Claims

Claims Guide

View your Claims Guide.

Who can claim?

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

Who cannot claim?

To protect members' benefits, GEMS is on a drive to provide a safer environment for processing claims. And with this aim, processes have been put in place to help us to better validate the submission and payment of claims.

View the list of healthcare providers on indirect payment. One of the process changes is the termination of direct payments to certain healthcare service providers due to restrictions placed against them by the Scheme.

These healthcare service providers' claims will be rejected and GEMS members will be responsible for submitting the claim for the services provided by these healthcare providers directly to the Scheme. This means members have to pay healthcare costs for services from these healthcare providers directly to them and thereafter can claim back from GEMS.

Please remember that the claims submission from the member must include corresponding details and valid proof of payment, signed by the principal member, in the form of:

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

Department of Health healthcare provider claims relating to RWOPS

Sections 30 - 31 of the Public Service Act of 1994 states that "an employee does not, without approval, undertake remunerative work outside his or her official duties or use office equipment for such work".

In light of this, we requested all Department of Health (DoH) healthcare providers who provide services to GEMS members, outside of the public service, send proof that they are allowed to be employed outside the public service and be remunerated. This documentation was required before 1 November 2014.

Where proof of approval was not submitted in time, GEMS has taken a decision to reject claims for services or products provided to GEMS members by DoH healthcare providers who do not have the required permission. This means that you will be responsible to pay for any claims relating to services provided by a DoH healthcare provider who does not have permission to perform Remunerated Work outside the Public Service (RWOPS) from 1 November 2014.

View the list of DoH healthcare providers that are allowed to be employed outside the public service and receive remuneration

Your support regarding these processes are appreciated as GEMS continues to protect members' benefits. If you have any queries in this regard, you can call GEMS on 0860 00 4367 or send an email to [email protected].

How is the claim processed?

The Claims Department receives the claim and assesses it according to the Scheme Rules. If the Scheme Rules allow, the claim will then be paid.

Sometimes additional information is required from you or your healthcare provider, e.g. ICD-10 code, clear copy of account, detailed account, proof of payment etc. when assessing claims. If this information is not available, some claims may be rejected.

When are claims paid?

There are two payments runs per month - mid month and then at the end of the month. Depending on when your claim is received, it can be settled at either of these runs. Click here to view the claims run dates for 2018.

Are medicine claims processed immediately?

Your pharmacy can send medicine claims to us electronically at the point of sale. The Scheme Rules will be applied immediately, so you will find out if GEMS will pay for the medicine right away. This means that you will get your medicine immediately, if you have available benefits, GEMS will pay for the medicine without you having to pay for it in cash. If the medicine is not on the Scheme list, you may face a co-payment or your claim may be rejected.

What information must be on your claims?

• Your membership number
• The Scheme's name (i.e. GEMS)
• Your benefit option (for example, Sapphire, 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 provider
• The valid practice code of the healthcare provider
• The date of service
• 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 service, attach proof of payment and highlight it clearly. Proof of payment can be either a valid receipt from the healthcare provider, an electronic fund transfer (EFT) slip or a bank deposit slip.

Submit your claims correctly

• By post: GEMS, Private Bag X782, Cape Town, 8000
• By fax: 0861 00 4367
• By email: [email protected]
• At a GEMS Walk-in Centre

Claims refunds

When you have paid a healthcare provider for a service, you may claim a refund from the Scheme. Your available benefits, the applicable Scheme Rules and the Scheme Rate will determine whether a refund will be paid and how much will be paid. When submitting a claim, you need to ensure that all supporting documents are attached to the claim, including a valid proof of payment. The proof of payment can be either a valid receipt from the healthcare provider, an electronic fund transfer (EFT) slip or bank deposit slip.

Refunds are paid to members electronically, so you need to make sure that we have your updated, correct banking details. We need the following banking information:

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

You can either fax this information to 0861 00 4367 or email it to [email protected], using your membership number as a reference. You can also deliver the information to one of the GEMS Walk-in Centres or post it to GEMS, Private Bag X782, Cape Town, 8000.

Should you wish to change or update your banking details, you are required to submit the following documents:

• A certified copy of your ID
• A bank account statement, crossed cheque or letter from the bank either signed or stamped (not older than three months)
• Proof of your residential address, which can be in the form of a utility bill such as your municipal account (not older than three months).

Claims alert SMS

You have the option to receive a claims alert SMS each time GEMS processes your claims. These SMSs acknowledge the receipt of claims, but it is not a guarantee of payment. To receive a claims alert SMS, please call 0860 00 4367 and make sure that we have your current cellphone number.

Remember: If you receive a claim alert SMS for a claim you are not aware of, please report it to the Scheme as soon as possible by calling us on 0860 00 4367.

Claims statement explained

Click here to understand your claims statement. You will receive a claims statement when a claim has been settled. Please read your claims statement to see if your claims were paid or not. If a claim was not paid, your claims statement will show the reason why it was not paid. If the reason should indicate an action, please resubmit the claim with the applicable information.

Paying a healthcare provider directly

To protect your benefits from irregular claims being submitted to the Scheme, GEMS has processes in place that allows us to better validate the submission and payment of claims.

One of these processes is the termination of direct payments to certain healthcare providers who have fraud sanctions placed against them by the Scheme. These healthcare providers' claims will be rejected and you will be responsible for submitting the claim for the services rendered directly to the Scheme. This means you will have to pay healthcare costs for services from this healthcare provider directly to them.

Your claims submission must include corresponding details and valid proof of payment, signed by the main member, in the form of:

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

Top reasons why claims are rejected (not paid)

1. Incorrect member or dependant information

• It is important that the Scheme receives up-to-date member information to process your claims. We need this information to make sure we pay claims correctly and that our member records are always complete and current.
• When making claims for dependants, ensure that they are registered and their details appear on the claim.

2. No pre-authorisation number for treatment such as oncology and hospitalisation

• Even after your treatment is authorised, your doctor needs to inform GEMS of any change in your treatment so that we can evaluate the treatment plan and update the authorisation. If your doctor does not inform us of the changes, GEMS may reject your claims or pay them from the incorrect benefit.
• Physiotherapy treatment in hospital must also be authorised.

3. No benefits are available

• When your benefits have reached the benefit limits or sub-limits, GEMS will not pay any more claims.

4. When a member or dependant does not keep a doctor's appointment

• GEMS will not pay penalties for that missed doctor's visit.

5. GEMS will not pay for claims for services given by a healthcare provider who is not registered in terms of a relevant law

• For example, if a doctor is not registered to practice medicine in South Africa). Speak to your doctor to ensure that your claims meet the necessary requirements before you send them to the Scheme.

6. Claims sent to us too late

• Claims must reach the Scheme by the last day of the fourth month following the month in which the service was rendered. For example, if the service is rendered on 15 February 2014, the claim must reach us by 30 June 2014 (i.e. 120 days). GEMS will not pay claims received after this timeframe. This is according to the Regulations of the Medical Schemes Act. You will have to pay for claims that you have not sent to us within four months of the treatment date. To avoid claims from becoming stale, double check with your healthcare provider if a claim will be submitted directly to the Scheme or whether you should submit the claim yourself.

7. Claims we receive for treatment after a member has resigned from 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 is not an employee or retired employee of the Public Service or a GEMS participating employer cannot belong to GEMS. If you resign, you cannot use your GEMS membership card for healthcare services. If you or a healthcare provider claims for services after the date that you resigned from the Public Service or from GEMS, you will have to pay this money back to GEMS.

8. Scheme exclusions

• For all GEMS options there are specific conditions and treatment facilities that are not paid for, in line with the Medical Schemes Act. The items or procedures that are not covered by the Scheme are called Scheme exclusions. You must make sure that the procedures, treatments or medicine you receive will be covered for, before getting them because GEMS will not pay for excluded services or items. You will be responsible for paying those costs. Scheme exclusions are listed in detail in Rule 16 and Annexure E of the Scheme Rules.

9. The ICD-10 codes on the claim are not correct

• Ensure that the ICD-10 code provided on the claim correctly identifies the condition the patient is being treated for.

10. Duplicate claim

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

11. Waiting periods apply 

• Underwriting in the form of waiting periods are applied to certain membership categories. If a waiting period has been applied to your membership, you will not be able to claim for benefits for the duration of the waiting period. Read more about underwriting.

Please remember that claims submitted incorrectly will not be paid. You will receive a claims statement explaining the reason why your claim has not been paid. Your claim will be returned and you or your healthcare provider would need to provide the correct information and resubmit the claim within 60 days following the date on which it was returned for correction. Please contact GEMS on 0860 00 4367 if you are not sure why your claim was rejected.

Submitting your claim incorrectly will cost you time - so save yourself the trouble and get it right the first time!