Claims

Click here to view your Claims Guide or go through the following questions for detailed information on how you can submit all your claims.

Who can claim?

The member or the healthcare service provider (for example, a doctor, pharmacy or hospital) can make a claim.

How is the claim processed?

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 service provider when assessing claims. If this information is not available, some claims may not be paid in part or in full.

When are claims paid?

Twice a month.

Are medicine claims processed immediately?

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.

Reasons why claims are rejected (not paid)

Incorrect member or dependant information

• 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.
  
• When making claims for dependants, ensure that they are registered and their details appear on the claim.

No pre-authorisation (PAR) number for treatments such as hospitalisation and oncology

• Even after your treatment is authorised, your doctor needs to inform GEMS of any change in your treatment so that we can evaluate the treatment plan and update the authorisation. If your doctor does not inform us of the changes, GEMS may
  reject your claims or pay them from the incorrect benefit. Please remember: Physiotherapy treatment in hospital must also be authorised.

No benefits are available

• When your benefits have reached the benefit limits or sub-limits, GEMS will not pay any more claims.

Stale claims

• Claims must reach the Scheme within four months (i.e. 120 days) of the treatment date. GEMS will not pay claims that are
  older than four months. This is according to the Regulations of the Medical Schemes Act. You will have to pay for claims that you have not sent to us within four months of the treatment date.

Claims we receive for treatment after a member has resigned from the Public Service or from GEMS

• GEMS is a restricted medical scheme designed for Public Service employees. Anyone who is not a member of the Public Service cannot belong to GEMS. If you resign, you cannot use your GEMS membership card for healthcare services. If you or a service provider claims for healthcare services after the date that you resigned from the Public Service or from GEMS, you will have to pay this money back to GEMS.

Scheme exclusions

For all GEMS options there are specific conditions and treatment facilities that are not paid for, in line with the Medical Schemes Act. The items or procedures that are not covered by the Scheme are called Scheme exclusions. Members must make sure that the procedures, treatments or medicine they receive will be paid for before getting them because GEMS will not pay for excluded services or items. Members will be responsible for paying those costs. Scheme exclusions are listed in detail in Rule 16 and Annexure E of the Scheme Rules.

Please remember that claims that are 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 for you or your healthcare service provider to provide the
correct information and resubmit. Submitting your claim incorrectly will cost you time - so, save yourself the trouble and get it right the first time.

What information must be on your claims?

• Your member number;
• The Scheme name;
• Your benefit option (for example, Emerald,Onyx, Ruby, etc);
• 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 pre-authorisation number, if applicable;
• 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 and highlight it clearly. Proof of payment can be either a receipt from
  the healthcare service provider, an electronic fund transfer (EFT) slip or a bank deposit slip.

Submit your claims correctly

• By post to GEMS, Private Bag X782, Cape Town, 8000;
• By fax to 0861 00 4367; or
• By email to enquiries@gems.gov.za.

You can also deliver your claims to one of our 18 walk-in centres across the country.  

Claims statement explained

Click here to understand your claims statement. 

Refunds

When you have paid a healthcare service provider for a service, you may claim a refund from the Scheme. Whether we pay the claim, and how much we pay, will be determined by the Scheme Rules. We make refund payments to members electronically, so you need to make sure that we have your updated, correct banking details.

We need the following banking information:

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

Please fax this information to 0861 00 4367 or send an email to enquiries@gems.gov.za, using your member number as a reference. You can also deliver the information to one of our walk-in centres  or post it to: GEMS, Private Bag X782, Cape Town, 8000.

Click here to view your Claims Guide.

Claims alert SMS

Members can receive claim alert SMSs each time GEMS processes their claims. These SMSs acknowledges the receipt of claims but it is not a guarantee of payment. Ensure that you read your claim statement to see if your claim was paid or not. To receive claim alert SMSs, 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 possible. Call us on 0860 00 4367.