The Network Options - Sapphire and Beryl

Providers: joining The GEMS Network

How do I become part of the GEMS Network?

You may contact the GEMS call centre at 0860 00 4367 to discuss network requirements and criteria. The call centre will also be able to provide you with information on how the network works, services offered, benefit limits and applications.

Providers: queries relating to claims on The GEMS Network

How do I get assistance with my claims queries with the GEMS Network?

You may obtain information relating to the GEMS claims submissions in respect to the network by contacting the call centre on 0860 00 4367.

Providers: queries relating to claims on The GEMS Network

Who do I contact to do pre-authorisation?

You can contact GEMS call centre at 0860 00 4367. In addition, the call centre is able to provide you with benefit validation and member confirmation as well.

Network Options Optometry and Dental

What optometry (eye treatment) benefits am I entitled to?

The benefit allows one eye examination by an optometrist per beneficiary per year and one pair of single or bifocal vision clear plastic lenses per beneficiary every 24 months. These services can only be obtained at an optometrists who belong to the Scheme Optometry Network. Please consult your benefit schedule for more detail around your benefit limits.

How do I find out more about my limits and advise on the nearest Network optometrists?

For more detail on your benefit limits and options please contact the call centre on 0860 00 4367 for more information. The call centre should also be able to provide you with a list of network optometrists in your area.

Can I visit any optometrists of my choice?

Yes provided that the optometrist is registered on the network. Please confirm this through the call centre or Lookup facility on the website. It should be easy to identify a Network optometrist through the scheme branding.

What happens if my dentist is not a Network provider?

Your claim will be rejected and you will be liable for the costs. Therefore, it's essential that you confirm beforehand if the dentist belongs to the Network.

What conservative dentistry benefits am I entitled to?

One dental consultation/examination per beneficiary is allowed every 6 months. This includes fillings, fluoride treatment, cleaning, scaling and polishing. All services are subject to an approved list of tariff codes, managed care protocols and processes.

What about emergencies? Can I visit the closest dentist?

Emergency, out-of-network visits for treatment of pain and sepsis are limited to one event per beneficiary per year and are subject to a list of pre-approved services. Please contact 0860 00 4367 for more details.

Do I qualify for dentures?

For the Sapphire and Beryl options:

• Only 1 (one) set of plastic dentures is allowed per beneficiary per 48 month benefit cycle.
• Only members and beneficiaries over the age of 21 years of age qualify for this benefit.
• Pre-authorisation via the GEMS Network call centre is required.
• A dentures benefit limit exists on the Beryl option. Please consult your benefit guide or contact the call centre for more detail.

What happens if I require medication?

All Network providers agreed to prescribe medication according to a medicine formulary. Your consulting provider would prescribe medication according to this list of medicines considered to be clinically appropriate and effective for the treatment of your disease or illness. If the provider is a dispensing practitioner, he will provide you with the acute medication. If not, you would be required to visit your closest network pharmacy. Chronic medication can be obtained from the GEMS Chronic DSP.

Where can I confirm benefits, limits and membership status?

You can contact the call centre on 0860 00 4367 to do these checks. Please note that the Scheme will not pay for services obtained from non-network providers or for services outside the list of specified services.

Where do I obtain pre-authorisation and what information is required?

Please contact the call centre on 0860 00 4367 for services which require pre-authorisation. If no pre-authorisation was obtained, your claim will be rejected and you will be liable for the costs. Please check the benefit schedule for more detail on these services. 

What happens if I receive services I am not entitled to?

The Scheme is not responsible for any services outside the list of approved services. Hence, you will be liable for these costs. Its crucial that you confirm which services and benefits you are entitled to via the service provider or the call centre on 0860 00 4367.