> Navigate

Fraud Awareness

Managing your claims - be alert

GEMS pays in excess of R400 million on average in member claims per month.

We would like to urge you to take an active role in managing your claims. Below is some information to help you do this.

How does the claim payment process work?

Members and dependants obtain the health service they require in accordance with their benefits and the service provider or the member submits the resulting claims to GEMS. The Claims Department receives, assesses and approves payment of valid claims subject to scheme rules and available benefits. Claims are paid twice a month, every month, without fail.

How do I submit claims?

Claims should be submitted as follows:

• By post to GEMS, Private Bag X782, Cape Town, 8000;
• By fax to 0861 00 4367; or
• By email to [email protected].

What information must appear on my claims?

The following details must be indicated on all claims:

• Your membership number
• The scheme name
• Your option
• Your surname and initials
• The patient's name and beneficiary code as it appears on your membership card
• The name and valid practice number of the service provider
• The date of service
• The nature and cost of treatment
• The tariff code
• The relevant ICD-10 code
•  Your signature to confirm that the account is correct.

What is GEMS doing to protect my benefits?

Claim alerts have been implemented on Ruby, Emerald and Onyx to ensure that all members have sight of claims which have been received against their membership before they are processed for payment. These alerts can be distributed by email or SMS and we would like to encourage you to register for this service by updating your communication profile under LOGIN. Please note that you need to register for a PIN to access this service.

If you do not have access to the internet, you need to check your claims statement thoroughly for any irregularities.