• It is important that the Scheme receives up-to-date member information to process your claims. We need this information to make sure we pay claims correctly and that our member records are always complete and current. It is also important that members supply the Scheme with their dependants' ID details. When submitting claims for dependants, ensure that they are registered and their details appear on the claim. Submit the documentation by post to: Premium Management, Private Bag X782, Cape Town 8000, by fax to 0861 00 4367 or by sending an email to enquiries@gems.gov.za.
• It is important to obtain a PAR for treatment such as oncology and hospitalisation. Once authorised, your doctor still needs to advise GEMS of any change in your treatment as your authorisation will need to be evaluated and updated. Should this not happen, your claims may be rejected or paid from the incorrect benefit as there will be no matching authorisation. Call GEMS on 0860 00 4367 before treatment is received or to amend an existing PAR.
• When your benefits have been exhausted, claims will not be paid. This may be due to claims for costs that are higher or more than the annual benefit limits that you are entitled to in terms of the rules of the Scheme.
• When a member or dependant fails to keep a doctor's appointment, claims for that doctor's visit will not be paid.
• The claims for services rendered by a healthcare service provider who is not registered in terms of an applicable law will not be paid. Ensure that your claims meet the necessary requirements before they are sent to the Scheme.
• Claims must reach the Scheme within four months of the treatment date. A claim submitted later than the cut-off date will be classified as "stale" and not paid in accordance with the Medical Schemes Act. In such cases the member is liable for the cost.
• Claims submitted after a member resigns from GEMS will not be paid. GEMS is a restricted medical scheme designed for Public Service employees. No one who is not a member of the Public Service may belong to GEMS. If you resign, please do not attempt to use your GEMS member card for healthcare services. Any claims paid to you or a healthcare service provider after your resignation from the Public Service, will have to be paid back to GEMS. It is in your best interest to ensure that you understand the claim payment process to avoid any inconvenience in settling your claims. Contact GEMS on 0860 00 4367 if you are not sure why your claim has been rejected.

• Your member number;
• The Scheme name;
• Your option;
• Your surname and initials;
• The patient's name and beneficiary code as it appears on your member card;
• The name and valid practice number of the service provider;
• The date of service;
• The nature and cost of treatment;
• The tariff code;
• The relevant ICD-10 code;
• Your signature to confirm that the account is valid and
• If you paid for the service, attach proof of payment.

Members who are stationed abroad, in particular, employees in the Department of International Relations and Cooperation, can submit their claims from abroad.

Firstly, ensure that the official GEMS travel/international claims form available on www.gems.gov.za is used when submitting all international claims. Submitting your claim on another form could result in the Scheme receiving incomplete information. This could lead to a reduced amount being paid or the claim being rejected.

Secondly, when you submit a claim from abroad, please ensure that your claim form is complete and provides a description of the treatment.

• Provider type (general practitioner, pharmacy, type of specialist, etc.);
• Service dates;
• Condition treated;
• Specified treatment performed (procedures and consultations);
• Specified tests performed (e.g. pathology and radiology);
• Medication individually named and priced and
• Additional items listed with full name and pricing.

• Account holder;
• Account number;
• Bank name;
• Branch code and
• Account type (cheque/current or savings).