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  • PMB-related questions
  • REPI questions
  • Network administration questions
  • Funding questions
  • Claims related questions
  • FWA questions
  • Pre-authorizations
  • Questions relating to modifiers
  • Medicine Management questions

PMB-related questions

  • If the review process results in a decline, the claim will be paid at 100% of Scheme Rate, with a reason given for the decision. If the review process results in an approval, the claim will be paid in one of the following ways: If the service provider billed 300% or less of the Scheme Rate, the claim will be paid in full. If the service provider billed more than 300% of the Scheme Rate, the final payment amount will be negotiated with the service provider.
  • GEMS has a claims query process in place to retrospectively review unpaid/short paid claims for possible PMB eligibility. This review process takes the following into account: Is the provider on the network? Is the ICD10 code a PMB? Was the event an emergency? Was the service PMB level of care as defined the PMB DTP code list? Was a DSP accessible?
  • GEMS covers PMBs at cost, unlimited, and subject to managed care protocols being followed. If the condition is classified as a Prescribed Minimum Benefit (PMB), the member must be treated by a Designated Service Provider (DSP) to avoid co-payments. The DSP for in-hospital PMBs is the State or government health facilities, and in the case of the Tanzanite One and Emerald Value options, also hospitals on the GEMS Network. If the DSP is not available or accessible, please contact the GEMS Customer Services on 0860 00 4367 to discuss alternatives. It is not compulsory for a member to use a DSP, but voluntary use of a non-DSP may result in a co-payment for both provider and hospital claims. The co-payment will be the difference between the rate that the DSP would charge and what the non-DSP hospital and / or provider charges. DSP does not apply in the event of an emergency or involuntary use of a non-DSP.
  • Yes, if – It is a qualifying medical emergency, or The DSP is not available within a reasonable distance, and / or The PMB service required is not available at the DSP, and / or The waiting period for the service at the DSP is deemed unreasonable. In other words, where the use of a non-DSP is involuntary due to any of the above, funding will be at cost. This process has been extensively reviewed and is continuously monitored to ensure that feedback is provided as soon as possible.  The turnaround time for such reviews is usually within 14 working days.
  • You may appeal if your claim for ‘PMB at cost’ is declined. All escalations and/or appeals should be submitted to enquiries@gems.gov.za.

REPI questions

  • REPI2 (Risk Equalized Performance Indicator) is a family practitioner (FP) profiling tool developed by Medscheme. This tool uses a combination of cost and quality components to assess the performance of a practice, relative to its peers. REPI2 was introduced into the FP environment in 2007 to promote coordination of care and to remunerate the FP for partnering with Medscheme and its administered schemes, such as GEMS, to achieve the goal of high quality, affordable healthcare for all beneficiaries. The foundation for REPI2 provider analytics is developed around a patient attribution model, whereby beneficiaries are attributed to a family practice through considering total consultations per 12-month period under review. The REPI2 model is run quarterly and uses 12 months of claims data to provide the most accurate presentation.
  • REPI2 forms the basis of the value-based enhanced remuneration model adopted by GEMS. This enhanced consultation fee is an additional ‘fee’ on top of the contracted consultation fee. Cost and quality components are combined in the assigning of an overall category of either 1, 2 or 3. FP’s who fall within category 1 or 2 are eligible for an enhanced fee over and above the determined FP network fee.
  • Various external aspects or models of FP practices might result in a practice with good clinical performance inappropriately falling within a lower REPI² category, as driven by an above average cost indicator profile. Such practices typically include, but are not limited to, specialised FPs who provide geriatric, obstetric, or other specialist level services. An appeals process has therefore been instated. Through this appeals process, all FPs can motivate and apply for a REPI² category upgrade by virtue of being a statistical outlier compared to their peers. Such motivations are considered and assessed by an independent REPI² category upgrades committee.
  • If you consider the clinical grounds for an upgrade appropriate, given the above, please email a detailed motivation letter REPIcorrespondence@medscheme.co.za.  The letter should include: the specific nature of the FP practice (GP anaesthetist, GP obstetrician, Emergency Practice, normal GP, etc.), special interests (geriatric care, etc.), and/or specific challenges that go above and beyond normal FP practice that might have a negative influence on overall cost indicators (rural practice, servicing old age homes, etc.). For more information pertaining to your practice review and category status, visit the Medscheme website (www.medscheme.com), log in or register as a Provider and click REPI² to access an online version of your full REPI² data set.

Network administration questions

  • In order to avoid having to pre-authorise a specialist consult, and/or avoid a 30% co-payment, GEMS beneficiaries on the Tanzanite One and Emerald Value options require a referral from their nominated network FP. The referring practitioner’s practice number (the nominated FP for Tanzanite One and Emerald Value options) needs to be stated on the claim of the specialist to avoid co-payments. Refer to the FP Network Guide for additional information.
  • The GEMS Family Practitioner Network Guide is published on the GEMS website and is available here.
  • The GEMS Tariff files are published on the GEMS website and are available here.
  • If you want to change your dispensing status, please do so in writing, and then email your change request to either networkscontracting@gems.gov.za or to gemsnetworkenquiries@medscheme.co.za, or fax it to 086 244 738 or 0860 222 453. In addition, if you wish to become a dispensing practice, you need to have a valid dispensing license, which needs to be updated with the Board of Healthcare Funders (BHF). 
  • Please send GEMS the relevant documents listed below to register your new/amended banking details on our system. You can either email these to implementation@mhg.co.za, or fax to 021 480 4087. A signed practice letterhead (ALL partners’ signatures) Companies and Intellectual Property Commission (CIPC) papers if the bank account is in the name of a registered company Bureau manager certified ID and signature on letterhead (if applicable) A bank letter / bank statement (not older than three months) with a bank stamp A certified copy of the owners’ IDs (ALL partners’ certified ID copies) A certified marriage certificate (if applicable) A ‘trading as’ letter (which can be indicated on the signed letterhead) if the practice name and the bank account holder names differ

Funding questions

  • GEMS will consider funding bariatric surgery and reduction mammoplasty in cases where they are deemed to be clinically indicated.  For funding to be considered – REDUCTION MAMMOPLASTY requires a clinical motivation by a plastic surgeon or general surgeon. Please email hospitalauths@gems.gov.za or call 086 043 6777 to request a GEMS Breast Reduction Template and to confirm GEMS-specific clinical criteria, does not apply to all options - only EVO. Emerald and Onyx, and requirements for this procedure.   BARIATRIC SURGERY requires a clinical motivation from the Multidisciplinary Team members. Please email hospitalauths@gems.gov.za or call 086 043 6777 to request a GEMS Bariatric Surgery Template and to confirm GEMS-specific clinical criteria, conditions, and requirements for this procedure. Furthermore, bariatric surgery may only be performed at a Proventi or South African Society for Surgery, Obesity and Metabolism (SASSO) accredited Centre of Excellence site, by a Proventi or SASSO accredited surgeon.
  • The mobile chronic haemodialysis category and tariff introduced by GEMS aims to compensate the provider for their time and expertise whilst managing the Scheme expenditure on non-acute haemodialysis. Claims using this tariff will only be approved in the following scenarios: Registered chronic haemodialysis patient. Admitted to general ward but is immobile (cannot be moved or their doctor has instructed that it is not advisable to move them). Admitted to a general ward and there is not an onsite renal dialysis facility. Admitted to a general ward and there is an onsite renal dialysis facility but the facility does not have capacity to treat the member.

Claims related questions

  • If a claim is rejected for motivation required, a letter of motivation must be completed by the treating provider and submitted to enquiries@gems.gov.za. The motivation will be reviewed by a Medical Advisor for a funding decision to be made.

FWA questions

  • Validate all member ID cards prior to rendering service; Ensure accuracy when submitting bills or claims for services rendered; Avoid unnecessary drug prescription and/or medical treatment; and Report lost or stolen prescription pads. If you suspect any fraud, please call the anonymous 24-hour toll-free GEMS Fraud Line Service on 0800 21 2202, email office@thehotline.co.za, or fax 0867 26 1681.

Pre-authorizations

  • The error messages were enhanced to be more descriptive and to include the next action to be taken. When a claim is received by the Scheme and a funding decision is made the claims statement includes an error message that indicates the reason a claim may not be paid in full, part paid or rejected. The action required for the claim to be reviewed for payment is also included on the claims statement.
  • This often happens when the date of service on the claim falls outside of the approved authorization dates if the hospital has not updated the authorization. This may also occur if the procedure claimed requires authorisation and was not authorized. To reduce the number of rejections certain claims related to in-hospital authorisations are put on hold for a period of 10 days to allow providers to obtain authorisation. This was done to reduce the number of rejections for pre-authorisation required.

Questions relating to modifiers

  • Endoscopic examinations done during a procedure. When a related endoscopic examination is done at an operation by the operating surgeon, or the attending anaesthesiologist, only 50% of the units for the endoscopic examination may be coded. Appropriate when a RELATED endoscopic examination is performed at the time of an operation. Identify the related procedure(s) when endoscopic examinations are performed when using this modifier. Modifier 0013 is not applicable to colorectal endoscopies (items 1653, 1565, 1676 and 1677) performed at the time of anal surgery e.g.  haemorrhoids, fissures and abscesses/fistulae. Modifier 0013 is not applicable when endoscopies are performed to exclude pathology e.g. bleeding or pain above anal canal. When performing a diagnostic endoscopic procedure not related to the therapeutic procedure, the appropriate ICD-10 code must be added to the procedure code to indicate the circumstances. Unrelated endoscopic procedure must be specified and a diagnosis provided to indicate the diagnostic endoscopic procedure(s) is unrelated to other (therapeutic) procedures performed 
  • Endoscopic procedures performed with own equipment: 0074 The basic procedure fee plus 33.33% (1/3) of that fee ("+" codes excluded) will apply where endoscopic procedures are performed with own equipment. Endoscopic procedures performed in own procedure room: 0075 (a) The value of modifier 0075 = 21,00 clinical procedure units, where endoscopic procedures are performed in rooms. (b) This fee is chargeable by medical practitioners who own or rent the facility. (c) Modifier 0075 may not be used in conjunction with modifier 0004. (d) Please note: Modifier 0075 is not applicable to any of the items for diagnostic procedures in the otorhinolaryngology sections of the structure.
  • Modifier 0011 is funded for emergency authorisations. If the authorisations is not approved as an emergency but the provider deems the event to be an emergency a motivation confirming the nature of the emergency will be reviewed by the Medical Advisor for a funding decision to be made.
  • Surgical modifier for persons with a BMI of 35> (calculated according to kg/m2): Fee for procedure +50% for surgeons and a 50% increase in anaesthetic time units for anaesthesiologists Provider to align modifier to appropriate tariff on submission of claim. Providers to provide BMI data. Format for BMI information to be submitted: Height in cm, e.g. 160cm no decimal. Weight in kg, 1 decimal. 76.5kg. BMI, 1 decimal. 27.9 Alphanumeric Length 13 concatenated 000/00.0/00.0 separated with a ‘/’, i.e. Height cm/Weight kg/BMI. Example - FTX+ITM+++160/76.5/27.9
  • Assistant fee billing rule: The fee for an assistant is 20% of the fee for the specialist surgeon, with a minimum of 36,00 clinical procedure units. For the correct application the provider must align the modifier to appropriate tariff on submission of the claim. The minimum fee payable may not be less than 36,00 clinical procedures units.

Medicine Management questions

  • Risk Management Responses (RMRs) assist healthcare providers in making informed financial and clinical risk management decisions at the point of service. These response messages are passed back to the provider as part of an electronic claim submission response. Top 5 RMRs (Claim Responses) and Explanations RMR Code RMR Description Comment Meaning Error Result Flag 553 Item processed as PMB Information The message specifies the PMB benefit that the claim/script was paid from. Warning 469 Submitted Gross Used Information The message confirms the Submitted Gross amount has been accepted and processed. Warning 7208 MPL Reference Price Exceeded Call to Action The dispensed product price is above the MPL reference price, and the member will incur a co-payment. Action to take, the provider is to consider an alternative within or below the MPL price. Warning 989 Price Difference on submitted Gross Call to Action The professional fee submitted for the product is above the contractually agreed amount and the difference will be a co-payment to the member. Action to take, the provider to comply with the contractual obligation. Warning 250 Out of formulary item Call to Action The dispensed product is outside the formulary list and the member will incur a co-payment. Action to take, provider to consider an alternative within the formulary. Warning
  • No need to complete a physical form - simply call our dedicated call centre agents to help you with a telephonic chronic medicine registration. CALL the GEMS service provider call centre on 0860 436 777, press 4 for enquiries on chronic medicine, then 3 for enquiries on authorisation of chronic medicine. Have your practice number handy. EMAIL the prescription to chronicdsp@gems.gov.za to enable a courier pharmacy to dispense medication for members who choose to have the medication delivered. GEMS will also remind the members to renew the prescription before it expires.
  • Administration fees (tariff code 0022) that are submitted alone without an accompanying vaccine NAPPI code will be rejected. A warning message of “admin fee was not submitted’ will be generated to remind providers if a vaccine NAPPI claim is submitted without an admin fee tariff code. 
  • GEMS applies a 'disease authorisation' to approve medicines for the treatment of chronic conditions, not just for a medicine. The disease authorisation provides access to a list of pre-approved medicines, referred to as a basket. Where a patient is already registered on the chronic medicine programme for a specific chronic condition, and the prescription is amended, the patient may present the prescription to the pharmacists to first submit the claim for the medication. Based on the real-time feedback received, the claim will either be processed successfully from the basket, or the pharmacist will be advised that pre-authorisation is required
  • GEMS covers medication prescribed by a registered PCDT pharmacist including the associated dispensing fee for medicines. Pharmacies must utilise the correct legislated ICD10 codes.
  • GEMS offers all members screening and preventative care benefits which are claimed from the risk benefit. Please refer to the GEMS Website for the list of available screening and preventative services or contact our Call Centre.
  • All pharmacies on the GEMS Network are measured on four (4) compliance measures, namely: Medicine Price List (MPL) Generic Substitution (GS) Dispensing Fee (DF) ICD-10 codes (OTC items only) Pharmacies compliance reports are distributed monthly, to ensure they can track performance against target. Pharmacies that are having challenges with meeting the compliance scores can request for engagements with the PNMP Provider Liaison Officers or compliance pharmacists, who will assist them on how to reach the mandated compliance scores.
  • As an FP, you can assist your patients who are GEMS members to avoid undesirable co-payments by ensuring that all scripted items are within the Acute/Chronic Formularies, and by encouraging members to make use of DSP pharmacies. More about co-payments: There are three types of co-payments: In order to contain the escalating costs of medicines, GEMS uses the MPL to determine the maximum price the Scheme will pay for those medicines with the same active ingredient based on the availability of generic equivalents on the market. The fundamental principle of the MPL is that it does not restrict a member’s choice of medicines, but instead limits the amount that will be paid should a member choose a medicine above the MPL. MPL reference prices are carefully determined so as to ensure adequate availability of generic equivalents within the price limit, without co-payments being necessary. (GEMS is also encouraging the use of reusable insulin pens and cartridges for diabetic members on insulin.) If a member uses a product that costs more than the MPL reference price, the member will attract an MPL co-payment. In addition, GEMS makes use of formularies for acute and chronic medicine, which are available on the website. Out-of-formulary co-payments are incurred when members use non-formulary drugs or medicine that is charged above the MPL reference price.  Finally, claims submitted from a non-DSP pharmacy will also attract a 30% non-DSP co-payment.
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