ALL GEMS TARIFFS ARE VAT INCLUSIVE.

The procedures codes listed in the schedule have, for the convenience in using the schedule, been divided into categories of services, based on the branches of clinical dental practice. The procedures are grouped under the category of service with which the procedures are most frequently identified and should not be interpreted as excluding certain categories of Oral Health Care Providers from performing such procedures. Individual procedure codes consist of a procedure code, procedure description (nomenclature), and when necessary, a descriptor, that provides further definition and/or guidelines to clarify the intended use of the procedure code.

ii. The first name of the patient;

iii. The name of the scheme;

iv. The membership number of the member;

v. The practice number;

vi. The date on which every service was rendered;

vii. The code number, description and fee/benefit of the procedure or service;

viii. The name of the dentist rendering the service;

ix. The name of the general dental practitioner/specialist assistant (when applicable);

x. The appropriate ICD-10 code(s) for the procedures performed.

The technician’s invoice shall be certified by the dentist (or a person appointed by the dentist) for correctness by means of a signature. The original invoice of the dental technician (or a copy thereof) shall accompany the invoice of the dentist and a copy (or the original) shall be filed by the dentist for record purposes.

The technician’s invoice shall be certified by the dentist (or a person appointed by the dentist) for correctness by means of a signature. The original invoice of the dental technician shall be filed by the dentist for record purposes.

Oral diagnosis defined.  The determination by the dentist of the oral health condition of an individual patient achieved through the evaluation of data gathered by means of history taking, direct examination, patient conference, and such clinical aids and tests as may be necessary in the judgement of the dentist.

Treatment plan defined.  The treatment plan is the sequential guide for the patient’s care as determined by the dentist’s diagnosis and is used by the dentists for the restoration and/or maintenance of optimal oral health

a. The treatment plan and type of treatment (treatment code number);

b. A diagnostic code (ICD-10) and

c. An orthodontic payment plan indicating the following:

i.  The total fee that will be levied for the treatment;

ii.  The total months of orthodontic treatment (retention period excluded);

iii. The initial fee payable by the patient (approximately 20% of the total fee); and

iv. The monthly payments of the balance of the fee.

Basic dentistry – designated as ( B ) in the treatment category column

Advanced dentistry – designated as ( A ) in the treatment category column

Surgery – designated as ( S ) in the treatment category column

+D Add fee/benefit for denture

+L Add laboratory fee

+M Add material fee

M Maxilla/Mandible

Q Quadrant

S Sextant

T Tooth

A Advanced dentistry

B Basic dentistry

S Surgery

25400  General Dental Practitioner

26200  Specialist Maxillo Facial and Oral Surgeon

26400  Specialist Orthodontist

29200  Specialist in Oral Medicine and Periodontics

29400  Specialist Prosthodontist

29800  Specialist Oral Pathologist

39500  Dental Therapist

The determination of a child or adult status of the patient should be based on the clinical development of the patient’s dentition. Where administrative constraints preclude the use of clinical development so that the chronological age must be used to determine the child or adult status, the patient is defined as an adult beginning at age 12 with the exclusion of treatment for orthodontics or sealants.

The South African Dental Association recommends to medical schemes, where considered necessary and appropriate, that contract limitations on the frequency of providing care for certain services be stated as “twice a calendar year” rather than once in every six months.

Radiographs should be taken only for clinical reasons as determined by the treating dentist. Postoperative radiographs should only be required as part of dental treatment. When a dentist determined it is appropriate to comply with a third-party payer’s request for radiographs, a duplicate set should be submitted and the originals retained by the dentist. Any additional costs incurred by the dentists in copying radiographs and clinical records for claims determination should be reimbursed by the third-party payer or the patient.

A new patient is one who has not received any professional services from the dentist or another dentist of the same speciality who belongs to the same group practice, within the past three years. An established patient (patient of record) is one who has received professional services from the dentist or another dentist of the same speciality who belongs to the same group practice, within the past three years.

In the instance where a dentist is on call for or covering for another dentist, the patient’s encounter will be classified as it would have been by the dentist who is not available.

Oral examinations may require the integration of information that is acquired through additional diagnostic procedures, which should be reported separately. The oral examination, diagnosis, and treatment planning are the responsibility of the dentist. The collection and recording of some data and components of the oral examination may however be delegated. Oral examinations and consultations include the issuing of prescriptions where medication is required.

Radiographs/diagnostic images should only be taken for clinical reasons as determined by the dentist and practitioners should comply with the Regulations concerning safe radiological practice and take the necessary precaution to minimise radiation of patients. Radiographs/diagnostic images are part of the patient’s clinical record, should be of diagnostic quality, properly identified and dated. The dentist should retain the original images and only copies should be used to fulfil requests made by patients or third party funders.

A complete series of intra-oral radiographs/images for diagnostic purposes is required once per treatment plan only.  A second series may be required in exceptional cases e.g., following periodontal surgery. The same applies to panoramic films, where additional films may be required for follow-up/re-evaluation purposes.

Diagnostic radiographs/diagnostic images preceding endodontic treatment, periodontal treatment, the surgical extraction of teeth or roots and fixed prostheses are fundamental to ethical clinical practice.