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gems.gov.za : Government Employees Medical Scheme Claims Process

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Name of the Organization : GEMS
Type of Facility : Government Employees Medical Scheme Claims Process
Head Office : Cape Town

Website : http://www.gems.gov.za/default.aspx?g7m5/1PZKLT7KKHRD7kX7iTVAyWsOGShbG06Rba7qoE=

GEMS Government Employees Medical Scheme Claims

Who can claim?
** The registered member/dependant. The healthcare provider can submit a claim on behalf of the registered member/dependant.

Related : How to join Government Employees Medical Scheme : www.southafricain.com/2546.html

Who cannot claim?

** To protect members’ benefits, GEMS is on a drive to provide a safer environment for processing claims.
** And with this aim, processes have been put in place to help us to better validate the submission and payment of claims.

** View the list of healthcare providers on indirect payment.
** One of the process changes is the termination of direct payments to certain healthcare service providers due to restrictions placed against them by the Scheme.

** These healthcare service providers’ claims will be rejected and GEMS members will be responsible for submitting the claim for the services provided by these healthcare providers directly to the Scheme.
** This means members have to pay healthcare costs for services from these healthcare providers directly to them and thereafter can claim back from GEMS.

Please remember that the claims submission from the member must include corresponding details and valid proof of payment, signed by the principal member, in the form of :
** A valid stamped receipt from the provider;
** An electronic funds transfer (EFT) slip; or
** A bank deposit slip.

How is the claim processed?

** The Claims Department receives the claim and assesses it according to the Scheme Rules.
** If the Scheme Rules allow, the claim will then be paid.
** Sometimes additional information is required from you or your healthcare provider, e.g. ICD-10 code, clear copy of account, detailed account, proof of payment etc. when assessing claims.
** If this information is not available, some claims may be rejected.

When are claims paid?
** There are two payments runs per month – mid month and then at the end of the month.
** Depending on when your claim is received, it can be settled at either of these runs.

Are medicine claims processed immediately?
** Your pharmacy can send medicine claims to us electronically at the point of sale.
** The Scheme Rules will be applied immediately, so you will find out if GEMS will pay for the medicine right away.
** This means that you will get your medicine immediately, if you have available benefits, GEMS will pay for the medicine without you having to pay for it in cash.
** If the medicine is not on the Scheme list, you may face a copayment or your claim may be rejected.

What information must be on your claims?

** Your membership number
** The Scheme’s name (i.e. GEMS)
** Your benefit option (for example, Sapphire, Beryl, Emerald, Onyx, or Ruby)
** Your surname and initials
** The patient’s date of birth and dependant code as it appears on your membership card

** The name of the healthcare provider
** The valid practice code of the healthcare provider
** The date of service
** The type and cost of treatment

** The pre-authorisation number, if applicable
** The Tariff code
** The relevant ICD-10 code
** Your signature to confirm that the account is valid
** If you paid for the service, attach proof of payment and highlight it clearly. Proof of payment can be either a valid receipt from the healthcare provider, an electronic fund transfer (EFT) slip or a bank deposit slip.

Submit your claims correctly :
By post: GEMS, Private Bag X782, Cape Town, 8000
By fax: 0861 00 4367
By email: enquiries AT gems.gov.za

Claims refunds

** When you have paid a healthcare provider for a service, you may claim a refund from the Scheme.
** Your available benefits, the applicable Scheme Rules and the Scheme Rate will determine whether a refund will be paid and how much will be paid.

** When submitting a claim, you need to ensure that all supporting documents are attached to the claim, including a valid proof of payment.
** The proof of payment can be either a valid receipt from the healthcare provider, an electronic fund transfer (EFT) slip or bank deposit slip.
** Refunds are paid to members electronically, so you need to make sure that we have your updated, correct banking details.

We need the following banking information :
** Account holder’s name
** Account number
** Bank name
** Branch code

** Account type (cheque, current or savings).
** You can either fax this information to 0861 00 4367 or email it to enquiries AT gems.gov.za, using your membership number as a reference.
** You can also deliver the information to one of the GEMS Walk-in Centres or post it to GEMS, Private Bag X782 [Call – X782] , Cape Town, 8000.

Should you wish to change or update your banking details, you are required to submit the following documents :
** A certified copy of your ID
** A bank account statement, crossed cheque or letter from the bank either signed or stamped (not older than three months)
** Proof of your residential address, which can be in the form of a utility bill such as your municipal account (not older than three months).

Claims alert SMS :
** You have the option to receive a claims alert SMS each time GEMS processes your claims. These SMSs acknowledge the receipt of claims, but it is not a guarantee of payment. To receive a claims alert SMS, please call 0860 00 4367 and make sure that we have your current cellphone number.

Remember :
** If you receive a claim alert SMS for a claim you are not aware of, please report it to the Scheme as soon as possible by calling us on 0860 00 4367.

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