Claims Guide

Who can claim?

The registered member or his/her dependant. A healthcare provider can submit a claim on behalf of the registered member or dependant.

 Who can’t claim?

GEMS has introduced processes to improve claim submissions and payment validations.

Please note that the following service providers are currently not receiving direct payments from GEMS due to previous findings of irregular claims that contravened the scheme’s rules and the Medical Schemes Act 131 of 1998. See the list of healthcare providers we’ve placed on indirect payments.

Claims submitted by service providers on our indirect payments list will be rejected and the relevant GEMS member will be held responsible for submitting the claim for the services rendered by the healthcare providers. Members will have to pay the medical costs for the services rendered by the relevant healthcare provider and can claim back from GEMS.

Please remember that when you submit your claims you must include the following information and valid proof of payment, signed by the principal member, in the form of:

• A valid stamped receipt from the service provider;
• An electronic funds transfer (EFT) receipt; or
• A bank deposit receipt.           

How is the claim processed?

When we receive a claim our claims department assesses it according to our scheme rules. If the claim meets our scheme rules, GEMS will pay the claim.

We may require additional information from you (the member) or your healthcare service provider (example: ICD-10 code, detailed copy of your account, proof of payment etc) when we assess your claim.  Unfortunately, we may reject your claim if we don’t receive this information.

When are claims paid?

We have two payment runs per month (one mid-month and another one at the end of the month). Your claim will be settled on either one of these runs, but that depends on the date when we receive your claim and the necessary supporting documentation.

Click here to view our claims run dates for 2023.

Are claims for over-the-counter medication processed immediately?

Your pharmacy can send medicine claims to us electronically at the point of sale. We will apply our scheme rules, so that you know if GEMS will pay for the medication. You will get your medication immediately if you have available funds or benefits. If your medication isn’t on the scheme list, we may need a co-payment from you, or we may regrettably have to reject your claim.

What information to include with your claims?

• Your membership number
• The medical scheme's name (GEMS in this case)
• Your medical Options(Tanzanite One, Beryl, Emerald Value, Emerald, Onyx, or Ruby)
• Your surname and initials
• The patient's date of birth and dependant code as it appears on your membership card
• The name of the healthcare service provider
• The valid practice code of the healthcare service provider
• The date of the service rendered
• The type and cost of treatment
• The pre-authorisation number (if applicable)
• The tariff code
• The relevant ICD-10 code
• Your signature to confirm that the account is valid
• If you paid for the healthcare service or treatment, please attach the proof of payment and highlight it clearly. Proof of payment can either be a valid receipt from the healthcare service provider, an electronic fund transfer (EFT) or a bank deposit receipt.

You can submit your claims by:

• Post: GEMS, Private Bag X782, Cape Town, 8000
• Fax: 0861 00 4367
• Email: enquiries@gems.gov.za; or a
• GEMS walk-in centre

Claim refunds

You can claim a refund from the scheme when you pay a healthcare service provider in advance. Your medical Option and benefits, the applicable scheme rules and rates will determine whether we pay a refund and the refund amount.

We pay refunds to members electronically. You need to ensure that we have your correct banking details to process your refunds. We need the following banking details:

• Account holder's full name
• Account number
• Bank name
• Branch code
• Account type (current or savings).

You can fax this information to 0861 00 4367 or you can send an email to enquiries@gems.gov.za (use your membership number as a reference). You can also drop off the information at one of our GEMS walk-in centres or post it to: GEMS, Private Bag X782, Cape Town, 8000.

You need to submit the following documents if you want to change or update your banking details:

• A certified copy of your ID
• A bank account statement, crossed cheque or account confirmation letter from your bank signed or stamped (not older than three months)
• Proof of your residential address (a utility bill, clothing or other credit account statement with your address (not older than three months).

Claims alert SMS

You can sign-up to get a claims alert SMS every time GEMS processes your claims. These SMSs acknowledge that we’ve received your claim(s), but it doesn’t serve as a guarantee of payment. Please call 0860 00 4367 if you’d like to get a claims alert and ensure that we have your current cell phone number.

Please note: If you get a claim alert SMS for a claim that you don’t know, report it to the scheme by calling us on 0860 00 4367 and we’ll investigate the matter.

How to read your claims statement?

Click here to understand your claims statement. You will get a claims statement when your claim has been settled. Please read your claims statement carefully to see if your claims were processed. If we didn’t pay your claim your claims statement will state the reason why we didn’t pay it. If the reason requires an action, please resubmit the claim with the applicable information.

Direct payments to healthcare providers

 We’ve implemented processes that have improved our ability to validate our member’s claims submitted by healthcare providers.

We’ve stopped making direct payments to certain healthcare providers that we’ve found guilty of fraud. We won’t accept claims submitted by these healthcare providers and members will be responsible for submitting their own claims to us. Therefore, our members will have to pay the costs for the services rendered by the healthcare provider.

Your submission must include the details of the claim and valid proof of payment, signed by the principal member, in the form of:

• A valid stamped receipt from the service provider;
• An electronic funds transfer (EFT) receipt; or
• A bank deposit receipt.

Why claims are rejected (not paid)?

1. Incorrect member or dependant information

• It is important that your information is up-to-date member so that we can process your claims promptly. We rely on your correct information to ensure that we process your claims.
• When you make a claim on behalf of your dependant(s), please ensure that they’re registered with the scheme and their details are captured on the claim. 

2. No pre-authorisation number for oncology treatments and hospitalisation

• Although your treatment is authorised, your doctor needs to inform GEMS about any changes in your treatment so that we can evaluate your treatment plan and update the authorisation accordingly. If your doctor doesn’t inform us about the changes, we may reject your claim (as per our scheme rules).
• We need to authorise your physiotherapy treatments in hospital. 

3. No available benefits

• When you’ve reached your benefits threshold, GEMS can’t make any more claim payments on your behalf.

4. Member or dependant missing a doctor's appointment

• GEMS will not be held liable for the costs if you (or your dependants) miss a doctor's appointment.

5. GEMS won’t pay for claims for services rendered by a healthcare provider who isn’t registered in terms of the relevant law

• If a doctor isn’t registered to practice medicine in South Africa You need to speak to him/her to ensure that your claims meet the necessary requirements before you submit them to GEMS.

6. Late claim submissions

• Claims must be submitted to the scheme before the last day of the fourth month after the medical service was rendered. Example: if the service is rendered on the 15th February 2014, the claim must be submitted to us by the 30th June 2014. GEMS won’t pay any claims after this 4-month period in accordance with the Regulations of the Medical Schemes Act. You will be liable to pay for the claims that you haven’t submitted to us within the 4-months.  Consult your healthcare provider to find out if they’ll submit your claim to the scheme or if you should submit your claim.

7. Treatment claims we receive after a member has resigned from working in the public service or from GEMS

• GEMS is a restricted medical scheme designed for public service employees or participating employers approved by the Board of Trustees. Anyone who isn’t a public service employee, retired employee or a GEMS participating employer can’t become a member of the scheme. If you resign from your public service job, your GEMS membership is terminated immediately. If you or your healthcare provider claims for services rendered after you resigned from the public service or from GEMS, you will be held liable the relevant medical costs. 

8. Scheme exclusions

• There are specific conditions and treatment facilities that we can’t pay for, in line with the Medical Schemes Act. We call the items or procedures that aren’t covered by the scheme exclusions. You must ensure that the procedures, treatments or medication you receive are covered because GEMS won’t pay for excluded medical services or items. Refer to Rule 16 and Annexure E of the Scheme Rules for the list of exclusions.

9. Incorrect ICD-10 codes on the claim

• Ensure that the ICD-10 code on your claim is correct.

10. Duplicate claim

• We’ll reject a claim if the same claim was already submitted by a member or service provider and paid by the scheme.

11. Waiting period

• We apply waiting periods to certain membership categories as a form of underwriting. If there’s a waiting period on your membership, you can’t claim for benefits during the waiting period. However, you can claim for benefits after this waiting period. Read more about underwriting.

Please note: Claims that are submitted incorrectly will not be paid by the scheme. We’ll send a claims statement to you explaining the reason why your claim wasn’t paid. We’ll return your claim to you or your healthcare provider and you need to give us the correct information and resubmit the claim within 60 days after it was returned for correction. You can call us on 0860 00 4367 if you’d like to know why your claim was rejected.

Save yourself the trouble and submit your claim correctly the first time!

12. Why some claims from healthcare providers are rejected?

• There’s been cases where GEM had to terminate direct payments to certain healthcare providers after investigations found evidence of fraud, waste or abuse.  
• We reject claims from healthcare providers who’ve been sanctioned due to fraud, waste or abuse.  

Members are responsible for submitting refund claims to the scheme for the medical services rendered to them.   

•  The claims refund process is summarised below:

• Your refund claim must include the following information for us to consider and pay the claim:
• The service provider’s original claim;
• A valid, stamped receipt from the provider indicating that the claim was settled by the member;
• An electronic funds transfer (EFT) receipt and/or
• A bank deposit receipt. 

13. Common reasons why claims are rejected or partially paid?

Incorrect member or dependant information

• The personal details on the claim may be incorrect (e.g. the incorrect name, incorrect gender, incorrect date of birth).
• The claim is lodged by a terminated member or someone who isn’t on your medical aid.

      No pre-authorisation number for hospitalization

• A preauthorization is required for certain medical services to be rendered. This includes hospital care, specialised out-patient care (such as oncology) and a referral authorisation to see a specialist is required in some instances (even for out-of-hospital care).
• If you have authorisation for chronic medication and your doctor changes your treatment, your doctor needs to inform GEMS of the treatment plan change so that we can update the authorisation.
• If your doctor doesn’t inform us of the treatment changes, GEMS may reject your claim or only process a partial pay.
• Physiotherapy treatment in hospital must also be authorised. 
• If a preauthorization is required, but isn’t specified on the claim when it is assessed, we’ll reject the claim or we may pay for the incorrect benefit (e.g. if you claim for in-hospital doctor consultation without hospital authorisation, your claim will be settled from the available out-of-hospital consultation benefit (your day-to-day or medical savings account).

No available benefits

• GEMS won’t pay any claims after you’ve reached your benefits threshold.
• We won’t pay the claim If the medical service rendered is a scheme exclusion.

When a member or dependant doesn’t honour a doctor's appointment

• GEMS won’t pay any penalties if you miss a doctor's visit.

Unregistered healthcare provider billing

• GEMS won’t pay for claims for services rendered by a healthcare provider who isn’t registered as per scheme rules and the Medical Scheme’s Act.
• All healthcare providers must have an active practice number which they must use when they claim from our scheme.
• GEMS may reject a claim lodged by an unregistered healthcare provider, if their practice number is invalid or incorrect.

Late claims submissions

• According to the Medical Schemes Act, a healthcare provider has 120 days to submit a claim.
• Claims must reach the scheme by the last day of the fourth month after the month on which the service was rendered (example: if the service is rendered on 15 February, the claim must be submitted to GEMS before 30 June.
• GEMS won’t pay the claim if it’s submitted after the 4-month period.
• The member will responsible for settling the claim after the 4-month period.

Claims received after a member resigns from the schem

• When you resign, you can’t use your GEMS membership card to access healthcare services.
• If we receive a claim for a service received after you’ve resigned, GEMS will reject the claim because you’re no longer an active member. 

Scheme exclusions

• There are specific conditions, treatments, procedures or services that we don’t cover on all our medical Options.
• We refer to these items as ‘scheme exclusions’.
• You’re responsible for paying for exclusions. See Rule 16 and Annexure E of the scheme rules.
• Check the treatment, services, procedures and conditions you seek from your healthcare provider is covered by GEMS.

Incorrect ICD-10 codes on the claim

• The ICD-10 code stated on the claim must be correct for a claim to be processed.

Duplicate claim

• A claim will be rejected if the same claim was already submitted to the scheme and paid for.

Applicable waiting periods

• Underwriting in the form of waiting periods are applied to certain membership categories.
• If there’s a waiting period on your membership, you can’t claim for benefits for the duration of the waiting period. Read more about underwriting.

Partial payments

• Claims are partially paid in instances where:
• The service provider bills more than the scheme rate for that specific service
• The member’s benefit is insufficient to cover the claim
• The claim could also be partially paid if the billed codes are not authorised for payment
• Please remember that claims that are incomplete, invalid or have expired won’t be paid by GEMS.
• Your claims statement will explain the reason(s) why your claim wasn’t paid.
• You or your healthcare provider would need to provide the correct information and resubmit the erroneous claim within 60 days after the date it was returned for correction.

Please call GEMS on 0860 00 4367 if you’d like to know why your claim was rejected or partially paid.