PPN 2009 Contract Please sign the document and return to ...optimum.ppn.co.za/downloads/PPN Contracts 2009.pdf · ANNEXURE D PPN 2009 Contract Please sign the document and return

ANNEXURE D

PPN 2009 Contract

Please sign the document and return to PPN no later than 1 February 2009

PARTICIPATING SERVICE

PROVIDER AGREEMENT

of

PREFERRED PROVIDER NEGOTIATORS (PTY) LTD

REGISTRATION NUMBER : 1992/00075/07

PPN PARTICIPATING SERVICE PROVIDER AGREEMENT INDEX

SIGNATURE DOCUMENT

CLAUSE NO. CLAUSE HEADING PAGE NUMBER

1. Contracting Parties 1

2. Interpretation Guidelines 1 – 8

3. Business Purpose 8 – 9

4. Duration 9

5. Performance Obligations of the Participating Service Provider 9 – 13

6. Claims Submissions 13 – 17

7. Cost Structure and Cost Containment 17 – 18

8. Indemnity Insurance 18

9. Matters relating to Beneficiaries 18

10. Optometric Advisory Committee 19

11. Grievance Procedure 19

12. Temporary Suspension and Peer Review 19

13. Liability or Non-liability 19 – 20

14. Breach 20 – 23

15. Governing Law 23

16. Relationship and Good Faith 23 – 24

17. Dispute Resolution 24 – 26

18. Cession / Assignment 26

19. Domicilium Citandi Et Executandi 26 – 27

20. Notices 27

21. Costs 27

22. Counterparts 28

23. Whole Agreement 28

24. Amendments 28

25. Extension of Time 28

26. Execution 28 - 29

PARTICIPATING SERVICE PROVIDER MANUAL

DESCRIPTION

Annexure A List of Optometric Benefits

Annexure B List of Frames

Annexure C List of Designated Laboratory Service Providers

Annexure D Consultation- and Optometric Appliance Prices

Annexure E List of Participating Medical Schemes

Annexure F Medical Scheme Benefit Option

Annexure G Beneficiary Information

Annexure H PPN Patients Charter

Annexure I Participating Service Provider Details

Annexure J PPN Complaint and Grievance Procedure

Annexure K PPN Peer Review Procedure

Annexure L Format of Beneficiary Consent

PPN PARTICIPATING SERVICE PROVIDER AGREEMENT SIGNATURE DOCUMENT

PM.NvD.P581.2008.10.08 Potgieter-Marais Attorneys © 1019 Schoeman Street, Hatfield, Pretoria, Gauteng

Page 1 of 1

1. CONTRACTING PARTIES

This agreement is entered into between:

1.1 PREFERRED PROVIDER NEGOTIATORS (PTY) LTD Registration Number : 1992/00075/07

and

1.2 ____________________________________________________________

Registration / Identity Number : ___________________________________

Trading Title : _________________________________________________

BHF No. : ____________________________________________________

2. INTERPRETATION GUIDELINES

2.1 The clause headings in this agreement are for the purpose of convenience only and shall not be

taken into account in the interpretation of nor modify the terms of this agreement.

2.2 Unless inconsistent with or a contrary intention clearly appears from the context words importing:

2.2.1 any reference to a gender includes the other genders;

2.2.2 any reference to the singular includes the plural and vice versa; and

2.2.3 any reference to natural persons includes created entities (corporate or unincorporated)

and the state and vice versa.

2.3 The expressions in bold italics shall have the meanings assigned to them hereunder:

2.3.1 "administrator" means any person who has been accredited by the Council in terms of

Section 58 of the Medical Schemes Act;

2.3.2 "agreement" means this signature document and the PPN participating service provider manual and all annexures referred to therein which may be accessed

electronically on the PPN website at www.ppn.co.za;



Page 2 of 2

2.3.3 “beneficiary” means an eligible member of a Participating Medical Scheme and his /

her co-insured dependents who are entitled to the optometric benefits in terms of the

Medical Scheme Benefit Option, whose name(s) appear(s) in the list of beneficiaries;

2.3.4 "business day" means any day other than a Saturday, Sunday or an officially recognized

public holiday in the Republic of South Africa;

2.3.5 "capitation agreement(s)" means the agreement for the provisions of the optometric benefits to beneficiaries entered into between PPN as mhco, and a Participating

Medical Scheme;

2.3.6 "claims" mean all claims for payment of provider remuneration submitted by the participating service provider to PPN for optometric benefits rendered to

beneficiaries in terms of this agreement;

2.3.7 "co-insured dependents" means the dependants of an eligible member entitled to

benefits in terms of a Medical Scheme Benefit Option, in respect of whom the

Participating Medical Scheme has paid the capitation fees in terms of the capitation agreement to PPN;

2.3.8 “Complaint and Grievance Procedure” means the procedure, as amended from time to

time by PPN, set out in Annexure J of the PPN participating service provider manual which beneficiaries, Participating Medical Schemes, - service providers and PPN

must follow when lodging a complaint in terms of this agreement;

2.3.9 "consultation" means the visit of a beneficiary to the participating service provider for

optometric services in respect whereof the participating service provider may claim a

consultation fee;

2.3.10 "consultation fee" means the fee agreed to and recorded in Annexure D of the PPN

participating service provider manual, as adjusted by agreement from time to time,

payable to the participating service provider by PPN, for a consultation;

2.3.11 "contracting parties" mean PPN and the participating service provider;



Page 3 of 3

2.3.12 "co-payment" means any amount payable by a beneficiary to a participating service provider in terms of the Medical Scheme Benefit Option for optometric benefits

provided by the participating service provider;

2.3.13 "data, data message, electronic communication, web page and website" shall have

the meanings as defined in the ECTA;

2.3.14 "designated laboratory service provider" means the optometric laboratories

recommended by PPN from time to time to provide optometric laboratory services to

participating service providers for purposes of rendering the optometric benefits in

terms of this agreement, listed in Annexure C of the PPN participating service

provider manual, as amended from time to time by PPN in its sole discretion;

2.3.15 "disqualified member" means a beneficiary and his / her co-insured dependents who

are no longer entitled to benefits in terms of the Medical Scheme Benefit Option,

because such member has been temporarily suspended, or because his / her

membership was terminated by the Participating Medical Scheme;

2.3.16 "ECTA" means the Electronic Communications And Transactions Act, 2002 (No 25 of

2002) and the Regulations promulgated thereunder which full text can be viewed on

www.doc.gov.za;

2.3.17 "effective date" means the date of signature of this agreement;

2.3.18 “eligible member” means a natural person who is deemed to be a member of the

Participating Medical Scheme entitled to benefits in terms of the Medical Scheme

Benefit Option in respect of whom a capitation fee was paid to PPN by the

Participating Medical Scheme;

2.3.19 “fee for service agreement(s)” means the agreement whereby PPN process and pay

claims on behalf of the Participating Medical Scheme;

2.3.20 "frame" means a spectacle frame suitable to fit lenses to correct errors of refraction

prescribed by the participating service provider and selected from the range of

spectacle frames inventorised in Annexure B of the PPN participating service provider

http://www.doc.gov.za/



Page 4 of 4 manual, as amended from time to time in the sole discretion of the optometric advisory committee;

2.3.21 "HP Act" means the Health Profession Act, Act 56 of 1974;

2.3.22 “list of beneficiaries” means the personal information of beneficiaries entitled to benefits

in terms of the Medical Scheme Benefit Option made available to the participating service provider:

2.3.22.1 on the PPN website, utilizing the software application specified in Annexure G of

the PPN participating service provider manual; or

2.3.22.2 from the PPN Call Centre during business hours, and such additional hours of

operation as PPN may determine from time to time,

to enable the participating service provider to confirm the status of a beneficiary;

2.3.23 "managed health care" means:

2.3.23.1 the clinical and financial risk assessment of beneficiaries; and

2.3.23.2 the management of the health care of beneficiaries, with a view to facilitating

appropriateness and cost-effectiveness of relevant health services within the

constraints of what is affordable, through the use of rules- and clinical

management-based programmes;

2.3.24 “mhco” means a managed health care organisation, accredited as such in terms of the

Medical Schemes Act;

2.3.25 "Medical Schemes Act" means the Medical Schemes Act, Act 131 of 1998;

2.3.26 “Medical Scheme Benefit Option” means the benefits offered to beneficiaries by the

Participating Medical Scheme recorded in Annexure F of the PPN participating service provider manual, in respect of which PPN is contracted to provide the

optometric benefits only;

2.3.27 "Medical Schemes Regulations" mean the General Regulations, GNR1262/1999

promulgated in terms of the Medical Schemes Act;



Page 5 of 5

2.3.28 “Medical Scheme Rules” mean the provisions, interventions and limitations relating to the

benefits which are granted to beneficiaries in terms of the Medical Scheme Benefit Option, and the contributions which are payable to the Participating Medical Scheme by

eligible members and their co-insured dependants, submitted to the Registrar of

Medical Schemes in terms of regulation 2(1)(d) and referred to in regulation 3(1)(g) of the

Medical Schemes Regulations, as amended from time to time;

2.3.29 "month" means a calendar month;

2.3.30 "Optimum" means the web-based interface for the capturing of claims of participating

service providers for providing optometric benefits in terms of this agreement payable

by PPN;

2.3.31 “optometric advisory committee” means a committee consisting of the director

professional affairs of PPN, and such optometrists as may be nominated and co-opted

onto the committee by the said director;

2.3.32 "optometric appliance" means frames, ophthalmic lenses, and contact lenses dispensed

to correct errors of refraction;

2.3.33 “optometric benefits” mean the ophthalmic services which may be rendered and the

optometric appliances which may be dispensed to beneficiaries in terms of the Medical

Scheme Benefit Option, specified in Annexure A of the PPN participating service provider manual, to be provided to beneficiaries by PPN, through a network of

participating service providers, on the terms agreed and recorded in this agreement;

2.3.34 "Participating Medical Scheme" means the legal persons:

2.3.34.1 registered as Medical Schemes in terms of section 24(1) of the Medical Schemes Act read with regulation 2 of the Medical Schemes Regulations; or

2.3.34.2 registered as administrators in terms of section 58 of the Medical Schemes Act read with regulation 18 of the Medical Schemes Regulations;

2.3.34.3 who have entered into capitation agreements of fee for service agreements;



Page 6 of 6 2.3.34.4 listed in Annexure E of the PPN participating service provider manual, as

amended by PPN from time to time, and notified to the participating service

provider;

2.3.35 "participating service provider" means the optometrist whose particulars appear in

clause 1.2 above;

2.3.36 "participating service provider manual" means the terms agreed and stored in electronic

format as a data message on a webpage on the PPN website, to be amended and

updated from time, which at the signature date included:

2.3.36.1 Annexure A - list of optometric benefits;

2.3.36.2 Annexure B - list of frames;

2.3.36.3 Annexure C - list of designated laboratory service providers;

2.3.36.4 Annexure D - consultation- and optometric appliance prices;

2.3.36.5 Annexure E - list of Participating Medical Schemes;

2.3.36.6 Annexure F - Medical Scheme Benefit Option;

2.3.36.7 Annexure G - beneficiary information;

2.3.36.8 Annexure H - PPN Patients Charter;

2.3.36.9 Annexure I - participating service provider details;

2.3.36.10 Annexure J - Complaint and Grievance Procedure;

2.3.36.11 Annexure K - PPN Peer Review Procedure;

2.3.36.12 Annexure L - Format of Beneficiary consent;

2.3.37 "PBODO" means the Professional Board for Optometry and Dispensing Opticians

established in terms of section 15 of the HP Act read with GN R313 of 1998, as amended;



Page 7 of 7 2.3.38 “personal information” means information about an identifiable beneficiary obtained by,

disclosed to and kept by a participating service provider in a professional capacity and

includes:

2.3.38.1 information relating to the race, gender, marital status, national, ethnic or social

origin, colour, age, physical or mental health, blood type, language, identity number

or date of birth of the beneficiary;

2.3.38.2 any identifying number, or symbol assigned to the beneficiary by the participating service provider for purposes of rendering optometric benefits in

terms of this agreement;

2.3.38.3 information relating to the optometric benefits rendered by, and the financial and

other practice records pertaining thereto, of the participating service provider or

his designated laboratory service provider or suppliers of frames;

2.3.38.4 the physical-, postal-, facsimile-, and / or e-mail address of the beneficiary;

2.3.38.5 correspondence exchanged between the participating service provider and the

beneficiary that is explicitly written and marked as "private or confidential",

essential for verifying any claims;

2.3.39 “PPN” means Preferred Provider Negotiators (Pty) Ltd, Registration Number :

1992/00075/07, a limited liability company registered and incorporated under the laws of

South Africa, herein represented by _______________________________;

2.3.40 "PPN website" means the location on the Internet containing a home page or web page of

PPN hosted on the World Wide Web and accessible at www.ppn.co.za;

2.3.41 "practice" means the optometric practice conducted by the participating service provider from the physical address recorded in Annexure I of the PPN participating service provider manual, under the trading title in clause 1.2;

2.3.42 "prescription" means a written order for the dispensing of spectacles or lenses to correct

errors of refraction in a beneficiary issued by the participating service provider after

consultation with a beneficiary;



Page 8 of 8 2.3.43 "provider remuneration" mean the agreed fees for professional services and sale prices

of optometric appliances payable by PPN to participating service providers for

rendering optometric benefits to beneficiaries in terms of this agreement, as amended

by agreement from time to time;

2.3.44 "service date" means in the case of:

2.3.44.1 a consultation resulting in the supply of an optometric appliance, the date upon

which the consultation took place;

2.3.44.2 any optometric appliance where no consultation was performed, the date upon

which it was dispensed;

2.3.45 "stale claim" means a claim submitted more than sixty (60) days after the service date.

3. BUSINESS PURPOSE

3.1 The contracting parties record that:

3.1.1 their authorised representatives have reached consensus on their reciprocal rights, their

performance obligations and remedies as recorded in this agreement; and

3.1.2 they enter into this agreement on the basis of the representations of fact recorded in this

clause 3, which representations are by agreement between the contracting parties

elevated to material terms going to the root of this agreement;

3.1.3 they consulted independently and received advice from legal advisors specialising in the

law applicable to health care providers and funders and without limiting the generality of

the aforegoing, the law applicable to the provision of managed health care services to be

rendered and paid for on the terms recorded in this agreement.

3.2 Accessible and affordable health care has necessitated changes to the health care delivery system

and environment in South Africa and especially the manner and terms of providing such services to

private patients within a managed health care delivery system. Such need has resulted in

legislative changes which in turn require specific contractual arrangements to ensure compliance.

3.3 PPN has contracted with the Participating Medical Schemes to provide the optometric benefits

to beneficiaries through a network of contracted optometrists.



Page 9 of 9

3.4 PPN as a mhco, and as a result of the aforegoing is contractually obliged to establish an

infrastructure enabling it to provide the optometric benefits on a managed health care basis

through a network of optometrists.

3.5 The participating service provider is:

3.5.1 an optometrist duly registered in terms of the HP Act and in good standing with the

PBODO;

3.5.2 able and willing to render the optometric benefits to beneficiaries on the terms agreed

to and recorded in this agreement.

3.6 This agreement is entered into in compliance with the Medical Schemes Regulations.

3.7 In terms of the statutory requirements for the provision of the optometric benefits in a managed health care environment a beneficiary may not be held liable by a participating service provider

for any amount due in respect of the optometric benefits provided, unless a co-payment or

deductible is required from or imposed on a beneficiary in terms of the Medical Scheme Rules or

–Benefit Option.

3.8 As a result of the facts in clause 3.7 PPN shall be responsible to pay the participating service provider, the provider remuneration, for providing the optometric benefits to beneficiaries;

provided such beneficiary qualifies for such benefit in terms of the Medical Scheme Benefit Option.

3.9 The optometric benefits shall be provided and the provider remuneration paid on arms length

commercial terms between two independent parties duly licensed or accredited to do business as

such.

4. DURATION

4.1 This agreement commences on the effective date and shall continue indefinitely, subject to the

reciprocal right in clause 4.2 to unilaterally terminate this agreement by means of written notice.

4.2 Other than during the month of January of each year, either contracting party shall have the right

to terminate this agreement by giving 3 (three) calendar month's notice to be received by the other

contracting party, prior to the commencement of the notice.



Page 10 of 10

5. PERFORMANCE OBLIGATIONS OF THE PARTICIPATING SERVICE PROVIDER

5.1 The participating service provider:

5.1.1 and his / her staff shall at the request of PPN meet with a PPN relationship manager on a

quarterly basis for purposes of training and providing information regarding the Medical Scheme Benefit Option, the optometric benefit codes, the claims procedure, tariffs and

sale prices of optometric appliances, any updates or amendments to the aforegoing, and

such other matters as PPN may deem necessary for purposes of ensuring effective and

efficient service delivery to Participating Medical Schemes and beneficiaries;

5.1.2 shall ensure that he / she fully understands the terms of this agreement, and his / her

performance obligations in terms hereof, and without limiting the generality of the

aforegoing his / her obligations in providing the optometric benefits, and claiming the

provider remuneration; and

5.1.3 shall verify the Medical Scheme Benefit Option to which a beneficiary is entitled before

providing optometric benefits;

5.1.4 shall, before providing optometric benefits to a beneficiary, ensure that the beneficiary

is in possession of a valid membership card and that the beneficiary’s name appears on

the list of beneficiaries of that Participating Medical Scheme for that particular month

and that there is no restriction on providing the optometric benefits to such beneficiary;

5.1.5 shall only provide optometric benefits in terms of the Medical Scheme Benefit Option;

5.1.6 shall only use the PPN optometric benefit codes, if applicable, when providing

optometric benefits, and submitting claims in terms of this agreement;

5.1.7 shall obtain the necessary authorisation prior to providing the optometric benefits;

5.1.8 shall submit claims for optometric benefits provided, electronically in the prescribed

format, within 7 (seven) days of rendering such optometric benefits;

5.1.9 shall provide the optometric benefits to which a beneficiary is entitled in accordance

with the guidelines or rules of conduct issued by the PBODO;



Page 11 of 11 5.1.10 shall not make him- / herself guilty of unprofessional conduct as prescribed in The Rules

Specifying The Acts Or Omissions In Respect Of Which Disciplinary Steps May Be Taken

By A Professional Board And The Council, GN R717 of 2006 (“Unprofessional Conduct Rules”);

5.1.11 shall not involve him-/herself in any perverse incentive scheme in providing the

optometric benefits;

5.1.12 shall inform PPN of any approach by a beneficiary to provide services and supply

optometric appliances other than the optometric benefits;

5.1.13 shall advise PPN if any disciplinary inquiry into his/her conduct is being instituted by the

PBODO or any of its sub-committees;

5.1.14 shall inform PPN if his / her right to practise as an optometrist is suspended or cancelled

for any reason;

5.1.15 shall inform PPN in writing in accordance with the PPN Complaint and Grievance Procedure should he / she receive any complaint from a beneficiary regarding the

provision of optometric benefits by him / her;

5.1.16 shall not file or institute any claim against any beneficiary for optometric benefits

provided by him / her in terms of, and covered by this agreement, and waives any claim

which he / she might have had against a beneficiary, other than a claim for a co-payment;

5.1.17 shall not file or institute any claim against the Participating Medical Scheme for

optometric benefits provided to a beneficiary in terms of this agreement and waives

any such claims against the Participating Medical Schemes;

5.1.18 shall only be entitled to claim payment of the provider remuneration for optometric

benefits rendered to beneficiaries from PPN, when entitled to do so in terms of this

agreement;

5.1.19 as a result of:

5.1.19.1 the Constitution of the Republic of South Africa, 1996 ("the Constitution") and the

Promotion of Access to Information Act, 2000 (Act 2 of 2000) ("PAIA") guarantees



Page 12 of 12 the right of access to information that is held by another person and that is required

for the exercise or protection of any rights; and

5.1.19.2 the provisions of section 59(3) of the Medical Schemes Act and Regulation 15J of

the Medical Schemes Regulations, PPN, and the transfer of risk from the Participating Medical Scheme to PPN for payment of the provider

remuneration, which guarantees PPN a statutory right to all information regarding

optometric benefits rendered to a beneficiary and claims submitted in respect

thereof, held by the participating service provider, for purposes of risk

assessment and verification of claims; and

5.1.19.3 the provisions of regulation 15A of the Medical Scheme Regulations which entitles

a Participating Medical Scheme, and PPN as a mhco, access to any treatment

record held by a participating service provider pertaining to the diagnosis,

treatment and health status of a beneficiary in terms of this agreement; and

5.1.19.4 the express consent by eligible members, personally and on behalf of their co-

insured dependants, in terms of the Medical Scheme Rules and -Benefit Option to disclosure of personal information obtained and held by the

participating service provider in his / her professional capacity, for purposes of

claims verification.

shall add an express consent, that complies with the requirements prescribed by the

PBODO, the ECTA and the Medical Schemes Act or the Medical Schemes Regulations and PAIA, in the format of Annexure L to the participating service

provider manual, to his / her / its patient record card, and request every beneficiary at

the first consultation to sign it, thereby authorising:

5.1.19.5 the participating service provider to furnish PPN with such personal

information regarding the beneficiary and the opthalmic conditions for which he /

she is being treated; and

5.1.19.6 PPN to collect, collate, process, store, and use such data for statistical and other

utilization review purposes and for providing monthly reports to the Participating

Medical Schemes;

5.1.19.7 PPN to access the personal information of the beneficiary for purposes of

clause 6.13 of this agreement;



Page 13 of 13

5.1.20 shall accept temporary suspension of the operation of this agreement in the instances

referred to in clause 12.1 and voluntarily submits to the PPN peer review procedure.

5.2 The participating service provider shall at all material times:

5.2.1 be registered with the PBODO; and

5.2.2 have a BHF number; and

5.2.3 support PPN in its efforts of managing cost and risk demands for the Participating

Medical Schemes and subsequently support the managed health care initiatives

implemented by PPN;

5.2.4 not interfere with or disturb the existing relationship between PPN and the Participating

Medical Schemes;

5.2.5 refer selective laboratory work in respect of the optometric benefits to the designated laboratory service provider; provided that the laboratory services are of an acceptable

professional standard when objectively evaluated and are provided at competitive rates;

and provided further that any dispute regarding the quality of service or the charges of the

designated laboratory service provider shall be resolved in terms of clause 17;

5.2.6 ensure that PPN is at all times advised of any change in the participating service provider's details as provided herein, including, but not limited to:

5.2.6.1 banking details;

5.2.6.2 relevant details relating to the ownership of the participating service provider's

practice and any change in regards thereto,

it being recorded that the participating service provider bears the sole onus in this

regard.

6. CLAIMS SUBMISSION

6.1 The participating service provider shall submit all invoices in respect of claims to PPN for

processing in accordance with the following express procedures:



Page 14 of 14

6.1.1 invoices shall be delivered within sixty (60) days of the service date, failing which, the

invoice shall be deemed to be a stale claim and will be rejected;

6.1.2 all invoices shall be submitted in the format prescribed by PPN from time to time.

6.2 The participating service provider shall assume sole responsibility for ensuring the correctness

of the information reflected in the invoices.

6.3 PPN shall be entitled to reject any invoice or claim (delivered in accordance with clause 6.1.2) if

PPN believes, on reasonable grounds, that the participating service provider has not complied

with the terms of this agreement in respect of such invoice or claim.

6.4 The participating service provider shall have 30 (thirty) days from date of rejection referred to in

clause 6.3 above to:

6.4.1 regularise any invoice or claim if rejected on administrative grounds; or

6.4.2 refer the matter to arbitration in accordance with the provisions of clause 17.

6.5 The participating service provider acknowledges that a membership card, or other proof of

membership by a beneficiary, shall not:

6.5.1 constitute automatic liability by PPN for payment of the provider remuneration;

6.5.2 automatically mean that a beneficiary is entitled to receive the optometric benefits and

that PPN has a concomitant.

6.6 The participating service provider shall satisfy himself that the relevant membership card issued

to the beneficiary by the scheme is prima facie valid and in order and that it conforms to the

requirements of this agreement and shall use all reasonable means to satisfy him- / herself that

the beneficiary is entitled to claim a benefit in terms of the Medical Scheme Benefit Option or -

Rules.

6.7 A claim for optometric benefits rendered by the participating service provider must be

submitted to PPN in the format prescribed in terms of this clause read with clause 8.1:

6.7.1 electronically by means of:



Page 15 of 15

6.7.1.1 QEDI/DI switch; or

6.7.1.2 Mediswitch, via DH Switch; or

6.7.1.3 Healthbridge; or

6.7.1.4 on the Optimum website (should service be applicable for scheme) on

www.optimum.co.za; and

6.7.1.5 such other electronic address as PPN may prescribe in writing from time to time.

6.8 Every claim submitted to PPN for optometric benefits rendered by a participating service

provider to a beneficiary, must specify the following particulars:

6.8.1 the name, address and practice and PBODO registration number of the participating service provider;

6.8.2 patient’s surname, initials, identity number and sex;

6.8.3 main beneficiary's surname, initials and membership number;

6.8.4 physical address and telephone number of main beneficiary;

6.8.5 the Participating Medical Scheme of the beneficiary;

6.8.6 the applicable Medical Scheme Benefit Option;

6.8.7 the diagnosis including ICD-10 and a description of the optometric benefits provided with

reference to the relevant PPN codes, if applicable;

6.8.8 a description of spectacles or lenses dispensed, using applicable Nappi codes, if

applicable;

6.8.9 visual acuity (va);

6.8.10 intra ocular pressure;

http://www.optimum.co.za/



Page 16 of 16 6.8.11 visual fields;

6.8.12 National Verification System (NVS) frame number;

6.8.13 any additional information as may be required by PPN from time to time;

6.8.14 the pre-authorisation number, where appropriate.

6.9 The participating service provider shall advise PPN of any change in his banking details as

specified in Annexure I of the PPN participating service provider manual, within 1 (one) month

of any change thereof.

6.10 Claims which do not comply with the prescribed format may be rejected, by PPN.

6.11 Claims correctly submitted to PPN shall be paid within 30 (thirty) days, from the date on which they

were submitted, and will be accompanied by a payment remittance advice issued by PPN.

6.12 Any queries regarding payment of a claim submitted, must be directed directly to the PPN Call

Centre, Telephone 086 110 3529 or 086 110 1477.

6.13 The contracting parties as a result of the fundamental and statutory right to access personal

information, and the contractual obligation in clause 5.1.19, agree that PPN may at any time

conduct an audit of the optometric practices of the participating service provider for the specific

purpose of verifying claims by the participating service provider in terms of this agreement, and that for such purpose:

6.13.1 the participating service provider expressly undertakes and authorises:

6.13.1.1 PPN to enter the business premises of the participating service provider during

normal business hours and to have the right to inspect all books, documents,

correspondence and records that form the subject matter of this agreement or

such books and records that arise incidental thereto, as a consequence of a

claims investigation;

6.13.1.2 PPN to access, examine and copy the participating service provider's practice

records with regards to the rendering of optometric benefits, which shall include

but not be limited to the purchase of frames, the orders placed on, and delivery



Page 17 of 17 notes of the designated laboratory service providers for any bifocal or multifocal

lenses, dispensed or to be dispensed to beneficiaries in terms of this agreement;

6.13.1.3 suppliers of optometric appliances to make their records of sales of optometric

appliances to the participating service provider available to PPN;

6.13.2 PPN may access the Trans Union ITC database for the purposes of determining the

existence of information detrimental to PPN and / or the Participating Medical Schemes'

risk management decisions;

6.13.3 PPN may transmit to, and share the details of all information pertaining to fraudulent or

dishonest conduct by the participating service provider with Trans Union ITC and other

participants of the Medical Schemes Fraud Database ("MSFD") for the purposes of making

risk management decisions;

6.13.4 PPN shall give the participating service provider reasonable notice prior to submitting

his / her / its details for listing to the Trans Union ITC database.

6.14 All information obtained by PPN shall be kept strictly confidential by PPN and shall not be disclosed

to any third party other than to a Participating Medical Scheme, or for purposes of a peer review

process in terms of Annexure K of the PPN participating service provider manual, or other

legal proceedings and any investigation that flows from that.

7. COST STRUCTURE AND COST CONTAINMENT

The participating service provider acknowledges that:

7.1 that PPN has the right to amend the provider remuneration to give effect to any cost containment

program or variation in cost structures, provided that such amendments shall be implemented on

no less than one (1) month's notice to the participating service provider; and

7.2 the provider remuneration contained in this agreement is acceptable in order to achieve the

objectives set out in the preamble to this agreement and that the participating service provider is bound to any amended provider remuneration, subject to the participating service provider's

right to terminate this agreement.

7.3 PPN undertakes to:



Page 18 of 18 7.3.1 furnish the participating service providers from time to time with any amendments,

alterations or deductions to the provider remuneration;

7.3.2 negotiate professional fee increases on an annual basis with the participating service

provider.

8. INDEMNITY INSURANCE

The participating service provider shall provide and maintain professional liability insurance against any

claim for damages for personal injury or death arising directly or indirectly or in connection with the

performance of optometric benefits by the participating service provider and indemnifies PPN against

any and all claims to be made against PPN arising out of the negligence, dishonesty or any other action or

omission on the part of the participating service provider.

9. MATTERS RELATING TO BENEFICIARIES

PPN shall ensure that the Participating Medical Schemes shall:

9.1 issue beneficiaries with membership numbers and cards reflecting the personal information of

such member, his / her co-insured dependents, the applicable PPN Benefit Package and the

date upon which such beneficiary and his / her co-insured dependents became eligible

members;

9.2 update the list of beneficiaries before the last business day of every month;

9.3 include a consent by its beneficiaries and their co-insured dependents which entitle PPN to use

his / her personal information for research, statistical data and commercial purposes;

9.4 before the 15th of the month, advise PPN should a beneficiary become a disqualified member.

10. OPTOMETRIC ADVISORY COMMITTEE

10.1 PPN shall, when in its sole discretion deems it necessary, be entitled to consult with the

optometric advisory committee and the optometric advisory committee shall advise PPN on

the appropriateness of the terms of this agreement.

10.2 The optometric advisory committee shall, in furnishing advice, act as an expert and not as an

arbitrator.



Page 19 of 19

10.3 In the event of a dispute regarding the appropriateness of an optometric benefit, or a refusal of a

request for authorisation of an optometric benefit or procedure not covered by the Medical Scheme Benefit Option, by PPN, then the arbitrator shall be entitled but not obliged to consult

with the optometric advisory committee in order to come to a decision.

11. GRIEVANCE PROCEDURE

The participating service provider will participate in the PPN Complaint and Grievance Procedure in

Annexure A, to the extent necessary, to ensure a speedy and satisfactory outcome for all concerned.

12. TEMPORARY SUSPENSION AND PEER REVIEW

12.1 If the Head of the Service Excellence Department of PPN, in his / her sole discretion, based on

prima facie evidence, is of the opinion that a participating service provider has made him-

/herself guilty of fraud, professional negligence in providing the optometric benefits to a

beneficiary, or conduct which is deemed to bring PPN or a Participating Medical Scheme into

disrepute, then the Head of the Service Excellence Department of PPN shall be entitled to suspend

the participating service provider concerned from participating in this agreement, pending an

inquiry in terms of the PPN Peer Review Procedure.

12.2 In the event of the participating service provider not discharging his contractual obligations in

clause 4 read with clause 7, PPN shall be entitled to institute the PPN Peer Review Procedure in

Annexure H and the participating service provider, by accepting the terms of this agreement, accept and agree to submit him- / herself to such procedure voluntarily, to the extent necessary.

13. LIABILITY OR NON-LIABILITY

13.1 Neither PPN nor any Participating Medical Scheme shall be liable for payment of:

13.1.1 optometric services rendered or an optometric appliance provided not covered by the optometric benefits;

13.1.2 services or optometric appliances, in addition to the optometric benefits.

13.2 A contracting party shall not be liable towards third parties for financial loss or damages of

whatever nature, caused by the other contracting party.



Page 20 of 20 13.3 The contracting parties indemnify each other reciprocally in respect of claim for damages being

instituted against a contracting party and such damages resulting from optometric benefits

rendered or any act done or omitted by the other contracting party in terms of this agreement.

13.4 The contracting parties agree to arrange for adequate professional and / or public indemnity

insurance to cover any liability that may result from the conduct of the participating service

provider and if called upon, shall submit proof of such insurance to the other contracting party.

The cost of professional indemnity insurance shall be an own expense for the contracting party

who takes it out.

14. BREACH

14.1 Should any one of the contracting parties breach any of their obligations in terms of this

agreement then the non-defaulting party shall be entitled as a remedy of first choice to claim

specific performance and any damages which it may have suffered, and if specific performance is

not possible or indicated, and as an alternative to such remedy, or if the defaulting party does not

remedy the breach after having received 5 (five) days written notice to do so, to cancel this

agreement and claim damages, which shall include consequential damages as a result of such

breach notwithstanding the fact that such breach or the consequential damages were not foreseen

by or within the contemplation of the contracting parties at the date of signature of this agreement.

14.2 Should PPN, without limiting the generality of the event in clause 14.1:

14.2.1 fail to discharge its obligations in paying the provider remuneration to the participating

service provider;

14.2.2 unilaterally terminates this agreement other than as agreed to in clause 8 of this agreement;

14.2.3 loose its accreditation as a mhco,

then the participating service provider shall be entitled to cancel this agreement without

cancelling the individual agreements constituted as a result of the signing of an acceptance form

which shall be deemed to remain operative on the terms of this agreement between PPN and

each individual participating service provider;

14.3 Should the participating service provider, without limiting the generality in clause 14.1:



Page 21 of 21

14.3.1 fail to render the optometric benefits to beneficiaries;

14.3.2 fail to discharge its obligations set out in clauses 5 and 6;

14.3.3 breach any of his confidentiality undertakings and restraints;

14.3.4 unilaterally terminate this agreement otherwise than as agreed in terms of clause 8;

14.3.5 be sequestrated or liquidated as the case may be;

14.3.6 be deregistered as an optometrist in terms of the HP Act;

14.3.7 be guilty of unprofessional conduct following a peer review hearing; or

14.3.8 commit fraud with regard to a claim, or submit an unlawful claim for payment of provider remuneration;

14.3.9 make him- / herself guilty of any conduct which brings PPN or the Participating Medical

Scheme into disrepute, save as provided for in sub-regulation 15E(1)(c) and (d) of the Medical Schemes Regulations;

14.3.10 fail to provide PPN with personal information requested in terms of clause 6.13;

14.3.11 fail to obtain an express consent in terms of clause 5.1.19,

(hereafter referred to as "the trigger events") then PPN shall be entitled to the additional remedies

in clause 14.5.

14.4 This agreement shall:

14.4.1 in the event of the trigger event in clause 14.3.6 applying, be cancelled ipso iure from the

date of deregistration;

14.4.2 in the event of the trigger events in clause 14.3.7 or 14.3.8 applying, ipso facto be

cancelled from the date of the finding of the peer review committee that the participating service provider has breached this agreement in this manner.



Page 22 of 22

14.5 PPN shall in addition to the aforegoing be entitled:

14.5.1 to claim specific performance and any damages which it may have suffered; or

14.5.2 if specific performance is not possible or indicated, and as an alternative to such remedy,

or if the participating service provider does not remedy the breach after having received

5 (five) days written notice to do so, to cancel this agreement and claim damages, which

shall include consequential damages as a result of such breach notwithstanding the fact

that such breach or the consequential damages were not foreseen by or within the

contemplation of the contracting parties at the date of signature of this agreement;

14.5.3 in the event of the trigger event in clause 14.3.8 applying, be entitled to withhold payment

of all provider remuneration due to the participating service provider, pending

outcome of a peer review procedure or criminal investigation and to set it off against any

fraudulent or-unlawful claim;

14.5.4 in the event of the trigger event in clause 14.3.11 applying to withhold payment of any

provider remuneration, until such time as the participating service provider can:

14.5.4.1 provide satisfactory documentary proof of compliance;

14.5.4.2 lawfully discloses personal information requested from the participating service

provider in terms of clause 16.13.

14.6 Without prejudice and in addition to any other rights or remedies which the contracting parties

may have and as has been set out in this clause, the defaulting party shall pay to the non-

defaulting party interest at the publicly quoted prime rate of interest charged by Nedbank Ltd on

overdraft facilities, plus 3 % (three percent), on any monies due but unpaid by the defaulting party

to the non-defaulting party, whether as due consideration or damages. Such interest shall be

computed as from the due date for the payment of the monies in respect of which the interest is

chargeable, until payment of such monies in full is received by the non-defaulting party. The

interest will be calculated on a daily basis on the amount due, compounded monthly and is payable

on demand.

14.7 The non-defaulting party shall furthermore be entitled to recover from the defaulting party all legal

costs and disbursements incurred by reason of any notice having to be given or dispute resolution

process or legal proceedings instituted in terms of this agreement. Such costs and disbursements



Page 23 of 23 shall be recovered on an attorney-and-own-client basis, and the fees portion of such account shall

be calculated at the hourly rate agreed to between the non-defaulting party and its legal advisors.

An hour shall for purposes of this clause be divided into 10 units of 6 minutes each.

15. GOVERNING LAW

This agreement shall be governed by and interpreted in accordance with the laws of the Republic of South

Africa.

16. RELATIONSHIP AND GOOD FAITH

16.1 This agreement shall not constitute a partnership or joint venture between the contracting parties. It forms the basis for doing business between individuals, in delivering services, and

charging agreed rates or prices for providing the optometric benefits.

16.2 The contracting parties shall at all times display the highest degree of good faith towards each

other in all matters pertaining to this agreement.

16.3 No contracting party shall:

16.3.1 release, compromise or compound any debt owing to the other contracting party;

16.3.2 notwithstanding anything to the contrary contained in this agreement, cede or in any way

dispose of or encumber its rights in terms of this agreement or delegate its obligations;

16.3.3 do anything or permit anything to be done whereby the other contracting party may

become(s) liable to a third party.

16.4 Neither the participating service provider nor PPN will use any incentive to directly or indirectly

compensate or reward any person for ordering, providing, recommending or approving any service,

forming part of the optometric benefits that is medically inappropriate.

16.5 The contracting parties agree to each make a suitably mandated representative available to

meet, discuss or negotiate on any issue of mutual interest that may not be covered in this

agreement. The contracting parties agree to re-negotiate the terms of this agreement should

any market related factors and / or legislation change the sustainability and / or profitability of PPN.



Page 24 of 24

17. DISPUTE RESOLUTION 17.1 In this clause unless the context clearly indicates a contrary meaning:

17.1.1 "arbitrator" means the person appointed in terms of clause 17.6;

17.1.2 "applicant" means the party at whose request a dispute was referred to arbitration in

terms of clause 17.6;

17.1.3 "Arbitration Rules" means the procedural rules determined by the arbitrator in terms of

clause 17.9, and failing a procedural determination by the arbitrator, the provisions of the

Arbitration Act shall apply and if necessary thereafter, the 5th Edition of the Rules for

Conduct of Arbitrations of the Association of Arbitrators (Southern Africa);

17.1.4 "dispute" means the dispute between the applicant and the respondent as formulated

during the mediation process in the statements of claim and defence;

17.1.5 “disputing parties” mean the applicant and the respondent;

17.1.6 "respondent" means the other party to the dispute.

17.2 Any contracting party who alleges or claims that a dispute has arisen in respect of the interpretation

of any term of this agreement or the discharge of any performance obligation, the applicant shall

formulate the dispute in writing and give notice of such dispute to the respondent at its

domicilium of choice in terms of this agreement and to the mediator in clause 17.4, which notice is

hereinafter referred to as "the statement of claim".

17.3 A party receiving the statement of claim shall within 5 (five) days of receipt of such document, if

he wants to be part of the dispute resolution process, respond thereto by recording his defence and

provide the applicant and the mediator with a copy in writing, hereafter referred to as "the statement of defence".

17.4 An independent person nominated by the Insurance Ombudsman shall act as mediator in order to

assist the disputing parties in reaching a mutually acceptable self-negotiated settlement within 5

(five) days of the statement of defence being filed.



Page 25 of 25

17.5 If the disputing parties are unable to reach a settlement of the dispute then the dispute shall be

referred to arbitration in terms of clause 17.6.

17.6 An arbitrator shall be appointed by agreement between the disputing parties to the dispute, and

in appointing the arbitrator, due regard shall be had to the nature of the dispute, the experience

of the person in arbitration proceedings, his availability and affordability; provided that if the disputing parties cannot come to an agreement with regard to the appointment of an arbitrator,

then anyone of them shall be entitled to request the mediator to appoint an arbitrator, regard being

had to the aforementioned criteria.

17.7 The arbitration proceedings shall take place in Pretoria.

17.8 The nature of the proceedings and the process to be followed shall notwithstanding the definition of

the Arbitration Rules, firstly be determined by the arbitrator in conjunction with the disputing

parties, subject to the right of the arbitrator:

17.8.1 to determine whether the proceedings shall be of an inquisitorial and / or adversarial

nature;

17.8.2 to determine who shall carry the burden of filing the claim documents, the reply and the

format of such documents with or without an obligation to discover all relevant documents

and / or witness statements simultaneously with the filing thereof;

17.8.3 to rule on the manner in which evidence shall be taken down;

17.8.4 to lay down time limits and the consequences of non-compliance with procedural rules and

time limits as well as the conditions for any postponements, if any;

17.8.5 the procedure for determining interim legal points without reference to a court of law;

17.8.6 to determine to what extent the strict laws of evidence shall apply; provided that the arbitrator shall be entitled to allow hearsay evidence and to determine the evidential value

thereof;

provided that if the arbitrator has failed to determine a step in the process, the Arbitration Rules as

defined, shall apply.



Page 26 of 26

17.9 The cost of:

17.9.1 the arbitration proceedings, both in respect of interim and final cost orders, shall be in the

sole discretion of the arbitrator;

17.9.2 the arbitrator shall, in the event of the dispute being settled outside of the process of

arbitration, but after it had been initiated, be determined by G T Avvakoumides, cost

consultants of Pretoria and shall be borne in equal shares by both disputing parties

unless otherwise agreed.

17.10 The mediation-and arbitration process shall be treated as confidential and be respected as such by

the disputing parties, and their legal representatives.

17.11 The award of the arbitrator shall be final and binding on all disputing parties.

17.12 This clause shall not preclude either party to approach any court with competent jurisdiction for any

interim or urgent relief, to protect its rights in terms of this agreement.

18. CESSION / ASSIGNMENT

Neither party shall be entitled to cede, delegate, transfer or otherwise alienate any of the rights or duties

deriving from this agreement without the written consent of the other party, which consent shall not

unreasonably be withheld.

19. DOMICILIUM CITANDI ET EXECUTANDI

19.1 Any notice and / or process issued in terms of this agreement shall be served, delivered or sent to

the contracting parties to this agreement at the following addresses and in the following manner:

PARTY

PHYSICAL ADDRESS

POSTAL ADDRESS

TELEFAX ADDRESS

(a) PPN

1401/2 Oasim North Building

Havelock Street

Central Port Elizabeth

P O Box 12450

Centrahill

6006

For Attention : Ian Wiese

(041) 506 5740

(b) The participating service provider



Page 27 of 27

19.2 Any one of the contracting parties may at any time during the existence of this agreement

change the addresses in 19.1 above by giving written notice to the other contracting party of such

change of address provided that the new domicilium shall include a postal, delivery and telefax

address in the Republic of South Africa.

20. NOTICES 20.1 PPN may give notice of any amendment, which may in terms of the provisions of this agreement

be effected unilaterally by PPN, by posting such notice to the PPN website established on the

World Wide Web under www.optimum.co.za / www.ppn.co.za and shall be deemed to have come

to the notice of the participating service provider on the first business day after the day on

which it was posted to the website as proved by a certificate issued by any manager of the website

administrator.

20.2 Any other notice which any contracting party gives in terms of this agreement, must be in writing

and addressed or sent or delivered to the addresses referred to in 19.1, above, and shall be

deemed to have been given properly and to have come to the notice of the addressee on the fourth

business day after the day on which the notice was sent by pre-paid registered post, if posted, or

on the business day after the date and time which appears on the telefax control sheet of the

addressor, if sent by way of telefax, or on the first business day after the date and at the time (if

any) which appears on the acknowledgement of receipt on the notice and/or document, if delivered

by hand.

21. COSTS

PPN shall pay the legal costs of Messrs. Potgieter-Marais Attorneys in drafting this agreement, at the

rates agreed with the said attorneys by the representative of PPN prior to the preparation of this agreement, on demand.

22. COUNTERPARTS

This agreement is constituted by this Signature Document in printed format and the preferred provider

manual in electronic format on the PPN website and may be signed in counterparts, including by way of

facsimile, each of which shall be deemed to be an original.

23. WHOLE AGREEMENT

http://www.optimum.co.za/

http://www.ppn.co.za/



Page 28 of 28

This agreement constitutes the whole agreement between the contracting parties relating to the

provisions of the optometric benefits to beneficiaries in a managed health care environment.

24. AMENDMENTS

No amendment or consensual termination of this agreement or any provision or term hereof shall be

binding unless recorded in a written document signed by the contracting parties.

25. EXTENSION OF TIME

25.1 No extension of time or waiver or relaxation of time stipulated for performance in terms of this agreement or any agreement, bill of exchange or other document issued or executed pursuant to

the terms of this agreement unless agreed to and reduced to writing in terms of clause 24, shall

operate as an estoppel against either contracting party or preclude such contracting party

thereafter from exercising his / her / its rights strictly in accordance with this agreement.

25.2 To the extent permissible by law neither contracting party shall be bound by any implied or tacit

term, representation, warranty, promise nor the like not recorded in this agreement.

26. EXECUTION

THE PARTY DATE PLACE AS WITNESSES

26.1 PPN

The terms of this agreement were accepted on behalf of PPN by the

representative referred to in clause 1.1 above at the place and date

mentioned in the presence of the subscribing witness. The signatory

warrants his principal’s capacity and his own authority to contract.

_________________

q.q. PPN

1. ___________________

2. ___________________



Page 29 of 29

26.2 The participating service provider

The terms of this agreement were accepted by or on behalf of the

participating service provider by the natural person referred to in clause

1.2 read with Annexure I of the PPN participating service provider

manual, at the place and date mentioned and in the presence of the

subscribing witness. The signatory warrants his/her principal’s capacity

and his/her own authority to contract, if acting in a representative capacity.

_________________________________________

The participating service provider

1. ___________________

2. ___________________

PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE A

LIST OF OPTOMETRIC BENEFITS ANNEXURE A As communicated in the annual year end PPN communication and updated via the Optimum practice website.


PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE B

LIST OF FRAMES ANNEXURE B DESCRIPTION SIZE COLOUR PPN 61 51/18 L.BROWN LADIES GOLD PPN 62 51/18 GOLD LADIES G.DEMI PPN 63 47/17 S.PINK LADIES L.BROWN PPN 64 54/19 GOLD MEN GUN PPN 65 52/19 GOLD MEN S/BRWN PPN 66 51/20 BROWN MEN S/BRWN GUN PPN 67 44/18 GUN UNISEX GOLD PPN 68 45/19 L.BROWN UNISEX GUN PPN 69 48/20 BROWN UNISEX 48/20 GOLD UNISEX PPN 70 PINK UNISEX M/VIOLET UNISEX


PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE C

LIST OF DESIGNATED LABORATORY SERVICE PROVIDERS ANNEXURE C Lab No. Name 001 BASIC 002 ESSILOR 003 FOCUS TOTAL EYECARE 004 GENOP/ZEISS 005 HILL 006 INDEPENDENT 007 ITELENI 008 LUSTRE 009 OPTISPEED 010 SOLA 011 LENSLAB STANDERTON 012 OPTILAB 013 EYEDEAR OPTICAL 014 N & K OPTICAL 015 C-CLEAR 016 OSMANS OPTICAL 017 PRECISION VISION (PTY) LTD 018 NALEDI OPTICAL 019 OPTICAL TECHNOLOGIES 020 RAMS OPTICAL 021 I L SHAI 022 LENSLAB MANUFACTURING 023 SPEC SAVERS GREENACRES 024 SPEC SAVERS KING WILLIAMS TOWN) 025 SPEC SAVERS KUILRIVIER 026 SPEC SAVERS HERMANUS 027 SPEC SAVERS SOMERSET WEST 028 SPEC SAVERS PIETERSBURG 029 SPEC SAVERS MUSGRAVE 030 P E OPTICAL 031 SPEC SAVERS GATEWAY 032 SPEC SAVERS TYGERVALLEY 033 SPEC SAVERS VINCENT PARK 034 SPEC SAVERS THE REDS 035 M S OPTICAL 036 SPEC SAVERS PAVILION 037 DR DAVIES OPTOMETRIST 038 VISION OPTICAL 039 LENSCAPE 040 KAY KEEBLE AGENCIES 041 EUROTECH OPTICAL 042 LENS-A-HEAD 043 MORAKA OPTICAL LABORATORY 044 KEEVAN SHER EYECARE 045 OS OPTICAL CC 046 R G MABASO OPTOMETRISTS



047 M J ALLI 048 ULTIMATE OPTICAL 049 RXPRESS OPTICAL 050 D M RADUE OPTOMETRISTS 051 ATHLONE OPTICAL 052 EXCELENS LABORATORY 053 CLASSIC EYES 054 LINES OPTICAL 055 VISION OPTICAL 056 S D OPTICAL 057 QUALITY OPTICAL 058 TOPCO CC 059 EYE TO EYE OPTOMETRIST 060 VISION CARE 061 EDISON OPTCAL 062 STORM 063 DISCOVERY 064 CLEAR - VUE OPTOMETRIST 065 MAFIKENG 066 R JITHOO & SON 067 R D SINGH 068 Y M CHABALALA 069 BALOYI OPTOMETRIST 070 LAWRENCE OPTOMETRIST 071 EXPRESS OPTICAL SERVICES 072 TORGA OPTICAL WESTGATE 073 STEF & KRIEL OPTOMETRIST 074 SPEC SAVERS BRITS 075 L MHANGWANA OPTOMETRIST 076 SELE MAPUTLA 077 SPEC SAVERS NELSPRUIT 078 SPEC SAVERS PARKLANDS 079 E C OPTICAL 080 WOUTER BURGER 081 MFUNDISI OPTOMETRIST 082 WARDECK OPTICS 083 VISION CENTRE 084 ISN EYELUTIONS 085 SPEC SAVERS STELLENBOSCH 086 SPECTIVISION 087 TORGA OPTICAL PAARL 088 HEINRICH AND MANN 089 TORGA OPTICAL WONDERPARK 090 WILFRED S HEINRICH 091 MASILU MOSWATSI 092 AXIS OPT MFG 093 MALESELA OPTOMETRIST 094 DIMENSION OPTICAL

095 SLABBERT & SLABBERT ( OUDTSHOORN)




096 CALOPTICS EYE CARE 097 NABIL BISMILLA 098 AUM OPTICS 099 RAMATSETSE OPTOMETRIST 100 NARINDI JANSEN OPTOMETRIST 101 CLASSIC EYES PAVILON 102 MAYISELA OPTOMETRIST 103 DUBE OPTOMETRIST 104 Peer Optometrist 105 Torga Optical 106 Spec-Crafters 107 Infocus Technologies 108 Dr Specs 109 Lustre Optical 110 C.V. LIEBENBERG OPTOMETRIST 111 Gauteng Optical 112 Itebeng Optometrist 113 C.M. Phatudi 114 Super Optical 115 Creative Optical Lab 116 G.T. Ramaswe Lab 117 Dikeledi Optical 118 Vue Optical 119 Leshabane Eyeworld 120 Corporate Optical Gauteng 121 L.G. Thivhafuni Optometrist 122 Unique Lab 123 P.E Optical 124 A Z Optical 125 Strategic Lab 126 Ten Lab 127 Eva Park Lab 128 Infinite Trading t/a Vision Optical 129 Fair & Square Trading t/a Value Optics 130 Tenyiko Construction 131 Other/ PPN LAB 132 Eye Max Optical Lab 133 Video Optical Lab 134 Lens Q Lab 135 Lenz Xpress c.c. 136 Wim Lottering Optometrist 137 S.M. Moagi Lab 138 M L MASEKO LAB linked Hi Tech 139 Divine Lab 140 Pro-Optic 141 Zanko optical

PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE D

CONSULTATION- AND OPTOMETRIC LENS PRICES ANNEXURE D Consultations: Composite Consultation 70001 R400 Examination Only 70002 R275 Consultation incl. Tonometry/Visual Fields 70003 R305 Re-examination 70004 R220 Lenses: PPN1 Single Vision R110 Bifocal R230 Multifocal R420 PPN2 Single Vision R135 Bifocal R320 Multifocal R560 PPN3 Single Vision R168 Bifocal R400 Multifocal R700


PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE E

LIST OF PARTICIPATING MEDICAL SCHEMES ANNEXURE E As communicated in the annual year end PPN communication and updated via the Optimum practice website.


PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE F

MEDICAL SCHEME BENEFIT OPTION ANNEXURE F As communicated in the annual year end PPN communication and updated via the Optimum practice website.


PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE G

BENEFICIARY INFORMATION ANNEXURE G G1. The information of beneficiaries of Participating Medical Schemes agreed to and

recorded in G4 below shall be made available:

G1.1. in electronic format on the PPN website which is accessible at

www.optimum.co.za;

G1.2. to the participating service provider by contacting the PPN Call Centre on

0861103529 or 0861101477.

G2. The participating service provider will be required to register as a user and must

obtain a username and password from the PPN Call Centre on 041-5065938.

G3. PPN will provide the participating service provider with an instruction manual on

how to use the software in clause G1.1 after registration as a user.

Beneficiary Surname First Name Identity

Number

Benefit

Option

Membership

Number

Available

Benefits

Eligible Member

Co-insured dependent 1






PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE H

PPN PATIENTS CHARTER ANNEXURE H H1. Every patient has a constitutional right of access to affordable health care services, including

ophthalmic care.

H2. Every patient has a constitutional right to be treated with respect and dignity, and equally

regardless of sex, pregnancy, marital status, ethnic or social origin, colour, sexual orientation,

age, disability, religion, conscience, belief, culture, language and birth.

H3. Every patient has the right to confidentiality of personal information, save to the extent that:

H3.1. he / she has expressly consented to disclosure of such information; or

H3.2. to the extent that disclosure by a participating service provider is authorised in

terms of the Medical Schemes Act and the Medical Schemes Regulations or an

order of court;

H3.3. to the extent that disclosure by a participating service provider is authorised in

terms of the Medical Schemes Benefit Option.

H4. Every patient has a constitutional right to complete and accurate information regarding his /

her:

H4.1. diagnosis, prognosis and treatment of his / her ophthalmic condition in a manner that

he / she is able to understand; and

H4.2. Medical Scheme Benefit Option, and the limitations on his / her right to optometric services.

H5. Every patient has the right to discuss the costs of the optometric services with the

participating service provider.

H6. Every patient in a managed health care environment has the right to choose a particular

health care provider from the network of participating service providers.

H7. Every patient has the right to complain about the quality of the optometric services if not

provided in terms of universally accepted standards in ophthalmic care.

H8. Every patient has the right to refuse the prescribed ophthalmic care.


PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE I

PARTICIPATING SERVICE PROVIDER DETAILS ANNEXURE I I, the undersigned, ___________________________________________________, by signing this document:

1. declare that I have read the PPN Participating Service Provider Agreement entered into between

Preferred Provider Negotiators (Pty) Limited, Registration Number : 1992/00075/07 (“PPN”) and myself

or my incorporated company (“the Participating Service Provider Agreement”);

2. declare that I am a registered optometrist and in good standing with the PBODO, and that there are no

cases of unprofessional conduct, fraud or litigation concerning my professional negligence or any other

investigation by the PBODO, pending against me.

3. My personal & practice details are:

Surname : _____________________________________________________

First Name & Initials : _____________________________________________________

Identity Number : _____________________________________________________

Qualifications : _____________________________________________________

_____________________________________________________

Trading title : _____________________________________________________

PBODO Registration No : _____________________________________________________

BHF Practice Number : _____________________________________________________

Physical Address : _____________________________________________________

(Practice) _____________________________________________________

________________________________ Code : ______________

Postal Address : _____________________________________________________

(Practice) _____________________________________________________

________________________________ Code : ______________

Telephone Number (W) : ( __________ ) ________________________________________

Telephone Number (H) : ( __________ ) ________________________________________

Fax Number (W) : ( __________ ) ________________________________________

Cell : _____________________________________________________

E-mail address : _____________________________________________________

Number of optometrists in the practice : _________________

Personnel - Admin _________________

- Other _________________

Practice Management Software System : ____________________________________________

Form of Submission of claims : Mediswitch QEDI Health Bridge


PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE I

PM.NvD.P581.2008.07.24

Other, specify: _______________________________

4. The practice's banking details for EFT payments are:

Account name : ____________________________________________________

Bank : ____________________________________________________

Branch : ________________________ Branch Code : _______________

Account number : ____________________________________________________

Type of Account :

Current Savings Other : specify ___________

5. undertakes to inform PPN, in writing, of any change to the above details within 7 days.

SIGNED AT ______________ ON THIS ______ DAY OF ____________________ 20____. AS WITNESSES: 1. _____________________ 2. _____________________ ___________________________ The Participating Service Provider

Potgieter-Marais Attorneys © 1019 Schoeman Street, Hatfield, Pretoria, Gauteng

PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE J

PPN COMPLAINT AND GRIEVANCE PROCEDURE ANNEXURE J J1. Purpose

This PPN Complaint and Grievance Procedure is introduced to ensure a transparent and effective

process prior to a formal peer review procedure to receive and resolve complaints:

J1.1. received from beneficiaries and Participating Medical Schemes with regard to service

delivery, whether clinical or administrative;

J1.2. received from the participating service provider in respect of PPN's administrative

procedures and payment of the provider remuneration;

J1.3. received from PPN in respect of service delivery, or co-operation of the participating service

provider, or administrative procedure of the Participating Medical Scheme.

J2. Complaints

J2.1. Complaints can be submitted in writing or orally to Service Excellence Department of PPN at

PO Box 12450, Centrahill 6006 or by calling PPN Switchboard: 041-5065900, who shall

categorise the complaint into unprofessional or administrative in nature; provided that oral

complaints shall be acknowledged in writing by the said Department; and provided further that

complaints relating to unprofessional conduct of a participating service provider must be in

writing.

J2.2. Complaints must contain adequate information to enable Service Excellence Department to

properly investigate the complaint, which shall include at least the following information:

J2.2.1. the date of the complaint;

J2.2.2. the identity of the participating service provider, if applicable; or

J2.2.3. the identity of the PPN or Participating Medical Scheme's staff member involved in

the incident complained of; and

J2.2.4. the nature of the alleged unprofessional-, or unacceptable administrative conduct

complained of; and

J2.2.5. the date of the incident complained of.

J2.3. Service Excellence Department shall ensure that:

J2.3.1. complaints of alleged unprofessional conduct on the part of a participating service

provider shall be investigated and responded to by an optometrist;


PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE J


J2.3.2. complaints of an administrative nature shall be dealt with by a member of PPN's

administrative staff on a managerial level.

J3. Investigation

J3.1. Complaints shall be investigated by the relevant PPN delegate clause J2.3 above and

completed within 72 (seventy two) hours.

J3.2. The PPN delegate instructed to investigate the complaint shall compile a written report of the

investigation and hand it to Service Excellence Department who shall consider it and advise

the complainant of the findings and on:

J3.2.1. the remedial action to be taken, if any; or

J3.2.2. the preventative action or procedures to be introduced.

J3.3. Service Excellence Department shall refer a complaint of unprofessional conduct against a

participating service provider to the Director : Professional Affairs of PPN to decide whether

the complaint requires to be dealt with in terms of the PPN Peer Review Procedure in

Annexure K to the PPN participating service provider manual.

PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE K

PPN PEER REVIEW PROCEDURE ANNEXURE K K1. Contractual rights of investigation

K1.1. If the Service Excellence Department of PPN suspends a participating service provider in

terms of clause 12.1 of the Signature Document of this agreement or if he / she or his / her

authorised representative receives a complaint of unprofessional conduct against, or a breach

of the terms of this agreement by a participating service provider (hereafter referred to as

“the respondent”) following an investigation in terms of the PPN Complaint and Grievance

Procedure, which in the opinion of the said director is of a serious nature when regard is had

to the provisions of clauses 5 and 6 of the Signature Document, and the said director is

furthermore of the opinion that the complaint or breach constitutes prima facie proof of

unprofessional conduct, or a breach contemplated in clauses 14.3.3.2, 14.3.3.7 or 14.3.3.8, he

/ she must inform the respondent in writing of the nature of the complaint or breach and

furnish such particulars regarding the complaint or breach, as are available, and request the

respondent to furnish his / her written response thereto before a date specified in the notice,

and give reasons why he / she is of the opinion that the complaint or breach does not constitute

unprofessional conduct, or a breach of the terms of this agreement, and warn the respondent

that his / her written response and the reasons advanced, may be used as evidence at any

subsequent peer review hearing.

K1.2. The Service Excellence Department of PPN, or his authorised representative shall, prior to

exercising his right to appoint a peer review committee in terms of clause K1.5, be entitled to:

K1.2.1. consult with or seek further information regarding the complaint or breach from any

person, including the respondent;

K1.2.2. request in writing from any person whom he, on reasonable grounds, believes to be in

possession of a document, photograph, computer record, contract, book, item, article,

administrative or financial record or computer data relevant to the complaint or

breach, before any hearing, for the purpose of investigating the complaint in terms of

clause 12 of the signature document and this Annexure;

K1.2.3. seek legal, or other advice regarding the complaint, or breach of the terms of this

agreement.

K1.3. The Service Excellence Department of PPN, after having investigated the complaint or breach,

and after having considered the response from the respondent, if any, must:

K1.3.1. if he / she is of the opinion that further action in terms of these peer review procedures

would not be appropriate, inform the complainant and the respondent accordingly;

K1.3.2. if he / she is of the opinion that it would be appropriate to hold a peer review hearing:



K1.3.2.1 appoint a pro forma complainant;

K1.3.2.2 prepare a notice in a format substantially corresponding with Annexure K(1)

notifying the respondent, the pro forma complainant and members of the

peer review committee appointed in terms of clause K1.5 to attend a peer

review hearing at a time, on a date and at a venue indicated in the notice;

and

K1.3.2.3 arrange for a peer review hearing to be held at the time, on the date and at

the venue indicated in the notice referred to in clause K1.3.2.2 above.

K1.4. The Service Excellence Department of PPN shall consider the following factors in deciding

whether or not to hold a peer review hearing:

K1.4.1. the nature and frequency of the complaint or breach;

K1.4.2. the consequences of the alleged unprofessional conduct or breach of the respondent

for the beneficiary, the Participating Medical Scheme or PPN;

K1.4.3. the sanction, which the peer review committee could impose, if the respondent is

found guilty of unprofessional conduct, or a breach of this agreement.

K1.5. The director professional affairs of PPN must appoint a peer review committee if he is of the

opinion that there is prima facie proof of a complaint or breach of the nature referred to in

clause K1.1 above and that it justifies a formal peer review inquiry when regard is had to the

provisions of clauses 5 or 6 read with clause 14.1.4 of the signature document of this

agreement.

K1.6. The peer review committee, appointed in terms of cause K1.5, shall comprise at least two

persons:

K1.6.1. one of whom shall be an optometrist nominated by the managing director of PPN or

his authorised delegate, other than the Service Excellence Department of PPN;

K1.6.2. one of whom shall be a person nominated by the chief executive officer of the

Participating Medical Scheme concerned, if applicable, alternatively a person

nominated by the managing director of PPN or his authorised delegate for his or her

knowledge of the law of contract and medical jurisprudence;

K1.7. One of the nominated persons shall act as chairperson of the peer review committee.



K2. Peer Review Procedure

K2.1. Disqualification to serve as member of committee

Neither the director professional affairs of PPN, nor the complainant may serve on the peer

review committee in connection with a complaint or breach investigated or filed by him / her.

K2.2. Pro forma complainant

The Service Excellence Department of PPN may appoint any person to act as pro forma

complainant at the peer review hearing to present the complaint or alleged breach of this

agreement; provided that the pro forma complainant is not an admitted attorney or advocate of

the High Court of South Africa.

K2.3. The respondent

K2.3.1. The respondent, if he / she disputes the fact that he / she is guilty of unprofessional

conduct or a breach of this agreement as alleged, he / she may appear in person at

the peer review hearing, or may be presented by a representative who is not an

admitted attorney or advocate of the High Court of South Africa:

K2.3.1.1 to hand in written submissions to the peer review committee; or

K2.3.1.2 to lead oral evidence; or

K2.3.1.3 to present argument,

in order to rebut the complaint of unprofessional conduct or a breach of the terms of

this agreement.

K2.3.2. The respondent, if he / she agrees that he / she has made him- / herself guilty of

unprofessional conduct or a breach of this agreement, may propose a finding on the

facts and agree to a sanction imposed and sign it before a commissioner of oaths and

hand it to the peer review committee before the start of the peer review hearing, who

may on the date scheduled for such hearing, make the proposed finding their order, if

it is acceptable to the committee and the pro forma complainant, and to recommend

an appropriate sanction.

K2.4. Respondent’s failure to exercise an option

If the respondent fails to exercise any of the options referred to in clauses K2.3.1 or K2.3.2,

and fails to appear at the hearing, the peer review committee may proceed with the peer review

hearing in the absence of the respondent and adjudicate the complaint or breach in

accordance with the procedure set out in clause K2.6 to K2.9 of this Annexure.



K2.5. Terms of reference of the peer review committee

On the date determined for a peer review hearing, the peer review committee must:

K2.5.1. if the respondent has proposed a consent order as contemplated in clause K2.3.2

which has been accepted by the committee and the pro forma complainant, make the

proposed consent order a final order, confirming the finding of fact and the sanction

proposed for such conduct or breach, and instruct the Service Excellence Department

of PPN to inform the respondent and PPN management and the Participating Medical Scheme accordingly;

K2.5.2. if the respondent has elected to proceed in terms of clause K2.3.1, proceed to hold a

peer review hearing in accordance with clauses K2.6 toK2.8 hereunder.

K2.6. Attendance of witnesses

K2.6.1. The peer review committee, the pro forma complainant and the respondent may

request the Service Excellence Department of PPN to arrange the attendance as

witnesses of all persons whom they wish to testify at the peer review hearing. The

request to attend shall substantially correspond with Annexure K(2) to this Annexure.

K2.6.2. If the attendance of witnesses are required at the hearing at the instance of the

respondent, the chairperson of the peer review committee may require the

respondent to deposit a sum of money which is sufficient to cover witness fees and

expenses applicable to expert witnesses in civil actions in the Magistrates’ Court, with

the Service Excellence Department of PPN for this purpose.

K2.7. Format of hearing

K2.7.1. Neither the pro forma complainant nor the respondent is entitled to legal

representation at the hearing.

K2.7.2. The peer review hearing must take the form of an inquisitorial investigation and the

pro forma complainant and the respondent must each be given an opportunity to

present their respective cases by means of written submissions, oral evidence or

argument.

K2.7.3. The peer review committee need not keep a record of its proceedings.

K2.8. Finding by peer review committee

The peer review committee, at the completion of hearing, must:




K2.8.1. if it was able to negotiate a consent order acceptable to the respondent, the peer

review committee and the pro forma complainant, draft a consent order as agreed,

and request the respondent and the pro forma complainant to sign the consent

order, which must contain a finding as to the facts proved and a recommendation to

PPN and the participating service provider of the sanction to be imposed in terms

of the consent order;

K2.8.2. if it was unable to negotiate a consent order:

K2.8.2.1 make a finding of the facts proved to its satisfaction and whether such facts

constitute unprofessional conduct or a breach of this agreement;

K2.8.2.2 and if it finds that the respondent is guilty of unprofessional conduct or a

breach of this agreement:

a) recommend that the respondent be suspended as a participating

service provider, for a specified period of time; or

b) recommend the recovery or withholding of payment of the provider

remuneration in an amount specified, by way of set-off, or otherwise;

or

c) recommend cancellation of this agreement in terms of clause 14.1 of

this agreement; and

d) refer the matter to the PBODO in the event of the respondent being

found guilty of unprofessional conduct; or

e) refer the matter to the South African Police Services in the event of it

being found that the respondent committed a criminal offence.

K2.9. Final and binding

The finding of the peer review committee and any sanction, if any, imposed as a result of the

recommendation of the peer review committee shall be final and binding on the participating

service provider, the respondent and PPN, unless it is referred to arbitration in terms of

clause 17 to the Signature Document within 7 (seven) days.

ANNEXURE K(1)

PPN PEER REVIEW PROCEDURE

In the matter of:

PREFERRED PROVIDER NEGOTIATORS (PTY) LTD Registration Number : 1992/00075/07 herein represented by B_________________________

(hereafter referred to as “PPN”)

and

____________________________________________

(hereinafter referred to as “the respondent”)

NOTICE TO ATTEND PEER REVIEW HEARING

The respondent is hereby notified to appear before a peer review committee appointed in terms

of clause 15 of the Signature Document of the Participating Service Provider Agreement

entered into between the respondent and PPN ("the agreement") at ______ (time) on

___________ (date) at ________________________________________________ (address), to

answer to the following complaint(s) or alleged breach(es) of the said agreement.

You are guilty of *unprofessional conduct / or a breach of the agreement in that you:

1. ____________________(give particulars of complaint) _________________________;



ISSUED AT ______________ ON ______________________________________ 200__.

_________________________________ Director : Professional Affairs

Preferred Provider Negotiators (Pty) Ltd

ANNEXURE K(2)

NOTICE TO APPEAR AT A HEARING OF A PPN PEER REVIEW COMMITTEE TO GIVE EVIDENCE AND / OR TO PRODUCE DOCUMENTARY EVIDENCE

In the matter between:

PREFERRED PROVIDER NEGOTIATORS (PTY) LTD (hereafter referred to as “PPN”)

and

___________________________________ (hereafter referred to as “the respondent”)

Witness’s full names : _______________________________________________

Postal address : _______________________________________________

Physical address : _______________________________________________

You are requested to-

1. appear at _______ (time) on ____________________ (date) before the peer review

committee of PPN (hereafter referred to as “the committee”), to give or produce

evidence at a peer review hearing into the conduct of the respondent, in his / her

capacity as a participating service provider providing optometric benefits in terms

of the Medical Scheme Benefit Option of _______________________ (name of

Medical Scheme Benefit Option) to the beneficiaries listed in Annexure K(2.1);

2. submit to the director : professional affairs of PPN before _________________ (date)

all documents, photographs, computer records, books, items, articles, administrative

or financial records or computer data, listed in the Annexure K(2.2)hereto, if any.

GIVEN ON _________________________ (date) AT __________________ (place). ________________________________ Director : Professional Affairs of PPN

PPN PARTICIPATING SERVICE PROVIDER AGREEMENT ANNEXURE L


BENEFICIARY CONSENT ANNEXURE L

I, the undersigned, whose particulars appear at the top of the patient record card (hereinafter referred to as *“the patient” / the patient’s legal guardian in the event of a minor / the responsible care giver of the patient in the event of the patient being temporarily incapacitated): 1. hereby confirm that: 1.1. I have read the undermentioned rights of the patient as contained in the National

Patients’ Charter: 1.1.1. Participation in Decision Making – Everyone has the right to participate in

decision-making on matters affecting one’s own health; 1.1.2. Choice of Health Services – Everyone has a right to choose a particular

health care provider for services or a particular health facility for treatment; provided that such choice shall not be contrary to the ethical standards applicable to such health care provider or facility;

1.1.3. Treated by a named Health Care Provider – Everyone has a right to know

the person that is providing health care and, therefore, must be attended to by only clearly identified health care providers;

1.1.4. Confidentiality and Privacy – Information concerning one’s health, including

information concerning treatment may only be disclosed with informed consent, except when required in terms of any law or any order of court;

1.1.5. Informed Consent – Everyone has the right to be given full and accurate

information about the nature of one’s illnesses, diagnostic procedures, the proposed treatment and the costs involved;

1.2. declare that I am aware of the fact that the practice has access to the confidential

personal information of the patient and his / her medical history / current medical condition and / or his / her medical condition and / or treatment by the practice and his / her prognosis (“the patient’s data”), and that the practice may be approached by the managed health care organisation, Preferred Provider Negotiators (Pty) Ltd, contracted to the patient's Medical Scheme, and / or by the patient's Medical Scheme itself, and / or the patient’s next of kin, and / or the South African Police Services and / or lawyers acting on behalf of the patient, for providing them with some or all of the patient’s data;

2. hereby consent to: 2.1. the practice disclosing the patient’s data to the persons mentioned in clause 1.2; 2.2. the practice anonymising the patient’s data for statistical and commercial purposes

and selling it to whoever may be interested therein. SIGNED AT _____________________ ON THIS ______ DAY OF __________________ 200___.

_______________________________ *in the abovementioned capacity

Documents

PPN 2009 Contract Please sign the document and return to ...optimum.ppn.co.za/downloads/PPN Contracts 2009.pdf · ANNEXURE D PPN 2009 Contract Please sign the document and return