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Preventative screening

Preventative care and screening benefit

Preventative health screening is one of the most important healthcare strategies to facilitate early diagnosis and treatment of disease, as well as to improve quality of life and prevent premature death. GEMS offers comprehensive screening and preventative care benefits to members and beneficiaries across all options, and this is payable from the risk benefit.. 

A separate limit of R908 per beneficiary per year applies for vaccinations not listed in the table below, and funding is allowed for Practice types 14, 15, 60, 61, 63, 110 and Specialists. Tariffs codes 0022 should be used for pharmacy administration,0017 for GP administration and 99378 for Nurses administration of immunisation.

The tables below indicate the preventative care and screening services at pharmacies and selected providers. Visit the GEMS Tariff file for tariff codes applicable per discipline.

 
SCREENING SERVICES
Procedure Tariff codes Frequency Eligible beneficiaries Disciplines allowed
Blood Pressure Monitoring

0015 (Pr 60)

99371 (Pr 88)

Once per benefit year All beneficiaries 18 years and older Allowed for Practice: 60 and 88
Cholesterol Screening

4027 (Pr 14/15)

0013 (Pr 60)

99384 (Pr 88)

Once per benefit year Beneficiaries 20 years and older Allowed for Practice: 14/15, 88 and 60
Osteoporosis Screening (Bone Densitometry Scan)

50120 (Pr 38)

3604 (Pr 16, 18, 28)

Once per benefit year Female beneficiaries 65 years and older Allowed for Practice: 38, 16, 18, 28
Cytology Screening (Pap smears)

Code 99385 (Sterile tray and specimen handling fee) to be billed together with tariff 0190-0193

99385,0201, 0190 – 0193 (Pr14/15,16)

Procedure codes 99385 and 0201 to be billed together with consultation code 190-193 for Pr 14/15 and Pr 16

 

020, 301, 005, 006, 001, 002 (Pr 88)

 

Specimen code 020, 301 to be charged with consultation 005, 006, 001, 002,

4566, 4559 (Pr 37/52)

 

CER1 / 999930 (Pr 37/52)

Once per benefit year Female beneficiaries12 - 65 years Allowed for Practice: 37, 52, 14/15, 16 and 88
HIV / AIDS pre-test counselling with no test

7016 (Pr 14/15)

0016 (Pr 60)

99376 (Pr 88)

Once per benefit year All beneficiaries Allowed for Practice: 60, 14/15 and 88
HIV / AIDS (Screening test, post-test counselling, confirmatory test, and condoms)

7017 (Pr 14/15)

0017 (Pr 60)

99376 (Pr 88)

Once per benefit year All beneficiaries Allowed for Practice: 60, 14/15 and 88
Mammography Screening

34100 (Pr 38)

39175 (Pr 39)

3605 (Pr 14/15)

Once per benefit year Female beneficiaries 40 years and older Allowed for Practice: 38, 39, 14/15
Peak Flow Measurement

0019 (Pr 60)

99383 (Pr 88)

Once per benefit year Beneficiaries 4 years and older Allowed for Practice: 60 and 88
Pregnancy Screening Test

0018 (Pr 60)

99381 (Pr 88)

 

 

Once per benefit year Female beneficiaries 12 years and older Allowed for Practice: 60 and 88
Prostate Screening (PSA)

4519 (Pr 37, 52)

 

Once per benefit year Male beneficiaries 45 - 69 years Allowed for Practice: 37, 52
Faecal Occult blood test

4352 (Pr 37, 52)

 

Once per benefit year Beneficiaries 50 - 75 years Allowed for Practice: 37, 52
Glucose Screening

4050 (Pr 14/15)

0012 (Pr 60)

99370 (Pr 88)

 

 

Once per benefit year Beneficiaries 20 years and older Allowed for Practice: 14/15, and 88 and 60
Glaucoma Screening

11202, 11212 (Pr 70,71)

3014, 3017, 3018 (Pr 26)

 

40 years and older Beneficiaries 40 years and older Allowed for Practice: 70,71 and 26
Neonatal Hypothyroidism 4507 (Pr 52) Once per beneficiary Neonatal beneficiaries up to 28 days old Allowed for Practice: 52
Childhood Hearing Screening

1010, 1011, 1115, 1100, 1105, 1200 (Pr 82)

Once per beneficiary Beneficiaries from 1 year to 7 year Allowed for Practice: 82
Childhood Hearing Screening for infants

1505 (Pr 82) (May not be charged with 1510)

1010, 1011, 1580 (Pr 82)

 

Once per beneficiary Beneficiaries from 3 months to 1 years Allowed for Practice: 82
Childhood Optometry Screening

94000 (Pr 70)

Once per beneficiary

Beneficiaries from 3 months to 7 years Allowed for Practice: 70
Syphilis Screening

3949, 3951 (Pr 52, 37)

Once per benefit year All beneficiaries Allowed for Practice: 52, 37
Chlamydia / Gonorrhoea Screening 3946, 3948, 3923,3925, 3960 (Pr 52, 37) Once per benefit year All beneficiaries Allowed for Practice: 52, 37
TB Screening

0221 (Pr 52, 14/15)

0201 (0201 with Nappi 872938-027 Tuberculin PPD RT/23 Vial 1.5ml)

Once per benefit year All beneficiaries Allowed for Practice: 52, 14/15
Urine Analysis

0014 (Pr 60)

99382(Pr 88)

 

 

Once per benefit year All beneficiaries Allowed for Practice: 60 and 88

 *From 2024, no referral is required for members to have a mammogram in a Pr 38 or 39.

VACCINATION SERVICES

Vaccine Frequency Eligible beneficiaries Disciplines allowed
Influenza vaccination Once per annum All beneficiaries from 6 months and older

Allowed for Practice: 14/15, 60, 61, 63, 88, 110 and specialists

Pneumococcal vaccination Once every 5 years
  • All beneficiaries 65 years and older
  • High risk beneficiaries between the ages of 2 and 64 with the relevant chronic or hospital admission
Allowed for Practice: 14/15, 60, 61, 88, 110 and specialists
HPV vaccination (1 course = 3 doses) One course per beneficiary per lifetime

Female beneficiaries: 

  • Ages between 9 – 14 years of age: 1 course = 2 doses (Initial single dose, then follow-up dose to be given at 6 or 12 months) 
  • Ages between 15 – 45 years of age: 1 course = 3 doses (Initial single dose, then follow-up doses given at 2 and 6 months, respectively)  
 Allowed for Practice: 14/15, 12, 32, 60, 61, 88, 110
   

 *99378 (Administration of Immunisation) allowed for Pr 88.

If you have any further queries regarding this, kindly contact us on 0860 00 4367, fax us on 0861 00 4367 or send an email to enquiries@gems.gov.za 

 

 

 

 

 

If you have any further queries regarding this, kindly contact us on 0860 00 4367, fax us on 0861 00 4367 or send an email to enquiries@gems.gov.za