Claims Guide

Who can claim?

In terms of the Medical Schemes Act, a medical scheme shall, in the case where an account has been rendered, subject to the provisions of this Act and the rules of the medical scheme concerned, pay to a member or a supplier of service, any benefit owing to that member or supplier of service within 30 days of the day on which the medical scheme received the claim in respect of such benefit.

The Scheme's rules make provision for the Scheme to pay any claim in line with the member's benefit option directly to the supplier (or group of suppliers) who rendered the service. Notwithstanding the provisions of this rule, the Scheme has the right to pay any benefit directly to the member concerned.

The registered member or their dependant(s). 

A healthcare service provider can submit a claim on behalf of the registered member or dependant provided that the claim is valid and the member or dependant is an active member of the Scheme.

Who can’t claim?

A member who is not an active member at the time of receiving service from a healthcare provider cannot submit a claim. This includes a member who is suspended (e.g. when contributions are not up to date and the membership is suspended or terminated, or as a result of resignation).

A provider without a valid practice number or a provider on termination of direct payment by the Scheme cannot submit a claim on behalf of a member. GEMS refers to indirect payment as termination of direct payment, which requires the member to pay for the services received and then submit a refund claim to the Scheme. This differs from the concept of indirect payment, which means that a member would receive the funds from the Scheme prior to consulting the service provider. This is to avoid instances where the member submits a claim to the Scheme and fails to reimburse the provider for the services rendered.

A member who has a waiting period is also not eligible to claim for the services obtained during the waiting period.          

How is the claim processed?

When we receive a claim, our Claims department assesses the claim according to our Scheme rules. If the claim meets the Scheme's funding guidelines, GEMS will pay the claim from the available benefits, provided the membership is active and valid when the service is obtained.

When we assess a claim, we may require additional information from the member or healthcare service provider (for example, ICD-10 code, a detailed copy of your account, or proof of payment). Unfortunately, we may reject the claim if we do not receive the required information. 

We have two monthly payment runs (one during mid-month and another at the end of the month). Your claim may be settled on either one of these payment runs, depending on the date the claim and the necessary supporting documentation were received.

Click here to view our claims run dates for 2024.

 Are claims for over-the-counter medication processed immediately?

Your pharmacy can send medicine claims to us electronically at the point of sale. We will apply our Scheme rules so that you know if GEMS will pay for the medicine. You will get your medicine immediately if you have available funds or benefits. If your medicine is not on the Scheme list, we may need a co-payment from you, or we may regrettably have to reject your claim. The pharmacist will share this information with you, and you will likely receive an SMS from GEMS if your cellphone details are up to date on our database.

What information should you include with your claims?

• Your membership number
• The medical scheme's name (GEMS in this case)
• Your medical Options(Tanzanite One, Beryl, Emerald Value, 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 service provider
• The valid practice code of the healthcare service provider
• The date of the service rendered
• The type and cost of treatment
• The pre-authorisation number (if applicable)
• The tariff code (this is from the treating healthcare service provider)
•  The relevant ICD-10 code/s
• Your signature to confirm that the account is valid
• If you paid for the healthcare service or treatment, please attach the proof of payment and highlight it clearly. Proof of payment can either be a valid receipt from the healthcare service provider, an electronic fund transfer (EFT) or a bank deposit receipt.

You can submit your claims by:

• Post: GEMS, Private Bag X782, Cape Town, 8000
• Fax: 0861 00 4367
• Email: enquiries@gems.gov.za; or a
• Drop off: GEMS walk-in centre

Claim refunds

You can claim a refund from the Scheme when you pay a healthcare service provider in advance for a service the Scheme would ordinarily cover. Your medical option, available benefits, and the applicable Scheme rules and rates billed by the service provider will determine whether we will issue a refund. 

We pay refunds to members electronically; therefore, as the main member, you need to ensure that we have your correct banking details to process your refunds. 

• Account holder's full name
• Account number
• Bank name
• Branch code
• Account type (current or savings).

Should you wish to change or update your banking details, you need to submit the following FICA documents: 

• A certified copy of your ID
• A bank account statement or an account confirmation letter from your bank that has been signed or stamped (not older than three months)
• Proof of your residential address in the form of a utility bill, a clothing or other credit account statement with your address (not older than three months).
• You can fax this information to 0861 00 4367, or you can send an email to enquiries@gems.gov.za (use your membership number as a reference). You can also drop off the documents at one of our GEMS walk-in centres or post it to: GEMS, Private Bag X782, Cape Town, 8000.

Claims alert SMS

You can sign up to get a claims alert SMS every time GEMS processes your claims. These SMSs acknowledge that we've received your claim(s), but it doesn't guarantee payment. Please call 0860 00 4367 if you'd like to get a claims alert and ensure that we have your current cell phone number.

Please note: If you get a claim alert SMS for a claim you do not recognise, report it to the Scheme by calling us on 0860 00 4367, and we'll investigate the matter.

How to read your claims statement?

Click here to understand your claims statement. You will get a claims statement after a payment claims run in which the claim was settled. Please read your claims statement carefully to understand how your claim was processed. If we did not pay your claim, your claims statement will state the reason why the claim was not paid using a rejection code. The rejection code is described in full at the end of the claims statement with the next steps/action steps to be followed. Please resubmit the claim with the applicable information if the reason requires an action. 

Please note: Claims that are submitted incorrectly will not be paid by the Scheme.  The Scheme will return your claim to you or your healthcare service provider for correction and re-submission, and you will need to resubmit the claim within 60 days after it was returned for correction. You can call us on 0860 00 4367 if you would like to know why your claim was rejected.

Save yourself the trouble and submit your claim correctly the first time!

It is important to note that medical schemes are obliged to implement a proper system of financial control, which would include systems that prevent payments being made to providers where it is reasonably certain that such providers are engaged in fraud, theft, professional misconduct or negligent behaviour which is causing the scheme loss. The provisions of the Medical Schemes Act takes this into consideration.

In the event of a review pertaining to alleged fraudulent or irregular activity taking place, the Scheme may suspend the payment of the claim unless doing so would not be in the best interest of the Scheme. Where there is suspicion of possible irregular claims, the Scheme is obliged to act in terms of its policies to prevent further loss, which it may do by terminating direct payment to the provider concerned.

The Scheme will not accept claims submitted by the healthcare provider, and the member will be responsible for submitting their own claims to us for a refund. Members, in this instance, will have to pay the medical costs for the services rendered by the relevant healthcare provider and can then claim the costs back from GEMS. 

Please remember that when you submit your claims, your submission must include a complete invoice for the service rendered and a valid proof of payment signed by the principal member in the form of:

• A valid stamped receipt from the service provider;
• An electronic funds transfer (EFT) receipt; or
• A bank deposit receipt.

Why claims are rejected, not paid or short paid?

1. Incorrect member or dependant information

• Your information must be updated so that we can process your claims promptly. We rely on your correct information to ensure that we process your claims.
• When you make a claim on behalf of your dependant(s), please ensure that they are registered with the Scheme and that their details are captured on the claim. 
  
   

2. No pre-authorisation number for oncology treatments and hospitalisation

• Although your treatment is authorised, your doctor needs to inform GEMS about any changes in your treatment so that we can evaluate your treatment plan and update the authorisation accordingly. If your doctor does not inform us about the changes, we may reject your claim (as per the Scheme rules).

3. No available benefits

• When you've reached your benefit limits, GEMS will not be able to make any more claim payments on your behalf, unless you are PMB eligible.

4. Member or dependant missing a doctor's appointment

• GEMS will not be held liable for the costs if you (or your dependants) miss a doctor's appointment. Any costs billed in such an event by your healthcare service provider will be for your own account.

5. GEMS won’t pay for claims for services rendered by a healthcare provider who isn’t registered in terms of the relevant law

• GEMS will not cover the claim if the doctor is not registered to practice medicine in South Africa.
• You will need to ask the healthcare service provider to confirm that they have a valid practice number to add to the claim. 
  
   

6. Late claim submissions

• Claims must be submitted to the Scheme before the last day of the fourth month after the medical service was rendered. For example, if the service is rendered on the 15th of February 2024, the claim must be submitted to us by the 30th of June 2024.  GEMS will not pay any claims after the 4-month (120 days) period in accordance with the Regulations of the Medical Schemes Act.  This means the member will be liable to pay for the claims that have not been submitted to us within the 4 months. Please consult your healthcare service provider to find out if they will submit your claim to the Scheme or if you should submit your claim.

7. Treatment claims we receive after a member has resigned from working in the public service or from GEMS

• GEMS is a restricted medical scheme designed for public service employees or participating employers approved by the Board of Trustees. Anyone who is not a public service employee, a retired employee or a GEMS participating employer cannot become a member of the Scheme. If you resign from your public service job, your GEMS membership will be terminated immediately. If you or your healthcare service provider claims for services rendered after you have resigned from the public service or from GEMS, you will be held liable for the relevant medical costs. The use of the medical aid after your resignation from the public service is fraudulent.

8. Scheme exclusions

• There are specific conditions and treatments which GEMS cannot pay for, in line with the Medical Schemes Act. We call the items or procedures that are not covered by the Scheme exclusions. Please ensure that the procedures, treatments, or medication you receive are covered as GEMS will not pay for excluded medical services or items. Refer to Rule 16 and Annexure E of the Scheme Rules for the list of exclusions.

9. Incorrect ICD-10 codes on the claim

• Request the healthcare service provider to ensure that the ICD-10 code on your claim is correct. This is the diagnostic code that tells the Scheme what service was rendered.

10. Duplicate claim

• The Scheme will reject a claim if the same claim was already submitted by the member or service provider and has been paid out.

11. Waiting period

• The Scheme applies waiting periods to certain membership categories as a form of underwriting. If there is a waiting period on your membership, you cannot claim for benefits during the waiting period. However, you can claim for benefits after the waiting period has lapsed. For more information, read more underwriting. 

12. Why some claims from healthcare providers are rejected?

• Full rejections may be due to the following reasons:
• Service not covered. 
• Benefits exhausted.
• The benefit option does not cover the service provided. 
•  The service provider may be undergoing an investigation.
•  Membership issues such as suspensions, terminations or not being a GEMS member.
•  Partial payments may be due to the following reasons:
•  Limited benefits available.
• The service provider charges more than the Scheme's rate.
•  Some services obtained may be items not covered by the Scheme.
•  Some information still awaited, such as clinical information.
•  Duplicate services will be rejected and are not payable
•  Incorrect billing or the billing by the provider is not in line with the billing rules 
• You may contact GEMS to confirm the reason why your claim was not paid or was short paid. Please feel free to call the call centre on 0860 00 4367 or visit a walk-in centre to obtain some assistance in this regard.

The claims refund process is summarised below: 

When claiming a refund, ensure that you include a valid proof of payment and a fully specified account, with the following information: 

• Your membership number (9 digits - include the zeroes)
• The Scheme name (GEMS)
•  Your benefit option (for example, Emerald, Onyx, Ruby, etc.)
•  Your surname and initials, as captured on GEMS’s records
•  The patient’s name and beneficiary code as it appears on your membership card with date of birth (for example, John 01 DOB: DD/MM/YYYY)
•  The name and practice number of the healthcare service provider
•  The date of service (this is the date you visited the provider for service)
•  The pre-authorisation number, if applicable
•  The Tariff code(s) and description
•  The relevant ICD-10 code (diagnosis description).

Proof of payment can either be a receipt from the healthcare service provider, an electronic fund transfer (EFT) slip, a virtual card payment, or a bank deposit slip. If you make cash payments, a receipt must be supplied with a clear stamp of the practice details to verify the proof of payment. 

We encourage you to familiarise yourself with your medical aid benefits and the requirements for submitting claims by visiting the GEMS website at www.gems.gov.za. Once on the site, use the search icon to search for the Claims Guide.