GEMS strives to build strong, long-term relationships with the healthcare professionals who provide care to the growing Scheme membership. GEMS healthcare provider networks were established in January 2010 to ensure that employees in the public sector could access quality and cost-effective healthcare services.
The GEMS healthcare provider networks aim to support participating healthcare providers to deliver appropriate care for GEMS members. This is the key to addressing the cost of healthcare relative to the quality in the South African healthcare sector.
GEMS has established networks for the following Specialists types.
- Anaesthesiology
- Obstetricians and Gynaecologists
- Physicians
- Surgeons
- Paediatricians
- Psychiatrists
Specialists participating in these networks enjoy an array of benefits listed below
1.Scheme membership coverage
Participating network specialists are assured of an increased patient footprint from the nation-wide GEMS membership pool of over 2 million beneficiaries. All beneficiaries are directed to network participating specialists through:
- GEMS Website
- Call Centre
- GP to Specialists referrals
- Referrals to participating network hospitals – specialists practicing at these GEMS Network hospitals will have access to an ever-increasing patient base.
2. Higher reimbursement rate for Network specialists
| Network Specialist | Non-Network Specialist | |
|---|---|---|
| GEMS tariff rates for in- and out-of-hospital | 130% | 100% |
3.Improved payment efficiency and reduced administration
Claim payment runs are conducted bi-monthly and in certain months, GEMS has up to 3 payment runs.
Network specialists are guaranteed prompt payments with no need for PMB retrospective reviews
4.Higher annual rate increases for Network Specialists
Network participants receive a higher annual inflationary rate increase than non-network participant
In addition to the above generic network benefits, the following discipline specific benefits apply to network specialists on select tariffs. Click here for more details
Obstetricians & Gynaecologists
Network Obstetricians receive enhanced reimbursement for the following tariff codes 2614 and 2615.
Ophthalmologists
| Network Specialist | Non-Network Specialist | |
|---|---|---|
| GEMS Intra-ocular lens mark-up* | 25% mark-up | 15% mark-up |
* Limited to a maximum of R3 650 per lens per annum and subject to the prosthesis benefit
Anaesthesiologists
Network Anaesthesiologists are reimbursed at 200% for pre-anaesthetic assessment codes as per below table
| Network Specialist | Non-Network Specialist | |
|---|---|---|
| Professional Fees | and 0153 are re- imbursed at 200% of scheme rates % | 0153 are re- imbursed at 100% of scheme rates |
Paediatricians
Network Paediatricians are reimbursed at 200% for the following ICU tariff codes (1205, 1206, 1207, 1208, 1210,1212 and 1213) inclusive of modifiers and PMBs.
5.Communications
Network participants also enjoy the following benefits:
- Communication with network participants to ensure the objectives and scheme rules are understood and adhered to
- Extensive year-end communication
- Direct engagements through the Provider Liaison Officer function to address
- Scheme information
- Scheme benefits,
- Provider education,
- Campaigns,
- Claims administration and management.
6.Current and Future Provider Value Proposition
More GEMS information at your fingertips
Our website offers a wealth of information to members and providers alike – please visit www.gems.gov.za for
- Provider guides
- ICD10 codes
- Formulary lists
- Tariff files
- Healthcare programmes
- and much more.
7.How to join the GEMS Network?
If you would like to join the Specialist Network or have any queries, please let us know via the following channels:
- Send an email to networkscontracting@gems.gov.za;
- Call us on 0860 436 777, weekdays between 08:00 and 17:00;
- Send a fax to 0861 004 367.
Last Updated on 3 October 2022 by HPCSA Corporate Affairs