Claims

Item: Gems (Government Employees Medical Scheme)
Rating: 1
Author: Karien H

Good Day

I have been struggling since September to get a claim resolved. Gems keep rejecting our claim; at first they requested the dental laboratory registrations docs, which I sent in. Then the next excuse – the lab is not an active member of the Board of Healthcare Funders. Please provide more details in this regard, as the dental lab says all their other patient claims gets paid by the various medical aids. So why is GEMS not paying out. With every claim, authorisation etc there are issues, it’s a permanent fight with GEMS to get service. We pay over R7000 p/m for medical aid and yet when we need to use it, GEMS tries their best not to pay out. This is unacceptable. Please advise asap in order for us to move on with this claim.

Helpful (0)

Replies (4)

Gems (Government Employees Medical Scheme)'s replyOfficial

29 Jan 2019, 10:12

Good day

Thank you for giving us the opportunity. We are looking into this and will provide feedback.

Kind regards
The GEMS online team

Gems (Government Employees Medical Scheme)'s reply29 Jan 2019, 10:12

Official

Good day

Thank you for giving us the opportunity. We are looking into this and will provide feedback.

Kind regards
The GEMS online team

Karien H's updateReviewer Update

04 Feb 2019, 11:43

So I received a phone call from a very nice lady from GEMS on the 29th January (6 days ago) saying that she is investigating the matter and will provide feedback. I have not heard a word since 6 days ago. Gems must be using the delayed tactics to avoid paying claims. Ridiculous.

Karien H's update04 Feb 2019, 11:43

Reviewer Update

Gems (Government Employees Medical Scheme)'s replyOfficial

06 Feb 2019, 13:12

Good day

Thank you for affording GEMS the opportunity to respond to your concerns regarding your account.

Please be advised that the account was not paid due the practice being inactive with Board of Healthcare Funders.

As per the Medical Schemes Act, all healthcare providers must be registered with the Board of Healthcare Funders who will issue them with a Practice number to allow the provider to render services. Without a practice number medical Schemes are unable to reimburse providers.

The claim will only be resubmitted once the practice is active.

We trust the above is in order.

Kind regards

The GEMS online team

Gems (Government Employees Medical Scheme)'s reply06 Feb 2019, 13:12