family practitioner network guide 2020
TRANSCRIPT
Family PractitionerNetwork Guide
2020
Table of Contents
1. Introduction
6. The authorisation process
2. Tariffs and fees
7. Preventative care and screening services
3. IncredibleschemebenefitsforallGEMSoptions
8. PrescribedMinimumBenefits
4. FP nomination
9. Medicine
5. Specialistreferral
10. Value add programmes
11. Useful resources
1
2
7
9
9
10
12
14
16
18
19
1 GEMS Medical Scheme
Introduction
GEMSconsiderstheFamilyPractitioner(FP)tobeattheheartofthehealthcareprocessandtheSchemeappreciates the intensive work done by FPs to ensure that its members receive the healthcare they need. This guidehasbeencreatedspecificallytoassistyouinsupportingGEMSmembersasitcontainsalltheimportantinformation required to navigate our programmes and processes.
FPs occupy a unique and fundamental position as the overall coordinator of care for our members. It is well documented that low quality healthcare is increasing the burden of illness and healthcare costs globally. In order toimprovepatienthealthcareoutcomes,GEMSembracesalleffortstocoordinatethecareofitsmembers.
Introducing Tanzanite One GEMSisveryexcitedtoofferitsmembersevenmorebenefitsin2020.TheSapphireoptionhasundergonea name change and from 1 January 2020 will be called TANZANITE ONE. In addition, TANZANITE ONE memberswillhaveaccesstoenhancedbenefitsandprivatehospitalsthroughtheGEMSHospitalNetwork.
From 1 January 2020 SapphirewillbeknownasTANZANITEONE.
Tanzanite One Option
1 GEMS Medical Scheme
FamilyPractitionerNetworkGuide20202
Tariffs and fees
For 2020 family practitioner reimbursement, kindly refer tothe tables below.
GEMSFPNetworkTariffsandFees:
Consultation Rates (Codes: 0190-0193)
Enhanced Fees
GEMS Network tariff fee REPI2 Cat 1 REPI2 Cat 2
REOFPs R405.90 R57.28 R26.00
Family Physicians R521.40 R57.28 R26.00
Level Dispensing doctor tariff Non-dispensing doctor tariff
TanzaniteOne&BerylFPs
Level 1 R407.90 R311.20
Level 2 R392.20 R311.20
Level 3 R357.70 R289.40
GEMSFPNon-NetworkTariffsandFees:
GEMS Beneficiary Consulting GEMS Non-Network tariff fee
REO R374.80
TanzaniteOne&BerylDispensing FP Non-Dispensing FP
R374.80 R374.80
Family Physicians R387.60
– TheGEMSREO(Ruby,Emerald,EmeraldValueandOnyx)FPNetworkreimbursementmodelfor2020willcontinuetoincludeanenhancedfeedependingontheprovider’sREPI²categoryscore.
– TheTanzaniteOneandBerylFPNetworkreimbursementmodelfor2020willcontinuetoincludeanenhancedfeedependingontheprovider’sREPI²categoryscore.
– AperformancereportisdistributedquarterlytokeepnetworkFPsup-to-datewiththeirlatestGEMSandREPI2 categories as well as adherence performance.
– FPscanmotivate to change theirREPI2 category on clinical grounds by sending an email to [email protected].
3 GEMS Medical Scheme
New in 2020 – Family Physicians will receive an enhanced fee for consultation codes 0190, 0191, 0192 and 0193.
– FamilyPhysicianswillstillformpartoftheREPI2 categorisation and enhanced remuneration programme.
– Allpractitionerswillreceiveenhancedremunerationforscreeningandpreventativeservices(seepage12-13forapplicabletariffcodes).
In-Room proceduresGEMShasidentifiedcertainprocedureswhichcansafelybeperformedinthedoctor’sroomswithouttheneedfor hospital admission. We urge you to consider performing these procedures in your rooms if appropriate. Please ensure that your procedure rooms are accredited under the health and safety guidelines.
Thefollowinglistofproceduresareremuneratedat200%ofSchemerateifperformedinthedoctor’srooms.Therateisinclusiveofequipmentand/orinstrumentationusedfortheproceduresanditappliestoallSchemeoptions.Pleasenotethatcertainproceduresaresubjecttopre-authorisation.
Code Procedure Pre-authorisation required
0244 Repairofnailbed(onlyforingrowntoenail) No
0307Excisionandrepairbydirectsuture;excisionnailfoldorotherminorproceduresofsimilarmagnitude(onlyforingrowntoenail)
No
0310 Radicalexcisionofnailbed(onlyforingrowntoenail) No
1018 Flexiblenasopharyngolaryngoscopyexamination No
1587 Upper gastrointestinal endoscopy Yes
1653 Totalcolonoscopy(includingbiopsy) Yes
1656 Left-sidedcolonoscopy Yes
1676 Flexiblesigmoidoscopy(includingrectumandanus) No
1677 Sigmoidoscopy:Firstandsubsequent,withorwithoutbiopsy No
1679 Sigmoidoscopywithremovalofpolyps:Firstandsubsequent No
1681 Proctoscopywithremovalofpolyps:Firsttime No
1683 Proctoscopywithremovalofpolyps:Subsequenttimes No
2207 Vasectomy No
3045, 3047, 3050, 3051, 3052
Cataract surgery Yes
Circumcisionprocedurescanalsobeperformedinthedoctor’sroomsandaresubjecttopre-authorisation,managedcareprotocolsandprocesses,andtheuseofaGEMSNetworkFP.CircumcisionsarelimitedtoaglobalfeeofR1576whichincludesallpost-procedurecare,consultationsandmedicinewithinamonthofthe procedure.
FamilyPractitionerNetworkGuide20204
Obtain authorisation
Perform procedure
Submit claim
Claim paid @ 100% Scheme rate
How to request authorisationWhenrequestingauthorisation,pleasecall0860004367orsendanemailtoHospitalauths@gems.gov.zaandsupplythefollowinginformation:
– Membershipnumber
– Dependant number
– Treating provider practice number
– Clinicalcodes(ICD10andrelevanttariffcodes)
Onceapproved,theauthorisationnumberwillbesenttoboththememberandthehealthcareprovider.
Simplified process for authorisation of doctor’s room procedures
Y
N
N
Y N
Y
Is the procedure listed above?
Is the procedure to be conducted in rooms?
Does the procedure require authorisation?
Obtain authorisation
Perform procedure
Submit claim
Claim paid @ 200% Scheme rate
5 GEMS Medical Scheme
Procedure codes that can be charged in addition toa consultation code
Procedure codes that can be charged in addition to a consultation code but subject to authorisation*
GEMS tariff code Procedure
0300 Stitchingofawound
0301 Stitchingofanadditionalwound
0307 Excisionandrepair
0255 Drainage of subcutaneous abscess and avulsion of nail
0259 Removalofforeignbodysuperficialtodeepfascia
0887 Limbcast(includingcostofPOPandmaterial)
1725 Drainageofexternalthrombosedpile
GEMS tariff code Procedure
1186 Flowvolumetest:Inspiration/expiration
1188 Flowvolumetest:Inspiration/expiration/pre-andpost-bronchodilator
1234 ECGbicycle
1235 ECGmultistagetreadmill
2713 Lumbar puncture
*Notethatthesecodeswillonlybeallowedforthediagnosisandmanagementofapprovedchronicconditionsforregisteredchronic
membersaspartofthechronicconditionbenefit,subjecttoPMBtreatmentguidelines.Paymentwillbesubjecttothedoctorsubmitting
theresultsforthesetests.RatesareavailableinthetarifffileontheGEMSwebsiteatwww.gems.gov.za.
Note:OnlyapplicabletoTanzaniteOneandBeryl
FamilyPractitionerNetworkGuide20206
Codes which are included in the consultation fee**
**Thislistonlyreferstocommonlyusedcodesandisnotexhaustive.
Note:OnlyapplicabletoTanzaniteOneandBeryl
GEMS tariff code Procedure0145-1049 Modifiers
0017 Injections by practitioner
0199 Completion of chronic medicine forms by medical practitioners
0202 Settingsteriletray
0205 Intravenousinfusions(patientunder3years)
0206 Intravenousinfusions(patientover3years)
0222 Intralesionalinjectionintoareasofpathologye.g.Keloid:Single
0223 Intralesionalinjectionintoareasofpathologye.g.Keloids:Multiple
0233 Biopsywithoutsuturing:Firstlesion
0234 Biopsywithoutsuturing:Subsequentlesions
0235 Biopsywithoutsuturing:Maximumformultipleadditionallesions
0145-1049 Modifiers
0017 Injections by practitioner
0199 Completion of chronic medicine forms by medical practitioners
0202 Settingsteriletray
0205 Intravenousinfusions(patientunder3years)
0206 Intravenousinfusions(patientover3years)
0222 Intralesionalinjectionintoareasofpathologye.g.Keloid:Single
0223 Intralesionalinjectionintoareasofpathologye.g.Keloids:Multiple
0233 Biopsywithoutsuturing:Firstlesion
0234 Biopsywithoutsuturing:Subsequentlesions
0235 Biopsywithoutsuturing:Maximumformultipleadditionallesions
0241 Treatmentofbenignskinlesionbychemo-cryotherapy:FirstLesion
0242 Treatmentofbenignskinlesionbychemo-cryotherapy:Subsequentlesions(each)
0243Treatmentofbenignskinlesionbychemo-cryotherapy:Maximumformultipleadditionallesions
0244 Repair nail bed
0245 Removal of benign lesion by curetting under local or general anaesthesia
0661 Aspirationofjointorintra-articularinjection
0663 Multipleintra-articularinjectionsforrheumatoidarthritis:Firstjoint
0763 Muscleandtendonrepair:Tendonorligamentinjection
1063 Removal of foreign bodies from nose in rooms
1136 Nebulisationinrooms
1192 Peak Flow
1228 ECG:Withouteffort
1232 Electrocardiogram:Withouteffort
1233 Electrocardiogram:Withandwithouteffort
1996 Bladdercatheterisation:Male(notatoperation)
1997 Bladdercatheterisation:Female(notatoperation)
2442 Insertionofintrauterinecontraceptivedevice(IUCD):Excludingcostofdevice
2565 Implantation hormone pellets
3275 Audiometry – tympanometry
3287 Spinaljointandligamentinjection
4188 Urinedipstick,perstick(irrespectiveofthenumberoftestsonstick)
7 GEMS Medical Scheme
Incredible Scheme benefits forallGEMSoptions
AllGEMSoptionsincludeanout-of-hospitalbenefittofacilitatetheefficientmanagementofhealthcare.Someofthesebenefitsarehighlightedinthetablebelow.Moredetailisavailablehere.
Option Radiology PathologyOut-of-Hospital benefits
Personal Medical Savings Account
Allied health
servicesMaternity
Acute & Chronic
Medicine
Tanzanite One(Network option)
✓ ✓ ✓ ✓ ✓ ✓
Beryl ✓ ✓ ✓ ✓ ✓ ✓
Ruby ✓ ✓ ✓ ✓ ✓ ✓ ✓
Emerald Value(Network option)
✓ ✓ ✓ ✓ ✓ ✓
Emerald ✓ ✓ ✓ ✓ ✓ ✓
Onyx ✓ ✓ ✓ ✓ ✓ ✓
FamilyPractitionerNetworkGuide20208
Important points to keep in mind:
Tanzanite One
– UnlimitedFPconsultationstonominatedFPswithintheGEMSFPNetwork.
– MembersmustnominateaFPandusethenominatedFPforalltheirconsultations.
– A30%co-paymentwillapplyonaclaimfromanon-nominatedGEMSNetworkFP.
– Referral from a nominated FP is required for all specialist consultations.
– Voluntaryadmissiontoanon-networkhospitalwillattractaR12000co-payment.
Ruby
– MembershaveaPersonalMedicalSavingsAccount(PMSA)andablockbenefittocoverout-of-hospitalbenefits.
Emerald Value
– ConsultationsmustbebynominatedFPswithintheGEMSFPNetwork.
– MembersmustnominateaFPandusethenominatedFPforalltheirconsultations.
– A30%co-paymentwillapplyonaclaimfromanon-nominatedGEMSNetworkFP.
– Referral from a nominated FP is required for all specialist consultations.
– Voluntaryadmissiontoanon-networkhospitalwillattractaR12000co-payment.
9 GEMS Medical Scheme
FP nomination
Specialist referral
In2020,itwillbecompulsoryforallTanzaniteOneandEmeraldValueoptionbeneficiariestonominatetheirtreatingNetworkFPwhowillcoordinatetheircare.Beneficiariesonotheroptions(Ruby,Beryl,Emerald,andOnyx)arealsoencouragedtonominatetheirFPtocoordinatetheircare.
NominationscanbemadebycontactingtheGEMScallcentreon0860004367.
Guide to specialist referrals for Tanzanite One and Emerald Value options
100% of Scheme rate for Non-Network SpecialistsAnd
130% of Scheme rate for Network Specialists
Referral by nominated
network FP
Referral by non-nominated
non-network FP
No referral
30% co-payment
Y N
Pre-authorisation
30% co-payment
Y N
Referral by non-nominated
network FP
Pre-authorisation
30% co-payment
Inordertoavoidhavingtopre-authoriseaspecialistconsult,and/oravoida30%co-payment,GEMSbeneficiariesontheTanzaniteOneandEmeraldValueoptionsrequireareferralfromtheirnominatednetworkFP.Thereferralpractitioner’spracticenumber(thenominatedFPforTanzaniteOneandEmeraldValueoptions)needstobestatedontheclaimofthespecialisttoavoidco-payments.
FamilyPractitionerNetworkGuide202010
The authorisation process
How to find a GEMS network provider: MemberscanaccessthelistofFPandSpecialistNetworkprovidersat:
– GEMSwebsite:www.gems.gov.za
– GEMSCallCentre:0860004367
– Email:[email protected]
When is pre-authorisation required?
– Specialistreferralbyanon-nominatedFP
– Certain doctor’s room procedures
– Certainconsultationsand/orprocedures(e.g.specialistconsultationswhenreferralisfromanon-nominated/non-networkFP)
– Hospitaladmissions
– Specialisedradiologyinvestigations(e.g.CT,MRI,angiogram,radio-isotopescans)
Mandatory details required for pre-authorisation:
– Membershipnumber
– Patient’s details
– Patient’sbeneficiarynumber
– Patient’sdateofbirthintheformatDDMMYYYY
– Provider’s practice number
– Provider’spracticetype(e.g.18foraphysician)
– Reason for authorisation
– Specialistreferral:Thenumberofmonthsthatyouwantthepatienttovisitthespecialist(between1and6,e.g.3)
– Hospitalisation:Dateofadmissionorevent
– Diagnosis(ICD10codes)
– Proposedsurgical,diagnosticprocedureorspecialisedradiologicalintervention(CCSA,RPLcodes)
AnauthorisationcanbeobtainedbycallingGEMSon0860436777.
Below is a quick reference guide for specialist practice types requiring a specialist referral:
Specialist Type
Specialist Type Description
12 Dermatologist
16Gynaecologist(excludingmaternitycases)
17 Pulmonologist
18 Physician
19 Gastroenterologist
20 Neurologist
21/33 Cardiologist and paediatric cardiologist
24 Neurosurgeon
28 Orthopaedicsurgeon
Possible responses to a pre-authorisation request – APPROVED:FundedbySchemeaccordingtoschemeratesandPMBlegislation
– DECLINED:NOTfundedbySchemeforvariousreasons
– PENDING: Clinical information required to assess medical necessity and clinical appropriateness
Communication of the authorisation response will be sent to both the member and healthcare provider via telephone,fax,SMS,emailorpost.
The member or treating healthcare provider may appeal a funding decision but must be able to provide additional information and/or documentation to support an appeal.
GEMS Medical Scheme11
Specialist Type
Specialist Type Description
30 Otorhinolaryngologist(ENT)
31 Rheumatologist
32Paediatrician (excludingchildrenunder2yearsofage)
33 Cardiology paediatrician
36 Plastic and reconstructive surgeon
42 Surgeon
44 Cardiothoracic surgeon
46 Urologist
FamilyPractitionerNetworkGuide202012
SCREENING SERVICES
Procedure Tariff code Frequency Eligible beneficiaries
Cholesterol screening
GPCode4027 Twice per annum 20 years and older
Osteoporosisscreening(bonedensitometryscan)
50120, 3604 Onceperannum Females 65 years and older
CytologyScreening(Papsmears)
4566, 4559
FP Procedure code 0202 to be billed together with tariff 190-193
Onceperannum Females12-65years
HIV/AIDSpre-testcounselling with no test
7016(GP) Twice per annum Allbeneficiaries
HIV/AIDS(screeningtest,post-testcounselling, confirmatorytestandcondoms)
7017(GP) Twice per annum Allbeneficiaries
Mammographyscreening
39175(Pr39)34100(Pr38,39)3605(Pr14/15)
Onceperannum Females 40 years and older
Prostate screening (PSA)
4519 Onceperannum Males45-69years
Faecal occult blood test
4352 Onceperannum 50-75years
GlucoseScreeningGP4050(Glucosestrip-testwith photometric reading
Twice per annum 20 years and older
Glaucomascreening
11202(Pr70&71)11212(Pr70&71)3014(Pr26)3017(Pr26)3018(Pr26)
Onceperannum 40 years and older
Neonatalhypothyroidism
4507 Singlescreening Up to 28 days old
Preventative care and screening services
Alloptionshaveapreventativecareandscreeningbenefitwhichpaysfromrisk.Inordertoensurepayment,please use the correct tariff code.
SCREENING SERVICES (cont.)
Procedure Tariff code Frequency Eligible beneficiaries
Childhood hearing screening
1010, 1011, 1115, 1100, 1105, 1200
Onceperbeneficiary
≥1–7years
Childhood hearing screening for infants
1505,1010, 1011, 1580Onceperbeneficiary
Birth–1year(excludingfirstx3monthsoflife)
Childhood optometry screening
94000Onceperbeneficiary
Birth–7years(excludingfirstx3monthsoflife)
Syphilisscreening 3951, 3949Twice per beneficiaryperannum
Allbeneficiaries
Chlamydia/gonorrhoea screening
3946, 3948, 3923, 3925, 3960
Twice per beneficiaryperannum
Allbeneficiaries
TBScreening0221,0201(0201withNappi872938-027TuberculinPPDRT/23Vial1.5ml)
Twice per beneficiaryperannum
Allbeneficiaries
VACCINATIONS
Procedure Tariff code Frequency Eligible beneficiaries
Influenzavaccination
732826Influvac813338Vaxigrip0017GPmodifier,tobecharged together with a Nappicodeiftherewasnoconsultation
Onceperannum Allbeneficiaries≥6monthsofage*
Pneumococcal vaccination
755826Pneumovax23715858Prevenar13pre-filledsyringe 0.5ml FP Administration Code 0017
Onceevery5years
Highriskbeneficiaries:≥65years2-64yearswithachronicregistration/ relevant hospital admission*
HPVvaccination(1course=3doses)
710020(CervarixPre-filledSyringe),710249(GardasilInjection)GPadministrationcode0017
Onecourseperbeneficiaryperlifetime
Females9-14years
Injectionsadministeredbypractitioners:When desensitisation, intravenous, intramuscular or subcutaneous injections are administered by the practitioner him-/herself to patients who attend the consulting rooms, a first injection forms part of the consultation/visit and only all subsequent injections for the same condition should be charged at 7.50 consultative services units using modifier 0017 to reflect the amount (not chargeable together with a consultation item) *Chronicheartdisease,includingcongestiveheartfailureandcardiomyopathies;Chronic lung disease, including chronic obstructive pulmonary disease, emphysema and asthma (smokers with chronic lung disease secondary to smoking); Diabetes mellitus; Cerebrospinal fluid leaks; Cochlear implant(s); Alcoholism; Chronic liver disease; Congenital or acquired immunodeficiencies (includes B- (humoral) or T-lymphocyte deficiency, complement deficiencies), and phagocytic disorders (excluding chronic granulomatous disease); HIV infection; Chronic renal failure or nephrotic syndrome; Leukaemia or lymphoma; Hodgkin disease; Generalised malignancy; Iatrogenic immunosuppression (diseases requiring treatment with immunosuppressive drugs, including long-term systemic corticosteroids and radiation therapy); Solid organ transplant; Multiple myeloma
GEMS Medical Scheme13
FamilyPractitionerNetworkGuide202014
Prescribed Minimum Benefits
PrescribedMinimumBenefits(PMBs)areminimumbenefitsthatGEMSprovidesforinaccordancewiththeMedicalSchemesAct.
GEMS offers these benefits for all members for the diagnosis, treatment and care of the specified medical conditions, including:
– Alistof270medicalconditions;
– Anyemergencymedicalconditions;
– 26chronicconditionsthatcanbefoundontheChronicDiseaseList(CDL);
– The complete lists are available at www.medicalschemes.com
Designated Service Provider (DSP) ADSPisahealthcareproviderorgroupofproviderswhohavebeenselectedbyandhaveacontractwithGEMStoprovidememberswiththediagnosis,treatmentandcareinrespectofmedicalconditions,includingPMBconditionsaccordingtoanagreedfeeschedule.
GEMShascontractedwithhealthcareprovidersorgroupsofproviders toprovidehealthcareservices tomembers.AlthoughallGEMSmembersmayaccesscarefromprivateprovidersforPMBservices,thelevelofcareandservicesfundedasPMBaredeterminedbythatprovidedinState.TheGEMSDSPsforout-of-hospitalservicesare:
Claimsforanymembervoluntarilymakinguseofanon-DSPwillbefundedatSchemeratesonly.Networkproviderswillbefundedatnetworkrates.Shouldamembermakeuseofanon-DSPinvoluntarily,asinthecase of an emergencyorwheretheserviceisnotavailableoraccessibleataDSP,theclaimwillbefundedatcost. These rules also apply for all anaesthetist claims.
Chronic MedicineCourier
Pharmacy
The State
Chronic MedicinePharmacy
GEMSDental Network
GEMSEmergencyMedicalServicesNetwork
GEMSOpticalNetwork
PMB conditionsGEMSwillfundthediagnosis,treatmentandcareofanumberofchronicconditionsasPMBs.Alloptionsenjoyfundingfor26PMBconditionsandadditionalconditionsareincludeddependingontheoptionselected.
Out-of-hospitalPMBsaremanagedintheformoftreatmentplansorbasketsofcarewhicharevalidforabenefityear(1Jan-31Dec).Treatmentplansoutlinetheannualnumberandtypeofconsultations,pathologyandradiologypercondition.MembersaccessthesebenefitsbycompletingandsubmittingthePMBrequestform or when a chronic medicine authorisation is generated.
If a member is registered for more than one chronic condition, the various care plans will be merged and the memberwillbeauthorisedforthemaximumofthehighestnumberoftreatmentsintheplanforeachserviceand not an accumulative quantity.
ItisalsoimportantthatthecorrectICD10codesaresubmittedonallclaimstoensurecorrectpayment.Oncethetreatmentplanhasbeenloaded,theapplicableclaimswillbepaidfromtherelevantday-to-daybenefits.Shouldthesealsobecomedepleted,claimswillbepaidfromriskaccordingtotheauthorisationgiven.
Ifamemberhasanactivewaitingperiod imposedbytheunderwritersandnoPMBeligibility, theclaims/requests will be declined.
✓ TheCarePlansarecommunicatedatthestartofabenefityear,andthereafter inMay,AugustandOctobershouldtherehavebeenanyadditionsorchangestotheplan.
✓ The PMBrequestformisavailableontheGEMSwebsiteandtelephonicallyon0860004367viaclientservices.
✓ The treating doctor and patient must complete the relevant information and sign the form before submitting.
✓ FPs may contact 0860 436 777 to request a copy of the Care Plan.
AlthoughallGEMSmemberpatientsmayaccesscarefromprivateprovidersforPMBservices,theavailabilityoftheprocedureorserviceatastatehospitalinformsthefundingdecisionintermsoftherateofpayforPMBcasesforprovidersassociatedwithin-hospitalevents.
PMB Retrospective Review ProcessThereisaclaimsqueryprocessinplacetoretrospectivelyreviewunpaid/shortpaidclaimsforpossiblePMBeligibility.
The review process takes the following into account:
– IstheICD10codeaPMB?
– Is the event an emergency?
– Istheprovideronthenetwork?
– IstheservicePMBlevelofcare?
– IsaDSPaccessible?
GEMS Medical Scheme15
FamilyPractitionerNetworkGuide202016
The outcome of the review process will be any of the following:
Theprocessoutlinedabovehasbeenextensively reviewedand iscontinuouslymonitored toensure thatfeedback is provided as soon as possible.
HealthcareprovidersmayappealthedecisionifPMBatcostisdeclined.Thisfollowsadefinedprocesswhichincludesobtainingadditionalinformation,internalcommitteereviewandexternalconsultantreviewifnecessary.Allescalationsand/[email protected]
Decision Payment Outcome
PMBatcostdeclined 100%Schemeratewithreason
PMBatcostapproved Upto300%Schemerate
PMBatcostapproved Ifbilledamount>300%,negotiatefinalrate
Medicine
Acute MedicineAllbenefitoptionshaveanacutemedicinebenefit.AcutemedicinecanbeobtainedfromadispensingFPoraPharmacywhenprescribedbyanon-dispensingFP.Acutemedication,dispensedbytheGEMSTanzaniteOneandBerylFPs,isincludedintheconsultationfee.Theirdispensingstatusanddispensinglicensenumbermustbeindicatedontheapplicablecontractannexure.
Non-dispensingnetworkFPsarenotlicensedtodispensemedicationbutcanprescribeacutemedicationfromtheGEMSacuteformulary.ForTanzaniteOneandBeryl,prescribedacutemedicineshouldbeobtainedfromGEMSDSPNetworkpharmacies,subjecttoSchemerules.
Chronic Medicine Chronic medicine benefits are managed using the following tools:
✓ Clinical and reimbursement guidelines
✓ PMBmedicineformularies
✓ MedicinePriceList(MPL)
New registration and updates ✓ Members,doctorsandpharmacistscancontacttheChronicAuthorisationDepartmenttoregisternewapplicationsorupdateexistingauthorisations.Alternatively,theymayobtainthechronicapplicationformontheGEMSwebsitebyclickinghere or request it telephonically by calling 0860 00 4367.
✓ When calling, the membership details will be required, as well as a valid prescription with the diagnosis orICD-10code.
✓ Alternatively, both the treating doctor and patient must complete the relevant information on the chronic application form and sign it before submitting.
✓ Thechronicapplicationformorvalidprescriptionmaybesubmittedtochronicdsp@gems.gov.za.
✓ Pleasenotethatunderwritingwillapply(e.g.Generalandcondition-specificwaitingperiods).
✓ HealthcareprovidersmaycontacttheChronicAuthorisationDepartmenton0860436777,andmembersmay call 0860 00 4367.
Co-PaymentsCo-paymentsareincurredwhenmembersusenon-formularydrugsormedicinethatischargedabovetheMPLreferenceprice.
Inordertocontaintheescalatingcostsofmedicines,GEMSusestheMPLtodeterminethemaximumpricetheSchemewillpayforthosemedicineswiththesameactiveingredientbasedontheavailabilityofgenericequivalentsonthemarket.ThefundamentalprincipleoftheMPListhatitdoesnotrestrictamember’schoiceof medicines, but instead limits the amount that will be paid should a member choose a medicine above the MPL.MPLreferencepricesarecarefullydeterminedsoastoensureadequateavailabilityofgenericequivalentswithinthepricelimit,withoutco-paymentsbeingnecessary.
AsaFP,youcanassistmemberstoavoidundesirableco-paymentsbyensuringthatallscripteditemsarewithintheAcute/ChronicFormularies.Inadditionclaimssubmittedfromanon-DSPPharmacywillalsoattracta30%co-payment.
Co-payments on chronic medicine can be avoided by doing the following:
✓ Toavoida30%non-DSPco-payment,patientsmustensurethattheyclaimtheirchronicmedicinefromanallocatedDSPthatformspartoftheGEMSPharmacyNetwork.
– ToconfirmorchangeanallocatedNetworkPharmacy,apersonmaycontactGEMSon0860004367andthenfollowthepromptsbelow:
– Press‘4’forPre-authorisationsandselectyourpreferredlanguage;
– Press‘3’and‘2’astheseselectionsareashortcuttogethelpselectingaNetworkpharmacyorwith other general chronic medicine queries.
✓ Toavoida30%out-of-formularyco-payment,theFPmustprescribemedicineslistedontheGEMSformulary.
✓ Toavoidgenericco-paymentsonmedicines,patientsshouldspeaktotheirpharmacistaboutgenericmedicinesandmedicineswithintheGEMSMPL.
GEMS Medical Scheme17
FamilyPractitionerNetworkGuide202018
Acute and Chronic Medicine Formularies ✓ FormulariesareavailabletomembersandhealthcareprovidersontheGEMSwebsite.Healthcare
providers may access the most recent formularies via this link.
✓ Formularies are reviewed and updated throughout the year.
Value add programmes
Chronic Back and Neck Rehabilitation ProgrammeGEMShasestablishedaChronicBackandNeckRehabilitation(CBNR)programmewhichprovidesGEMSbeneficiarieswithappropriatetreatmenttomanagetheirbackandneckpain.Positiveoutcomesofthisnon-surgicalprogrammeincludeimprovedflexibility,restoringfunctionality,reducingpainandadecreaseordelayin the need for surgery, which leads to a more productive life.
ThefocusoftheCBNRprogrammeisonbackandneckrehabilitationwiththemajorcomponentsbeingcontrolledexercises,biopsychosocialsupportandpaineducation.TheFPlocatedinthecentresisthecoordinatorofthespinalcareandhe/sheissupportedbyamultidisciplinaryteam(includingaphysiotherapistand/orbiokineticistand/oroccupationaltherapist).Clinicalmeasurementsaretakenandrecordedandtheseareusedtoevaluatethe progress of treatment over time.
ThecostoftheprogrammeispaidfromaseparateCBNRbenefitandsothereisnofinancialimpactonday-to-daybenefitsorsavings.
ShouldyourGEMSpatientrequireareferraltoaCBNRnetworkfacility,kindlysendanemailtoenquiries@gems.gov.za.ForanupdatedCBNRnetworklistclickhereorcalltheGEMSCallCentreon0860436777.
FP-UpskillingAsfrom2020,GEMSwillintroduceanonlineFP-upskillingprogramme.Detailswillbecommunicatedoncethis is up and running.
GEMS Medical Scheme
Useful resources
SERVICE PURPOSE TELEPHONE EMAIL ADDRESS/LINKS FOR QUERIES
GEMScontactcentre
GeneralqueriesrelatedtoGEMS
0860 436 777 [email protected]
GEMSwebsiteViewGEMSproductsandservices
- www.gems.gov.za
GEMStarifffile,formularies and forms
ToviewGEMStarifffile,formularies and forms
-
www.gems.gov.za,selectHealthcareProviders>Tools>SelecteitherTarifffile,ICD10CodesorFormsfromthemenu.
GEMSnetworkcontract management and provider liaison consultants
Contractingqueries,REPI2 categorisation queries or provider liaison consultant assistance
-
TANZANITEONE-BERYL:[email protected]
Alternative:[email protected]
Chronic medicine management – new registrations and updates
Chronic registrations 0860 436 777 [email protected]
Chronic medicine authorisation queries
Queries related to the authorisation of chronic medicines
0860 436 777 [email protected]
FraudHotline Fraud-relatedmatters 0800 212 [email protected]@thehotline.co.za
Hospitalpre-authorisation
Allhospitalpre-authorisationsfornon-emergencyevents
0860 436 777 [email protected]
Submissionofclaims
SubmissionsofclaimsforGEMSbeneficiaries
0860 436 777 [email protected]
Queries of claimsQueries relating to a claim for GEMSbeneficiary
0860 436 777 [email protected]
Oncologyservices Oncology-relatedqueries 0860 436 777 [email protected]
AmbulatoryPMB AmbulatoryPMBqueries 0860 436 777 [email protected]
HIV/Aidsmanagement
HIV/AIDSrelatedqueries 0860 436 736 [email protected]
19
Contact details
GEMS Contact Centre0860 436 777 for provider queries0860 00 4367 for member queries
Fax0861 00 4367
Webwww.gems.gov.za
Postal addressGEMS,PrivateBagX782, Cape Town, 8000
GEMS Emergency Services0800 444 367
GEMS Fraud hotline0800 212 [email protected]
ThedigitalmembershipcardisavailableontheGEMSMemberappandis
convenientformembersandtheirbeneficiaries.Makeuseofthemulti-function
GEMSMemberapptointeractwiththeSchemeathomeoronthegotomake
yourlifeeasier.UsetheQRcodetodownloadtheGEMSMemberApp.