Family Practitioner Nomination

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

Consulting the same FP 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 FP during 2015. We believe that this will help you and your family receive the best care and realise the benefits of using one provider.

Why do I need to have a nominated Family Practitioner (FP)?

By consulting the same FP 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 Family Practitioner (FP)?

To assist you with the process of FP 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 FP has been allocated to you.

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

If you would like to change the allocated FP or if you were not allocated a FP, please phone the GEMS Call Centre. You can change your nominated FP as many times as required during the course of 2015. Once the FP nomination claims rules are applied, the nominated FP may be changed only once every six (6) months.

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

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

What happens if my current Family Practitioner is not on the GEMS Network?

The Family Practitioner you choose to nominate will need to be on the GEMS Network in 2015. If your current FP is not on the GEMS Network, GEMS will actively assist you to get your FP on the Network during 2015. Should your FP choose not to join the GEMS Network, you will be notified and given the option to select a network FP of your choice.

What happens if my nominated Family Practitioner (FP) is NOT available?

FP nomination claims rules will not be enforced in 2015.  Members are however encouraged to consult with their nominated FPs in order for their nominated FP to coordinate their care.  Members on the SB options can continue to consult with SB Network FPs.  Should they need to visit a non-network FP, that will continue to be reimbursed from the Out-of-Network FP benefit as before.  Members on the REO options can continue to consult with REO network FPs  who are reimbursed at the contracted rate.  Consults to a non-network FP will be reimbursed at Scheme rate and might result in a co-payment to the member as before.   

Once the FP nomination claims rules are applied, visits to a non-network FP will be paid from the ‘non-nominated' benefit.  Once the ‘non-nominated' benefit is depleted:
SB members - the claim will not be paid
REO members- the claim will attract a 30% co-payment

May I have more than one nominated Family Practitioner (FP)?

Yes, a GEMS member can have up to two nominated FPs.  The list below contains examples of when a GEMS member may need a second nominated FP. Note: examples below are not limited to this list:

• When parents are divorced or separated and children live in different locations with both parents at different times.
• Where a person's work is of such a nature that he / she is situated at different locations for a period longer than three (3) months at a time. This includes members that live in a township (for example) and work in the city and want a doctor in both places.
• When children are at boarding school.
• When children are in foster care, living with grandparents or extended family member(s).
• When members have to travel for work or are involved in special projects for work.
• When students are studying away from home.
• Members with a chronic condition who visit a different FP for their chronic condition. For example, a member with diabetes may visit a FP who has a special interest in diabetes, who may not necessarily be their nominated FP.

Coordination of Care

Specialist referral is currently in place for the Sapphire and Beryl options and will not change for 2015. The SB network family practitioner will still request a specialist referral number via the GEMS call centre for their patient. However,once the FP nomination rules are activated, it is the nominated FP that will need to request the specialist referral number. If no specialist referral number is obtained, specialist claims will not be paid. This is the same as for 2014.

Although the Specialist Referral claims rules will not apply in 2015, GEMS REO members are advised to visit their nominated FP.   Going forward, once the Specialist Referral rules are activated, specialist claims without a referral will attract a 30% co-pay. A specialist referral number via the call centre is not required, but the nominated FP's practice number must be submitted with the specialist's claim in order for it to be paid in full.

Specialist referral will apply to the following list of practice types for members on the REO options once the rules are applied.  Note that specialist referral rules will not be applied in 2015.
 

Practice Type	Description	Practice Type	Description
12	Dermatologist	28	Orthopaedic surgeons
16	Gynaecologists*	30	Otorhinolarynologists (ENT)
17	Pulmonology	31	Rheumatologist
18	Physician	32	Paediatricians*
19	Gastroenterology	33	Cardiology paediatricians
20	Neurologists	36	Plastic and reconstructive surgeons
21	Cardiology	42	Surgeons
22	Psychiatrists	46	Urologist
24	Neuro surgeons

*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