General Practitioner Nomination

The General Practitioner plays a vital role in providing you with quality healthcare. To help your General Practitioner (GP) keep track of your healthcare, it is important that you consult the same GP for all your healthcare needs.

Consulting the same GP helps him or her develop a good understanding of your health and treatment history so that they can make informed decisions about your care, such as determining if you need to be referred to a Specialist. This means you will receive the best possible healthcare from the right person, with the right skills and knowledge about your history and have better control over how your benefits are being managed.

It is because of these benefits that GEMS is requiring you and your dependants to nominate a GEMS network GP during 2018 if you have not already done so. Although failure to nominate a GP will not result in any penalties for Ruby, Emerald and Onyx (REO), we believe that GP nomination will benefit each member of the Scheme. Sapphire, Beryl and Emerald Value members must nominate a GP to coordinate their care. Failure will result in a co-payment penalty per consultation according to the Scheme rules.

• Once your nominated network GP is selected, you will receive communication confirming this. GEMS members are encouraged to present this communication to their GP at the time of the consultation.

Why do I need to have a nominated General Practitioner (GP)?

By consulting the same GP you will help to ensure that:

• your doctor develops a good understanding of your health and treatment history so that they can make informed decisions about your health
• no duplicate diagnostic tests are done -this will help to preserve your benefits
• hospital admissions and re-admissions are reduced

How do I select or change my nominated General Practitioner (GP)?

To assist you with the process of GP nomination, GEMS will automatically allocate you and your dependants a GEMS Network doctor that you currently visit. You and your dependants will receive communication confirming which Network GP has been allocated to you.

If GEMS could not allocate you a network GP, you will receive communication informing you of this and requesting that you inform us who your nominated GP should be.

If you would like to change the allocated GP or if you were not allocated a GP, please phone the GEMS Call Centre. You can change your nominated GP as many times as required during the course of 2018. Once the GP nomination claims rules are applied, the nominated GP may be changed only once every six (6) months.

The information below will assist you in selecting or changing your nominated GP:

• Sapphire and Beryl (SB) members must select a GP from the SB GP Network and Ruby, Emerald and Onyx (REO) members must select a GP from the REO GP Network.
• Click here to find a GP on the GEMS SB or REO FP Networks.
• Adult dependants (e.g. spouses) can select their own GP different from the main member's GP. If a child dependant is below sixteen (16) years of age, then a nominated GP will be selected by the registered Main Member of the Scheme.
• Once your nominated GP is selected, you will receive an SMS confirming this.

What happens if my nominated General Practitioner (GP) is not available?

• Members on the SB options can consult with any other SB network GP. Should the member need to visit a non-network/ nominated GP, the visit will be reimbursed from the out-of-network GP benefit subject to benefits available.
• Members on the REO options can consult with any other REO network GP who is reimbursed at the contracted rate. Consults to a non-network GP will be reimbursed at Scheme rates and might result in a co-payment to the member.
• Members on the Emerald Value option can consult with any other GP on the Network, for up to 3 consultations per family per year, without penalties being imposed. 
• Once the 3 consultations with a non-nominated GP have been used, there will be a penalty (30% co-payment) applicable to Emerald Value option members on out of hospital GP claims from a non-nominated GP.
• The GP can also be updated every 6 months.

We realise that under exceptional circumstances, such as where a child is studying away from home, you may need an additional nominated GP. In such cases, the affected main member and each beneficiary will be  are allowed two nominated GPs.

If you have any queries about GP nomination or nominating an additional GP, please contact the GEMS Call Centre on 0860 00 4367 or send an email to [email protected].

Please contact the GEMS Call Centre on 0860 00 4367 to report any irregularities relating to healthcare providers on the GEMS Network.

Coordination of Specialist Care

Specialist referral is currently in place for the Sapphire and Beryl options. The SB network general practitioner will still request a referral number via the GEMS call centre for their patient before an appointment to see a specialist can be made. This can be done by calling the Provider GEMS Call Centre on 0860 436 777.

We encourage our Ruby, Emerald and Onyx (REO) members to consult their network GP before making an appointment to consult a specialist. This will ensure that the patient is referred to the appropriate specialist.

Members on the Emerald Value option must obtain a referral number before making an appointment to see a Specialist. This can be done by calling the Call Centre on 0860 436 777.

When the referring practice field on the Specialist claim is not populated or populated with the Specialist's own practice number, a penalty (30% co-payment) will be applied to the Emerald Value option member, irrespective of the PMB status of the claim. Furthermore, if the GP in the referring practice field is not the nominated GP, a penalty (30% co-payment) will also be applied to the Emerald Value option member, irrespective of the PMB status of the claim.

Specialist practice types requiring a referral from a nominated GP:
 

*Remember to ask for a Specialist on the GEMS Specialist Network (only applicable to Paediatricians, Obstetricians and Gynaecologists). A Network Specialist has agreed to bill a contracted rate so that they are paid in full, provided you still have available benefits.

Members on the Sapphire and Beryl options need to keep the following in mind:

• Your GEMS GP, who will obtain authorisation from the Call Centre, must refer you to a specialist or allied healthcare provider (physiotherapist or speech therapist). 
• Make sure that your GP, specialist, pharmacy, optometrist or dentist is on the GEMS Network before you visit them. This will ensure that you do not have to pay out of your pocket for the appointment or treatment.
• All Medication from a specialist is subject to the formularies.
• You need pre-authorisation to see your GP on the Sapphire and Beryl Network after the first six consultations.
• Members registered on any disease management program will have 8 consultation before they need to obtain an authorisation.
• Ask your GP whether he/she can dispense medicine or not. If they can dispense, you should not obtain your medicine from a pharmacy as you then may have to make a co-payment. All medicine should be prescribed from the Sapphire and Beryl Acute Formulary list. All GPs have a copy in their GEMS General Practitioner (GP) guide.
• Pathology and radiology tests must be in line with the GEMS Formulary. (list of approved tests or services) for Sapphire and Beryl and your GEMS GP also needs to refer you for these tests. GEMS has introduced a pathology and radiology claims validation service. This will ensure that these claims are managed appropriately when you claim.