REFERRAL FROM NOMINATED GP - NOT TAKEN INTO ACCOUNT (CO-PAYMENT NOT JUSTIFIED)

On 16 August 2018 I was referred by our NOMINATED GP (DR J JURGENS – Jurgens & Botha Inc - practice number : PR ********** ) to DR H ROODT (Orthopaedic surgeon - practice number : PR ********** ) due to an injury to my right foot.

On 20 August 2018 I was consulted by DR H ROODT. The invoice sent to GEMS for this consultation did not state my GP's details as referral, as, according to DR H ROODT's staff (MARINDA & DIHANA), they were "not aware" of the fact that the referring GP's practice number must be filled in on the invoice - although I have SPECIFICALLY requested them to ensure that these details are on the invoice PRIOR to sending it to GEMS.

However, upon receiving my September GEMS statement, I noticed that I have been charged a co-payment code 7906 “Co-payment: Not referred by nominated GP”. I then sent an e-mail on 05 September 2018 to GEMS ********** and ********** with a copy of the referral letter. I received an acknowledgement for this e-mail on Wed 2018/09/05 11:21 AM from ********** . However, NO action whatsoever has been taken in order to remedy this situation.

I have sent NUMEROUS e-mails and made NUMEROUS telephone calls in order to get GEMS to respond. NO SUCCESS !!! On 10 October 2018 I spoke to MARCEL (refno : MH ********** 6) Marcel advised that the invoice for DR H ROODT (dated 20 August 2018) must be RE-SUBMITTED with the referral GP's details. According to DR H ROODT's staff, this was done towards the end of October 2018. However, the full payment has still not been done to DR H ROODT.

On 05 November 2018 I received a call from DR H ROODT's rooms "threatening me with legal action and possible ITC listing". I then also obtained my Latest GEMS statement from GEM's site. And noticed that the RE-SUBMITTED claim was "REJECTED DUE TO DUPLICATION".

I then phoned GEMS again on 05 November 2018 and spoke to NATALIE (ref no : MH ********** 6)

NATALIE advised me that the RE-SUBMISSION for DR H ROODT's invoice has INDEED been received, but unfortunately the person who was supposed to handle this matter "MISUNDERSTOOD" the reason for the RE-SUBMISSION for the claim and did not rectify it. NATALIE also informed me that "within 48 hours" I was to receive an sms notification in order to confirm that this matter has now been dealt with. Needless to say, almost TWO weeks later, and STILL NO ACTION !!!

For my own protection, I ALSO record each and every telephone call I make and receive. Should it be required, I am more than willing to forward these recordings to GEMS.

Please assist with the reversal of the co-payment and settle DR H ROODT's invoice in total as I have followed the fund rules to the T and cannot be penalised for 3rd party mistakes.

Thank you.