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External Medical and Surgical Appliance Management

 

GEMS has designed its medical appliance benefit in such a way as to ensure that all beneficiaries have access to cost-effective, quality medical devices and appliances, prostheses and associated professional services, irrespective of their benefit option.

The devices and appliances that are covered by GEMS are divided into two broad categories:

  • Those for which no pre-authorisation is required; and
  • Those for which pre-authorisation must be obtained from GEMS.

 There are also certain devices and appliances that are specifically excluded in the Scheme rules, and that are therefore not covered by GEMS.

Pre-approved list of medical appliances – no pre-authorisation required

When prescribing an appliance for their GEMS patients, healthcare providers can choose from a wide variety of medical appliances, without any need for pre-authorisation from GEMS.  The medical appliance list can be viewed by clicking here.

 

Medical appliances that require pre-authorisation

If the required appliance is not on the list mentioned above, it means that it will have to be pre-authorised. The reason for this is that GEMS wishes to assist members in avoiding unforeseen co-payments, specifically where benefit sub-limits apply.

The following categories of appliances require pre-authorisation from GEMS:

  • Blood pressure monitors
  • Braces (knee and back)
  • Commodes
  • Hearing devices and repairs
  • Insulin pumps
  • Nebulisers
  • Orthotic shoes
  • Pulse oximeters above R400
  • Oxygen concentrators
  • Prosthetics
  • Sleep apnoea devices
  • Specialised beds
  • Suction units
  • Wheelchairs, accessories and repairs
  • Wigs

 

How to obtain pre-authorisation for medical appliances

The member or provider should submit the following to GEMS, either via email to enquiries@gems.gov.za or via fax to 0861 004 367:

  • A prescription or letter of motivation.
  • A quotation from a registered provider (a provider with a practice number) that includes the diagnosis ( ICD-10) code,a description of the device or appliance, the Nappi code, the quantity requested, and the price.

 

IMPORTANT: Please ensure that the patient’s membership number appears on all the relevant documents and in the subject line of the email (if applicable).

 

What will happen next?

Once the request has been attended to by GEMS, a letter with the outcome will be emailed to the member and provider.

 

Where a request has been declined, the letter will specify why it has been declined and what the process for appeal is.

 

Similarly, the letter will advise if, based on the member’s available benefits and the Scheme rules, there will be a shortfall for which the member would be liable.

 

PLEASE NOTE: The intentional misuse of membership details in order to submit fraudulent claims or refund requests to GEMS may result in termination of Scheme membership, criminal prosecution and disciplinary action by the employer. It is your responsibility to ensure that all claims made on your behalf are valid.