View your Claims Guide.
The registered member/dependant. The healthcare provider can submit a claim on behalf of the registered member/dependant.
To protect members' benefits, GEMS is on a drive to provide a safer environment for processing claims. And with this aim, processes have been put in place to help us to better validate the submission and payment of claims.
View the list of healthcare providers on indirect payment. One of the process changes is the termination of direct payments to certain healthcare service providers due to restrictions placed against them by the Scheme.
These healthcare service providers' claims will be rejected and GEMS members will be responsible for submitting the claim for the services provided by these healthcare providers directly to the Scheme. This means members have to pay healthcare costs for services from these healthcare providers directly to them and thereafter can claim back from GEMS.
Please remember that the claims submission from the member must include corresponding details and valid proof of payment, signed by the principal member, in the form of:
Department of Health healthcare provider claims relating to RWOPS
Sections 30 - 31 of the Public Service Act of 1994 states that "an employee does not, without approval, undertake remunerative work outside his or her official duties or use office equipment for such work".
In light of this, we requested all Department of Health (DoH) healthcare providers who provide services to GEMS members, outside of the public service, send proof that they are allowed to be employed outside the public service and be remunerated. This documentation was required before 1 November 2014.
Where proof of approval was not submitted in time, GEMS has taken a decision to reject claims for services or products provided to GEMS members by DoH healthcare providers who do not have the required permission. This means that you will be responsible to pay for any claims relating to services provided by a DoH healthcare provider who does not have permission to perform Remunerated Work outside the Public Service (RWOPS) from 1 November 2014.
View the list of DoH healthcare providers that are allowed to be employed outside the public service and receive remuneration
Your support regarding these processes are appreciated as GEMS continues to protect members' benefits. If you have any queries in this regard, you can call GEMS on 0860 00 4367 or send an email to email@example.com.
The Claims Department receives the claim and assesses it according to the Scheme Rules. If the Scheme Rules allow, the claim will then be paid.
Sometimes additional information is required from you or your healthcare provider, e.g. ICD-10 code, clear copy of account, detailed account, proof of payment etc. when assessing claims. If this information is not available, some claims may be rejected.
There are two payments runs per month - mid month and then at the end of the month. Depending on when your claim is received, it can be settled at either of these runs. Click here to view the claims run dates for 2016.
Your pharmacy can send medicine claims to us electronically at the point of sale. The Scheme Rules will be applied immediately, so you will find out if GEMS will pay for the medicine right away. This means that you will get your medicine immediately, if you have available benefits, GEMS will pay for the medicine without you having to pay for it in cash. If the medicine is not on the Scheme list, you may face a copayment or your claim may be rejected.
When you have paid a healthcare provider for a service, you may claim a refund from the Scheme. Your available benefits, the applicable Scheme Rules and the Scheme Rate will determine whether a refund will be paid and how much will be paid. When submitting a claim, you need to ensure that all supporting documents are attached to the claim, including a valid proof of payment. The proof of payment can be either a valid receipt from the healthcare provider, an electronic fund transfer (EFT) slip or bank deposit slip.
Refunds are paid to members electronically, so you need to make sure that we have your updated, correct banking details. We need the following banking information:
You can either fax this information to 0861 00 4367 or email it to firstname.lastname@example.org, using your membership number as a reference. You can also deliver the information to one of the GEMS Walk-in Centres or post it to GEMS, Private Bag X782, Cape Town, 8000.
Should you wish to change or update your banking details, you are required to submit the following documents:
You have the option to receive a claims alert SMS each time GEMS processes your claims. These SMSs acknowledge the receipt of claims, but it is not a guarantee of payment. To receive a claims alert SMS, please call 0860 00 4367 and make sure that we have your current cellphone number.
Remember: If you receive a claim alert SMS for a claim you are not aware of, please report it to the Scheme as soon as possible by calling us on 0860 00 4367.
Click here to understand your claims statement. You will receive a claims statement when a claim has been settled. Please read your claims statement to see if your claims were paid or not. If a claim was not paid, your claims statement will show the reason why it was not paid. If the reason should indicate an action, please resubmit the claim with the applicable information.
To protect your benefits from irregular claims being submitted to the Scheme, GEMS has processes in place that allows us to better validate the submission and payment of claims.
One of these processes is the termination of direct payments to certain healthcare providers who have fraud sanctions placed against them by the Scheme. These healthcare providers' claims will be rejected.
1. Incorrect member or dependant information
2. No pre-authorisation number for treatment such as oncology and hospitalisation
3. No benefits are available
4. When a member or dependant does not keep a doctor's appointment
5. GEMS will not pay for claims for services given by a healthcare provider who is not registered in terms of a relevant law
6. Claims sent to us too late
7. Claims we receive for treatment after a member has resigned from the Public Service or from GEMS
8. Scheme exclusions
9. The ICD-10 codes on the claim are not correct
10. Duplicate claim
Please remember that claims submitted incorrectly will not be paid. You will receive a claims statement explaining the reason why your claim has not been paid. Your claim will be returned and you or your healthcare provider would need to provide the correct information and resubmit the claim within 60 days following the date on which it was returned for correction. Please contact GEMS on 0860 00 4367 if you are not sure why your claim was rejected.
Submitting your claim incorrectly will cost you time - so save yourself the trouble and get it right the first time!
Download various forms relating to your membership in easy-to-use PDF format. Click Here >