Your GEMS 2020 Dental Provider Guide

Your GEMS 2020 Dental Provider Guide

Table of contents

01 Introduction 1

02 TanzaniteOneandBeryl:Generaladministration,benefitsandprocedurescovered 2

03 Ruby, Emerald Value, Emerald and Onyx: Generaladministration,benefitsandprocedurescovered 7

04 AllGEMSoptions:Generalexclusionsandrestrictions -excludesPMB(prescribedminimumbenefits) 11

05 Dental medicine formulary 14

06 Pre-authorisation 15

07 Claimprocedures 15

08 Memberverificationandvalidation 16

09 Ex Gratia 16

10 Forms 17

1GEMS 2020 Dental Provider Guide

GEMS ensures that members have access to cost-effective,qualitydentalhealthcare.TheSchemereliesonyou,asavalueddentalprovider,toensureallmembers’expectationsarerealised.

This guide will assist you with the 2020 GEMS dentistry benefitsandtheScheme’sdentalmanagedcarerules.These include time and age rules, general principlesand exclusions. The guide also stipulates how therules are applied to various dental procedures andthespecificapplicationtothedifferentGEMSoptions,namely Tanzanite One, Beryl, Ruby, Emerald Value, EmeraldandOnyx.

GEMS Dental Network

Since high-quality clinical and administrative servicesis a team effort between the Scheme and healthcare providers,GEMSinvitesyoutobecomeanintegralpartof this team by joining the GEMS Dental Network and FriendsofGEMS.Fordetailsandassistanceonjoiningthegrowingnetwork,pleasecontact0860 436 777 or [email protected].

Pre-authorisation, pre-notification and patient registrationPatient registration

Duringthepatient’sfirstvisittoyourpractice,aonce-offdental charting and full oral examination in association with code 8101 (as per normal prescribed guidelinesforchargingofcode8101)needstobeperformedand

thensubmittedtoGEMS.

The ‘Dental report for patient registration’ form forbenefit applications should be completed and sent totheScheme.Thisfacilitatescentralisedcapturingofthepatient’sexistingoralhealthstatustoensureproperandappropriatedentalmanagedcareandriskmanagementinaccordancewithinternationallyrecognisedstandards.It also allows the Scheme to compile an actual anddynamicepidemiologicdatabaseofitspatientpopulationforfuturebenefitandbudgetaryplanning.

Pre-authorisationand/oratreatmentplan

Thisisrequiredforcertaindentalproceduresasindicatedin the procedure schedules in this guide pertaining toeachoption.Theyincludecertainspecialisedandsurgicalprocedures,orthodontics,periodontaltreatmentandanyprocedures to be performed in an operating theatre orunderconscioussedation.

Where pre-authorisation is required for periodontaltreatment, the ‘Periodontal pre-authorisation’ formshouldbecompletedandforwardedtotheScheme.

Where pre-authorisation and/or treatment plans arerequired,thestandard‘Patientregistration,pre-notificationand pre-authorisation’ form should be completed. It isnecessarytocompleteonlytheapplicablesections-forinstance, it is not necessary to complete the chartingsectionwitheachrequest,and itcanbeuseduntil thecompletionofatreatmentplan.

Introduction01

NOTE: The‘Dentalreportforpatientregistration’and‘Dentalreportforperiodontalpre-authorisation’formsareavailableatwww.gems.gov.za.Emailthecompletedformstoenquiries@gems.gov.za or fax to 0861 00 4367.

NOTE: Shouldyouhaveanyqueriesonbenefits,rules,exclusions,pre-authorisationoryourpatient’sSchemeoption,pleasecontact 0860 436 777 or [email protected].

2 GEMS 2020 Dental Provider Guide

Tanzanite One and Beryl: Generaladministration,benefitsandprocedurescovered02

TanzaniteOneandBeryl-summarisedbenefitspecificationsandspecificrules

Benefit specifications

Tanzanite One Beryl

Essential dentistry Approvedservices/codesarecoveredat 100% of the agreed tariff subject to availabilityoffunds

Approvedservices/codesarecoveredat 100% of the agreed tariff subject to availabilityoffunds

GEMS Dental Networkprovider

ServicesmustbeprovidedbyaGEMSDentalNetworkprovideronly

ServicesmustbeprovidedbyaGEMSDentalNetworkprovideronly

Out-of-networkvisit Oneemergencyout-of-networkvisitperbeneficiaryperyear

Oneemergencyout-of-networkvisitperbeneficiaryperyear

Emergency dentistry •Emergencypainandsepsistreatmentonly

•Codescovered–8132,8201and8307

•Pulpotomy(code8307)appliesonlyonprimaryteeth

•Anyadditionaltreatmentrequiresfundingbypatient

•Oneeventperbeneficiaryperbenefityearallowed for emergency dentistry

•Emergencypainandsepsistreatmentonly

•Codescovered–8132,8201and8307

•Pulpotomy(code8307)appliesonlyonprimaryteeth

•Anyadditionaltreatmentrequiresfundingbypatient

•Oneeventperbeneficiaryperbenefityearallowed for emergency dentistry

Examinations and preventivetreatment

Two consultation/examination and preventivetreatmentepisodesperbeneficiaryperbenefityear

Two consultation/examination and preventivetreatmentepisodesperbeneficiaryperbenefityear

Restorativetreatment

•Limitedtofourrestorationsperbeneficiaryperyear

•Posteriorresinfillingspaidatthesamerandvalueasamalgamfillings

•Limitedtofourrestorationsperbeneficiaryperyear

• Pre-authorisation needed for more than fourfillings

Specialiseddentistrybenefit

Nospecialiseddentistrybenefit–limitedtoPMBs

• Specialiseddentistryservices(periodontaltreatment,partialmetalframedenturesandmaxillofacialtreatment)limitedtoR3612perbeneficiaryperyear

•Alldenturesandspecialiseddentistrysubjecttopre-authorisation



Tanzanite One Beryl

Maxillofacial surgery Subject to an annual sub-limit of R23 088perfamily

Subject to an annual sub-limit of R23088perfamily

General anaesthesia and sedation

SubjecttoSchemerules,relevantmanagedcareprotocolsandpre-authorisation

SubjecttoSchemerules,relevantmanagedcareprotocolsandpre-authorisation

Hospitalnetwork Hospitalisationsubjecttouseofstateornetworkhospital,failingwhichtheSchemeshallnotbeliableforthefirstR12000oftheotherfacility’sbill

Anyhospital,subjecttoPMB

Radiology Allservicessubjecttoanapprovedlistoftariffcodes,managedcareprotocolsandprocesses

Allservicessubjecttoanapprovedlistoftariffcodes,managedcareprotocolsandprocesses

TanzaniteOneandBeryl–specificrulesfordentures


Tanzanite One Beryl

Dentures • Plasticdenturessubjecttopre-authorisation.

• Oneset*ofplasticdenturesallowedperbeneficiaryper48-monthbenefitcycle

• Nobenefitformetalframedentures

• Plasticdentureslimitedtotheapproved2020 Scheme tariff

• Onlymembersandbeneficiariesovertheageof21qualifyforthisbenefit

• Alldentures(plasticandmetalframe)subjecttopre-authorisation

• Oneset*ofplasticdenturesallowedperbeneficiaryper48-monthbenefitcycle

• Partialmetalframedentureavailableonceperbeneficiaryinafive-yearperiod

• MetalframedentureiscoveredfromthespecialiseddentistrylimitofR3612perbeneficiaryperyear

• Plasticdentureslimitedtotheapproved2020 Scheme tariff

• Onlymembersandbeneficiariesovertheageof21qualifyforthisbenefit

*A set of dentures is defined as follows: •Completeupperorlowerdentures(nottwoupperortwolower)•Partialupperorlowerdenture(nottwopartialupperortwopartiallower)

Charting: Pleasenotethataspartofcode8101,aonce-offpatientchartingandoralexaminationwillberequiredforeachbeneficiaryvisitingyourpracticeforthefirsttime.ThechartingistobesubmittedtotheSchemeonthe‘Dentalreportforregistration,pre-notificationandpre-authorisation’form.


The following table details the reimbursement codes for dentures:

• Whenclaimingviaelectronicdatainterchange(EDI),useindividualninecodesfordentallaboratories.Laboratoryinvoicestoberetainedbythepracticeforpossibleauditing.

• Whensubmittingpaperclaimsuse,individualninecodesfordentallaboratoriesandsubmitthedentallaboratoryinvoicewiththepaperinvoice.

• Noclaimwillbeacceptedwithouttheprofessionalfeeandlaboratorycodessubmittedtogetherorbeingmatchedifalaboratoryperformsself-billing.

Denture codes funded Denture codes not funded

8231(completedentures–maxillaryandmandibular)8232(completedentures–maxillaryormandibular)8233(partial–onetooth)to8241(partialdenture–nineormoreteeth)

8658(interimcompletedenture)

8269(repairofadentureorotherintraoralappliance) 8659(interimpartialdenture)

8271(addtoothtoexistingpartialdenture) 8661(diagnosticdentures)

8273(impressiontorepairormodifyadenture,orotherremovableintraoralappliances)

8244(immediateupperdenture)

8259(rebasecompleteorpartialdenture-laboratory) 8245(immediatelowerdenture)

8263(relinecompleteorpartialdenture-intraoral) OntheTanzaniteOneoption:8281,8663,8279(metalbasecodes)notfunded

Individualninelaboratorycodes 8099(dentallaboratoryservice)

Note:Noadditionalcoverifdenturesarelostduetonegligence.Amotivationisrequiredforthereplacementofdentures.PleasedirectallmotivationstotheGEMScallcentreon0860 436 777 or [email protected].


mailto:[email protected]


TanzaniteOneandBeryl-approvedservicecodesandtableofbenefits

Code CodeDescription LimitationsCovered:Tanzanite One

Covered:Beryl

8101 Consultation Twoperbeneficiaryperyear Yes Yes

8104 Examinationforaspecificproblemnotrequiringfull mouth examination

Twoperbeneficiaryperyear Yes Yes

8107 Intraoralradiographs,perfilm Maximumoftwoperbeneficiaryperyear Yes Yes

8112 Bitewings Maximumoffourperbeneficiaryperyear Yes Yes

8115 Panoramic x-ray Benefitfromtheageofsix–maximumoneeverythreeyears

Yes Yes

8155 Polishing–completedentition Twoperbeneficiaryper12months;cannotbecharged with 8159 in same year

Yes Yes

8159 Scalingandpolishing Twoperbeneficiaryper12months;onlyoverthe age of 10

Yes Yes

8161 Topicalapplicationoffluoride(children) Fromtheagesofthreeto11;onceperbenefi-ciaryper12months

Yes Yes

8162 Topicalapplicationoffluoride(adults) Fromtheagesof12to16.Onceperbeneficiaryper12months

Yes Yes

8163 Fissuresealant,pertooth Patientyoungerthan14;maximumoftwoperquad-rantonposteriorpermanentteethonly

Yes Yes

8341 Amalgam one surface Anyfouramalgamfillingsperbeneficiaryperyear, limited to four restorations

Yes Yes

8342 Amalgam two surfaces

8343 Amalgam three surfaces

8344 Amalgam four and more surfaces

8351 Resin restoration, one surface anterior Anyfourresinfillingsperbeneficiaryperyear(anteri-or),limitedtofourrestorations

Yes Yes

8354 Resin restoration, four and more surfaces

8367 Resinrestoration,onesurfaceposterior Anyfourresinfillingsperbeneficiaryperyear(posteri-or),limitedtofourrestorations

Yes, but to the same randvalueas surfaces amalgam filling

Yes

8368 Resinrestoration,twosurfacesposterior

8369 Resinrestoration,threesurfacesposterior

8370 Resin restoration, four and more surfaces

8307 Amputationofpulp(pulpotomy) Onlyonprimaryteeth Yes Yes

8132 Rootcanaltherapy–grosspulpaldebridement

Onceperbeneficiaryper12months.Oneeventperbeneficiaryperbenefityearallowedforemergencydentistry.

Yes Yes

8201 Extraction,singletooth.Code8201ischargedforthefirstextractioninaquadrant

Anyfournon-surgicalextractionsperbeneficiaryperyear,onlyifclinicallyindicated

Yes Yes

8202 Extraction, each additional tooth Anyfournon-surgicalextractionsperbeneficiaryperyearapply(inassociationwithcode8201)

Yes Yes

Code 8202 is charged for each additional extractioninthesamequadrant

8937 Surgicalremovaloftooth* Maximumoftworemovals-pre-authorisationnecessary for more than two

Yes, from the age of 12



Code CodeDescription LimitationsCovered:Tanzanite One

Covered:Beryl

8213 Surgicalremovalofresidualroots,firsttooth-pertooth*

Maximumofoneprocedure-morethanonerequiresclinicalmotivation



8214 Surgicalremovalofresidualroots,secondandsubsequentteeth’sroots*

Maximumofoneprocedure-morethanonerequiresclinicalmotivation



8941 Surgicalremovalofimpactedtooth–firsttooth* Pre-authorisationrequiredforin-hospital Yes Yes

8943 Surgicalremovalofimpactedtooth–secondtooth*

Pre-authorisationrequiredforin-hospital Yes Yes

8945 Surgicalremovalofimpactedtooth–thirdandsubsequentteeth*

Pre-authorisationrequiredforin-hospital Yes Yes

8220 Sutures Limited to once a year in association with surgi-calextractionsand/orimpactions

Yes Yes

8935 Treatmentofsepticsocket Yes Yes

8109 Infectioncontrol/barriertechniques.Code8109includesprovisionbydentistofnewrubbergloves,masksetcforeachpatient

Twopervisit Yes Yes

8110 Sterilised instrumentation Onepervisit Yes Yes

8145 Local anaesthetic Onepervisit Yes Yes

8231 Completedentures-maxillaryandmandibular • Onesetofplasticdenturesallowedperbeneficiaryper48months

• Pre-authorisation necessary

• Onlymembersandbeneficiariesovertheageof21

• OnlyplasticdenturesfortheTanzaniteOneoptions

• Beryl:Metalframeworkeveryfiveyears

Yes Yes

8232 Completedentures–maxillaryormandibular Yes Yes

8233 Partialdenture(resinbase)–onetooth Yes Yes

8234 Partialdenture(resinbase)–twoteeth Yes Yes

8235 Partialdenture(resinbase)-threeteeth Yes Yes

8236 Partialdenture(resinbase)–fourteeth Yes Yes

8237 Partialdenture(resinbase)–fiveteeth Yes Yes

8238 Partialdenture(resinbase)–sixteeth Yes Yes

8239 Partialdenture(resinbase)seventeeth Yes Yes

8240 Partialdenture(resinbase)-eightteeth Yes Yes

8241 Partialdenture(resinbase)–nineteethandmore Yes Yes

8259 Rebasecompleteorpartialdentures(laboratory) Rebaseallowedonlyonceeverytwoyears Yes Yes

8269 Repairdenture Cannotbecompletedwithsixmonthsoffittinga new denture

Yes Yes

8263 Relinecompleteorpartialdentures(chairside) Relineallowedonlyonceeverytwoyears Yes Yes

8271 Addtoothtoexistingpartialdentures Cannotbecompletedwithinsixmonthsoffittinganewdenture

Yes Yes

8273 Impressiontorepair/addition Cannotbecompletedwithinsixmonthsoffittinganewdenture

Yes Yes

TanzaniteOneandBeryl-approvedservicecodesandtableofbenefits(continued)


Ruby, Emerald Value, Emerald and Onyx - shared dental sublimit

Ruby Emerald Value and Emerald Onyx

Shareddentalsub-limitofR3548perbeneficiaryperyearforin-hospitaldentistryprofessionalfeesandallout-of-hospitaldentistry

Shareddentalsub-limitofR5 454perbeneficiaryperyearforin-hospitaldentistryprofessionalfeesandallout-of-hospitaldentistry

Shareddentalsub-limitofR9 730perbeneficiaryperyearforin-hospitaldentistryprofessionalfeesandallout-of-hospitaldentistry

Ruby,EmeraldValue,EmeraldandOnyx-summarisedbenefitscovered

Provider limitations ServicesnotlimitedtoGEMSDentalNetworkproviders

Conservative and restorative dentistry (including plastic dentures)

100%ofSchemeratesubjecttoavailablefunds

Specialised dentistry (including metal base partial dentures)

•Nopre-authorisationrequiredforpartialmetalbasedentures

•Pre-authorisationrequiredforallotherspecialiseddentistryprocedures

•Excludesosseo-integratedimplants,allimplant-relatedproceduresandorthognathic surgery

•Excludesorthodontictreatmentonpatientsolderthan21

General anaesthesia and conscious sedation

•Subjecttopre-authorisation,andmanagedcareprotocolsandprocesses

•Applicableonlytobeneficiariesyoungerthansix,severetraumaandimpactedteeth

•Impactedthirdmolars:200%ofSchemeratepayableforremovalunderconscioussedationindoctor’srooms

•Anaesthetistsrequiredtoobtainaseparateauthorisationfordental-relatedconscioussedationprocedures

Ruby, Emerald Value, Emerald and Onyx: Generaladministration,benefitsandprocedurescovered03

Charting: Aspartofcode8101,aonce-offpatientchartingandoralexaminationwillberequiredforeachbeneficiaryvisitingyourpracticeforthefirsttime.ThechartingistobesubmittedtotheSchemeonthe‘Dentalreportforregistration,pre-notificationandpre-authorisation’form.

Pleaseensurethatpre-authorisationsareperformedbeforestartingtreatmentwhereindicatede.g.specialiseddentistry,orthodontictreatment,in-hospital(theatre)andconscioussedation-associatedtreatment.


Ruby, Emerald Value, Emerald and Onyx – general rules

Generalprinciples:

• AlldentalproceduresarecoveredbytherulesapplicableperspecificSchemeoption.

• Allspecialiseddentistryandin-hospitaldentistryaresubjecttopre-authorisationbeforestartoftreatmentexcept

inanemergencywhereretrospectiveauthorisationshouldbeobtainedwithin72workinghoursaftertheevent.

• Anauthorisationgrantedisnotaguaranteeofpayment–paymentremainsstrictlysubjecttoavailabilityoffunds.

• Confirmationofbenefitsisnotaguaranteeofpayment–paymentremainsstrictlysubjecttoavailabilityoffunds.

• Hospitalauthorisationsarevalidforaonemonthandallotherauthorisationsarevalidforthreemonths.

• Wherethedentaltreatmentplanchanges,authorisationsmustbeupdatedbeforesubmittingtheclaim.

Orthodontic treatment:

• Benefitsapplicableonlytobeneficiariesunder21.

• AuthorisationandatreatmentplanapplyandbenefitssubjecttopriorevaluationaccordingtotheICONcriteria–

IndexofComplexity,OutcomeandTreatmentNeed.

• Onceapproved,aninitialamountwillbepayableandthebalanceinincrementssubjecttoavailabilityoffunds.

• Approvedtreatmentplansarevalidforoneyear.

• Shouldacasebetransferredtoanotherprovider,onlythebalancedueasperoriginaltreatmentplaniscovered.

• Orthodonticexclusions:Referto‘Generalexclusionsandrestrictions’.

• When relocating or seeking second opinions, kindly request records from the first service provider to avoid

overexposuretoradiation.

Hospitalisation

• Coveredonlyforpatientsundertheageofsix,impactedteethandseveretraumaasperSchemerules.

• Nootherproceduresapply.

• Subjecttopre-authorisation.

• Children under the age of six:

− Consideredonlywherenootheroptionsareavailable.

− Allproceduresnecessarytobecompletedinonetheatre-associatedevent.

− Only necessary restorative and surgical (e.g. extractions) procedures may be performed. No preventive

treatment(polish,fluoridetreatment,fissuresealants)willbecoveredintheatre.

• EmeraldValueoption:Aco-paymentofuptoR12000maybeleviedshouldyounotuseaGEMSnetworkhospital.


Tableofbenefits:Ruby,EmeraldValue,EmeraldandOnyx

Ruby Emerald Value and Emerald Onyx

Dental consultation yearly check-up

Twoannualconsultationsperbeneficiary,oneeverysixmonths



Diagnostics 8107:Diagnosisandtreatmentprocedureswherenecessary

8107:Diagnosisandtreatmentprocedureswherenecessary

8107:Diagnosisandtreatmentprocedureswherenecessary

8108:Benefitfromtheageofsix-oneevery24months



8112:Maximumoffourper12months 8112:Maximumoffourper12months 8112:Maximumoffourper12months

8115:Benefitfromtheageofsix–maximumoneevery36months



8116,8114:Fororthodontictreatmentonly,benefitsubjecttopre-authorisation



Infection control 8109: Infection control/barrier techniques-twicepervisit

8109: Infection control/barrier techniques-twicepervisit

8109: Infection control/barrier techniques-twicepervisit

8110: Sterilised instrumentation - once pervisit



Preventive dentistry

Scaleandpolish8159:Onceeverysixmonths–fromtheageof10only



Polish8155:Onceeverysixmonths Polish8155:Onceeverysixmonths Polish8155:Onceeverysixmonths

Fluoridetreatment:8161paidonceeverysixmonthsundertheageof12



Fluoridetreatment:8162paidonceeverysixmonthsfromtheagesof12to 16



Dentalsealant:Maximumtwoperquadrantandonceeverytwoyearspertooth–nobenefitiftoothalreadyin mouth for more than four years and forthoseover18



Restorations/ fillings

Benefitsavailablewhereclinicallyindicated–oncepertoothperyear



Dentures Onesetoffull,orfullupperorfulllower,orpartialupperand/orpartiallowerplasticdentureseveryfouryears;relines,rebase,softbaseeverytwoyears;metalframeworkeveryfiveyears

Onesetoffull,orfullupperorfulllower,orpartialupperand/orpartiallowerplasticdentureseveryfouryears;relines,rebase,softbaseeverytwoyears;metalframeworkeveryfiveyears

Onesetoffull,orfullupperorfulllower,orpartialupperand/orpartiallowerplasticdentureseveryfouryears;relines,rebase,softbaseeverytwoyears;metalframeworkeveryfiveyears

Endodontic (root canal) treatment

Pre-authorisation necessary for patientsunder14



Note:8132notallowedonsamedayasroottreatment.Maximumofthreetreatment-associatedperiapicalx-raysallowed(thereafter,pre-authori-sationnecessary)

Note:8132notallowedonsamedayasroottreatment.Maximumofthreetreatment-associatedperiapicalx-raysallowed(thereafter,pre-authori-sationnecessary)

Note:8132notallowedonsamedayasroottreatment.Maximumofthreetreatmentassociatedperiapicalx-raysallowed(thereafter,pre-authorisationnecessary)


Specialised dentistry

Crowns and bridges Pre-authorisationnecessary.

Benefitoncepertoothperfour

years

Pre-authorisationnecessary.


years

Pre-authorisationnecessary.


years

Orthodontics Treatmentplannecessary–

limitedtopatientsunder21

Treatmentplannecessary–


Treatmentplannecessary–


Periodontics Treatmentplannecessary Treatmentplannecessary Treatmentplannecessary

Maxillofacial and

oral/dental surgery

Pre-authorisation necessary

when done in theatre or under

conscioussedation;impacted

wisdomteethpaidat200%of

ratewhenperformedundercon-

scioussedationindentist’srooms













Dental hospitalisation

Dental

hospitalisation*

Forpatientsundertheageof

six,bonyimpactionsandsevere

trauma(PMB).Subjecttopre-

authorisation,treatmentprotocols

andPMBconditionsapplying


6,bonyimpactionsandsevere





six,bonyimpactionsandsevere




*EmeraldValue:Non-networkhospitalusemayattractaco-paymentofuptoR12000



Diagnostic/preventivetreatment

• Specialreport• Dental testimony • Microbiological studies • Cariessusceptibilitytests• Diagnosticmodelscoveredonlyinassociationwithorthodontictreatment• Appointmentnotkept• Nutritional counselling • Tobacco counselling• Oralhygieneinstructionand/orassociatedvisits• Removalofgrosscalculus• Behaviourmanagement• Costoftoothbrushes,toothpastesandmouthwashes• Fissuresealantsinpatientsolderthan18orwhereteethhavebeeninthemouthformorethanfouryears• Oraland/orfacialimage(digitalandconventional)coveredonlywhereorthodontictreatmentapplies• Fluoridetreatmentforpatientsolderthan16

Fillings, restorations

• Resinbondingforrestorationschargedseparatelyfromtherestoration• Enamel micro-abrasion• Electivereplacementoffillings• Gold or gold foil restorations

ExclusionsPleaserefertothesummaryofbenefits,detailedprocedurebenefitlists/schedulesandgeneralexclusionsdetailedearlierinthisguidepertainingtoeachSchemeoptiontoensurecompliancewiththebenefitsallowed,exclusionsandmanagedcarerules(e.g.pre-authorisation,numberofannualevents,agerulesetc).

Where treatment isperformedwhereanexclusionexistsorwhenthepatient’sbenefitshavebeenexceeded, thepatientwillhavetoself-fund–pleaseensurethe‘Patientconsent’formforlimitsexceedediscompletedbythepatientandkeptonfileatthepractice.

All GEMS options: General exclusions and restrictions (excludesPMB)04


Dentures

• Diagnostic dentures• Snoringapparatus• Clasporrest–castgold• Clasporrest–wroughtgold• Inlay in denture• Metal base to full dentures• Metalframesforpartialdentureslimitedtooneperjawandonceeveryfiveyears

Crown and bridge

• Where an underlying periodontal condition (e.g. extensive loss of alveolar bone) compromises anacceptabletermprognosis

• Wherealackofremainingtoothstructurecompromisesanacceptableprognosis• Where enough remaining tooth structure does not justify a crown as the restoration of choice• On a failed root canal-treated tooth• For cosmetic reasons• Allowedoncepertootheveryfouryears• Emergencycrownsnotplacedforimmediateprotectionofinjuredteeth• Temporaryandprovisionalcrowns,includinglabcosts• Pontics on second molars• Onprimaryteethorthirdmolars• Costofgold,semi-preciousmetalandplatinumfoil• 8570–computer-generatedrestoration:Laboratorynotallowedwiththiscode(only8560)

Implants

All implant-related clinical and laboratory associated procedures (includes implant placement, cost ofcomponents,restorations/crowns/bridges/dentures/repairsassociatedwithimplants)

Endodontic treatment

• On third molars• Onprimaryteeth• Emergencyrootcanaltreatmentchargedonthesamedayasthecompletedrootcanaltreatment• Retreatmentnotcoveredwithintwoyearsofinitialtreatment• Motivationrequiredfortreatmentundertheageof14


Orthodontic treatment exclusions

• Retreatment of orthodontic treatment• Lostappliancesnotcovered• Lingualorthodonticsnotcovered• Ceramicbracketsnotcovered• Refixingoforthodonticbracketsnotcovered• Retainerslimitedtooneperjaw• Treatmentplanningfororthognathicsurgery

In-hospital(theatre)

• Forpatientsundertheageofsix,bonyimpactionsandseveretraumaasperSchemerules-nootherproceduresapply

• Preventivedentalproceduresaspartofthedentaltreatmentperformedonchildrenundertheageofsixnotcovered

Inlays and onlays:

• Excludetoothnumbersonetothreeinallquadrants• Nobenefitforgoldorpreciousmetal• Allowedonceeveryfouryears

Other

• Cosmetic dentistry• ThetreatmentofanycomplicationrelatedtotreatmentnotfundedbytheScheme• Intramuscular and subcutaneous injections• Allproceduresrelatedtobleaching(exceptinternalbleachingonpreviouslyendodonticallytreatedteeth)• PerioChipreplacement• Treatmentplancompleted(code8120)• Cost of mineral trioxide• Ozonetherapy• Costofgold,semi-preciousmetalandplatinumfoil• Orthognathicsurgeryandrelatedhospitalcosts• Occlusaladjustmentminor(pre-authorisationnecessaryformajorocclusaladjustment)• Boneregenerationprocedures• Costofboneregenerative/repairmaterial• Anylaboratorycostswheretheassociatedprocedureisnotcovered• DentalMRIorCATscansnotcovered


TheGEMSdentalmedicineformularyisavailableatwww.gems.gov.za.

Medicinemaybeprescribed:

• According to the GEMS dental medicine formulary• By an approved GEMS network dentist or dentaltherapist(withinhis/herscope)

For Tanzanite One and Beryl options, medicinemustbe dispensed by approved GEMS network, courierpharmaciesordispensingdentists.

Keytoquantitiesandlimitations

‘Consumables’ means the medication may beadministrated only by a designated service provider(DSP)attherooms.AllinjectablesareconsumablesandclaimsforscriptsgiventopatientstocollectfromDSPpharmacieswillberejected.

‘MaxRx/7daysand3Rx/annum’meansascriptfilledto a maximum of seven days’ medicine supply andthreeprescriptionsperyearmaybeclaimed.

Benefits formedicine are subject to reference pricinglists(MPLs)andexclusionlists(MELs).ShouldthecostoftheitemexceedMPL,thepatientisliableforpaymentofthedifferenceincost.Ifthisisthecasepleaseinformthepatientthatitisforhis/herownpersonalaccount.

DentaltherapistsmayprescribeasperthelatestgovernmentgazettepublishedbytheDepartmentofHealth.

Note: Providertradenamesarenotlistedonformulary, allowing for generic substitution, but applyingMPLsandMELs.

Disclaimer

The formulary is reviewed regularly by clinical andpharmaceuticaladviserstoensurethatitcomplieswiththelatestindustrynormsforthetreatmentoftheseconditions.GEMS reserves the right to change medicines on theformularywhenimportantinformationcomestolightthatrequiresit,e.g.newfindingonthesafetyofadrug.

Dental medicine formulary05


http://www.gems.gov.za


Inallcaseswherepre-authorisationisrequired,asspecifiedearlierandperoptioninthisguide,pleasecompletetherelevantsectionsofthe‘Dentalreportforregistration,pre-notificationandpre-authorisation’formandsubmittotheSchemebeforestartingtreatment.

Should you be unsure whether pre-authorisation isrequired, contact the call centreon0860 436 777 to preventrejectionofthepatient’saccountbytheScheme.

Orthodontic treatment: Before treatment, submit to the Scheme a pre-authorisation form and treatmentplan,whichshouldincludethediagnosisandpaymentquotationforapproval.Emailenquiries@gems.gov.za or fax to 0861 00 4367.

Periodontal treatment: Complete and submit the‘Periodontal treatment pre-authorisation’ form,downloadable from www.gems.gov.za.

Pre-authorisation

Claim procedures

06

07Requiredinformationonclaims

• Mainmemberdetailssuchasmembershipnumber,option,

name and contact details

• Patient details, including date of birth, name and identity

number

• Provider details, including a valid Board of Healthcare

Funderspracticenumber,nameandcontactdetails

• Diagnosisandsummaryofmedicalproceduresperformed,

medicinedispensed,otheritemsdispensedtopatient

• Relevanttariffcodes

• Completelistofindividuallaboratorycodes

• Associated costs

Rejection of claims

• Ifthedetailsareincompletetheclaimwillberejected

• The clinical and laboratory codes are to be submitted together,

reflectingcorrespondingservicedates,correspondingdetails

of codes used and authorisation numbers for laboratory

codeswhereclinicalcodesrequirepre-authorisation

• Self-claiming laboratories may not submit their claim without

confirmationwiththedentalproviderthattheclinicaldelivery

wascompleted

• Anyotherproceduresdoneoutsidethescopeofbenefitwill

notbepaid

• All claims fromnon-networkdental providers onTanzanite

One and Beryl options, except emergency consultations

(limitedtooneeventperyear),willnotbefunded

• All claims requiring pre-authorisation - if no valid pre-

authorisation exists, the claim will be rejected

Note: Toothchartingontheformisnotnecessaryforpre-authorisationortreatmentplan(chartingneedstobecompletedonlyatthepatient’sfirstvisittothepracticeintermsofcode8101).


http://www.gems.gov.za/


Verificationonbenefits

• AlwaysensurethatavailablebenefitcodesandtariffvaluesareverifiedwiththeScheme• Thedentalproviderisrequiredtoverify membershipdetailsandconfirmtheidentityofthepatient• TheSchemewillnotberesponsibleforpaymentofservicesexcludedbyitormanagedcarerules• Memberswillbeliableforclaimsincurredonbenefitsfallingoutsidethebenefitschedule• Benefitconfirmationviapre-authorisationisrequiredwhereindicated

ApplicationforanExGratiaconsiderationforbenefitsnotcoveredmaybelodgedwiththeSchemeinaccordancewith Scheme rules

Member verification and validation

Ex Gratia

08

09


Forms10

Example:Dentalreportforregistration,pre-notificationandpre-authorisation

(Formsareavailableatwww.gems.gov.za.Emailthecompletedformtoenquiries@gems.gov.zaorfaxto0861004367).




Example:Dentalreportforperiodontalpre-authorisation





Example:Patientconsentform




Contact details

GEMS Contact Centre0860436777

Webwww.gems.gov.za

[email protected]

GEMS Emergency Services0800444367

HIV Aids Helpline0860436 736

Date post:	18-Dec-2021
Category:	Documents
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Your GEMS 2020 Dental Provider Guide

Documents