Dear Dental Provider As from 1 January 2013 the GEMS Dental Management Programme will be managed by Prime Cure Health. The Dental Managed Care Programme will incorporate all five GEMS benefit options. For dental pre-authorisations or any dental queries, please contact the GEMS Call Centre on 0860 00 4367 and follow the voice prompts. All GEMS dental claims for services rendered from 1 January 2013 are to be sent as follows: System | Destination code | QEDI | 642P | Mediswitch | PCUR0001 | Health Bridge | 642P | Lenasia Computers | 642P | Medinol | 642 | EMD | 642P |
Paper claims are to be emailed to enquiries@gems.gov.za, faxed to 0861 00 4367 or posted to: GEMS
Private Bag X782
Cape Town
8000 If you are already contracted to GEMS, please refer to the GEMS dental manual for 2013 for the detailed benefits and managed care rules of all five GEMS options – Sapphire, Beryl, Ruby, Emerald and Onyx. The detailed benefits can also be found on the GEMS website at http://www.gems.gov.za/. If you are not contracted to GEMS, please contact 0860 00 4367 to join the rapidly growing GEMS Network. Beryl and Sapphire options
Members on these two options may only obtain services from a GEMS contracted network provider. Please contact the GEMS Call Centre on 0860 00 4367 to obtain a pre-authorisation for certain procedures. Summarised benefits offered by Sapphire: - Services must be provided by a GEMS dental network service provider only.
- Examinations and preventative treatment: One consultation/examination and preventative treatment episode per beneficiary per benefit year.
- One emergency visit per beneficiary per year for pain and sepsis.
- Plastic dentures subject to pre-authorisation.
- No specialised dentistry benefit – limited to PMBs.
- All services are subject to an approved list of tariff codes, managed care protocols and processes.
- Charting: Please note that as part of code 8101 a once-off patient charting and oral-examination will be required for each beneficiary visiting your practice from January 2013 to be submitted to the Scheme on the Dental Report for Registration, Pre-notification and Pre-authorisation Form.
Summarised benefits offered by Beryl: - Services must be provided by a GEMS dental network service provider only.
- Examinations and preventative treatment: One consultation/examination and preventative treatment episode per beneficiary per benefit year.
- One emergency visit per beneficiary per year.
- Dentures and specialised dentistry services limited to R2 581 per beneficiary per annum.
- All dentures and specialised dentistry subject to pre-authorisation.
- All services are subject to an approved list of tariff codes, managed care protocols and processes.
- Charting: Please note that as part of code 8101 a once-off patient charting and oral-examination will be required for each beneficiary visiting your practice from January 2013 to be submitted to the Scheme on the Dental Report for Registration, Pre-notification and Pre-authorisation Form.
Summarised benefits offered by Ruby: - Services not limited to network dental service providers.
- Shared overall dental limit with in-hospital dentistry of R2 405 per beneficiary per annum.
- Conservative and restorative dentistry (including plastic dentures): 100% of Scheme rate subject to available funds.
- Specialised dentistry (including maxillo-facial benefits):
o Pre-authorisation needed (except for metal-based dentures).
o Excludes osseo-integrated implants, all implant related procedures and orthognatic surgery.
o Excludes orthodontic treatment on patients older than 21 years. - General anaesthesia and conscious sedation:
o Subject to pre-authorisation and managed care protocols and processes.
o Only applicable to beneficiaries under the age of eight years, severe trauma and impacted third molars.
o Impacted third molars: 200% of Scheme rate payable for removal under conscious sedation in doctors’ rooms. - Charting: Please note that as part of code 8101 a once-off patient charting and oral-examination will be required for each beneficiary visiting your practice from January 2013 to be submitted to the Scheme on the Dental Report for Registration, Pre-notification and Pre-authorisation Form.
Summarised benefits offered by Emerald: - Services not limited to dental network service providers.
- Shared overall dental limit with in-hospital dentistry of R3 696 per beneficiary per annum.
- Conservative and restorative dentistry (including plastic dentures):
o 100% of Scheme rate subject to available funds.
o Limited to R1 760 per beneficiary per year. - Specialised dentistry (including maxillo-facial benefits):
o Pre-authorisation needed (except for metal-based dentures).
o Excludes osseo-integrated implants, all implant related procedures and orthognatic surgery.
o Excludes orthodontic treatment on patients older than 21 years.
o Subject to the stated overall dental limit of R3 696 per beneficiary per annum (except when utilised for metal-based dentures where a limit of R 1 936 will apply for the metal-based portion, which is classified under specialised dentistry). - General anaesthesia and conscious sedation:
o Subject to pre-authorisation and managed care protocols and processes.
o Only applicable to beneficiaries under the age of eight years, severe trauma and impacted third molars.
o Impacted third molars: 200% of Scheme rate payable for removal under conscious sedation in doctors’ rooms. - Charting: Please note that as part of code 8101 a once-off patient charting and oral-examination will be required for each beneficiary visiting your practice from January 2013 to be submitted to the Scheme on the Dental Report for Registration, Pre-notification and Pre-authorisation Form.
Summarised benefits offered by Onyx: - Services not limited to dental network service providers.
- Shared overall dental limit with in-hospital dentistry of R6 123 per beneficiary per annum.
- Conservative and restorative dentistry (including plastic dentures): 100% of Scheme rate subject to available funds.
- Specialised dentistry (including maxillo-facial benefits):
o Pre-authorisation needed (except for metal-based dentures).
o Excludes osseo-integrated implants, all implant related procedures and orthognatic surgery.
o Excludes orthodontic treatment on patients older than 21 years. - General anaesthesia and conscious sedation:
o Subject to pre-authorisation and managed care protocols and processes.
o Only applicable to beneficiaries under the age of eight years, severe trauma and impacted third molars.
o Impacted third molars: 200% of Scheme rate payable for removal under conscious sedation in doctors’ rooms. - Charting: Please note that as part of code 8101 a once-off patient charting and oral-examination will be required for each beneficiary visiting your practice from January 2013 to be submitted to the Scheme on the Dental Report for Registration, Pre-notification and Pre-authorisation Form.
Should you require further information, please do not hesitate to contact GEMS on 0860 00 4367.
Yours sincerely
Dental Management Programme
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2014-05-30 @ 3:27 pm
i have a mexilo operation/surgery for the left side of my face, where they will be removing a non cancerous tumor, i want to do a pre authorisation as per doctors instructions,but i do not have the email address. i am under the gems medical aid.
please help.
2014-06-01 @ 8:55 am
Please to get in touch with GEMS medical aid directly via their website.
2015-08-26 @ 9:10 pm
I had a dental procedure done in Feb this year at hospital, and received authorization for the procedure. My option on Gems is Emerald.Thereafter prime cure has not paid the hospital up to now, I followed them up since April. Every time I enquired I was told it was a legitimate claim and will be sorted out in a week or so, but up to now prime cure hasn’t settled it. The hospital has even send me the bill of R19.000 to pay them since the medical aid is not responding to settle account. I was given a very bitter experience by dental prime cure, and at the end they said to me that they were going to pay part of that claim, though my option states 100% coverage in hospital. One of their consultants said it was my duty to ensure how much they are going to be paying prior to the hospital admission, despite my option stating 100% in-hospital coverage. The worse thing is that each time I follow matter up I get a different person who promises that he will sort matter out, but all in vain or else, my call is put on hold for hours until I drop it ,very, very frustrating! And I am not referred to any senior person to talk to, if I ask to, who can probably give me some sense of this matter. I was even advised by the media to go to the medical aid ombudsman for help, and also sort legal aid as well, which I hope will help me resolve my problem. I wouldn’t recommend them to anyone and even decided to terminate my contract with Gems since they contract with some service providers which gives clients a very, very raw deal, because at least if they called me and communicated with me stating why they are not honoring this claim since Feb I could have understood. UNHAPPY CLIENT.