• Who do I contact if I am not getting feedback?
• Please use the reference number on your correspondence when making enquiries. For assistance, you may: Contact the designated mailbox. Contact the assigned Claims Risk Analyst. If there has been no response within the expected period, escalate the matter through the complaints channel.
• Who do I contact if I am unhappy with the review?
• If you are unhappy with how the review is being handled, you may use the designated GEMS complaints process. Once you have exhausted all internal mechanisms, you may also: Lodge a complaint with the relevant external regulatory body, where appropriate.

• How do I correct a mistake or repay overpaid amounts?
• If you identify an error, notify the Claims Risk Management team handling the matter as soon as possible. Depending on the circumstances, the following actions may be taken: Claims may be reversed. An acknowledgement of debt and repayment arrangement may be concluded. Repayment may include instalments. Repayment may be offset against future valid claims, where approved.

• Can Pharmacies claim for screening and preventative services? And for which services does GEMS pay for?
• GEMS offers all members screening and preventative care benefits which are claimed from the risk benefit. Please refer to the GEMS Website for the list of available screening and preventative services or contact our Call Centre.
• Does GEMS cover the Primary Care Drug Therapy PCDT meds?
• GEMS covers medication prescribed by a registered PCDT pharmacist including the associated dispensing fee for medicines. Pharmacies must utilise the correct legislated ICD10 codes.
• How can I help a GEMS patients avoid or minimise co-payments?
• As an FP, you can assist your patients who are GEMS members to avoid undesirable co-payments by ensuring that all scripted items are within the Acute/Chronic Formularies, and by encouraging members to make use of DSP pharmacies. More about co-payments: There are three types of co-payments: In order to contain the escalating costs of medicines, GEMS uses the MPL to determine the maximum price the Scheme will pay for those medicines with the same active ingredient based on the availability of generic equivalents on the market. The fundamental principle of the MPL is that it does not restrict a member’s choice of medicines, but instead limits the amount that will be paid should a member choose a medicine above the MPL. MPL reference prices are carefully determined so as to ensure adequate availability of generic equivalents within the price limit, without co-payments being necessary. (GEMS is also encouraging the use of reusable insulin pens and cartridges for diabetic members on insulin.) If a member uses a product that costs more than the MPL reference price, the member will attract an MPL co-payment. In addition, GEMS makes use of formularies for acute and chronic medicine, which are available on the website. Out-of-formulary co-payments are incurred when members use non-formulary drugs or medicine that is charged above the MPL reference price.  Finally, claims submitted from a non-DSP pharmacy will also attract a 30% non-DSP co-payment.
• How can pharmacies improve their compliance scores?
• All pharmacies on the GEMS Network are measured on four (4) compliance measures, namely: Medicine Price List (MPL) Generic Substitution (GS) Dispensing Fee (DF) ICD-10 codes (OTC items only) Pharmacies compliance reports are distributed monthly, to ensure they can track performance against target. Pharmacies that are having challenges with meeting the compliance scores can request for engagements with the PNMP Provider Liaison Officers or compliance pharmacists, who will assist them on how to reach the mandated compliance scores.
• How do I register a GEMS member on the chronic medicine programme?
• No need to complete a physical form - simply call our dedicated call centre agents to help you with a telephonic chronic medicine registration. CALL the GEMS service provider call centre on 0860 436 777, press 4 for enquiries on chronic medicine, then 3 for enquiries on authorisation of chronic medicine. Have your practice number handy. EMAIL the prescription to chronicdsp@gems.gov.za to enable a courier pharmacy to dispense medication for members who choose to have the medication delivered. GEMS will also remind the members to renew the prescription before it expires.
• What are Risk Management Responses (RMRs)?
• Risk Management Responses (RMRs) assist healthcare providers in making informed financial and clinical risk management decisions at the point of service. These response messages are passed back to the provider as part of an electronic claim submission response. Top 5 RMRs (Claim Responses) and Explanations RMR Code RMR Description Comment Meaning Error Result Flag 553 Item processed as PMB Information The message specifies the PMB benefit that the claim/script was paid from. Warning 469 Submitted Gross Used Information The message confirms the Submitted Gross amount has been accepted and processed. Warning 7208 MPL Reference Price Exceeded Call to Action The dispensed product price is above the MPL reference price, and the member will incur a co-payment. Action to take, the provider is to consider an alternative within or below the MPL price. Warning 989 Price Difference on submitted Gross Call to Action The professional fee submitted for the product is above the contractually agreed amount and the difference will be a co-payment to the member. Action to take, the provider to comply with the contractual obligation. Warning 250 Out of formulary item Call to Action The dispensed product is outside the formulary list and the member will incur a co-payment. Action to take, provider to consider an alternative within the formulary. Warning
• What is the difference between a Chronic Authorisation and a Disease authorisation?
• GEMS applies a 'disease authorisation' to approve medicines for the treatment of chronic conditions, not just for a medicine. The disease authorisation provides access to a list of pre-approved medicines, referred to as a basket. Where a patient is already registered on the chronic medicine programme for a specific chronic condition, and the prescription is amended, the patient may present the prescription to the pharmacists to first submit the claim for the medication. Based on the real-time feedback received, the claim will either be processed successfully from the basket, or the pharmacist will be advised that pre-authorisation is required
• Why it is important to add an immunisation administration fee on a claim?
• Administration fees (tariff code 0022) that are submitted alone without an accompanying vaccine NAPPI code will be rejected. A warning message of “admin fee was not submitted’ will be generated to remind providers if a vaccine NAPPI claim is submitted without an admin fee tariff code. 

• Does GEMS fund reduction mammoplasty and bariatric surgery?
• GEMS will consider funding bariatric surgery and reduction mammoplasty in cases where they are deemed to be clinically indicated.  For funding to be considered – REDUCTION MAMMOPLASTY requires a clinical motivation by a plastic surgeon or general surgeon. Please email hospitalauths@gems.gov.za or call 086 043 6777 to request a GEMS Breast Reduction Template and to confirm GEMS-specific clinical criteria, does not apply to all options - only EVO. Emerald and Onyx, and requirements for this procedure.   BARIATRIC SURGERY requires a clinical motivation from the Multidisciplinary Team members. Please email hospitalauths@gems.gov.za or call 086 043 6777 to request a GEMS Bariatric Surgery Template and to confirm GEMS-specific clinical criteria, conditions, and requirements for this procedure. Furthermore, bariatric surgery may only be performed at a Proventi or South African Society for Surgery, Obesity and Metabolism (SASSO) accredited Centre of Excellence site, by a Proventi or SASSO accredited surgeon.
• How does GEMS fund mobile chronic haemodialysis?
• The mobile chronic haemodialysis category and tariff introduced by GEMS aims to compensate the provider for their time and expertise whilst managing the Scheme expenditure on non-acute haemodialysis. Claims using this tariff will only be approved in the following scenarios: Registered chronic haemodialysis patient. Admitted to general ward but is immobile (cannot be moved or their doctor has instructed that it is not advisable to move them). Admitted to a general ward and there is not an onsite renal dialysis facility. Admitted to a general ward and there is an onsite renal dialysis facility but the facility does not have capacity to treat the member.

• How do I change my dispensing status with GEMS?
• If you want to change your dispensing status, please do so in writing, and then email your change request to either networkscontracting@gems.gov.za or to gemsnetworkenquiries@medscheme.co.za, or fax it to 086 244 738 or 0860 222 453. In addition, if you wish to become a dispensing practice, you need to have a valid dispensing license, which needs to be updated with the Board of Healthcare Funders (BHF). 
• How do I update my banking details with GEMS?
• Please send GEMS the relevant documents listed below to register your new/amended banking details on our system. You can either email these to implementation@mhg.co.za, or fax to 021 480 4087. A signed practice letterhead (ALL partners’ signatures) Companies and Intellectual Property Commission (CIPC) papers if the bank account is in the name of a registered company Bureau manager certified ID and signature on letterhead (if applicable) A bank letter / bank statement (not older than three months) with a bank stamp A certified copy of the owners’ IDs (ALL partners’ certified ID copies) A certified marriage certificate (if applicable) A ‘trading as’ letter (which can be indicated on the signed letterhead) if the practice name and the bank account holder names differ
• What is chronic medicine?
• Chronic medicine is medicine used on an ongoing basis to treat disabling and/or potentially life-threatening chronic (long-lasting) illnesses, like diabetes, that have a negative effect on your health and quality of life. Chronic medicine must be pre-authorised by the Medicine Management Department to ensure appropriateness and cost effectiveness. Some medicines are not paid in full if they are not on the Scheme's formulary or Medicine Price List (MPL). Always check with your doctor to see if the most cost effective medicine is prescribed according to the MPL and the formulary so that you do not need to pay out of your own pocket.
• When is a specialist referral required?
• In order to avoid having to pre-authorise a specialist consult, and/or avoid a 30% co-payment, GEMS beneficiaries on the Tanzanite One and Emerald Value options require a referral from their nominated network FP. The referring practitioner’s practice number (the nominated FP for Tanzanite One and Emerald Value options) needs to be stated on the claim of the specialist to avoid co-payments. Refer to the FP Network Guide for additional information.
• Where can I access the GEMS Family Practitioner Guide?
• The GEMS Family Practitioner Network Guide is published on the GEMS website and is available here.
• Where can I access the GEMS Tariff files?
• The GEMS Tariff files are published on the GEMS website and are available here.

• What do I do if a claim is rejected for motivation required?
• If a claim is rejected for motivation required, a letter of motivation must be completed by the treating provider and submitted to enquiries@gems.gov.za. The motivation will be reviewed by a Medical Advisor for a funding decision to be made.

• Do these changes reduce available benefits?
• No. There is no reduction in benefits. The enhancements focus on appropriate utilisation of benefits. A structured exception management process is available to accommodate clinically justified cases.
• What does restorative treatment validation involve?
• For cases involving two or more restorations for dental therapists, additional validation may be applied to confirm: Clinical necessity. Appropriate treatment planning. Alignment with accepted clinical standards. This is a utilisation management and verification measure, not a restriction on care. All clinically justified cases remain eligible for exception review.
• Why is there specific validation applied in cases involving dental therapists?
• Validation supports alignment with scope of practice, ensuring: Appropriate case selection. Consistency in restorative care delivery. It is recognised that: Dentists undertake complex and specialised procedures. Dental therapists play a key role in primary oral healthcare delivery. Exception pathways are available where treatment requirements fall outside standard parameters.
• How does the exception management process work?
• The exception process allows practitioners to submit clinical motivation where: Treatment falls outside standard benefit rules. Patient-specific clinical circumstances warrant flexibility. Key principles: Case-by-case clinical review. Evidence-based decision-making. Fair and consistent application.
• How should practitioners approach cases that fall outside standard rules?
• Providers should: Proceed with clinically appropriate care planning. Submit a clear clinical motivation where required. Include relevant supporting information. This ensures timely review and appropriate benefit consideration.
• What is the intended clinical and operational outcome?
• These enhancements are designed to: Promote appropriate utilisation of services. Maintain high clinical standards. Ensure equitable treatment across providers. Support benefit sustainability. Retain flexibility through exception pathways.
• Why are these changes being implemented?
• These measures aim to: Strengthen claims verification. Promote clinical appropriateness. Support cost sustainability. The overall objective is to ensure consistent, high-quality care while protecting member benefits long term.
• What is the updated restorations time rule?
• The benefit interval for restorations on the same tooth is now: 3 years (1,080 days) This supports: Improved durability of restorations. Reduced frequency of repeat procedures. Alignment with quality-focused care. Where earlier replacement is clinically necessary, practitioners may submit a clinical motivation for exception consideration.
• What is the update to periodontal examinations (Code 8176)?
• The benefit has been aligned to: Members aged 21 years and older. This supports: Age-appropriate identification of periodontal risk. Preventive intervention at optimal life stages. Improved long-term oral health outcomes. Practitioners may submit exception requests for members and beneficiaries outside this age group where clinically indicated (e.g. aggressive periodontitis).
• Will these changes increase administrative burden?
• Minimal. The process is designed to: Integrate with existing workflows. Be efficient and user-friendly. Avoid unnecessary delays in patient care.

• How long do sanctions last?
• Sanctions are determined on a case-by-case basis according to the severity of the conduct and the applicable FWA policy. The following will be communicated in writing: The duration of the sanction. Any applicable reinstatement process. Attempts to bypass sanctions may constitute further misconduct.
• What happens if irregular claims are found?
• The Claims Risk Analyst prepares a case report with findings and recommendations for the relevant Scheme forum. The forum considers the evidence and may approve actions such as: Recovery. Sanctions. Monitoring. Referral to regulatory or law-enforcement bodies, where appropriate.

• Why is GEMS contacting my patients?
• Member verification is a standard claims-validation process used to confirm that services billed were actually rendered. Contact may occur through: Telephone. Electronic communication. Other approved means in exceptional cases.

• How long does a review take?
• GEMS aims to finalise reviews as quickly as possible. Review timeframes depend on the complexity of the matter: Hotline matters are prioritised and may be completed within 60 business days. More complex reviews may take longer, depending on responsiveness, completeness of submissions, and the number of parties involved.

• Are there preventative screening benefits in optometry?
• Yes. GEMS offers a childhood optometry screening benefit across all options for beneficiaries from three (3) months up to and including seven (7) years of age. This benefit is available once per lifetime and is paid from the preventative screening benefit, preserving the normal optical benefit. The screening code is 94000 – Childhood screening. Additionally, GEMS promotes wellness and preventative care by providing a glaucoma screening benefit for beneficiaries aged 40 years and older. This benefit is available once per benefit year and is paid from the risk benefit, ensuring that the optometry benefit remains unaffected. The relevant procedure codes are: 11202: Tonometry without anaesthetic 11212: Tonometry with anaesthetic Please note that glaucoma screening cannot be billed together with a routine eye examination
• Can optometrists prescribe medication?
• Optometrists with appropriate ocular therapeutics training and certification (sub-discipline 002 on the PCNS/BHF file) are authorised to prescribe both the topical and oral pharmaceutical substances for schedules 1 to 4 for adult and paediatric patients within their scope of practice in accordance with the Schedules to Medicines and Substances Act. GEMS covers medication prescribed by authorised optometrists, provided it is included in the GEMS formulary and complies with the medication rules of the specific option. Formularies can be accessed on the website at: https://www.gems.gov.za/en/Healthcare-Providers/Formularies-List
• Does GEMS fund children’s spectacles?
• Yes, GEMS provides funding for children's spectacles. However, proof of the services rendered may be required for beneficiaries aged nine (9) and younger. Only the test card is necessary for validation, which applies solely to spectacle claims and not eye tests.  The test card should be submitted to enquiries@gems.gov.za  when requested.
• How can I join the optometry network?
• To join the optometry network, simply email network@gems.gov.za, expressing your interest. Our provider liaison officer will assist you in obtaining a network contract.
• Where do I find the GEMS Optometry network tariffs?
• The GEMS Optometry Network tariffs are available on the GEMS website (https://www.gems.gov.za/en/Healthcare-Providers/Tariff-Files). Providers on the GEMS Optometry Network should use the GEMS Optometry tariff codes and tariff rates when submitting claims for payment.

• How am I protected from false allegations?
• Not all allegations result in a review. A matter may be closed without proceeding further if: The preliminary assessment cannot validate the allegation. Proof of service adequately addresses the concern.
• How does GEMS verify allegations before a review?
• Before a review is opened, allegations are assessed using risk-based criteria, including: Possible breaches of legislation. Scheme Rules. Clinical protocols. Evidence of misrepresentation or financial prejudice. Irregular billing practices. Conduct inconsistent with ethical standards. Only matters that pose a material risk to the Scheme and member benefits progress to investigation.
• Why is my practice being reviewed?
• GEMS initiates reviews when risk indicators are identified from sources such as: Hotline reports. Data analytics. Member complaints. Anonymous tip-offs. Industry referrals. Media reports. Other healthcare intelligence. All matters undergo assessment before a formal review is initiated.

• Do I need member consent to share records?
• GEMS requests information for claims verification and member protection purposes. Member information is handled in line with applicable privacy requirements. Where the request is linked to claims already submitted to the Scheme: The process should be handled through approved legal and privacy protocols.
• What happens if I do not provide the requested information?
• The review may continue based on the allegation, claims profile, and information available from other sources. You will still be given the opportunity to: Provide your explanation. However, non-response does not stop the review process.
• Why am I receiving requests for more information?
• Information received is assessed against the allegation and the findings that emerge during the review. Additional requests may be issued where: Submissions are incomplete. New anomalies are identified. Further clarification is required to conclude the investigation fairly and efficiently.
• Why are you asking about claims from 2 years ago?
• Historic claims may be reviewed to establish whether an anomaly is isolated or forms part of a broader claiming pattern over time. Comparative periods can also assist in: Quantifying potential exposure. Identifying trends.
• Why is so much information being requested?
• Requested documents are linked to the claims or irregularities under review. Providers are expected to retain records as required by law. Response requirements include: Typical response periods of 7 to 14 days. Reasonable extensions may be granted upon request.

• What is REPI²
• REPI2 (Risk Equalized Performance Indicator) is a family practitioner (FP) profiling tool developed by Medscheme. This tool uses a combination of cost and quality components to assess the performance of a practice, relative to its peers. REPI2 was introduced into the FP environment in 2007 to promote coordination of care and to remunerate the FP for partnering with Medscheme and its administered schemes, such as GEMS, to achieve the goal of high quality, affordable healthcare for all beneficiaries. The foundation for REPI2 provider analytics is developed around a patient attribution model, whereby beneficiaries are attributed to a family practice through considering total consultations per 12-month period under review. The REPI2 model is run quarterly and uses 12 months of claims data to provide the most accurate presentation.
• How does REPI² affect an FP’s remuneration?
• REPI2 forms the basis of the value-based enhanced remuneration model adopted by GEMS. This enhanced consultation fee is an additional ‘fee’ on top of the contracted consultation fee. Cost and quality components are combined in the assigning of an overall category of either 1, 2 or 3. FP’s who fall within category 1 or 2 are eligible for an enhanced fee over and above the determined FP network fee.
• When will a REPI² upgrade be considered?
• Various external aspects or models of FP practices might result in a practice with good clinical performance inappropriately falling within a lower REPI² category, as driven by an above average cost indicator profile. Such practices typically include, but are not limited to, specialised FPs who provide geriatric, obstetric, or other specialist level services. An appeals process has therefore been instated. Through this appeals process, all FPs can motivate and apply for a REPI² category upgrade by virtue of being a statistical outlier compared to their peers. Such motivations are considered and assessed by an independent REPI² category upgrades committee.
• How can one motivate for a REPI² upgrade?
• If you consider the clinical grounds for an upgrade appropriate, given the above, please email a detailed motivation letter REPIcorrespondence@medscheme.co.za.  The letter should include: the specific nature of the FP practice (GP anaesthetist, GP obstetrician, Emergency Practice, normal GP, etc.), special interests (geriatric care, etc.), and/or specific challenges that go above and beyond normal FP practice that might have a negative influence on overall cost indicators (rural practice, servicing old age homes, etc.). For more information pertaining to your practice review and category status, visit the Medscheme website (www.medscheme.com), log in or register as a Provider and click REPI² to access an online version of your full REPI² data set.

• Does GEMS have a process to verify allegations against health practitioners before reviewing their practice?
• The allegations are tested against the following criteria: Whether there was a possible breach of the Medical Schemes Act and its regulations, regulatory requirements, directives, or guidelines. Whether there was a possible breach of the GEMS Scheme Rules or clinical norms and protocols. Whether there is prima facie evidence of unlawful and/or intentional misrepresentation resulting in actual or potential prejudice to the Scheme. Whether there are any other activities that may be against policies (e.g. irregular billing practices such as code unbundling or failure to apply the appropriate modifiers) or applicable laws. Whether activities are not in line with acceptable ethical or professional standards.
• Why is GEMS calling my patients?
• A review may indicate that a claims validation process should be undertaken. Claims validation with members may be conducted through: Telephone calls. Email. Physical visits in exceptional circumstances. Engaging members to validate processed and paid claims is a standard practice across the medical schemes industry and is not unique to GEMS or any particular healthcare provider. GEMS randomly selects a sample of members to participate in the claims verification process.
• Why am I being asked about claims that date back 2 years?
• Historic data helps GEMS effectively assess potential exposure to irregular claiming patterns. Historic data is used to: Quantify exposure to irregular claiming patterns. Compare claiming patterns with those of peers over the same period. Assess trends across a full benefit year using a comparative year. Determine whether disputed claims represent a once-off error or an established pattern of irregular claiming.
• What happens if the review finds that I have been submitting irregular claims?
• The Claims Risk Analyst prepares and submits a case report containing the findings and recommendations to the Scheme for consideration by the monthly Claims Risk Sub Forum. The Claims Risk Sub Forum may: Accept the recommendation. Reject the recommendation. Where a proposed sanction is accepted, it will be communicated and implemented without delay. The Claims Risk Sub Forum: Consists of at least eight objective individuals. Applies impartiality and consistency throughout the decision-making process. Where the conduct involves ethical concerns or evidence of criminality, the Claims Risk Sub Forum may recommend referral to: The relevant regulatory bodies. The South African Police Service (SAPS), where appropriate.
• What can I do if I feel unfairly treated in the review process?
• GEMS is committed to ensuring that healthcare practitioners are treated in a professional, lawful, and fair manner throughout the review process. To support fairness and transparency: GEMS is represented during meetings with the administrator. An external legal advisor is present to help ensure engagements are lawful, reasonable, and fair. Healthcare practitioners are informed of their right to representation, including representation by a legal practitioner or professional society. Meetings and discussions between the administrator, field investigators, and the relevant healthcare practitioners are recorded. If an allegation of unfair treatment is raised, the recordings may be reviewed to determine whether the allegation has merit.
• The information requested by GEMS is excessive and I do not always retain the records required?
• As a healthcare practitioner, you are required by law to retain records for a specified period. GEMS requests only the information necessary to validate the claims under review. Information requests are: Specific to the review being conducted. Limited to instances where irregularities have been identified. Not random or excessive. Response requirements include: Providers are generally given 7 to 14 days to respond to a request for information. Reasonable requests for an extension are granted.
• If I realize I made a mistake with the claims in question, how do I rectify this?
• Notify the Claims Risk Management team member handling your review as soon as you become aware of the error and clearly explain how and where it occurred. Depending on the circumstances, the following actions may be taken: The claims may be reversed. If reversal is not possible, an Acknowledgement of Debt agreement may be entered into to repay any overpayments. You will be required to sign the agreement once an equitable repayment plan has been agreed with the Scheme. The Scheme may agree to offset future valid claims against the outstanding debt, provided an acknowledgement of wrongdoing declaration has been signed and accepted. The Scheme will work with healthcare practitioners to identify the most equitable solution in each case. Following the conclusion of the process, the Scheme expects improved claiming behaviour and may elect to monitor and/or verify future claims before payment.
• If I am unhappy with the way my review is being handled in general, who can I contact?
• Please send all complaints and concerns to complaints@gems.gov.za. When submitting a complaint, please include: Your practice number. The name of the Claims Risk Analyst handling your review. If you would prefer your complaint to be handled by a regulatory body, you may complete a Complaints Form and submit it to the Council for Medical Schemes at complaints@medicalschemes.co.za. GEMS reiterates its zero-tolerance approach to unfair discrimination, including but not limited to racial discrimination. GEMS does not collect or maintain provider race information in its systems, nor is such information included in the Board of Healthcare Funders of Southern Africa (BHF) provider file shared with administrators. GEMS' systems do not contain a race category, and the Scheme does not engage in any form of racial profiling. GEMS remains committed to improving access to quality healthcare for all members. Where a decision is made to sanction a service provider, the Scheme's preferred approach is to apply corrective and rehabilitative interventions wherever appropriate.
• If I am unable to, or do not want to provide the information request, what will happen?
• The Claims Risk Analyst will continue to conduct a desktop review of the claims profile, taking into account the allegation and the information collected from various sources. Throughout the review process, you will have the opportunity to: Respond to requests for information. Provide your input and explanation. Not responding to requests for information will not suspend or delay the normal progress of the review. Once completed, the review will be submitted to the GEMS Claims Risk Sub Forum with a recommendation on the appropriate action to be taken. GEMS strongly advises providers to make full use of every opportunity to present their version of events when requested.
• I was asked to provide clinical notes for the GEMS member I treated. Do I require the member’s consent to submit that information and who is responsible for getting that consent?
• GEMS does not request information for arbitrary reasons. The purpose of the request is to ensure that members receive the medical services claimed for by the provider and to protect member benefits. Member information is requested to: Verify that services claimed were actually provided. Protect members and reduce risks relating to their benefits and associated costs. Support accurate claims validation. GEMS undertakes to handle member medical records in accordance with the Protection of Personal Information Act (POPIA) and the GEMS Rules. When a claim is submitted, the Scheme already receives confidential medical information, including the diagnosis (ICD-10 code) and the relevant treatment code. Where claims are submitted and the required member consent has been provided through the membership application process, additional information requested as part of a claims review should be provided through the approved legal and privacy processes.
• I responded to the first request for information and received further correspondence asking for more and different information from the initial request. Is GEMS just looking for reasons not to pay my claims?
• All information submitted is assessed against the initial allegation received. The initial request for information helps GEMS understand the claiming environment while reviewing the claims. Additional information may be requested where: Further anomalies are identified during the review. The information submitted is incomplete. The information provided indicates that further assessment is required. The Claims Risk Analyst determines that the information is inadequate to conclude the investigation fairly and efficiently. These requests help support the expedient and equitable conclusion of the investigation.
• I feel a face to face engagement will produce better understanding regarding the review findings against my practice, how do I request this?
• Notify the Claims Risk Management team member handling your review if you would like to request an engagement. Where requested, the following may be arranged: An engagement with senior members of the Claims Risk Management team and the Scheme. Attendance by the Scheme's Medical Advisor, where necessary.
• I am cooperating with the review, why is GEMS no longer paying my claims?
• GEMS may decide to suspend the payment of all or part of your claims as a risk mitigation measure. The suspension process includes the following: Claims and payments may be suspended for 30 days pending the finalisation of the review. This allows the Scheme time to validate the claims in terms of Section 59(2) of the Medical Schemes Act. If the claims are found to be valid upon conclusion of the review, the suspended claims will be released and all payments due will be made. The suspension of claims is not a standard practice and is only implemented where the risk of continuing to pay claims in good faith exceeds the Scheme’s risk appetite. GEMS is committed to conducting reviews fairly and encourages full cooperation throughout the review process to help minimise any potential adverse financial consequences.
• How does GEMS protect me from false and baseless allegations?
• Not all allegations received will result in a review of the practice. An allegation may be closed within 10 days if: The preliminary assessment is unable to validate the veracity of the allegation. The healthcare practitioner is able to provide proof of services rendered.
• If I am struggling to get timely feedback from the investigator dealing with my review, who can I contact?
• Please send all complaints and concerns to gemscomplaints@mhg.co.za. When contacting the team, please: Clearly state the reference number shown at the top of all correspondence between you and the Claims Risk Analyst handling your review. This is a central mailbox that is checked daily by Health Coordinators.
• Will I be given an opportunity to respond to the allegations and findings against me?
• At any point during the review, and before any recommendations are made to the Scheme’s Risk Forums, you are entitled to request a discussion about any anomalies identified. You may request: A virtual engagement with members of the Claims Risk Management team. A face-to-face engagement with members of the Claims Risk Management team.

• Are there any instances where the PMB requirements do not apply?
• Yes, if – It is a qualifying medical emergency, or The DSP is not available within a reasonable distance, and / or The PMB service required is not available at the DSP, and / or The waiting period for the service at the DSP is deemed unreasonable. In other words, where the use of a non-DSP is involuntary due to any of the above, funding will be at cost. This process has been extensively reviewed and is continuously monitored to ensure that feedback is provided as soon as possible.  The turnaround time for such reviews is usually within 14 working days.
• How do I appeal a PMB retrospective review decline?
• You may appeal if your claim for ‘PMB at cost’ is declined. All escalations and/or appeals should be submitted to enquiries@gems.gov.za.
• How does GEMS fund PMBs?
• GEMS covers PMBs at cost, unlimited, and subject to managed care protocols being followed. If the condition is classified as a Prescribed Minimum Benefit (PMB), the member must be treated by a Designated Service Provider (DSP) to avoid co-payments. The DSP for in-hospital PMBs is the State or government health facilities, and in the case of the Tanzanite One and Emerald Value options, also hospitals on the GEMS Network. If the DSP is not available or accessible, please contact the GEMS Customer Services on 0860 00 4367 to discuss alternatives. It is not compulsory for a member to use a DSP, but voluntary use of a non-DSP may result in a co-payment for both provider and hospital claims. The co-payment will be the difference between the rate that the DSP would charge and what the non-DSP hospital and / or provider charges. DSP does not apply in the event of an emergency or involuntary use of a non-DSP.
• What are the typical outcomes of a PMB retrospective review request
• If the review process results in a decline, the claim will be paid at 100% of Scheme Rate, with a reason given for the decision. If the review process results in an approval, the claim will be paid in one of the following ways: If the service provider billed 300% or less of the Scheme Rate, the claim will be paid in full. If the service provider billed more than 300% of the Scheme Rate, the final payment amount will be negotiated with the service provider.
• What is required for a claim to be considered for PMB reimbursement?
• GEMS has a claims query process in place to retrospectively review unpaid/short paid claims for possible PMB eligibility. This review process takes the following into account: Is the provider on the network? Is the ICD10 code a PMB? Was the event an emergency? Was the service PMB level of care as defined the PMB DTP code list? Was a DSP accessible?

• Application of Modifier 0009
• Assistant fee billing rule: The fee for an assistant is 20% of the fee for the specialist surgeon, with a minimum of 36,00 clinical procedure units. For the correct application the provider must align the modifier to appropriate tariff on submission of the claim. The minimum fee payable may not be less than 36,00 clinical procedures units.
• Application of modifier 0013
• Endoscopic examinations done during a procedure. When a related endoscopic examination is done at an operation by the operating surgeon, or the attending anaesthesiologist, only 50% of the units for the endoscopic examination may be coded. Appropriate when a RELATED endoscopic examination is performed at the time of an operation. Identify the related procedure(s) when endoscopic examinations are performed when using this modifier. Modifier 0013 is not applicable to colorectal endoscopies (items 1653, 1565, 1676 and 1677) performed at the time of anal surgery e.g.  haemorrhoids, fissures and abscesses/fistulae. Modifier 0013 is not applicable when endoscopies are performed to exclude pathology e.g. bleeding or pain above anal canal. When performing a diagnostic endoscopic procedure not related to the therapeutic procedure, the appropriate ICD-10 code must be added to the procedure code to indicate the circumstances. Unrelated endoscopic procedure must be specified and a diagnosis provided to indicate the diagnostic endoscopic procedure(s) is unrelated to other (therapeutic) procedures performed 
• Application of modifier 0018
• Surgical modifier for persons with a BMI of 35> (calculated according to kg/m2): Fee for procedure +50% for surgeons and a 50% increase in anaesthetic time units for anaesthesiologists Provider to align modifier to appropriate tariff on submission of claim. Providers to provide BMI data. Format for BMI information to be submitted: Height in cm, e.g. 160cm no decimal. Weight in kg, 1 decimal. 76.5kg. BMI, 1 decimal. 27.9 Alphanumeric Length 13 concatenated 000/00.0/00.0 separated with a ‘/’, i.e. Height cm/Weight kg/BMI. Example - FTX+ITM+++160/76.5/27.9
• How is modifiers 0074 & 0075 funded?
• Endoscopic procedures performed with own equipment: 0074 The basic procedure fee plus 33.33% (1/3) of that fee ("+" codes excluded) will apply where endoscopic procedures are performed with own equipment. Endoscopic procedures performed in own procedure room: 0075 (a) The value of modifier 0075 = 21,00 clinical procedure units, where endoscopic procedures are performed in rooms. (b) This fee is chargeable by medical practitioners who own or rent the facility. (c) Modifier 0075 may not be used in conjunction with modifier 0004. (d) Please note: Modifier 0075 is not applicable to any of the items for diagnostic procedures in the otorhinolaryngology sections of the structure.
• How is modifier 0011 funded for an emergency C-section Emergency C-section, what is the process for updating the case with the MCO before claims can be paid. In the last 2-3 months claims for 0011 have been rejecting.
• Modifier 0011 is funded for emergency authorisations. If the authorisations is not approved as an emergency but the provider deems the event to be an emergency a motivation confirming the nature of the emergency will be reviewed by the Medical Advisor for a funding decision to be made.

• What do I do if a claim is rejected for pre-authorisation required?
• This often happens when the date of service on the claim falls outside of the approved authorization dates if the hospital has not updated the authorization. This may also occur if the procedure claimed requires authorisation and was not authorized. To reduce the number of rejections certain claims related to in-hospital authorisations are put on hold for a period of 10 days to allow providers to obtain authorisation. This was done to reduce the number of rejections for pre-authorisation required.
• What do the error messages mean on a claims statement?
• The error messages were enhanced to be more descriptive and to include the next action to be taken. When a claim is received by the Scheme and a funding decision is made the claims statement includes an error message that indicates the reason a claim may not be paid in full, part paid or rejected. The action required for the claim to be reviewed for payment is also included on the claims statement.

• How can providers assist GEMS to manage Fraud Waste and Abuse (FWA)?
• Validate all member ID cards prior to rendering service; Ensure accuracy when submitting bills or claims for services rendered; Avoid unnecessary drug prescription and/or medical treatment; and Report lost or stolen prescription pads. If you suspect any fraud, please call the anonymous 24-hour toll-free GEMS Fraud Line Service on 0800 21 2202, email office@thehotline.co.za, or fax 0867 26 1681.

• How do I request a face-to-face engagement?
• You may request an engagement through the Claims Risk Management team member handling your review. Where appropriate, the following may also attend: Senior team members. Clinical or medical advisors.
• What if I feel I am being treated unfairly?
• GEMS seeks to ensure that reviews are conducted lawfully, professionally, and fairly. Providers may: Be represented during engagements. Submit concerns about process fairness through the designated complaints channels for formal review.
• Will I have an opportunity to respond?
• Yes. Before final recommendations are made, you may: Provide your explanation. Submit supporting evidence. Request a virtual or in-person engagement with the Claims Risk Management team.

• Why are my claims not being paid?
• GEMS may suspend payment of all or part of claims as a risk mitigation measure while validation is underway. If the claims are ultimately found to be valid: Suspended claims are released. Payment is made. Suspension is not applied as a standard measure and is used only where the risk of continued payment exceeds the Scheme’s tolerance.