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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 its members. These benefits are available on all options and payable from the risk benefit for eligible members and beneficiaries as per criteria. 

A separate limit of R863 per beneficiary per year applies for vaccinations not listed in the table below.

A limit of R863 per beneficiary per year applies and funding is allowed for Practice types 14, 15, 60, 61, 63, 110 and Specialists. Tariffs codes 0022 should be used for pharmacy administration and 0017 for GP administration.

The tables below indicate the preventative care and screening services at pharmacies and selected providers. Providers to visit the GEMS Tariff file for tariff code applicable per discipline.

 
SCREENING SERVICES
Procedure Tariff codes Frequency Eligible beneficiaries Disciplines allowed
Blood Pressure Monitoring 0015 (Pr 60) Once per benefit year All beneficiaries 18 years and older Allowed for Practice: 60
Cholesterol Screening

FP Code 4027

0013(Pr 60)

Once per benefit year Beneficiaries 20 years and older Allowed for Practice: 14/15, 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)

0201, 0202, 0210, 0190 – 0193 (Pr 14/15)

Procedure code 0201, 0202, 0210,0201 to be billed together with tariff 190-193 for Pr 14/15 and Pr16

0202, 0210, 0190 - 0193 and 0201 (PR16)

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
HIV / AIDS pre-test counselling with no test

7016 (Pr 14/15)

0016 (Pr 60)

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

7017 (Pr 14/15)

0017 (Pr 60)

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

39175 (Pr 39)

34100 (Pr 38)

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) Once per benefit year Beneficiaries 4 years and older Allowed for Practice: 60
Pregnancy Screening Test 0018 (Pr 60) Once per benefit year Female beneficiaries 12 years and older Allowed for Practice: 60
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

FP 4050

0012 (Pr 60)

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

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

1010, 1011, 1580 (Pr 82)

Once per beneficiary Beneficiaries from 3 months to 1 year Allowed for Practice: 82
Childhood Hearing Screening for infants 94000 (Pr 70) Once per beneficiary Beneficiaries from 3 months to 7 years Allowed for Practice: 70
Childhood Optometry Screening Once per beneficiary Birth - from 3 months to 7 years 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) Once per benefit year All beneficiaries Allowed for Practice: 60
VACCINATION SERVICES
Vaccine Frequency Eligible beneficiaries
Influenza vaccination Once per annum All beneficiaries from 6 months and older
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
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)  

 

 

 

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