MH
Monique H

1 reviews | Active since Oct 2018

15 Jul 2025, 13:48

PMB Highrisk pregnancy.

So I have been having a problem for medical aid paying my last 2 scans for my 3rd trimester from the 27 May. First my ICD 19 code was incorrect. Then the tarrif code does not exist. Now the dr did not put through the amount and it was according to gems not in my gestantional age. The scans was done as 29 weeks and 33 weeks and 6 days. My benefits clearly states the tariff code 43270 which was used and that it states I have 2 scans for the 3rd trimester. I have been in communication with Luyanda Njomose where there is no communication futher. The doctor already sended me a statement where I need to pay the 2 scans because medical aid is rejecting it. Which I am refusing to pay as medical aid provided me with 2 scans for my 3rd trimester. I want this sorted out ASAP as I have been doing my scans according to the right times according to the high risk benefits provided to me. The correct tariff codes and the correct ICD10 code. This is really pathetic. Gems must pay those two scans as it is part of my benefits. The dates is the 27 May and 30 June for dr Kekana. Icd 10 code 34.0 and tariff code 43270 and dont say it does not exist then you need to review your hish risk pregnancy careplan tariff codes as it is there and also to say that I have 2 scans for 3rd trimester.

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Replies (2)
MH
Monique H's update15 Jul 2025, 14:18
Reviewer Update
If this is not sorted out I am going to CMS and lay a complaint against GEMS for providing benefits which you guys cannot abide to follow. Providing tariff codes which is not correct or does not exist. Does not know that there is 2 scans available for 3rd trimester. The dr sended me the claim that was provided and amounts is shown. It probably does not show on your side because it states tariff code does not exist.

Since I am pregnant there is problems every month. A person can only take this much.
MH
Monique H's update15 Jul 2025, 15:37
Reviewer Update
This matter is going on since the 9 June 2025 and does not get resolved. I also spoke to the dr office where gems is stating that I do not have scans left to pay the last scan. I only took 2 scans on the medical aid for dr Foolchand. One scan from dr Kekana was reversed as it was not suppose to go through medical aid which medical ajd reversed. So I have 2 scans left which I used for the 29 May and 30 June. Also now the gestational age of the scans is incorrect. I had my 2 scans 29 weeks and 33 weeks 6 days. Which is in my 3rd trimester and I am allowed 2 scans in my 3rd trimester.

I have phoned gems and they told me problem was resolved and claims was rejected due to not having an amount for the scans that was not added to the claim. And my gestational age.

I have taken this further now with the CMS and all my proof etc attached. Someone clearly does not know what is going on as there is too many stories and I will fight this until medical aid pays as it is part of my benefits.