HIV Infection Mitigation CLAIMS PROCEDURES AND DEFINITIONS

IN THE EVENT OF A CLAIM MADISON HEALTH SOLUTIONS/GEMS MU - CARE CENTRE NUMBER: XXXXXXXXXXXXX
1. The Beneficiary shall comply with the following: Exercise all such due care and precaution to prevent or avoid an incident as is reasonable in the circumstances; IN THE EVENT OF A CLAIM The Beneficiary shall:1.1 1.2 notify the Care Centre within 24 Hours of the incident; obey all instructions given to the Beneficiary by the Care Centre operator. Failure to do so will result in the Service Provider being absolved from its obligations of this agreement. 1.3 within 48 hours of the occurrence visit a registered medical practitioner and complete all the necessary forms together with any supporting documentation to confirm the occurrence of the incident; 1.4 ensure that documentation furnishing details of the incident together with supporting documentation are received by the Service Provider; 1.5 give written consent to have blood taken for purposes of an HIV test and to disclose the results of the test to the Service Provider;

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warrant that he/she has or will disclose to the medical practitioner conducting an examination pursuant to an incident all known pre-existing medical conditions, which might affect the treatment or medication to be provided.

2.

The Service Provider will have no liability to a Beneficiary for:

2.1 consequential loss of any kind; 2.2 where the incident arises out of the unlawful act of the Beneficiary or that of any person acting with the connivance of the Beneficiary; 2.3 any condition, illness or injury arising from circumstances of facts known by the Beneficiary to have existed prior to the commencement date of this agreement; 2.4 any illness, injury death or liability arising from the negligence (whether gross or otherwise), wrongful acts and/or omissions of any of the persons employed or sub-contract to execute the obligations of the Service Provider under this agreement; 2.5 any illness or injury, death or liability arising from the negligence (whether gross or otherwise) wrongful acts and/or omissions of any doctors, paramedics, nursing staff or other medical and health care personnel consulted by the Beneficiary for any tests or medical examination prescribed by this agreement; 2.6 any treatment or medication unless same has been prescribed by a duly qualified registered medical practitioner; 2.7 any cost whatsoever resulting from a suicide or attempted suicide and/or any self inflicted injuries including self-inflicted work related injuries; 2.8 the availability, quality or result of any medical treatment nor for the Beneficiaries failure to obtain medical treatment or adhere to the medication prescribed; 2.9 consensual sexual intercourse; and 2.10 any benefit in terms of the Program if any fraudulent means or devices are used by the Beneficiary or anyone acting on the Beneficiary's behalf

(including collusion with the perpetrators of the incident) to obtain any benefit in terms of this agreement. If any such fraudulent means or devices are used the Service Provider shall be entitled to a refund of all and any amounts disbursed by it in term of this agreement. 3. The Beneficiary has access to the following:

In the event of an incident occurring and the Beneficiary voluntarily elects to adhere to the Program Protocols advised by the Service Provider, such Program Protocols are defined hereunder: 3.1 Unlimited access to the Care Centre Trauma Line which provides at 24 hour, 365 days a year professional counselling and guidance service to Beneficiaries for: 3.1.1 3.1.2 3.1.3 reporting of any incident; obtaining HIV information and advice required by the Beneficiary; obtain advice relating to drug adherence;

3.2 counselling the Beneficiary on the procedure he or she must follow: 3.2.1 obtaining details of the closest facility at which the member can obtain AntiRetroviral Therapy; 3.2.2 Post Traumatic Stress Syndrome counselling.

3.3 Advice relating to the benefits inherent in consulting an HIV specialist medical practitioner to draw blood and undertake a HIV Elisa Test within 48 hours of the incident. 3.4 Advice on how to access: Three Day Starter Pack (prophylactic starter pack), morning after pill; sexually transmitted infection preventative medication;

Anti-Retroviral Therapy treatment for a period of 28 days (upon the initial HIV Elisa Test being negative).

3.5 Advice relating to the benefits inherent in consulting an HIV specialist medical practitioner to draw blood and undertake the HIV Elisa Test 90 days after the occurrence of the incident (on receipt of a negative Elisa HIV Test result). 3.6 In the event of Sexual Exposure, financial assistance for; 3.6.1 face to face trauma counselling for both the beneficiary and his/her immediate family. 3.6.2 3.6.3 alternative therapies security

CARE CENTRE PROTOCOLS

1. 1.1 1.2 Level Description Level one (Care Centre Operator (CCO)) Basic advice Level two (Case Manager) basic advice, advanced advice, incident follow up counselling and case management 1.3 Level three (Case Manager, Doctor, Pharmacist) Case management, drug administration, medical protocols, pre and post test counselling, general counselling, follow up of practitioner and patient. 2. 2.1 Definitions:

Advice shall mean the provision of relevant information relating to HIV/AIDS or the services of the Product.

2.2 2.3

AIDS shall mean Acquired Immune Deficiency Syndrome. Anti Retroviral shall mean drugs that are utilised in the treatment of HIV according to the required protocol.

2.4

Beneficiaries shall mean any person as defined in the agreement as a beneficiary of the programme.

2.5

Blood test shall mean an Elisa test for attempting to determine the HIV status of a beneficiary

2.6

Care Centre shall mean an operational centre capable of handling telephone calls for the purposes of providing advice and managing the processes relative to the product.

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Care Centre Operator (CCO) a suitably telephonically trained person that has also been educated on the basics of first level HIV/AIDS advice.

2.8

Case Manager (CM) shall mean a person with the required knowledge and information enabling them to manage second level HIV/AIDS advice or to actually manage a patient who is already in the process of taking ART.

2.9

Telephonic Counselling shall mean advice and/or information provided to a member who has either had an exposure as defined in the contract or who utilises the programme for simple purposes of determining what to do in the event of an exposure.

2.10

Doctor a suitably qualified medical person registered with SAMA and qualified to provide third and/or fourth level HIV/AIDS advice or treatment.

2.11

Hospital A suitably qualified organisation accredited by HASA with the ability to provide ART and treat third or fourth levels.

2.12

Incident shall mean any case where a beneficiary qualifies for benefits under the Programme.

2.13

Pharmacist a suitably qualified person registered with PSSA and qualified to administer third and/or fourth level HIV/AIDS advice or treatment.

2.14

Process shall mean the escalation of telephone calls or patient procedures through the benefit utilisation.

2.15

Protocol a suitable process based on UN AIDS and WHO standards that should be followed in the event of a person requiring medication or medical treatment relative to an exposure to HIV.

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Starter Pack shall mean a three-day pack of Anti Retroviral as decided by a Care Centre Case Manager relevant to the particular incident or exposure of the patient.

2.17

90% of all calls made by beneficiaries of the Programme to the Care Centre must be answered within 10 seconds;

2.18

The care centre operators shall answer the telephone: Solutions Care Centre.

Madison

Health

3.

Advisory Services: (LEVEL 1) Step 1 Step 2 Call is received and answered. a) b) Step 3 Step 4 Step 5 CCO requests information according case report. CCO will record all patient details.

CCO records member inquiry and advice given in the relevant sections of case report. If the call requires advanced information within working hours it will be escalated to a Case Manager. The same process as step 3 will be followed. Calls not received during work hours will be carried over to the following day and the Case Manager will contact the patient.

4.

Counselling Services: (LEVEL 2) Step 1 Step 2

Call is received and answered. c) d) CCO requests information according case report. CCO will record all patient details.

Step 3 Step 4

CCO records member inquiry and escalates the call to the Case Manager or Counsellor. Follow up time is agreed and noted with reminders.

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Incident Process: (LEVEL 3) Step 1 Step 2 Step 3 Step 4 Step 5 Step 6

Patient has Exposure Establish nature of incident. In the case of sexual exposure STI medication and in the case of females, the morning after pill will be given. Ascertain geographic location. If later than 72 hours, explain that drugs will not be effective and therefore will not be covered; however telephonic Counselling benefit is still available. If within 72 hours, briefly explain programme procedure and benefits; i) 3 day starter pack must be taken within 72 hours ii) Sexual exposure patient treated prophylactically for STIs and morning after pill iii) Initial HIV test within 48 hours Patient advise to nearest clinic/centre for emergency care Clinic/Centre is contacted and advised of incoming patient Advise on incoming patient Explain programme and that payment is guaranteed to limits i) X 2 Consultation ii) X 2 HIV test (Elisa) iii) Starter pack iv) 28 day course ART therapy Email/fax standard letters through to consulting doctor including suggested treatment as per PEP CDC Guidelines Contact clinic and ensure receipt of documents 15 minutes later All documentation to be faxed to Care Centre Contact doctors rooms to obtain HIV results within 24 hours Results must be faxed to Care Centre HIV positive, patient will be advised on benefits of Clinical Disease Management HIV negative, 28 day course treatment to be dispensed. Patient re tested in 3 months, to determine HIV status HIV positive, patient will be advised on benefits of Clinical Disease Management

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