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Ntshadi S

1 reviews | Active since Apr 2011

19 Apr 2016, 10:52

Unexplained Delays

A claim for Member *** dependant 01 was submitted on 01/03/2016 for lenses and frames and it was rejected because the frame was overcharged.Ref 809553 . We were advised to resubmit the claim with the correct amount for the frame by the patient 's daughter after she called GEMS herself, which we did.The second claim was rejected reason being Duplication. Reversals were advised for both claims which were both reversed via email . Ref MH***0 and Ref 190135( Noloyiso) .Two weeks later we called to follow up if we could resubmit Ref 226004 and we were told to go ahead. A follow up was done on 13/04/2016 Ref 230947 and we were told to check the same Friday.Today we called to follow up Ref 242122 and the claim is still awaiting Assesor and the agent says the service date has changed.The service date is still the same as before which is 01/03/2016.The message on Optimum reads that the member is under Audit.Why does it take so long to Asses a claim when everything that we have been told to do has been done.This patient has undergone a cataract surgery and is battling with his old spectacles .

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Replies (3)
Gems (Government Employees Medical Scheme)
Gems (Government Employees Medical Scheme)'s reply19 Apr 2016, 11:13
Official
Hello LizNts,

Thank you for bringing your concerns to our attention.

We will investigate and provide feedback as soon as possible.

Kind regards
The GEMS Online Team
Gems (Government Employees Medical Scheme)
Gems (Government Employees Medical Scheme)'s reply10 May 2016, 13:34
Official

Good day LizNts,

Thank you once again for the opportunity afforded to GEMS to respond to your concerns. We believe a GEMS agent has been in contact with you, but for ease of reference we include a brief recap of the status of your enquiry.

Our records indicate that the first claim for services rendered which was dated 25 February was not paid as the patient’s benefits only became available on 1 March. With regards to the online claim for 1 March we can confirm that the claim was ***essed and rejected on 23 March.
On 3 March, the service provider captured another claim which was also ***essed and rejected on 23 March. Our investigation revealed that the claims were initially rejected as they were for the same prognosis on the same date but with different values. A hard copy of the invoice was requested from the service provider.


The service provider sent in a request for the cancellation of the initial claim but captured another claim to the same value but with a different service date online. In light of this, GEMS requested a copy of the record card, the lab order and a detailed statement. The required do***entation was received from the service provider on 20 April. The Scheme was at that point advised that the claim captured on 3 March was caused by a “finger error” as the patient was seen on 1 March.

We understand your frustration with the non-processing of the account but I am sure that you will understand our difficulties.
We are pleased to confirm that the member was paid on 29 April 2016. We trust that the above is in order.

Yours in service,

The GEMS Online Team

NS
Ntshadi S's update11 May 2016, 06:35
Reviewer Update
I would like to take this opportunity to apologise for the confusion caused in different date of service provided due to finger error when capturing the amended claim . I understand that this contributed to the claim being delayed. Thanks to Lebo and her team for resolving the matter timeously.