FAQs

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Dental Managed Care Programme ›

Where can I find the dental forms and provider manual?

You should have received these in your emailed manual, but if you have not received a provider manual, please call GEMS on 0860 436 777 to request one. You can also download the dental provider manual here

How can I confirm membership and dental benefits?

• Membership and benefits can be confirmed by signing into the GEMS website www.gems.gov.za using the provider online section.
• By contacting the GEMS call centre on 0860 436 777
• By sending a fax to: 0861 00 4367
• By emailing [email protected]

Do Sapphire members qualify for posterior resin fillings?

Although the benefit allows for any four resin fillings per beneficiary per year, a posterior resin filling will be paid to the same Rand value as a same surfaces amalgam filling. Two events per year applies.

What type/s of procedure/s require pre-authorisation?

All procedures performed in-hospital require pre-authorisation at least 48 hours before admission. All procedures which require pre-authorisation must be done by completing the form which is available on the GEMS website:click here to download.

In addition, certain out-of-hospital procedures also require pre-authorisation and these include:

Sapphire and Beryl options - More than four fillings and extractions and all denture-related procedures.



Ruby, Emerald and Onyx Options - Specialised dental procedures such as crowns, veneers, inlays or onlays and bridges, orthodontic treatment and periodontal treatment.

What processes and documents are needed when obtaining an authorisation?

• Submit the necessary x-rays associated with the authorisation request.
• Relevant clinical motivation
• Treatment estimate; and
• Breakdown of individual laboratory codes where necessary

This will ensure there are no unnecessary delays in the authorisation process.

For in-hospital cases the following are also required:

• Panorex x-ray, treatment estimate
• Tooth number; and
• Clinical motivation for medical conditions which require general anaesthetic

These must be emailed to [email protected]

For out-of-hospital cases the following are also required:

• An orthodontic treatment plan
• Orthodontic clinical photos
• Cephalometric tracing or analysis
• A periodontal screening form; and
• X-rays from provider
• A detailed estimate for crown and bridge dentistry; and
• Associated laboratory codes

For conscious sedation in the rooms we will require:

• Treatment codes
• A cost estimate
• The practice numbers of the treating providers

Does authorisation guarantee payment of full claims?

No, authorisations do not guarantee payment of any claim in full and is subject to available benefit limits.

What happens when my treatment differs from the authorised treatment?

If there is a difference in treatment your claims may be short paid. We suggest that any authorised treatment plan which has changed, be updated with the Scheme before treatment is received in order to avoid short-payment or non-payments of claims.

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