Is your GEMS Network provider sticking to the rules?

Do you know your rights as a GEMS member when visiting your GP, Dentist, Optometrist or Pharmacy on the Sapphire and Beryl
Service Provider Network?

If you are on the Sapphire or Beryl benefit options you must always make sure that your healthcare service provider is part of the GEMS Network. You can find a Network provider by contacting the Call Centre on 0860 00 4367, by using the ‘Friends of GEMS' SMS facility (33489) or by visiting www.gems.gov.za, clicking on ‘The GEMS Network' and using the ‘Find a Network provider' tool.

Remember that your Network service provider should display a sign in their practice which will confirm that they are part of the GEMS Network.

You will enjoy the following benefits if your healthcare providers are on the GEMS Network:

• You will not have any out-of-pocket expenses or co-payments as your service provider has agreed to bill within the Sapphire and Beryl rates.
• Your Network service provider has received a Sapphire and Beryl Provider Manual at the beginning of the year which indicates which tariffs and codes should be used when submitting your account to GEMS for payment.
• The manual also guides your Network GP as to what medicine may be prescribed within the given formularies (medicine lists) and also which blood tests and x-ray examinations must be marked on the GEMS test forms.

Your Network GP will refer you to a specialist if necessary by completing a specialist referral form and getting an authorisation number before your specialist visit.

Your GEMS Network provider has agreed to provide you with excellent service and care. They have also agreed to be profiled by the Scheme and to be mentored to improve their practice performance, if necessary.

What to do if your Network provider makes you pay co-payments out of your own pocket

We have terminated eight service providers from the Network since the beginning of 2012 because they have not conformed to the above requirements. It is your right as a GEMS member to inform us if your service provider does not comply to the GEMS Network requirements.

These service providers can be reported by calling the GEMS Fraud line on 0800 21 2202. You can also send an email to [email protected] or send a fax to 086 726 1681. Information can also be posted to: The Fraud Services Manager, PO Box 21076, Valhalla, 0137