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GEMS TARIFF FOR SERVICES BY CONTRACTED DENTAL PRACTITIONERS EFFECTIVE FROM 2022-01-01
Tariff Code Description of tariff code
In calculating the GEMS Tariff , the following rounding method is used: Values  R10 and below rounded to the nearest cent, R10+ rounded to the nearest 10cent. Modifier values are rounded to the nearest cent. When new item prices are calculated, e.g. when applying a modifier, the same rounding scheme should be followed.

ALL GEMS TARIFFS ARE VAT INCLUSIVE.
The schedule includes procedures and services for use by Oral Health Care Providers for purposes of keeping accurate patient records, reporting procedures on patients, and processing oral health care related insurance claims. The procedures are those performed by general dental practitioners, oral pathologists, prosthodontists, periodontists, orthodontists, maxillo-facial and oral surgeons and dental therapists.

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.
I. INTRODUCTION
A. Administrative and invoicing rules
001 Invoices:
a. A practitioner shall render a monthly invoice for every procedure which has been completed irrespective of whether the total treatment plan has been concluded.
b. An invoice shall contain the following particulars:
i. The surname and initials of the member;

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.
Note: Photocopies of original invoices shall be certified by way of a rubber stamp or the signature of the dentist.
002 Cost of direct materials:
The expenses incurred for direct materials identified in the Schedule may be billed in addition to the procedure code. These expenses are limited to the net acquisition cost of the materials and a handling fee. The price of the materials should be VAT inclusive. Use Modifier 8025 for handling fee.
003 Dental laboratory services:
Manual submission of invoices. Fees charged by dental technicians for laboratory services (PLUS L) shall be indicated on the dentist’s invoice by reporting code 8099 – Dental laboratory service with the appropriate laboratory fee on the line following the relevant dental procedure code.

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.
Electronic submission of invoices.  Fees charged by dental technicians for laboratory services (PLUS L) shall be indicated on the dentist’s invoice by submitting code 8099 – Dental laboratory service with the appropriate laboratory fee on the line following the relevant dental procedure code on the date on which the dental procedure was rendered. The laboratory fee shall be submitted for payment on the date on which the procedure code is submitted for payment, and the appropriate dental laboratory service codes shall be reported on the lines following code 8099.

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.
005 Procedure accompanied by unusual circumstances:
In exceptional cases where the proposed fee/benefit is disproportionately low in relation to the actual services rendered by a practitioner, such higher fee as may be mutually agreed upon between the dental practitioner and the patient/medical scheme may be billed. Use Modifier 8011 with a narrative description.
Under certain circumstances a service or procedure is partially reduced or eliminated at the practitioner’s election. Under these circumstances a lower fee may be billed. The service provided can be identified by its usual procedure code and the addition of Modifier 8012, signifying the service is reduced.
B. General coding rules
006 The schedule does not prescribe the scope of practice of a particular category of Oral Health Care Provider; neither does it confine the performing of procedures or services to a registered speciality. Fees listed within a column of a particular category of Oral Health Care Provider are customary fees, should the procedure or service be rendered by that provider category.
Specialists are however encouraged to confine their practice to the speciality or related specialities in which they are registered. Specialist may charge fees for procedures or services which usually pertain to some other speciality, if such procedures or services are also recognised in their speciality, and if it is carried out only for their bona fide patients. Such fees shall not be higher than those charged by general practitioners for the same procedures or services (HPCSA, Rule 25).
Fees for procedures or services not listed within the column of dental therapists that do fall within the field of dental therapy in terms of their scope of practice are regarded as being “by arrangement” until such fees are listed.
007 Procedures not listed in the Dental Schedule
When a procedure is performed that is not listed in the schedule, an appropriate procedure code, listed in the NHRPL for medical practitioners may be reported.
Unlisted procedures.  Any procedure that is neither described in the schedule, nor in the medical schedule, should be reported using code 9099 – Unlisted dental procedure or service. The fee for an unlisted dental procedure or service should be based on the fee of a comparable procedure. Code 9099 codes should not be used to report procedures where the fee is determined “by arrangement” with the patient and/or medical scheme.
C. Services rules
008 Oral evaluations and completion of treatment plans:
Oral examinations include an examination, diagnosis and treatment planning (when treatment is required). No further fees/benefits shall be levied for an oral examination (code 8101) or comprehensive examination (code 8102) until the treatment plan resulting from these type of examinations is completed.
The completion of a treatment plan effected from an oral examination and/or comprehensive examination should be indicated by reporting code 8120 – Treatment plan completed.

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
009 Surgery guidelines:
1. Follow-up care for therapeutic surgical procedures: The fee/benefit for an operation shall, unless otherwise stated, include normal post-operative care for a period not exceeding four months. If a practitioner does not him/herself complete the post-operative care, he/she shall arrange for post-operative care without additional charges. A fee/benefit for post-operative treatment of a prolonged or specialised nature may be charged as agreed upon between the practitioner and the scheme.
2. Multiple Procedures (Maxillo-facial and oral surgery):  The fee/benefit for more than one operation or procedure performed through the same incision shall be determined as the fee for the major operation plus fee/benefit for the subsidiary operation to the indicated maximum for each such subsidiary operation or procedure (Modifier 8005). The fee/benefit for more than one operation or procedure performed under the same anaesthetic but through another incision shall be determined on the fee/benefit for the major operation plus: 75% for the second procedure/operation (Modifier 8009). 50% for the third and subsequent procedures/operations (Modifier 8006). This rule shall not apply where two or more unrelated operations are performed by practitioners in different specialities, in which case each practitioner shall be entitled to the full fee/benefit of the operation. If, within four months, a second operation for the same condition or injury is performed, the fee/benefit for the second operation shall be 50% of that of the first operation (Modifier 8006).
3. Assistant Surgeon (Maxillo-facial and periodontal surgery): The fee payable to a specialist assistant is determined as 1/3 (of the fee of the practitioner performing the procedure (Modifier 8001). The fee payable to a general dental practitioner assistant is determined as 15% (of the fee of the practitioner performing the procedure (Modifier 8007). The patient must be informed beforehand that another dentist/specialist will be assisting at the operation and that a fee will be payable to the assistant. The assistant’s name must appear on the invoice rendered to the patient.
4. Surgical team (Maxillo-facial and oral surgery): The additional fee to all members of the surgical team for after hours emergency surgery shall be calculated by adding 25% to the fee for the procedure or procedures performed (Modifier 8008).
010 Orthodontic guidelines:
The documentation and first invoice to the patient/medical scheme regarding orthodontic services will include the following information:

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.
2. The fee for orthodontic treatment does not include a clinical oral evaluation and necessary diagnostic services.  The fee for corrective therapy (i.e. codes 8861 to 8888) is an inclusive fee and no additional fees may be levied for intra-operative oral evaluations and preventive services.  A pre-orthodontic treatment visit, an orthodontic retention, and an oral evaluation on completion of the treatment plan (retention phase included) are excluded and should be reported in addition to corrective orthodontic treatment as separate procedures (Code 8803 x3). Intra/post orthodontic treatment records consisting of radiographs/diagnostic images (limited to a cephalometric film and 5 oral/facial images) and diagnostic casts may be levied when a corrective orthodontic treatment plan is completed (retention phase included).
3. The fee for ‘Fixed appliance therapy’ (codes 8861 and 8865 to 8888), as determined by the individual practitioner, will be levied on a monthly manner over the treatment period (retention phase excluded).
4. When partial fixed appliance or preliminary orthodontic treatment (codes 8858, 8861, 8865 or 8866) is followed by full fixed appliance orthodontic treatment (codes 8873 to 8888) provided by the same orthodontist, the fees levied for the partial fixed appliance therapy or preliminary treatment will be deducted from the fee quoted for the full fixed appliance orthodontic treatment.
5. The total fee for multiple phases of full fixed appliance orthodontic treatment provided by the same orthodontist may not exceed the most recent fee (determined on commencement date of the final stage of full fixed appliance treatment) for the appropriate full fixed orthodontic procedure.
6. When the patient transfers to another practitioner during treatment, or treatment is terminated for any reason, the original treating practitioner must report the number of treatment months remaining and determine the balance of the fee by applying the following formula: Total payment (for treatment only) minus 20% of the total fee (for banding – when applicable) multiplied by the percentage of treatment remaining. For example, if the practitioner was paid R 10,000.00 for a 24-month treatment plan and 18 months of treatment were completed. The balance would be R 2,000.00 (or R 10,000.00 – R 2,000.00 x 6/24). The length of the treatment plan from the original request for authorisation will be used to determine the number of treatment months remaining. The practitioner continuing treatment will provide the information stipulated in paragraph 1 above. Report code 8891 (Orthodontic transfer) with the fee that will be levied for continuation of the treatment in addition to the appropriate orthodontic treatment code. The fee for continuous treatment is subject to prior authorisation by the patient’s medical scheme.
7. When an established orthodontic patient requires re-treatment, the information stipulated in paragraph 1 above and the cause(s) for re-treatment will be provided. Report code 8892 (Orthodontic re-treatment) with the fee that will be levied for re-treatment in addition to the appropriate orthodontic treatment code. Orthodontic re-treatment is subject to prior authorisation by the patient’s medical scheme.
011 Dento-legal fees:
Practitioners are entitled to remuneration if they are present at Court at the request of an advocate or attorney. Use code 8111 (Dental testimony) to report dento-legal work. The code is listed in the adjunctive general services sections in the code lists.
D. Modifiers
012 Modifiers:
Modifiers should be used with procedures identified throughout the NHRPL.
Modifiers provide the means by which the reporting practitioner can indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed it its definition or code. The sensible application of modifiers obviates the necessity for separate procedure listings that may describe the modifying circumstance.  Modifiers may be used to indicate to the recipient of the report that:
a. A service or procedure was performed by more than one practitioner.
b. A service or procedure has been increased or reduced.
c. Only part of a service was performed.
d. An adjunctive service was performed.
e. A service or procedure was provided more than once.
f. The fee/benefit was altered due to a financial agreement.
8001 Assistant surgeon – specialist (1/3 of the appropriate benefit)
8005 Maximum multiple procedures (same incision) – MFO surgeon
8006 Multiple surgical procedures –  third and subsequent procedures (50% of the appropriate benefit)
8007 Assistant surgeon – general dental practitioner (15% of the appropriate benefit)
8008 Emergency surgery – after hours (PLUS 25% of the appropriate benefit)
8009 Multiple surgical procedures – second procedure (75% of the appropriate benefit)
8010 Open reduction (PLUS 75% of the appropriate benefit)
8011 Procedure accompanied by unusual circumstances (Benefit PLUS X % as determined by the practitioner and agreed upon by patient/medical scheme)
8012 Reduced services (benefit MINUS X % as determined by the practitioner)
8013 Multiple modifiers
8023 Fabrication of inlay/onlay (PLUS 25% of the appropriate benefit)
8025 Handling fee – direct materials (26% of material cost to a maximum of R26.00)
E. Explanations
Tooth identification and designation of areas of the oral cavity:
Tooth identification and designation of areas of the oral cavity is compulsory for all invoices rendered. Tooth identification is applicable to procedures identified with the letter ( T ), and other designation of areas of the oral cavity with the letter ( Q ) for a quadrant and the letter ( M ) for the maxillary or mandibular area in the mouth part ( MP ) column of the Dental Coding. The International Standards Organisation (ISO) in collaboration with the FDI designated system for teeth and areas of the oral cavity should be used. For supernumeraries, the abbreviation SUP should be used.
Treatment categories:
Treatment categories (TC) of dental procedures are identified in the TC column of the Dental Coding as follows:

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
Abbreviations used in Dental Coding
DM Direct Material Column

+D Add fee/benefit for denture

+L Add laboratory fee

+M Add material fee
MP Mouth Part Column

M Maxilla/Mandible

Q Quadrant

S Sextant

T Tooth
TC Treatment Category Column

A Advanced dentistry

B Basic dentistry

S Surgery
Practice type codes:

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
F. Guidelines to medical schemes
Age of a Child.

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.
Frequency of benefits.

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 and records.

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.
New vs. established 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.
II. DENTAL PROCEDURES AND SERVICES
A. DIAGNOSTIC SERVICES
The branch of dentistry used to identify and prevent dental disorders and disease. Includes all services/procedures available to the dentist for evaluating existing conditions and determining any further dental care that may be required.
CLINICAL ORAL EXAMINATIONS
The purpose of oral examinations is to observe and record pertinent information, past and present, necessary to arrive at a diagnosis and treatment plan (when treatment is indicated).  A treatment plan is a list of procedures or services the dentist proposes to perform on a dental patient based on the results of the examination and diagnosis. Often more than one treatment plan is presented.

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.
8105 Case presentation – extensive treatment planning Use this code for the presentation of a treatment plan to a patient as a result of an extensive oral examination (Code 8103) and treatment planning (e.g. orthognathic case presentation to the patient and family). This code may not be reported on the same day as the examination or any other procedure
8893 Telephonic/electronic consultation
8894 Consultation without the patient (with family for consent or writing of special reports, or preparation of quotations)
8895 Examination under general anaesthesia
General Dental Practitioner
8101 Oral examination
8102 Comprehensive oral examination
8104 Limited oral examination
8189 Re-examination – existing condition
8176 Periodontal screening
8181 Administration of dermal filler within the peri-oral area.
8182 Cost of dermal filler.
8190 Consultation – second opinion or advice
Maxillo Facial Surgeon
8901 Consultation – MFOS
8902 Consultation – MFOS (detailed)
*8840 Treatment planning for orthognathic surgery – ALL
Orthodontist
8801 Consultation – Orthodontist
8802 Orthodontic consultation and treatment planning.
8803 Consultation – Orthodontis (subsequent, retention and post treatment)
8837 Diagnosis and treatment planning – Orthodontist
Periodontist/Oral Medicine
Codes 8701, 8703, 8705 and 8707 cannot be charged at one and the same visit.
8701 Consultation – periodontist
8703 Consultation – Periodontist (detailed)
8705 Re-examination – Periodontist
8707 Periodontal screening – Periodontist
8722 Cost of provisional splinting materials. See Rule 002 Appendix A.
8781 Consultation – Oral medicine (simple)
8782 Consultation – Oral medicine (complex)
8783 Consultation – Oral medicine (subsequent)
Prosthodontist
8501 Consultation – Prosthodontis
8507 Comprehensive consultation – Prosthodontist
8506 Detailed consultation – Prosthodontist
Oral Pathologist
9201 Consultation – oral pathologist
9205 Consultation – oral pathologist (subsequent)
RADIOGRAPHS/DIAGNOSTIC IMAGING
Diagnostic radiographs/diagnostic images include interpretation.

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.

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