GEMS short paid again on anaesthetia

I am the main member and my husband is dependent 1. My husband is has insulin dependent diabetes and we are both pensioners. Because of my husband's severe diabetes we are on the ONYX option of Gems.

My husband underwent two procedures during November 2018. On the 5th of November 2018 he underwent the first procedure. Today I have recieved an statement for the anaesthetist for the amount of R5 377,86 of which GEMS only paid R1 369,70, thus only 25% of the anaesthetist account was paid by GEMS.

On 19 November 2018 my husband underwent a hernia repair. Today I have recieved an statement for the anaesthetist for the amount of R7 299,38 of which GEMS only paid R2 495.40, thus only 34% of the anaesthetist account was paid by GEMS.

When I phoned the call centre of GEMS today, I was informed that the anaesthetist was paid at 100% of the GEMS rate. However, this claim can be referred to re-assessment for PMB benefits and thus the account could then be paid at 300% of the GEMS scheme rate. The call centre agent first said that this can not be referred for re-assessment for PMB benefits because it is not urgent. Also the call centre agent informed that only upon request will these claims be referred top re-assessment for PMB benefits and it is not done automatically. I was also informed that the GEMS only pay for one of the codes up to the age of 70? My husband is 74.

Also note that authorisation were obtain before hand for all the mentioned procedures.

How ridiculous, all of the procedures were done in hospital and it seems that GEMS is looking for excuses not to paid the service providers especially anaesthetia. Why will only emergencies be referred to re-assessment for PMB benefits? Now it will take approximately 7 (2 weeks) working days to get feedback and I am sure it will only be a waste of time as GEMS will just find another excuse why these accounts will not be paid!!