Preventative care and screening benefit
Preventative health screening is one of the most important healthcare strategies to facilitate early diagnosis and treatment of disease as well as to improve quality of life and prevent premature death. GEMS offers comprehensive screening and preventative care benefits to its members. These benefits are available on all options and payable from the risk benefit for eligible members and beneficiaries as per criteria.
A separate limit of R863 per beneficiary per year applies for vaccinations not listed in the table below.
A limit of R863 per beneficiary per year applies and funding is allowed for Practice types 14, 15, 60, 61, 63, 110 and Specialists. Tariffs codes 0022 should be used for pharmacy administration and 0017 for GP administration.
The tables below indicate the preventative care and screening services at pharmacies and selected providers. Providers to visit the GEMS Tariff file for tariff code applicable per discipline.
| Procedure | Tariff codes | Frequency | Eligible beneficiaries | Disciplines allowed |
|---|---|---|---|---|
| Blood Pressure Monitoring |
0015 (Pr 60) 99371 (Pr 88) |
Once per benefit year | All beneficiaries 18 years and older | Allowed for Practice: 60 and 88 |
| Cholesterol Screening |
4027 (Pr 14/15) 0013 (Pr 60) 99384 (Pr 88) |
Once per benefit year | Beneficiaries 20 years and older | Allowed for Practice: 14/15, 88 and 60 |
| Osteoporosis Screening (Bone Densitometry Scan) |
50120 (Pr 38) 3604 (Pr 16, 18, 28) |
Once per benefit year | Female beneficiaries 65 years and older | Allowed for Practice: 38, 16, 18, 28 |
| Cytology Screening (Pap smears) |
Code 99385 (Sterile tray and specimen handling fee) to be billed together with tariff 0190-0193 99385,0201, 0190 – 0193 (Pr14/15,16) Procedure codes 99385 and 0201 to be billed together with consultation code 190-193 for Pr 14/15 and Pr 16
020, 301, 005, 006, 001, 002 (Pr 88)
Specimen code 020, 301 to be charged with consultation 005, 006, 001, 002, 4566, 4559 (Pr 37/52)
CER1 / 999930 (Pr 37/52) |
Once per benefit year | Female beneficiaries12 - 65 years | Allowed for Practice: 37, 52, 14/15, 16 and 88 |
| HIV / AIDS pre-test counselling with no test |
7016 (Pr 14/15) 0016 (Pr 60) 99376 (Pr 88) |
Once per benefit year | All beneficiaries | Allowed for Practice: 60, 14/15 and 88 |
| HIV / AIDS (Screening test, post-test counselling, confirmatory test, and condoms) |
7017 (Pr 14/15) 0017 (Pr 60) 99376 (Pr 88) |
Once per benefit year | All beneficiaries | Allowed for Practice: 60, 14/15 and 88 |
| Mammography Screening |
34100 (Pr 38) 39175 (Pr 39) 3605 (Pr 14/15) |
Once per benefit year | Female beneficiaries 40 years and older | Allowed for Practice: 38, 39, 14/15 |
| Peak Flow Measurement |
0019 (Pr 60) 99383 (Pr 88) |
Once per benefit year | Beneficiaries 4 years and older | Allowed for Practice: 60 and 88 |
| Pregnancy Screening Test |
0018 (Pr 60) 99381 (Pr 88)
|
Once per benefit year | Female beneficiaries 12 years and older | Allowed for Practice: 60 and 88 |
| Prostate Screening (PSA) |
4519 (Pr 37, 52)
|
Once per benefit year | Male beneficiaries 45 - 69 years | Allowed for Practice: 37, 52 |
| Faecal Occult blood test |
4352 (Pr 37, 52)
|
Once per benefit year | Beneficiaries 50 - 75 years | Allowed for Practice: 37, 52 |
| Glucose Screening |
4050 (Pr 14/15) 0012 (Pr 60) 99370 (Pr 88)
|
Once per benefit year | Beneficiaries 20 years and older | Allowed for Practice: 14/15, and 88 and 60 |
| Glaucoma Screening |
11202, 11212 (Pr 70,71) 3014, 3017, 3018 (Pr 26)
|
40 years and older | Beneficiaries 40 years and older | Allowed for Practice: 70,71 and 26 |
| Neonatal Hypothyroidism | 4507 (Pr 52) | Once per beneficiary | Neonatal beneficiaries up to 28 days old | Allowed for Practice: 52 |
| Childhood Hearing Screening |
1010, 1011, 1115, 1100, 1105, 1200 (Pr 82) |
Once per beneficiary | Beneficiaries from 1 year to 7 year | Allowed for Practice: 82 |
| Childhood Hearing Screening for infants |
1505 (Pr 82) (May not be charged with 1510) 1010, 1011, 1580 (Pr 82)
|
Once per beneficiary | Beneficiaries from 3 months to 1 years | Allowed for Practice: 82 |
| Childhood Optometry Screening |
94000 (Pr 70) |
Once per beneficiary |
Beneficiaries from 3 months to 7 years | Allowed for Practice: 70 |
| Syphilis Screening |
3949, 3951 (Pr 52, 37) |
Once per benefit year | All beneficiaries | Allowed for Practice: 52, 37 |
| Chlamydia / Gonorrhoea Screening | 3946, 3948, 3923,3925, 3960 (Pr 52, 37) | Once per benefit year | All beneficiaries | Allowed for Practice: 52, 37 |
| TB Screening |
0221 (Pr 52, 14/15) 0201 (0201 with Nappi 872938-027 Tuberculin PPD RT/23 Vial 1.5ml) |
Once per benefit year | All beneficiaries | Allowed for Practice: 52, 14/15 |
| Urine Analysis |
0014 (Pr 60) 99382(Pr 88)
|
Once per benefit year | All beneficiaries | Allowed for Practice: 60 and 88 |
|
*From 2024, no referral is required for members to have a mammogram in a Pr 38 or 39. VACCINATION SERVICES |
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| Vaccine | Frequency | Eligible beneficiaries | Disciplines allowed |
|
| Influenza vaccination | Once per annum | All beneficiaries from 6 months and older |
Allowed for Practice: 14/15, 60, 61, 63, 88, 110 and specialists |
|
| Pneumococcal vaccination | Once every 5 years |
|
Allowed for Practice: 14/15, 60, 61, 88, 110 and specialists | |
| HPV vaccination (1 course = 3 doses) | One course per beneficiary per lifetime |
Female beneficiaries:
|
Allowed for Practice: 14/15, 12, 32, 60, 61, 88, 110 | |
|
*99378 (Administration of Immunisation) allowed for Pr 88.
|
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If you have any further queries regarding this, kindly contact us on 0860 00 4367, fax us on 0861 00 4367 or send an email to enquiries@gems.gov.za
At GEMS we believe that every one of our members matter. That is why we have prepared the member newsletter to focus on your specific needs.