1 reviews | Active since Feb 2014
Pre-authorization not needed as indicated by *********** consultant
My wife is a beneficiary of mine and is currently on the maternity programme.
On the 19th December 2018 we had an appointment at the fetal assessment center in Claremont for the detailed anatomical assessment scan. Our nominated gynaechologist refered us to this place for the scans etc.
On the 18th December 2018 I called in to gems in order to confirm whether I need pre-authorization for these scans/assessment. I also indicated to the consultant on the phone that on the maternity brochure, it was indicated clearly that the scan will be covered. The consultant then indicated to me that no pre-authorization was required (I did not take the consultants name or reference number but the recording can be pulled in order to confirm).
I then submitted the claim through to gems which I paid in cash for R2 270.
Subsequently I received the claims statement from gems which indicated that it won't be paid as no pre-authorization was obtained.
This is utterly ridiculous as incorrect information was relayed to me by an *********** gems consultant!
Gems is therefore liable to refund this money to me and if not, I demand that the consultant that gave me this information should refund me!
My membership number is ********** 96
I am currently out of the country till mid January 2019 and can only be contacted via email on **********
Thank you for bringing your concerns pertaining to your unpaid account to our attention.
After careful review we have found that when the claim was submitted the practice number used was a group practice number. As the member is on the Beryl option which means that network providers are to be used the claim could not be authorised.
The practice was however contacted and was asked to send an amended claim with the treating provider’s practice number.
Please be advised that the claim was received and processed as a refund amounting to R986.20 and will be settled on 1 February 2019. Please note that you will remain liable for an amount of R944.00 as tariff code 3637 is not covered under this option.
Please accept our sincere apologies for any inconvenience caused by the delay in resolution.
Thank you for bringing your concerns pertaining to your unpaid account to our attention.
After careful review we have found that when the claim was submitted the practice number used was a group practice number. As the member is on the Beryl option which means that network providers are to be used the claim could not be authorised.
The practice was however contacted and was asked to send an amended claim with the treating provider’s practice number.
Please be advised that the claim was received and processed as a refund amounting to R986.20 and will be settled on 1 February 2019. Please note that you will remain liable for an amount of R944.00 as tariff code 3637 is not covered under this option.
Please accept our sincere apologies for any inconvenience caused by the delay in resolution.