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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, improve quality of life, and prevent premature death. GEMS offers comprehensive screening and preventative care benefits to its members. These benefits are available on all options and payable from the risk-benefit for eligible members and beneficiaries as per the tabulated criteria below. 

 
SCREENING SERVICES
 

Procedure

Tariff Codes

Tariff description

Eligible beneficiaries and Frequency

Healthcare Providers allowed

 

Cholesterol Screening

4027

 

Blood Cholesterol (finger prick)

 

 

 

 

Once per Benefit year for all beneficiaries who are 20 years and older

General Medical Practice, Specialist Family Medicine

 

0013

Blood cholesterol and/or triglycerides

 

Pharmacy

 

99384

Cholesterol screening

Registered Nurses

 

Glucose Screening

4050

 

 

Blood glucose finger prick in rooms

(Glucose strip-test with photometric reading)

 

Once per benefit year for all beneficiaries 20 years and older.

General Medical Practice, Specialist Family Medicine

 

 

0012

 

Blood Glucose

Pharmacy

 

99370

Glucose Screening Test

Registered Nurses

 

Osteoporosis Screening:

Bone Densitometry scan

50120

 

X-ray bone densitometry

 

 

Once per benefit year for female beneficiaries who are 65 years and older.

Radiologist

 

3604

Bone densitometry (to be charged once only for one or more levels done at the same session)

Gynaecologist, Physician, Orthopaedics

 

Pap Smear screening

0190 - 0193

Consultation/visit

 

 

 

 

Once per benefit year for female beneficiaries who are 12 – 65years

General Medical Practice, Specialist Family Medicine, Gynaecologist

 

 

0201, 0202, 0210

 

Procedure codes: 0201- Cost of material

0202 – setting of sterile tray

0210 – collection of specimen

 

General Medical Practice, Specialist Family Medicine, Gynaecologist

 

99385

 

Procedure code: Sterile tray and specimen handling fee

 

 

General Medical Practice, Specialist Family Medicine, Gynaecologist, Registered Nurses

 

005,006,001,002

Consultation

 

Registered Nurses

 

020,301

Procedure codes: 020 Specimen code

301 Consumables used

 

Registered Nurses

 

4566

Vaginal or cervical smear

 

Pathologist, Medical Technology

 

4559

Cytology preparation using approved liquid-based cytology method: first unit

 

Pathologist, Medical Technology

 

CER1

HPV Polymerase chain reaction

Pathologist, Medical Technology

 

Blood Pressure Monitoring

0015

 

Blood Pressure Monitoring

 

Once per benefit year for beneficiaries 18 years and older

 

Pharmacy

 

99371

Blood Pressure Monitor

Registered Nurses

 

 

HIV and AIDS Pre-

test Counselling

(no test done)

7016

Pre-counselling

Once per benefit

year, per

beneficiary

General Medical Practice, Specialist Family Medicine

 

0016

Pre-counselling

(Without going

ahead with the HIV test)

Pharmacy

 

99376

HIV Pre-Test Counselling

Registered Nurses

 

 

HIV and AIDS testing (screening test, post-test counselling, confirmatory test, and condoms)

 

7017

 

 

 

 

 

 

 

Pre-counselling, Screen test, Post-test counselling, Confirmatory test (all-inclusive code)

 

 

Once per benefit year, per beneficiary

General Medical Practice, Specialist Family Medicine

 

0017

HIV and AIDS Testing and Post Counselling

Pharmacy

 

99377

HIV and AIDS testing and post counselling

Registered Nurses

 

Peak Flow measurement

0019

 

 

 

Peak Flow Measurement

Once per benefit year for beneficiaries 4 years and older

Pharmacy

 

99383

Peak Flow Measurement

Registered Nurses

 

Mammography Screening

39175

Mammography: Unilateral or bilateral

 

Once per benefit year for female beneficiaries who are 40 years and onwards.

Radiography

 

3934100

X-ray mammography including ultrasound

Radiologist

 

3605

Mammography: Unilateral or bilateral, including ultrasound and Doppler ultrasound examination, where necessary.

General Medical Practice, Specialist Family Medicine

 

Prostate Screening

4519

 

Prostate specific antigen

Once per benefit year for male beneficiaries who are 45 – 69 years.

 

Pathologist, Medical Technology

 

Faecal Occult blood test

4352

Occult blood: Monoclonal antibodies

Once per benefit year for all beneficiaries who are 50 – 75 years.

Pathologist, Medical Technology

 

Neonatal Hypothyroidism

4507

Thyrotropin (TSH)

Once per neonatal beneficiary up to 28 days of age

Pathologist

 

Glaucoma Screening

11202

 

Tonometry (non-contact)

 

Once per benefit year for all beneficiaries 40 years and older.

 

Optometrist, Optical dispensers

 

 

11212

Tonometry (Aplanation)

 

3014

Tonometry per test with maximum of 2 tests for provocative tonometry

(one or both eyes)

 

Ophthalmologist

 

 

3017

Retinal threshold test inclusive of computer disc storage for Delta of Statpak programs

 

 

3018

Retinal threshold trend evaluation (additional to Item 3017)

 

 

Pregnancy Screening

0018

 

Pregnancy Screening

 

Once per benefit year for a female beneficiary 12 years and older.

 

 

Pharmacy

 

99381

Pregnancy Screening

Registered Nurses

 

Urine Analysis

 

0014

 

Urine Analysis

 

Once per benefit year for beneficiaries of all ages.

Pharmacy

99382

Urine analysis

Registered Nurses

Childhood hearing screening for children

1010

 

 

 

 

Audiology consultation. Duration 5 - 15 mins

 

Once per beneficiary for the period from age one up to and including seven years.

Speech therapy and Audiology

 

1011

Audiology consultation. Duration 16 - 30 mins

 

1115

Speech audiogram screening

1100

Pure Tone Audiogram (Air conduction) (3273)

 

1105

Bone conduction pure tone audiogram

 

1200

Tympanometry

Childhood hearing screening for infants

1505

 

Diagnostic Audiological Click ABR (Auditory Brainstem

Evoked Response) – Bilateral Air conduction threshold determination using click stimuli.

 

 

Once per beneficiary for the period up to and including age 1 (but excluding beneficiaries in the first three months of life)

Speech therapy and Audiology

 

1010

Audiology consultation. Duration 5-15 mins

1011

Audiology consultation. Duration 16 - 30mins

 

1580

Evoked otoacoustic emissions (OAE); limited

Childhood optometry screening

94000

Individual Child Screening

Once per beneficiary for the period up to and including age seven (but excluding beneficiaries in the first three months of life)

Optometrist

Syphilis screening

3951

 

 

Quantitative Kahn, VDRL or other flocculation

 

Once per benefit year per beneficiary

Pathologist, Medical Technology

3949

Qualitative Kahn, VDRL or other flocculation

Chlamydia/gonorrhoea screening

 

3946

 

 

 

IgM: specific antibody titre: ELISA/EMIT: per Ag

 

Once per benefit year per beneficiary

Pathologist, Medical Technology

 

3948

IgG: specific antibody titre: ELISA/EMIT: per Ag

3923

Biochemical identification ofbacterium: abridged

 

3925

Serological identification of bacterium: abridged

 

3960

Gonococcal, listeria or echinoccoccus agglutination

 

TB screening

0221

Allergy: Skin-prick tests: Delayed hypersensitivity testing (Type IV reaction): Per antigen

Once per benefit year, per beneficiary (no age restriction)

General Medical Practice, Specialist Family Medicine, Pathologist

 

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

Cost of material in treatment: This item provides for a charge for material used in treatment.

 

Vaccinations from Preventative Care Services

 

Tariff code 0022 should be used for pharmacy administration of immunisation, 0017 for FP administration and 99378 for nurses.

 

Procedure

Codes

Frequency

Eligible beneficiaries

Healthcare Providers allowed

 

 

 

 

 

Once per year

 

 

 

 

General Medical Practice, Specialist Family Medicine, Pharmacy, Pharmacotherapies,

Primary Care Drug Therapist, Registered Nurses,

Clinical Pharmacokinetics, Anaesthetists,

Dermatology,

Gynaecologist,

Pulmonology,

Physician,

Gastroenterology,

Neurology,

Cardiology,

Oncologist,

Neurosurgeon,

Nuclear Medicine, Ophthalmologist,

Clinical Haematology, Orthopaedics, Otorhinolaryngology (ENT),

Rheumatology,

Paediatrician,

Paediatric Cardiologist,

Physical Medicine,

Plastic and Reconstructive Surgery,

Radiation Oncology, Surgeon,

Cardio Thoracic Surgery,

Urology

 

Influenza vaccination

 

 

 

3000826 Vaxigrip Tetra single dose 0.5ml pre-fill

 

732826 Influvac

All beneficiaries ≥6 months of age

 

 

 

 

 

 

 

0190-0193 consultation

 

 

 

Pneumococcal vaccination

755826 ** Pneumovax 23 single dose vial 0.5ml

715858 Prevenar 13 pre-filled syringe 0.5ml

 

 

Once every 5 years

Once every 5 years for:

 

high- risk beneficiaries between the ages of 2 and 64 with the relevant chronic or hospital admission.

 

all beneficiaries 65 years and older irrespective of the chronic or hospital authorisation.

 

HPV vaccination

710020 Cervarix Pre-filled Syringe 0.5ml

710249 Gardasil Injection

One course per beneficiary per lifetime**

 

Females 9 - 45 years

COVID-19

vaccination

3002823 COVID-19 Vaccine Administration Fee

 

 

 

3003366 COVID-19Vaccine Janssen**

 

Three doses perbeneficiary

18 years and older

3003282 COVID-19Vaccine Pfizer**

 

Four doses per

beneficiary ***

Two doses per beneficiary ***

18 years and older

 

12 to 17 years

3006073 COVID-19Paediatric Vaccine Pfizer **

Two doses perbeneficiary***

5 to 11 years

 

A separate limit of R950 per beneficiary per year applies for vaccinations listed in the table below.

 

700356 Engerix-b

700210 Engerix-b*

700767 Hiberix

700513 Avaxim**

700772 Priorix

701659 Heberbio hbv*

701658 Heberbio hbv

703442 Typherix**

892939 Varilrix**

703448 Havrix junior**

3000689 Boostrix

703846 Dukoral**

703994 Infanrix pre-filled

706829 Twinrix**

707285 Infanrix hexa

713048 Euvax b*

710935 Rotateq

714999 Synflorix

711258 Tetraxim

717194 Vivaxim**

713229 Adacel quadra

717466 Zostavax**

714133 Rotarix liquid oral

715349 Euvax b

716550 Priorix tetra**

720708 Menactra**

716655 Boostrix tetra

814970 Verorab**

719637 Hexaxim

814989 Stamaril**

3002554 Measles vaccine

822361 Havrix 1440**

722290 Measbio

822442 Typhim

723131 Onvara**

832693 Tetavax

724016 Omzyta

3002364 Tetanus Vaccine Cipla Ampoule 0.5ml

823678 OPV-merieux 10

848905 Avaxim**

823686 OPV-merieux 20

879460 Chirorab**

841307 OPV-merieux 10

3001925 Pneumovax 23**

872962 BCG

3002510 Adacel Vial 0.5ml

879452 Morupar

3004427 Tetanus toxoid

 

*Vaccinations must be pre-authorised.

** Certain vaccines require a prescription and therefore if obtained from your pharmacy you will require a prescription from your Healthcare Provider. Healthcare consultation is not included in the preventative benefit and are subject to day-to-day benefits.

  

Dental Services from Preventative Care

 

Procedure

Codes

 

Tariff description

Eligible beneficiaries and Frequency

Healthcare Providers allowed

Dental sealants

8163

Dental sealant: per tooth

  • All beneficiaries 17 years and younger
  • Maximum of 2 per quadrant in 12 months
  • Time rule of 1 per tooth in 730 days
  • Applicable to all permanent teeth except 3rd molars (wisdom teeth), REEVO options only.
  • Applicable to all permanent, premolars and molars excluding 3rd molars for Tanzanite One and Beryl

 

  • Dentist, Dental Therapy, Oral Hygienist
  • Dental Network providers only

 

 

Dental Polishing

8155

Polishing - complete dentition

  • All beneficiaries who are 3 - to 9 years of age
  • Limitation of 1 in 180 days (2 in 12 months)

 

  • Dentist, Periodontics, Dental Therapy, Oral Hygienist
  • Applicable to Ruby, Emerald, Emerald Value and Onyx options

 

 

 

 

If you have any further queries regarding this, kindly contact us on 0800 00 4367, fax us on 0861 00 4367 or send an email to enquiries@gems.gov.za