospice (79)
Mental Health Institutions (55)
Sub Acute Facilities/Step Down Facilities (49)
Private Rehabilitation Hospital (Acute) (059)
Other Benefit Services (specify)
Total Number of
Visits
Number of
Beneficiaries
Visiting at
least once per
year
PART 2.11
UTILISATION OF MEDICINES
Total Number of
Items Dispensed
2.11.1
2.11.1.1
2.11.1.2
2.11.1.3
Out-of-Hospital:
Medicines dispensed by Pharmacies
Medicines dispensed by General Practitioners
Medicines dispensed by Medical Specialists
Medicines dispensed by Supplementary and Allied Health
2.11.1.4
Professionals
2.11.1.5 Medicines dispensed by Other Health Professionals
PART 2.12
DISTRIBUTION OF MEMBERSHIP AT END OF FINANCIAL YEAR
Province
2.12.1
2.12.2
2.12.3
2.12.4
2.12.5
2.12.6
2.12.7
2.12.8
2.12.9
2.12.10
2.12.11
Members
Adult
Dependants
Child
Dependants
Beneficiaries
Adult
Dependants
Child
Dependants
Gauteng
Limpopo
Mpumalanga
North West
Free State
Kwa-Zulu Natal
Western Cape
Eastern Cape
Northern Cape
Outside the Republic
Total
Please indicate how the scheme is collecting the data for this part:
Members
Private Postal Address
Business Postal Address
Employer (Pay Point)
Residential Address
Other (specify)
Amount
paid from
risk
PART 2.13
UTILISATION OF PRIVATE HOSPITALS BY AGE GROUP AND GENDER
Age group
Female:
2.13.1.1 Less than one year
2.13.1.2 1-4 years
2.13.1.3 5-9 years
2.13.1.4 10-14 years
2.13.1.5 15-19 years
2.13.1.6 20-24 years
2.13.1.7 25-29 years
2.13.1.8 30-34 years
2.13.1.9 35-39 years
2.13.1.10 40-44 years
2.13.1.11 45-49 years
2.13.1.12 50-54 years
2.13.1.13 55-59 years
2.13.1.14 60-64 years
2.13.1.15 65-69 years
2.13.1.16 70-74 years
2.13.1.17 75-79 years
2.13.1.18 80-84 years
2.13.1.19 85 years +
2.13.1.20 Subtotal
Number of
beneficiaries
admitted as
inpatients
Number of
inpatient
admissions
Number of
inpatient days
PART 2.13
UTILISATION OF PRIVATE HOSPITALS BY AGE GROUP AND GENDER
Age group
Male:
2.13.2.1 Less than one year
2.13.2.2 1-4 years
2.13.2.3 5-9 years
2.13.2.4 10-14 years
2.13.2.5 15-19 years
2.13.2.6 20-24 years
2.13.2.7 25-29 years
2.13.2.8 30-34 years
2.13.2.9 35-39 years
2.13.2.10 40-44 years
2.13.2.11 45-49 years
2.13.2.12 50-54 years
2.13.2.13 55-59 years
2.13.2.14 60-64 years
2.13.2.15 65-69 years
2.13.2.16 70-74 years
2.13.2.17 75-79 years
2.13.2.18 80-84 years
2.13.2.19 85 years +
2.13.2.20 Subtotal
Number of
beneficiaries
admitted as
inpatients
Number of
inpatient
admissions
Number of
inpatient days
PART 2.14
UTILISATION OF PUBLIC HOSPITALS BY AGE GROUP AND GENDER
Age group
Female:
2.14.1.1 Less than one year
2.14.1.2 1-4 years
2.14.1.3 5-9 years
2.14.1.4 10-14 years
2.14.1.5 15-19 years
2.14.1.6 20-24 years
2.14.1.7 25-29 years
2.14.1.8 30-34 years
2.14.1.9 35-39 years
2.14.1.10 40-44 years
2.14.1.11 45-49 years
2.14.1.12 50-54 years
2.14.1.13 55-59 years
2.14.1.14 60-64 years
2.14.1.15 65-69 years
2.14.1.16 70-74 years
2.14.1.17 75-79 years
2.14.1.18 80-84 years
2.14.1.19 85 years +
2.14.1.20 Subtotal
Number of
beneficiaries
admitted as
inpatients
Number of
inpatient
admissions
Number of
inpatient days
PART 2.14
UTILISATION OF PUBLIC HOSPITALS BY AGE GROUP AND GENDER
Age group
Number of
beneficiaries
admitted as
inpatients
Male:
2.14.2.1 Less than one year
2.14.2.2 1-4 years
2.14.2.3 5-9 years
2.14.2.4 10-14 years
2.14.2.5 15-19 years
2.14.2.6 20-24 years
2.14.2.7 25-29 years
2.14.2.8 30-34 years
2.14.2.9 35-39 years
2.14.2.10 40-44 years
2.14.2.11 45-49 years
2.14.2.12 50-54 years
2.14.2.13 55-59 years
2.14.2.14 60-64 years
2.14.2.15 65-69 years
2.14.2.16 70-74 years
2.14.2.17 75-79 years
2.14.2.18 80-84 years
2.14.2.19 85 years +
2.14.2.20 Subtotal
Kindly confirm that no beneficiaries visited public hospitals:
Number of
inpatient
admissions
Number of
inpatient days
PART 2.15
UTILISATION OF HOSPITALS IN RESPECT OF SELECTED PRINCIPAL DIAGNOSIS TYPES PER ICD10
CODES
IDC 10
codes
2.15.1 A00–B99
2.15.2 C00–D48
2.15.3 D50–D89
2.15.4
2.15.5
2.15.6
2.15.7
2.15.8
2.15.9
2.15.10
2.15.11
2.15.12
E00–E90
F00–F99
G00–G99
H00–H59
H60–H95
I00–I99
J00–J99
K00–K93
L00–L99
2.15.13 M00–M99
2.15.14 N00–N99
2.15.15 O00–O99
2.15.16 P00–P96
2.15.17 Q00–Q99
2.15.18 R00–R99
2.15.19 S00–T98
2.15.20 U50-U98
2.15.21 Z00–Z99
2.15.22
2.15.23
Principal diagnosis
Certain infectious and parasitic diseases
Neoplasms
Diseases of the blood and blood-forming
organs and certain disorders involving the
immune mechanism
Endocrine, nutritional and metabolic diseases
Mental and behavioural disorders
Diseases of the nervous system
Diseases of the eye and adnexa
Diseases of the ear and mastoid process
Diseases of the circulatory system
Diseases of the respiratory system
Diseases of the digestive system
Diseases of the skin and subcutaneous tissue
Diseases of the musculoskeletal system and
connective tissue
Diseases of the genitourinary system
Pregnancy, childbirth and the puerperium
Certain conditions originating in the perinatal
period
Congenital malformations, deformations and
chromosomal abnormalities
Symptoms, signs and abnormal clinical and
laboratory findings, not elsewhere classified
Injury, poisoning and certain other
consequences of external causes
Codes for special purposes
Factors influencing health status and contact
with health services
Not reported
Total
Number of
beneficiaries
admitted as
inpatients
Number of
inpatient
admissions
Number of
inpatient days
PART 3
PART 3.1
ANALYSIS OF BENEFITS ACTUALLY PAID DURING THE FINANCIAL YEAR
Total amount
charged by
provider
R
General Practitioners (excl. medicine and
consumables)
Medical Specialists (excl. medicine and
3.1.2
consumables)
3.1.3 Dentists
3.1.1
3.1.4 Dental Specialists
Supplementary and Allied Health Professionals
3.1.5
(excl. medicine and consumables)
3.1.6 Hospitals
3.1.6.1 Unattached Operating Theatres/Day Clinics
3.1.6.1.1 Ward Fees
3.1.6.1.2 Theatre Fees
3.1.6.1.3 Medicine and consumables (i.e. all other claims)
3.1.6.1.4 Subtotal 1
3.1.6.2 Other Private Hospitals
3.1.6.2.1 Fee for service arrangements
3.1.6.2.1 Ward Fees
3.1.6.2.2 Theatre Fees
3.1.6.2.3 Medicine and consumables (i.e. all other claims)
3.1.6.2.4 Subtotal 2
3.1.6.3 Managed care arrangements (In hospital benefits)
3.1.6.3.1 Staff model-hospital care
Amount paid
from risk
Amount paid
from savings
R
R
PART 3.1
ANALYSIS OF BENEFITS ACTUALLY PAID DURING THE FINANCIAL YEAR
Total amount
charged by
provider
R
3.1.6.3.2 Fixed fee
3.1.6.3.3 Per diem fee
3.1.6.3.4 Other (specify)
3.1.6.3.5 Subtotal 3
3.1.6.4 State / Provincial Hospitals
3.1.6.4.1 Total
3.1.6.4.2 Subtotal 4
3.1.6.5 Total Hospitals
3.1.7 Medicine
3.1.7.1 Medicines dispensed by Pharmacies
3.1.7.2 Medicines dispensed by General Practitioners
3.1.7.3 Medicines dispensed by Medical Specialists
Medicines dispensed by Supplementary and
3.1.7.4
Allied Health Professionals
Medicines dispensed by Other Health
3.1.7.5
Professionals
3.1.7.6 Total Medicines
3.1.8 Ex-gratia-payments
3.1.9 Other Benefits
Managed care arrangements (Out of hospital
3.1.10
benefits)
3.1.10.1 Other (specify)
Total Managed Care Arrangements (Out of
3.1.10.4
Hospital Benefits)
3.1.11 Total Benefits
Amount paid
from risk
Amount paid from
savings
R
R
PART 3.2
ANALYSIS OF MEDICAL AND DENTAL SPECIALISTS
Medical Professional
Total amount charged by
provider
Amount paid
from risk
Amount paid from
savings
R
R
R
(BHF PCNS Discipline code)
Medical Specialists:
3.2.1 Dermatologists (12)
3.2.2 Obstetricians & Gynaecologists (16)
3.2.3 Pulmonologists (17)
3.2.4 Specialist Physicians (18)
3.2.5 Gastroenterologists (19)
3.2.6 Neurologists (20)
3.2.7 Cardiologists (21)
3.2.8 Psychiatrists (22)
3.2.9 Medical Oncologists (23)
3.2.10 Neurosurgeons (24)
3.2.11 Nuclear Medicine Specialists (25)
3.2.12 Ophthalmologists (26)
3.2.13 Clinical Haematologists (27)
3.2.14 Orthopaedic Surgeons (28)
3.2.15 Otorhinolaryngologists (30)
3.2.16 Rheumatologists (31)
3.2.17 Paediatricians (32)
3.2.18 Paediatric Cardiologists (33)
3.2.19 Physical Medicine Specialists (34)
Plastic & Reconstructive Surgeons
3.2.20
(36)
3.2.21 Radiation Oncologists (40)
3.2.22 Surgeons (42)
3.2.23 Cardiothoracic Surgeons (44)
3.2.24 Urologists (46)
Clinical Support Specialists:
3.2.25 Anaesthetists (10)
3.2.26 Diagnostic Radiologists (38)
3.2.27 Pathologists (52)
Other Medical or Clinical Support
3.2.28
Specialists (specify)
3.2.29 Total Specialists
PART 3.2
ANALYSIS OF MEDICAL AND DENTAL SPECIALISTS
Medical Professional
Total amount charged by
provider
Amount paid
from risk
Amount paid from
savings
R
R
R
(BHF PCNS Discipline code)
Dental Professionals:
3.2.30 Dental Therapists (95)
3.2.31 Dental Technicians (93)
3.2.32 Maxilla, Facial & Oral Surgeons (62)
3.2.33 Oral Pathologists (98)
3.2.34 Orthodontists (64)
3.2.35 Periodontists (92)
3.2.36 Prosthodontists (94)
3.2.37 Total Dental Professionals
PART 3.3
ANALYSIS OF SUPPLEMENTARY & ALLIED HEALTH PROFESSIONALS
Medical Professional
(BHF PCNS Discipline code)
3.3.1 Art Therapists (67)
3.3.2 Audiologists (82 - 002)
3.3.3 Biokineticists (75-009)
Clinical / Medical / Laboratory Technologists
3.3.4
(75)
3.3.5 Dieticians (84)
3.3.6 Hearing Aid Acousticians (83)
3.3.7 Medical Scientists (69)
3.3.8 Occupational Therapists (66)
3.3.9 Optometrists (70)
3.3.10 Orthoptists (74)
3.3.11 Pharmacies (60)
3.3.12 Physiotherapists (72)
3.3.13 Podiatrists / Chiropodists (68)
3.3.14 Psychologists (86)
3.3.15 Radiographers (39)
3.3.16 Registered Nurses (88)
3.3.17 Social Workers (89)
3.3.18 Speech Therapists (82 - 001)
Complementary Medicine Practitioners:
Acupuncturists & Chinese Medicine
3.3.19
Practitioners (105)
3.3.20 Ayurvedic Practitioners (104)
3.3.21 Chiropractors & Osteopaths (04 & 102)
3.3.22 Homeopaths (08)
3.3.23 Naturopaths & Phytotherapists (101 & 103)
Therapeutic Aromatherapists (106) /
3.3.24
Reflexologists (108) / Massage (107)
3.3.25 Community Dentistry (96)
3.3.26 Nurses Institute (80)
3.3.27 Orthotist and Prosthetist (87)
3.3.28 Psychometry (85)
3.3.29 Registered Councellor (81)
3.3.30 Dispensing Optometrists (71)
Other Supplementary & Allied Health
3.3.31
Professionals (specify)
3.3.26 Total
Total
amount
charged by
provider
R
Amount paid
from risk
Amount
paid from
savings
R
R
PART 3.4
ANALYSIS OF OTHER BENEFITS
Other Benefit Services
Total
amount
charged
by
provider
Amount paid
from risk
Amount
paid from
savings
R
R
R
(BHF PCNS Discipline code)
3.4.1 Ambulance Services - Basic Life Support (13)
3.4.2 Ambulance Services - Intermediate Life Support (11)
3.4.3 Ambulance Services - Advanced Life Support (09)
3.4.4 Blood and Blood Product Couriers (03)
3.4.5 Blood Transfusion Services (78)
3.4.6 Clinical Services - Oxygen Supplier (90-001)
Clinical Services - Appliance Supplier (903.4.7
002/007/013/014)
Clinical Services - Prosthetic Supplier (903.4.8
003/004/005/006)
3.4.9 Clinical Services - Other (90-008/009/010/011/012)
3.4.10 Community Health Services (97)
3.4.11 Drug and Alcohol Rehabilitation (47)
3.4.12 Group Practice (50)
3.4.13 Hospice (79)
3.4.14 Mental Health Institutions (55)
3.4.15 Sub Acute Facilities/Step Down Facilities (49)
3.4.16 Private Rehabilitation Hospital (Acute) (059)
3.4.17 Other Benefit Services (specify)
3.4.18 Total
PART 3.5
ANALYSIS OF TOTAL BENEFITS PAID IN RESPECT OF SELECTED PRINCIPAL DIAGNOSIS TYPES PER
ICD 10 CODES
ICD 10
codes
Other Benefit Services
Total
amount
charged by
provider
Amount
paid from
risk
Amount
paid from
savings
R
R
R
(BHF PCNS Discipline code)
3.5.1 A00–B99
Certain infectious and parasitic diseases
3.5.2 C00–D48
3.5.4 E00–E90
Neoplasms
Diseases of the blood and blood-forming organs and certain
disorders involving the immune mechanism
Endocrine, nutritional and metabolic diseases
3.5.5 F00–F99
Mental and behavioural disorders
3.5.6 G00–G99
Diseases of the nervous system
3.5.7 H00–H59
Diseases of the eye and adnexa
3.5.8 H60–H95
Diseases of the ear and mastoid process
3.5.9 I00–I99
Diseases of the circulatory system
3.5.10 J00–J99
Diseases of the respiratory system
3.5.11 K00–K93
Diseases of the digestive system
3.5.12 L00–L99
3.5.14 N00–N99
Diseases of the skin and subcutaneous tissue
Diseases of the musculoskeletal system and connective
tissue
Diseases of the genitourinary system
3.5.15 O00–O99
Pregnancy, childbirth and the puerperium
3.5.16 P00–P96
3.5.22
Certain conditions originating in the perinatal period
Congenital malformations, deformations and chromosomal
abnormalities
Symptoms, signs and abnormal clinical and laboratory
findings, not elsewhere classified
Injury, poisoning and certain other consequences of external
causes
Codes for special purposes
Factors influencing health status and contact with health
services
Not reported
3.5.23
Total
3.5.3 D50–D89
3.5.13 M00–M99
3.5.17 Q00–Q99
3.5.18 R00–R99
3.5.19 S00–T98
3.5.20 U50-U98
3.5.21 Z00–Z99
PART 3.6
ANALYSIS OF OUT-OF-HOSPITAL COSTS
Out-of-Hospital Costs
3.6.1 General Practitioners
3.6.2 Medical Specialists
3.6.3 Dentists
3.6.4 Dental Specialists
3.6.5 Supplementary and Allied Health Professionals
3.6.6 Total
Total amount
charged by
provider
Amount
paid from
risk
Amount
paid from
savings
R
R
R
PART 3.7
TOTAL PMB EXPENDITURE PAID PER AGE BAND: IN-HOSPITAL AND OUT-OF-HOSPITAL
In-Hospital
3.7.1
3.7.2
3.7.3
3.7.4
3.7.5
3.7.6
3.7.7
3.7.8
3.7.9
3.7.10
3.7.11
3.7.12
3.7.13
3.7.14
3.7.15
3.7.16
3.7.17
3.7.18
3.7.19
3.7.20
Female:
Less than one year
1-4 years
5-9 years
10-14 years
15-19 years
20-24 years
25-29 years
30-34 years
35-39 years
40-44 years
45-49 years
50-54 years
55-59 years
60-64 years
65-69 years
70-74 years
75-79 years
80-84 years
85 years +
Subtotal
Consolidated Total
Out-of-Hospital
Total per Age Band
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount
claimed
Amount
paid from
risk
Amount
claimed
Amount
paid from
risk
Amount
claimed
Amount
paid from
risk
Amount
claimed
Amount
paid from
risk
Amount
claimed
Amount
paid
from risk
R
R
R
R
R
R
R
R
R
R
PART 3.7
TOTAL PMB EXPENDITURE PAID PER AGE BAND: IN-HOSPITAL AND OUT-OF-HOSPITAL
In-Hospital
3.7.21
3.7.22
3.7.23
3.7.24
3.7.25
3.7.26
3.7.27
3.7.28
3.7.29
3.7.30
3.7.31
3.7.32
3.7.33
3.7.34
3.7.35
3.7.36
3.7.37
3.7.38
3.7.39
3.7.40
Male:
Less than one year
1-4 years
5-9 years
10-14 years
15-19 years
20-24 years
25-29 years
30-34 years
35-39 years
40-44 years
45-49 years
50-54 years
55-59 years
60-64 years
65-69 years
70-74 years
75-79 years
80-84 years
85 years +
Subtotal
Consolidated Total
Out-of-Hospital
Total per Age Band
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount
claimed
Amount
paid from
risk
Amount
claimed
Amount
paid from
risk
Amount
claimed
Amount
paid from
risk
Amount
claimed
Amount
paid from
risk
Amount
claimed
Amount
paid
from risk
R
R
R
R
R
R
R
R
R
R
PART 3.7
TOTAL PMB EXPENDITURE PAID PER AGE BAND: IN-HOSPITAL AND OUT-OF-HOSPITAL
In-Hospital
Consolidated Total
Out-of-Hospital
Total per Age Band
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount
claimed
Amount
paid from
risk
Amount
claimed
Amount
paid from
risk
Amount
claimed
Amount
paid from
risk
Amount
claimed
Amount
paid from
risk
Amount
claimed
Amount
paid
from risk
R
R
R
R
R
R
R
R
R
R
3.7.41 Total
Please provide the reasons why the sum of the DTP (part 3.8.271) and CDL (part 3.9.28) in-hospital expenditure paid does not agree with the total PMB
in-hospital expenditure (male and female: part 3.7.41) on the following benefit options:
Please provide the reasons why the sum of the DTP (part 3.8.271) and CDL (part 3.9.28) out-of-hospital expenditure paid does not agree with the total
PMB out-of-hospital expenditure (male and female: part 3.7.41) on the following benefit options:
PART 3.8
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY CDL CONDITION
(AMOUNT CLAIMED VS AMOUNT PAID)
3.9.1
3.9.2
3.9.3
3.9.4
3.9.5
3.9.6
3.9.7
3.9.8
3.9.9
3.9.10
3.9.11
3.9.12
3.9.13
3.9.14
3.9.15
3.9.16
3.9.17
3.9.18
3.9.19
3.9.20
3.9.21
3.9.22
3.9.23
3.9.24
3.9.25
3.9.26
Code
Diagnosis
ADS
AST
BCE
BMD
CHF
CMY
COP
CRF
CSD
DBI
DM1
DM2
DYS
EPL
GLC
HAE
HYL
HYP
IBD
IHD
MSS
PAR
RHA
SCZ
SLE
TDH
Addisons Disease
Asthma
Bronchiectasis
Bipolar Mood Disorder
Cardiac failure
Cardiomyopathy
Chronic Obs. Pulmonary Disease
Chronic Renal Disease
Crohns Disease
Diabetes Insipidus
Diabetes Mellitus 1
Diabetes Mellitus 2
Dysrhythmias
Epilepsy
Glaucoma
Haemophilia
Hyperlipidaemia
Hypertension
Ulcerative Colitis
Coronary Artery Disease
Multiple Sclerosis
Parkinsons Disease
Rheumatoid Arthritis
Schizophrenia
Systemic LE
Hypothyroidism
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.8
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY CDL CONDITION
(AMOUNT CLAIMED VS AMOUNT PAID)
Code
3.9.27 HIV
3.9.28
Diagnosis
HIV/AIDS
Total
Cumulative Total
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.1 906A
3.8.2 341A
3.8.3 950A
3.8.4 49A
3.8.5 213A
3.8.6 83A
3.8.7 902A
3.8.8 211A
3.8.9 905A
3.8.10 513A
3.8.11 510A
3.8.12 940A
Diagnosis
Acute generalised paralysis,
including polio and Guillain-Barre
Basal ganglia, extra-pyramidal
disorders; other dystonias NOS
Benign and malignant brain
tumours, treatable
Compound/ depressed fractures
of skull
Difficulty in breathing, eating,
swallowing, bowel, or bladder
control due to non-progressive
neurological (including spinal)
condition or injury
Encephalocele; congenital
hydrocephalus
Epilepsy (status epilepticus,
initial diagnosis, candidate for
neurosurgery)
Intraspinal and intracranial
abscess
Meningitis – acute and subacute
Myasthenia gravis; muscular
dystrophy; neuro-myopathies
NOS
Peripheral nerve injury with open
wound
Reversible CNS abnormalities
due to other systemic disease
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.13 1A
3.8.14 84A
3.8.15 941A
3.8.16 901A
3.8.17 28A
3.8.18 305A
3.8.19 265A
3.8.20 109A
3.8.21 684A
3.8.22 33C
3.8.23 482C
3.8.24 900C
3.8.25 950C
3.8.26 241C
Diagnosis
Severe / moderate head injury:
hematoma / oedema with loss of
consciousness
Spina Bifida
Spinal cord compression,
ischaemia or degenerative
disease NOS
Stroke – due to hemorrhage, or
ischaemia
Subarachnoid and intracranial
hemorrhage / hematoma;
compression of brain
Tetanus
Transient cerebral ischaemia;
life-threatening cerebrovascular
conditions NOS
Vertebral dislocations/ fractures,
open or closed with injury to
spinal cord
Viral meningitis, encephalitis,
myelitis and encephalomyelitis
Acute and chronic mastoiditis
Acute otitis media
Acute upper airway obstruction,
including croup, epiglottitis and
acute laryngotracheitis
Cancer of oral cavity, pharynx,
nose, ear, and larynx - treatable
Cancrum oris
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.27 38C
3.8.28 133C
3.8.29 910C
3.8.30 901C
3.8.31 12C
3.8.32 346C
3.8.33 521C
3.8.34 29C
3.8.35 339C
3.8.36 219C
3.8.37 132C
3.8.38 457C
3.8.39 240C
3.8.40 347C
Diagnosis
Choanal atresia
Cholesteatoma
Chronic upper airway
obstruction, resulting in cor
pulmonale
Cleft palate and/or cleft lip
without airway obstruction
Deep open wound of neck,
including larynx; fracture of
larynx or trachea, open
Epistaxis – not responsive to
anterior packing
Foreign body in ear and nose
Foreign body in pharynx, larynx,
trachea, bronchus & esophagus
Fracture of face bones, orbit,
jaw; injury to optic and other
cranial nerves
Leukoplakia of oral mucosa,
including tongue
Life-threatening diseases of
pharynx NOS, including
retropharyngeal abscess
Open wound of ear-drum
Peritonsillar abscess
Sialoadenitis; abscess / fistula of
salivary glands
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.41 543C
3.8.42 331K
3.8.43 951K
3.8.44 30K
3.8.45 950K
3.8.46 952K
3.8.47 61K
3.8.48 902K
3.8.49 447K
3.8.50 904K
3.8.51 31K
3.8.52 236K
3.8.53 901K
Diagnosis
Stomatitis, cellulites and abscess
of oral soft tissue; Vincent’s
angina
Acute thyroiditis
Benign and malignant tumours of
pituitary gland with/without
hypersecretion syndromes
Benign neoplasm of islets of
Langerhans
Cancer of endocrine system,
excluding thyroid - treatable
Cancer of thyroid - treatable;
carcinoid syndrome
Congenital hypothyroidism
Disorder of adrenal secretion
NOS
Disorders of parathyroid gland;
benign neoplasm of parathyroid
gland
Hyper and hypothyroidism with
life-threatening complications or
requiring surgery
Hypoglycemic coma;
hyperglycemia; diabetic
ketoacidosis
Iron deficiency; vitamin and other
nutritional deficiencies – lifethreatening
Life-threatening congenital
abnormalities of carbohydrate,
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.54 903K
3.8.55 47B
3.8.56 394B
3.8.57 586B
3.8.58 950B
3.8.59 901B
3.8.60 911B
3.8.61 405B
3.8.62 386B
3.8.63 389B
3.8.64 485B
3.8.65 909B
3.8.66 407B
3.8.67 419B
3.8.68 922B
3.8.69 904B
Diagnosis
lipid, protein and amino acid
metabolism
Life-threatening disorders of fluid
and electrolyte balance, NOS
Acute orbital cellulitis
Angle-closure glaucoma
Bell’s palsy; exposure
keratoconjunctivitis
Cancer of the eye and orbit treatable
Cataract; aphakia
Corneal ulcer; Superficial injury
of eye and adnexa
Glaucoma associated with
disorders of the lens
Herpes zoster & herpes simplex
with ophthalmic complications
Hyphema
Inflammation of lacrimal
passages
Open wound of eyeball and other
eye structures
Primary and open angle
glaucoma with failed medical
management
Purulent endophthalmitis
Retained intraocular foreign body
Retinal detachment, tear and
other retinal disorders
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.70 906B
3.8.71 409B
3.8.72 539M
3.8.73 288M
3.8.74
3.8.75
3.8.76
3.8.77
954M
952M
950M
953M
3.8.78 960M
3.8.79 645M
3.8.80 266M
3.8.81 53M
3.8.82 460M
3.8.83 951M
Diagnosis
Retinal vascular occlusion;
central retinal vein occlusion
Sympathetic uveitis and
degenerative disorders and
conditions of globe; sight
threatening thyroid optopathy
Abscesses of Bartholin's gland
and vulva
Acute pelvic inflammatory
disease
Cancer of Cervix - treatable
Cancer of ovary - treatable
Cancer of uterus - treatable
Cancer of vagina, vulva and
other female genital organs NOS
- treatable
Cervical and breast cancer
screening
Congenital abnormalities of the
female genitalia
Dysplasia of cervix and cervical
carcinoma-in-situ; cervical
condylomata
Ectopic pregnancy
Fistula involving female genital
tract
Hydatidiform mole;
choriocarcinoma
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.84 902M
3.8.85 528M
3.8.86 434M
3.8.87
3.8.88
3.8.89
3.8.90
3.8.91
237M
903M
435M
530M
296M
3.8.92 920F
3.8.93 41F
3.8.94 489F
3.8.95 254F
3.8.96 124F
3.8.97 337F
3.8.98 264F
3.8.99 9F
Diagnosis
Infertility (Explanatory Note 9 of
Annexure A of Regulations)
Menopausal management,
anomalies of ovaries, primary
and secondary amenorrhoea,
female sex hormones
abnormalities NOS, including
hirsutism
Non-inflammatory disorders and
benign neoplasms of ovary,
fallopian tubes and uterus
Sexual abuse, including rape
Spontaneous abortion
Torsion of ovary
Uterine prolapse; cystocele
Voluntary termination of
pregnancy
Anal Fissure; Anal fistula
Abscess of intestine
Acquired hypertrophic pyloric
stenosis and other disorders of
the stomach and duodenum
Acute diverticulitis of colon
Acute vascular insufficiency of
intestine
Amoebiasis; typhoid
Anal and rectal polyp
Appendicitis
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.100 952F
3.8.101 950C
3.8.102 95F
3.8.103 214F
3.8.104 516F
3.8.105 902F
3.8.106 901F
3.8.107 6F
3.8.108 20F
3.8.109
3.8.110
3.8.111
3.8.112
232F
498F
3F
555F
Diagnosis
Cancer of retroperitoneum,
peritoneum, omentum &
mesentery - treatable
Cancer of the gastro-intestinal
tract, including oesophagus,
stomach, bowel, rectum, anus treatable
Congenital anomalies of upper
alimentary tract – excluding
tongue
Oesophageal stricture
Oesophageal varices
Gastric or intestinal ulcers with
hemorrhage or perforation
Gastroenteritis and colitis with
life-threatening haemorrhage or
dehydration, regardless of cause
Hernia with obstruction and/or
gangrene; uncomplicated hernias
under age 18
Intestinal obstruction without
mention of hernia; symptomatic
foreign body in stomach,
intestines, colon & rectum
Paralytic ileus
Peritoneal adhesion
Peritonitis, regardless of cause
Rectal prolapse
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.113 292F
3.8.114 900F
3.8.115 507F
3.8.116 50S
3.8.117 168S
3.8.118 260S
3.8.119 113S
3.8.120 901S
3.8.121 277S
3.8.122 48S
3.8.123 900S
3.8.124
3.8.125
3.8.126
3.8.127
3.8.128
197S
338S
196S
916S
246S
Diagnosis
Regional enteritis; idiopathic
proctocolitis – acute
exacerbations and complications
only
Rupture of intra-abdominal organ
Thrombosed and complicated
haemorrhoids
Syphilis - congenital, secondary
and tertiary
HIV-infection
Imminent death regardless of
diagnosis
Acquired haemolytic anaemias
Acute leukemias, lymphomas
Anaerobic infections – life
threatening
Anaphylactic shock
Aplastic anemia;
agranulocytosis; other lifethreatening hereditary immune
deficiencies
Botulism
Cholera; rat-bite fever
Chronic Granulomatous disease
Coagulation defects
Cysticercosis; other systemic
cestode infection
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.129 903S
3.8.130 44S
3.8.131 179S
3.8.132 174S
3.8.133 201S
3.8.134 913S
3.8.135 912S
3.8.136 336S
3.8.137 252S
3.8.138 908S
3.8.139 907S
3.8.140 172S
Diagnosis
Deep-seated (excluding nail
infections), disseminated and
systemic fungal infections
Erysipelas
Hereditary angioedema;
angioneurotic oedema
Hereditary haemolytic anaemias
(e.g. sickle cell);
dyserythropoietic anemia
(congenital)
Herpetic encephalitis; Reye’s
syndrome
Immune compromise NOS and
associated life-threatening
infections NOS
Leprosy and other systemic
mycobacterial infections,
Excluding tuberculosis
Leptospirosis; spirochaetal
infections NOS
Life-threatening anaemia NOS
Life-threatening conditions due
to exposure to the elements,
including hypo and hyperthermia;
lighting strikes
Life-threatening rickettsial and
other arthropod-borne diseases
Malaria; trypanosomiasis; other
life-threatening parasitic disease
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.141 904S
3.8.142 910S
3.8.143 247S
3.8.144 911S
3.8.145 128S
3.8.146 122S
3.8.147 316S
3.8.148 11S
3.8.149 937S
3.8.150 15S
3.8.151 155E
3.8.152 108E
3.8.153 907E
3.8.154 284E
Diagnosis
Metastatic infections;
septiceamia
Multiple myeloma and chronic
leukaemias
Poisoning by ingestion, injection,
and non-medicinal agents
Sexually transmitted diseases
with systemic involvement not
elsewhere specified
Tetanus; anthrax; Whipple's
disease
Thalassemia and other
haemoglobinopathies – treatable
Toxic effect of gasses, fumes,
and vapors
Tuberculosis
Tumour of internal organ
(excludes skin): unknown
whether benign or malignant
Whooping cough, diptheria
Myocarditis; cardiomyopathy;
transposition of great vessels;
hypoplastic left heart syndrome
Pericarditis
Acute and subacute ischemic
heart disease, including
myocardial infarction and
unstable angina
Acute pulmonary heart disease
and pulmonary emboli
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.155 35E
3.8.156 908E
3.8.157 26E
3.8.158 204E
3.8.159 98E
3.8.160 97E
3.8.161 309E
3.8.162 210E
3.8.163 314E
3.8.164 902E
3.8.165 18E
3.8.166 915E
3.8.167 294E
3.8.168 450E
Diagnosis
Acute rheumatic fever
Aneurysm of major artery of
chest, abdomen, neck, Unruptured or ruptured NOS
Arterial embolism/thrombosis:
abdominal aorta, thoracic aorta
Cardiac failure: acute or recent
deterioration of chronic cardiac
failure
Complete, corrected and other
transposition of great vessels
Coronary artery anomaly
Diseases and disorders of aortic
valve NOS
Diseases of endocardium;
endocarditis
Diseases of mitral valve
Disorders of arteries: visceral
Dissecting or ruptured aortic
aneurysm
Gangrene; severe
atherosclerosis of arteries of
extremities; diabetes mellitus
with peripheral circulatory
disease
Giant cell arteritis, Kawasaki
disease, hypersensitivity angiitis
Hereditary hemorrhagic
telangiectasia
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.169 901E
3.8.170 111E
3.8.171 19E
3.8.172 903E
3.8.173 900E
3.8.174 497E
3.8.175 355E
3.8.176 905E
3.8.177 100E
3.8.178 209E
3.8.179 914E
3.8.180 16E
3.8.181 627E
3.8.182 99E
Diagnosis
Hypertension – acute lifethreatening complications and
malignant hypertension; renal
artery stenosis and other curable
hypertension
Injury to major blood vessels trunk, head and neck, and upper
limbs
Injury to major blood vessels of
extremities
Life-threatening cardiac
arrhythmias
Life-threatening complications of
elective cardiac and major
vascular procedures
Multiple valvular disease
Other aneurysm of artery –
peripheral
Other correctable congenital
cardiac conditions
Patent ductus arteriosus; aortic
pulmonary fistula - persistent
Phlebitis & thrombophlebitis,
deep
Rheumatic pericarditis;
rheumatic myocarditis
Rupture of papillary muscle
Shock / hypotension – lifethreatening
Tetralogy of Fallot (TOF)
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.183 93E
3.8.184 325G
3.8.185 327G
3.8.186 36G
3.8.187 910G
3.8.188 950G
3.8.189 255G
3.8.190 156G
3.8.191 910G
3.8.192 743G
3.8.193 27G
3.8.194 911G
3.8.195 231G
3.8.196 182T
3.8.197 910T
Diagnosis
Ventricular septal defect persistent
Acute necrosis of liver
Acute pancreatitis
Budd-Chiari syndrome, and other
venous embolism and
thrombosis
Calculus of bile duct with
cholecystitis
Cancer of liver, biliary system
and pancreas – treatable
Cyst and pseudocyst of pancreas
Disorders of bile duct
Gallstone with cholecystitis
and/or jaundice
Hepatorenal syndrome
Liver abscess; pancreatic
abscess
Liver failure; hepatic vascular
obstruction; inborn errors of liver
metabolism; biliary atresia
Portal vein thrombosis
Abuse or dependence on
Psychoactive substance,
including alcohol
Acute delusional mood, anxiety,
personality, perception disorders
and organic mental disorder
caused by drugs
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.198 901T
3.8.199 910T
3.8.200 908T
3.8.201 903T
3.8.202 184T
3.8.203 910T
3.8.204 902T
3.8.205 907T
3.8.206
3.8.207
3.8.208
3.8.209
3.8.210
3.8.211
909T
353H
32H
950H
206H
902H
Diagnosis
Acute stress disorder
accompanied by recent
significant trauma, including
physical or sexual abuse
Alcohol withdrawal delirium;
alcohol intoxication delirium
Anorexia Nervosa and Bulimia
Nervosa
Attempted suicide, irrespective of
cause
Brief reactive psychosis
Delirium: Amphetamine,
Cocaine, or other psychoactive
substance
Major affective disorders,
including unipolar and bipolar
depression
Schizophrenic and paranoid
delusional disorders
Treatable dementia
Abscess of bursa or tendon
Acute osteomyelitis
Cancer of bones - treatable
Chronic osteomyelitis
Closed fractures/ dislocations of
limb bones / epiphyses –
excluding fingers and toes
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.212 85H
3.8.213 147H
3.8.214 491H
3.8.215 500H
3.8.216 178H
3.8.217 445H
3.8.218 900H
3.8.219 34H
3.8.220 901H
3.8.221 67N
3.8.222 967N
3.8.223 71N
3.8.224 901N
3.8.225 904N
Diagnosis
Congenital dislocation of hip;
coxa vara and valga; congenital
clubfoot
Crush injuries of trunk, upper
limbs, lower limbs, including
blood vessels
Dislocations / fractures of
vertebral column without spinal
cord injury
Disruptions of the achilles /
quadriceps tendons
Fracture of hip
Injury to internal organs
Open fracture / dislocation of
bones and joints
Pyogenic arthritis
Traumatic amputation of limbs,
hands, feet, and digits
Low birth weight (under 1000g)
with respiratory difficulties
Low birth weight (under 2500
grams & > 1000g) with
respiratory difficulties
Birth trauma for baby
Congenital systemic infections
affecting the newborn
Haematological disorders of the
newborn
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.226 54N
3.8.227 74N
3.8.228 902N
3.8.229 903N
3.8.230 52N
3.8.231 56N
3.8.232 903D
3.8.233 158D
3.8.234 157D
3.8.235 125D
3.8.236 315D
3.8.237 340D
3.8.238 950D
3.8.239 170D
Diagnosis
Necrotizing enterocolitis in
newborn
Neonatal and infant GIT
abnormalities and disorders,
including malrotation and atresia
Neonatal endocrine, metabolic
and toxin-induced conditions
Neurological abnormalities in the
newborn
Pregnancy
Respiratory conditions of
newborn
Bacterial, viral, fungal pneumonia
Respiratory failure, regardless of
cause
Acute asthmatic attack;
pneumonia due to respiratory
syncytial virus in persons under
age 3
Adult respiratory distress
syndrome; inhalation and
aspiration pneumonias
Atelectasis (collapse of lung)
Benign neoplasm of respiratory
and intrathoracic organs
Cancer of lung, bronchus, pleura,
trachea, mediastinum & other
respiratory organs - treatable
Empyema and abscess of lung
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.240 934D
3.8.241 203D
3.8.242 900D
3.8.243 5D
3.8.244 465J
3.8.245 900J
3.8.246 950J
3.8.247 954J
3.8.248 952J
3.8.249 349J
3.8.250 901J
3.8.251 951J
3.8.252 953J
Diagnosis
Frank haemoptysis
Hypoplasia and dysplasia of lung
Open fracture of ribs and
sternum; multiple rib fractures;
flail chest
Pneumothorax and haemothorax
Acute lymphadenitis
Burns, greater than 10% of body
surface, or more than 5%
involving head, neck, hands,
perineum
Cancer of breast - treatable
Cancer of skin, excluding
malignant melanoma - treatable
Cancer of soft tissue, including
sarcomas and malignancies of
the adnexa - treatable
Cellulitis and abscesses with risk
of organ or limb damage or
septiceamia if untreated;
necrotizing fasciitis
Disseminated bullous skin
disease, including pemphigus,
pemphigoid, epidermolysis
bullosa, epidermolytic
hyperkeratosis
Lethal midline granuloma
Malignant melanoma of skin treatable
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.253 373J
3.8.254 356J
3.8.255 112J
3.8.256 354L
3.8.257 904L
3.8.258 903L
3.8.259 954L
3.8.260 953L
3.8.261 950L
3.8.262 952L
3.8.263 906L
3.8.264 901L
3.8.265 900L
Diagnosis
Non-superficial open wounds –
non life-threatening
Pyoderma; body, deep-seated
fungal infections
Toxic epidermal necrolysis and
staphylococcal scalded skin
syndrome; Stevens-Johnson
syndrome
Abscess of prostate
Acute and chronic pyelonephritis;
renal and perinephric abscess
Acute glomerulonephritis and
nephritic syndrome
Cancer of penis and other male
genital organ - treatable
Cancer of prostate gland treatable
Cancer of testis - treatable
Cancer of urinary system
including kidney and bladder treatable
Congenital anomalies of urinary
system - symptomatic and lifethreatening
End stage renal disease
regardless of cause
Hyperplasia of the prostate, with
acute urinary retention or
obstructive renal failure
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R
PART 3.9
PMB EXPENDITURE IN-HOSPITAL AND OUT-OF-HOSPITAL: BY DTP CONDITION
(AMOUNT CLAIMS VS AMOUNT PAID)
Code
3.8.266 905L
3.8.267 436L
3.8.268 43L
3.8.269 289L
3.8.270 359L
3.8.271
Diagnosis
Obstruction of the urogenital
tract, regardless of cause
Torsion of testis
Trauma to the urinary system
including ruptured bladder
Ureteral fistula (intestinal)
Vesicoureteral reflux
Total
Cumulative Total
Consolidated Total
In-Hospital
Out-of-Hospital
Total
Amount Amount Amount Amount Amount Amount
claimed
paid
claimed
paid
claimed
paid
R
R
R
R
R
R
Per Benefit Option
In-Hospital
Out-of-Hospital
Amount Amount Amount Amount
claimed
paid
claimed
paid
R
R
R
R