Sapphire & Beryl Family Practitioner Guide - Your GEMS 2019 Working towards a healthier you
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Your GEMS 2019
Sapphire & Beryl Family
Practitioner Guide
Working towards a healthier youTable of Contents 01 Introduction 1 02 Summary of Family Practitioner (FP) primary care benefits for Sapphire and Beryl 3 03 Family Practitioner tariffs and fees 5 04 Medicine 9 05 Ante-natal visits and the maternity benefit 11 06 Procedures performed in doctor’s rooms 12 07 Out-of-hospital specialist visits 13 08 Radiology 13 09 Pathology 14 10 Day-to-day benefits 14 11 Hospitalisation 15 12 Prescribed Minimum Benefits (PMBs) 15 13 HIV/AIDS registration 16 14 Circumcision 16 15 Disease management 17 16 Preventative care and screening services 18 17 Chronic Back and Neck Rehabilitation Programme 19 18 The referral management process for Sapphire and Beryl 20 19 Any other enquiries 20 20 Submitting claims 21 A Annexure A: GEMS Network Radiology Formulary 22 B Annexure B: GEMS Radiology Request Form 25 C Annexure C: GEMS Network Pathology Formulary 26 D Annexure D: GEMS Pathology Request Form 30 E Annexure E: GEMS Specialist Referral Form 31 F Annexure F: GEMS Sapphire and Beryl Re-order Form 32 G Annexure G: GEMS Comprehensive Chronic Medicine Formulary 33 H Annexure H: GEMS Sapphire and Beryl Network Acute Medicine Formulary 34 I Annexure I: GEMS Contraceptive Medicine Formulary 35 ii GEMS 2019 Sapphire & Beryl Family Practitioner Guide
01 Introduction
Thank you for being part of the GEMS Sapphire and Beryl Network. to the promotion of your services to improve access and promote
GEMS values the Family Practitioner’s role as the coordinator of care the FP as the coordinator of care. GEMS offers two low cost options
and believes the Family Practitioner (FP) has the best understanding namely Sapphire and Beryl, aimed at employees who previously
of a patient’s health and treatment history. It is because of these did not have access to healthcare cover. The contracted provider
reasons that GEMS encourages their members to nominate a Network networks for Sapphire and Beryl are available on our website at
FP in 2019. GEMS continuously strives to provide its members with www.gems.gov.za. Alternatively you may contact the GEMS Call
access to excellent, affordable healthcare and is therefore committed Centre on 0860 436 777.
Summarised benefits offered by Sapphire:
• Primary care benefits through the GEMS Network of healthcare of a 2D scan.
providers (Family Practitioners, dentists, optometrists, pharmacies • Circumcision is limited to a global fee of R1 498 per beneficiary,
and specialists) subject to network formularies. which includes all post-operative care within a month of the
• Access to public hospitals only, except for maternity and certain procedure.
admission types: • In-hospital benefits are limited to R219 482 per family per annum
• Circumcisions, myringotomies, tonsillectomies, retinal subject to Prescribed Minimum Benefit (PMB) sub-limits.
procedures, cataract procedures, hip replacements, knee • Preventative care services include Influenza vaccination, HPV
replacements , schizophrenia, anxiety, bipolar mood disorder, vaccination and Pneumococcal vaccination and are subject to
major depression, normal vaginal delivery, abortion, ante- managed care protocols and processes. Screening services
natal admissions, caesarean sections, hysterectomies, include Bone Density scan, Mammogram, Occult Blood Test,
cholecystectomies, hernias, spinal fusions and myomectomies, Pap Smear (including liquid based cytology), Prostate Specific
where a network of private hospitals can be accessed and Antigen, Glaucoma screening, TB, Syphilis, Chlamydia, Gonorrhoea,
subject to authorisation. Childhood Hearing, Childhood Optometry, Serum Cholesterol,
• The maternity benefit is subject to the Maternity Programme Serum Glucose, and Thyrotropin (TSH) for Neonatal Hypothyroidism,
Protocols and includes two 2D ultrasound scans per pregnancy. all subject to managed care protocols and processes.
Alternatively, should any such 2D scan be substituted with a
3D/4D scan, such 3D/4D scan shall be funded up to the cost
Summarised benefits offered by Beryl:
• Primary care benefits through the GEMS Network of healthcare include Bone Density scan, Mammogram, Occult Blood Test,
providers (Family Practitioners, dentists, optometrists, pharmacies Pap Smear (including liquid based cytology), Prostate Specific
and specialists) and subject to network formularies. Antigen, Glaucoma screening, TB, Syphilis, Chlamydia, Gonorrhoea,
• The maternity benefit is subject to Maternity Programme Childhood Hearing, Childhood Optometry, Serum Cholesterol,
Protocols and includes two 2D ultrasound scans per pregnancy. Serum Glucose, and Thyrotropin (TSH) for Neonatal Hypothyroidism,
Alternatively, should any such 2D scan be substituted with a all subject to managed care protocols and processes.
3D/4D scan, such 3D/4D scan shall be funded up to the cost • Circumcision is limited to a global fee of R1 498 per beneficiary
of a 2D scan. which includes all post-operative care within a month of the
• In-hospital benefits limited to R1 097 425 per family per annum procedure.
subject to PMB sub-limits. • Hospitalisation is at a network of private facilities as well as public
• Preventative care services include Influenza vaccination, HPV hospitals. The hospital network list is available on our website at
vaccination and Pneumococcal vaccination and are subject to www.gems.gov.za. Alternatively you may contact the GEMS
managed care protocols and processes. Screening services Call Centre on 0860 436 777.
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 1Sapphire and Beryl contribution rates for 2019:
Sapphire Beryl
Salary Band Member Adult Child Salary Band Member Adult Child
R0 – R9 066 R 992 R 784 R 427 R0 – R9 066 R1 149 R 1145 R 644
R9 066.01 - R12 722 R 1 039 R 832 R 460 R9 066.01 - R12 722 R1 246 R1 236 R 711
R12 722.01 - R21 795 R 1 105 R 875 R 488 R12 722.01 - R21 795 R1 360 R1 360 R 764
R21 795.01 + R1 228 R 1 039 R 587 R21 795.01 + R1 633 R1 633 R 927
2 GEMS 2019 Sapphire & Beryl Family Practitioner Guide02 Summary of Family
Practitioner (FP)
primary care benefits for
Sapphire and Beryl
Primary care benefits Sapphire Beryl
FP consultations • Reimbursed at the GEMS Network rate for visits to Network providers.
• GEMS members are encouraged to nominate a GEMS Network Family Practitioner (FP) who they will
visit for all their consultations in 2019.
• If a GEMS member wishes to change their nominated FP, they can call the GEMS call centre on
0860 00 4367. A FP can be changed every six (6) months.
• Specific procedures can be charged in addition to the consultation. Certain of these procedures are
subject to authorisation.
• Only listed tariff codes will be reimbursed. There will be no additional benefits for tariff codes that are
not listed in this guide.
• Gastroscopy, Colonoscopy, Cataract surgery will require and be subject to pre-authorisation.
• Sigmoidoscopy, Proctoscopy, Vasectomy, flexible Nasopharyngolaryngoscopy and ingrown toenail
procedures performed in doctor’s rooms reimbursed at 200% of the GEMS Scheme Rate do not
require pre-authorisation.
• Beneficiaries are allowed unlimited consultations to their Network FP without pre-authorisation.
Acute medicine • Subject to the GEMS Acute Medicine Formualry – Sapphire & Beryl .
• The formulary will consist of a list of drugs marked as either out-of-formulary or in-formulary and
annual quantity limits.
• Any medicine listed as out-of formulary will attract a 30% co-payment and medicine listed as in-
formualry will not attract a formulary co-payment. Medicine not listed on the formulary will not be paid.
Chronic medicine • The cost of acute medicine is included in the consultation fee for dispensing doctors.
• For non-dispensing doctors, acute medicine is to be dispensed by Network pharmacies.
• Subject to registration on the Chronic Medicine Management Programme and the GEMS Comprehensive
Chronic Medicine Formulary.
• Only on prescription by a Network FP or Specialist (provided that the specialist visit has been authorised
as per the referral management process).
• All chronic medicine to be dispensed by a Designated Service Provider (DSP) Pharmacy who is part
of the GEMS Pharmacy Network.
Specialist consultations • Specialist visit consultations has to be authorised • Limited to three consultations or R2 633 per
as per the referral management process and beneficiary and five consultations or R3 949
subject to PMBs. per family per annum. (This includes ante-natal
• Maternity cases are subject to the Maternity consultations as described in the ante-natal
Programmme and referral management (refer benefit section).
to the ante-natal benefit in this guide). • Only on referral from the Network FP and subject
to authorisation and the GEMS Specialist Network.
Please refer to the Specialist Referral form included in this guide.
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 3Primary care benefits Sapphire Beryl
Maternity benefit • Subject to registration on the Maternity Programme and the Maternity Programme Protocols.
• Two 2D ultrasound scans per pregnancy. Alternatively, should any such 2D scan be substituted with
a 3D/4D scan, such 3D/4D scan shall be funded up to the cost of a 2D scan.
• All specialist referrals require the Network FP to obtain authorisation.
Please refer to the Specialist Referral form included in this guide.
Pathology • Subject to PMBs and the GEMS pathology formulary.
• Only on referral from a Network FP.
• For tests not included in the formulary, please obtain authorisation.
Please refer to the Specialist Referral form included in this guide.
Radiology • Subject to PMBs and the GEMS radiology formulary.
• Only on referral from a Network FP.
• For tests not included in the formulary, please obtain authorisation.
Please refer to the Specialist Referral form included in this guide.
Screening Services and • Preventative care services include Influenza vaccination, HPV vaccination and Pneumococcal vaccination
Preventative Care and are subject to managed care protocols and processes. Screening services include Bone Density
scan, Mammogram, Occult Blood Test, Pap Smear (including liquid based cytology), Prostate Specific
Antigen, Glaucoma screening, TB, Syphilis, Chlamydia, Gonorrhoea, Childhood Hearing, Childhood
Optometry, Serum Cholesterol, Serum Glucose, and Thyrotropin (TSH) for Neonatal Hypothyroidism,
all subject to managed care protocols and processes.
• Only on referral from a Network FP or on referral from a Specialist where the specialist visit was referred
by the Network FP.
Rehabilitation • Ten post-surgery physiotherapy consultation sessions to be used within 60 days after shoulder, hip or
knee replacement surgery limited to R5 292 and subject to pre-authorisation.
Voluntary use of Out-of- • Limited to three visits per family per annum, and R 1 086 per event.
Network providers
Allied health services, • Benefits for allied health services are available • Limited to R2 126 per beneficiary and R3 197
including: Physiotherapy and subject to PMBs. per family per annum.
• Only on referral from the Network FP as per • Sub-limit of R1 599 per family for Social Workers
the referral management process and pre- and Registered Counsellors.
authorisation.
Occupational Therapy, • Only on referral from a Network FP and subject to authorisation.
Speech Therapy and • Benefits subjects to PMBs.
Audiology • Included under ‘Allied Health Services’ benefit limit, unless PMB.
The complete 2019 benefit schedule for Sapphire and Beryl can be viewed on the GEMS website at www.gems.gov.za.
4 GEMS 2019 Sapphire & Beryl Family Practitioner Guide03 Family Practitioner
tariffs and fees
The following information applies to both the Sapphire and Beryl options.
Family Practitioners on the Sapphire and Beryl GEMS Network are A performance report is distributed quarterly to keep Network FPs
paid according to a tiered performance based reimbursement model. up-to-date with their latest GEMS and REPI2 categories as well as
adherence performance. The quarterly practice performance report
The level of reimbursement is determined quarterly and is based on will highlight areas that may need change in order for a FP to obtain
the doctor’s GEMS score. The GEMS score is a combination of the an improved level.
following components:
In 2019, GEMS is focusing on diabetes, hypertension and cardiac
• The doctor’s level of adherence to protocols as contained in care. Network FPs will be profiled against quality measures relating
this guide, for example obtaining pre-authorisation for specialist to these conditions in their performance report. This profiling will
visits and adherence to formularies (in-room procedures, acute not influence the FPs network practice score for 2019, but GEMS
and chronic comprehensive medicine formulary, radiology and encourages the appropriate management of Sapphire and Beryl
pathology formulary). patients with these conditions.
• The doctor’s REPI2 score.
The following requirements will determine the level of reimbursement:
1 2 3
• Adherence to protocols and formularies • Adherence to protocols and formularies • Guidance is required with adherence to
within certain criteria. within certain criteria. formularies and protocols.
• REPI2 category 1 or 2 status. • REPI2 category 1 or 2 status. • REPI2 category 3 status.
Please take note that in order to sustain the Sapphire and Beryl options it is imperative to manage adherence to protocols and
formularies. Non-adherence to protocols and formularies will result in termination of the Sapphire and Beryl Network contract.
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 5Family Practitioner consultation fees
GEMS SB FP Network Score Dispensing doctor tariff Non-dispensing doctor tariff
Level 1 R 388.00 R 295.50
Level 2 R 373.00 R 295.50
Level 3 R 340.10 R 274.80
• Beneficiaries are allowed unlimited consultations per annum to their Network FP without necessitating pre-authorisation. Benefit limits
are subject to PMBs and managed care protocols.
• Doctors who do not adhere to the Scheme’s 2019 tariffs will no longer be able to participate in the network.
Family Practitioner tariff codes
The following tariff codes will be paid at the listed GEMS Network rates. Benefits will not be paid if the codes are not listed in this guide.
Beneficiaries are allowed unlimited consultations per annum to their Network FP without necessitating pre-authorisation. Benefit limits are
subject to PMBs and managed care protocols.
GEMS tariff code GEMS tariff code description
0190 – 0192 Family Practitioner visit
Emergency consultations at casualty wards or emergency rooms
There are no benefits in respect of private hospital casualty/emergency room facilities unless the condition is an emergency medical
condition as defined below:
“The sudden, and at the time
unexpected, onset of a life threatening
health condition that requires immediate
medical or surgical treatment, where
failure to provide medical or surgical
treatment would result in serious
impairment to bodily functions or
serious dysfunction of a bodily organ or
part, or would place the person’s life in
serious jeopardy”.
6 GEMS 2019 Sapphire & Beryl Family Practitioner GuideProcedure codes that can be charged in addition to a consultation code
GEMS tariff code GEMS tariff code description
0300 Stitching of a wound
0301 Stitching of an additional wound
0307 Excision and repair
0255 Drainage of subcutaneous abscess and avulsion of nail
0259 Removal of foreign body superficial to deep fascia
0887 Limb cast (including cost of POP and material)
1725 Drainage of external thrombosed pile
Procedure codes that can be charged in addition to a consultation code but
subject to authorisation
Family Practitioners need to obtain authorisation before charging for the following codes.
GEMS tariff code GEMS tariff code description
1186 Flow volume test: Inspiration/expiration
1188 Flow volume test: Inspiration/expiration/pre- and post- bronchodilator
1234 ECG bicycle
1235 ECG multistage treadmill
2713 Lumbar puncture
Note that these codes will only be allowed for the diagnosis and management of approved chronic conditions for registered
chronic members as part of the chronic condition benefit, subject to PMB treatment guidelines. Payment will be subject to the
doctor submitting the results for these tests. Rates are available on the Tariff file on the GEMS website www.gems.gov.za.
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 7Codes which are included in the consultation fee
The tariff codes listed below are examples of commonly used codes that cannot be billed separately as they form part of the consultation fee:
GEMS tariff code GEMS tariff code description
0145 to 0149 Modifiers
0017 Injections by practitioner
0199 Completion of chronic medicine forms by medical practitioners
0202 Setting sterile tray
0205 Intravenous infusions (patient under 3 years)
0206 Intravenous infusions (patient over 3 years)
0222 Intralesional injection into areas of pathology e.g. Keloid: Single
0223 Intralesional injection into areas of pathology e.g. Keloids: Multiple
0233 Biopsy without suturing: First lesion
0234 Biopsy without suturing: Subsequent lesions
0235 Biopsy without suturing: Maximum for multiple additional lesions
0241 Treatment of benign skin lesion by chemo- cryotherapy: First Lesion
0242 Treatment of benign skin lesion by chemo- cryotherapy: Subsequent lesions (each)
0243 Treatment of benign skin lesion by chemo- cryotherapy: Maximum for multiple additional lesions
0244 Repair nail bed
0245 Removal of benign lesion by curetting under local or general anaesthesia
0661 Aspiration of joint or intra-articular injection
0663 Multiple intra-articular injections for rheumatoid arthritis: First joint
0763 Muscle and tendon repair: Tendon or ligament injection
1063 Removal of foreign bodies from nose in rooms
1136 Nebulisation in rooms
1192 Peak Flow
1228 ECG: Without effort
1232 Electrocardiogram: Without effort
1233 Electrocardiogram: With and without effort
1996 Bladder catheterisation: Male (not at operation)
1997 Bladder catheterisation: Female (not at operation)
2442 Insertion of intra uterine contraceptive device (IUCD): Excluding cost of device
2565 Implantation hormone pellets
3275 Audiometry - tympanometry
3287 Spinal joint and ligament injection
4188 Urine dipstick, per stick (irrespective of the number of tests on stick)
*This list only refers to commonly used codes and is not exhaustive.
8 GEMS 2019 Sapphire & Beryl Family Practitioner Guide04 Medicine
All medicine for Sapphire and Beryl is subject to the GEMS Network comprehensive medicine formularies. Please refer to the comprehensive
medicine formularies included in this guide or visit the GEMS website at www.gems.gov.za.
Chronic medicine
Prescriber Benefit for Sapphire and Beryl
Dispensing and non-dispensing • All chronic medicine is subject to authorisation and registration of members on the Chronic
Network FPs Medicine Management Programme.
• Prescribed medicine is subject to the GEMS comprehensive chronic formulary which is limited
to PMB- CDL and DTP conditions.
• Chronic medicine can only be prescribed by GEMS Network FPs and Specialists, provided
that the specialist visit has been authorised as per the specialist referral management process.
• All chronic medicine is dispensed by the Scheme’s Chronic DSP Courier or Network Pharmacy.
• Chronic medicine obtained voluntarily from a pharmacy other than the Scheme’s Chronic
DSP Courier or Network Pharmacy, will incur a 30% member co-payment.
How to access the Chronic • The Chronic Medicine Application form can be accessed on the GEMS website at
Medicine Application form www.gems.gov.za, or
• You can contact us on 0860 436 777 and a copy will be faxed or emailed to you.
Return completed application form • Please fax the completed form to 0861 00 4367, or
• Mail to: GEMS, Private bag X782, Cape Town, 8000, or
• Email: chronicdsp@gems.gov.za
Reimbursement for completing • As Sapphire and Beryl are the low contribution GEMS options, there is no additional tariff
chronic applications applicable for the completion of the Chronic Member Benefit Application form.
• The fee is included in the consultation fee.
Changes or updates • The Chronic Medicine Application form is completed only once.
• Following registration on the Chronic Medicine Management Programme, all changes or
updates are done telephonically by calling 0860 436 777 or by faxing a prescription with the
amendments to 0861 00 4367 or email: chronicdsp@gems.gov.za
General:
• Please ensure that all test results and motivations (where applicable) are included when submitting the Chronic Medicine Application form.
• Also ensure that the member/patient completes their relevant section and signs the form.
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 9Acute medicine
Prescriber Benefit for Sapphire and Beryl
Dispensing Network FPs • Acute medicine is included in the consultation fee.
• Doctors are requested to display the NAPPI codes for medicine dispensed which will be used for
analysis purposes. The consultation fee will be paid irrespective of medicine dispensed or not.
• Acute pharmacy claims will not be covered where the scripting FP is contracted as a
dispensing FP.
• FPs contracted as dispensing FPs can, however, script chronic medicine as this is not
included in the fee structure.
Non-dispensing Network FPs • Subject to the GEMS Network comprehensive acute medicine formulary.
• Prescribed acute medicine is obtainable from GEMS DSP Network pharmacies.
• The network can be accessed on the GEMS website at www.gems.gov.za
• Acute medicine obtained voluntarily from a non-network pharmacy, will incur a non- refundable
30% member co-payment.
Over the counter (OTC) medicine
Benefit for Sapphire and Beryl
• Acute medicine is included in the consultation fee.
• Doctors are requested to display the NAPPI codes for medicine dispensed which will be used for analysis purposes. The consultation
fee will be paid irrespective of medicine dispensed or not.
• Acute pharmacy claims will not be covered where the scripting FP is contracted as a dispensing FP.
• FPs contracted as dispensing FPs can, however, script chronic medicine as this is not included in the fee structure.
• OTC Medicine is limited to a value of R90 per beneficiary per event and R250 per beneficiary per year.
Contraceptive benefit
Benefit for Sapphire and Beryl
• The contraceptive benefit is applicable to oral contraceptives, insertables, injectables or dermal patches.
• Limited to R2 822 per beneficiary per annum.
• Subject to managed care protocols and processes as well as the contraceptive formulary.
• Please refer to the contraceptive formulary in Annexure I in this guide or access the formulary by visiting www.gems.gov.za.
10 GEMS 2019 Sapphire & Beryl Family Practitioner Guide05 Ante-natal visits and the
maternity benefit
The following benefits apply to both Sapphire and Beryl members per pregnancy, payable from risk for members who are registered on the
Maternity Programme (members who are not registered on the Maternity Programme are limited to their day-to-day benefits as defined in
the Scheme rules and subject to PMB legislation):
Benefit for Sapphire and Beryl
Ante-natal visits, scans and blood The ante-natal benefit allows for six ante-natal consultations at the FP or midwife of which three
tests may be Gynaecologist visits. Gynaecologists form part of the GEMS Specialist Network and should
your Gynaecologist form part of the Network, they have agreed to charge at an agreed rate.
The schedule is as follows:
• Booking visit
• One (1) visit every 4 weeks (24-36 weeks), i.e. 4 visits
• One (1) visit at 38, 39 and 40 weeks gestation
• Two (2) 2D ultrasound scans. Alternatively, should any such 2D scan be substituted with a
3D/4D scan, such 3D/4D scan shall be funded up to the cost of a 2D scan.
The ultrasound scans must either be done by the doctor who will be responsible for the confinement
or a radiologist or gynaecologist.
Blood tests included in this benefit:
• Three (3) Hb estimations
• One (1) Blood group
• One (1) VDRL (Syphilis)
• Two (2) HIV of which one must be done in the third trimester
Specialist visits Please refer to the Specialist Referral form included in this guide.
All out-of-hospital specialist consultations must be referred by a GEMS Network FP and require
the FP to obtain authorisation by contacting the GEMS Call Centre on 0860 436 777.
Hospital network • Beryl members have access to private hospitals, subject to pre-authorisation.
• Sapphire members have access to private hospitals for maternity, subject to pre-authorisation.
FP services Subject to registration on the Maternity Programme and pre-authorisation.
Pre-natal vitamins Available as per Maternity vitamin list. Prenatal vitamins will be funded up to a cut-off of R85 per
month. Items must be prescribed by the FP or midwife. Subject to registration on the Maternity
Programme.
Benefit for Sapphire only
Post discharge complications of a Hospitalisation in designated private hospitals for post discharge complications of a new- born
newborn limited to six (6) weeks.
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 1106 Procedures performed in
doctor’s rooms
Procedures performed in doctor’s rooms
Details Benefit for Sapphire and Beryl
Procedure Benefit Diagnostic procedures - Gastroscopy, Colonoscopy, Cataract surgery, Sigmoidoscopy, Proctoscopy,
Vasectomy and flexible Nasopharyngolaryngoscopy including ingrown toenail procedures
performed in doctor’s rooms.
Reimbursement Rate Reimbursed at 200% of the GEMS Scheme Rate for Network FPs.
Authorisation Authorisation can be obtained by contacting the GEMS Call Centre on 0860 436 777 and following
the prompts for the Provider Network enquiries option.
Please note that authorisation is only required for Gastroscopy, Colonoscopy and Cataract surgery when performed in the
doctor’s rooms. Sigmoidoscopy, Proctoscopy, Vasectomy, flexible Nasopharyngolaryngoscopy and ingrown toenail procedures
do not require pre-authorisation.
12 GEMS 2019 Sapphire & Beryl Family Practitioner Guide07 Out-of-hospital
specialist visits
Specialist benefits apply as follows:
Sapphire and Beryl
• Specialist benefits are subject to PMBs. Ante-natal visits are subject to Maternity Programme Protocols.
• All specialist visits, including Allied Health services have to be authorised and is subject to referral from a Network FP/DSP. The member
may also obtain the authorisation before the specialist visit by contacting 0860 00 4367 and submitting the Specialist Referral form
that has been completed by the Network FP/DSP.
• Beryl Specialist visits, which include all Allied Health services, are limited to three visits per beneficiary or R2633 per beneficiary, and
five consultations or R3 949 per family per annum.
Authorising specialist visits
• Family Practitioners can obtain authorisation for specialist visits by contacting the GEMS Call Centre on 0860 436 777 and following
the prompts to the Provider Network enquiries option.
Please refer to the Specialist Referral form included in this guide.
08 Radiology
Out-of-hospital radiology Benefits for Sapphire and Beryl
Codes that apply • Out-of-hospital radiology is covered according to the GEMS radiology formulary and all limits
are subject to PMBs. See Annexure A of this guide.
• All additional tests not listed in the formulary will require a pre-authorisation.
• Please also refer to the Radiology Request form included in this guide.
Who can refer the member • Members must be referred by the DSP/FP or a Specialist, subject to authorisation of the
specialist visit, in order for tests to qualify for payment.
How to obtain authorisation • All additional investigations are subject to pre-authorisation as indicated in the radiology
formulary.
• Authorisation is required for in and out-of-hospital specialised radiology scans additional to
the hospital pre- authorisation and is subject to PMBs. This includes angiography, CT scans,
MUGA/PET/MRI scans, and radio- isotope studies.
• Please contact the GEMS Call Centre on 0860 436 777 to obtain authorisation.
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 1309 Pathology
Out-of-hospital pathology Benefits for Sapphire and Beryl
Codes that apply • Out-of-hospital pathology is covered according to the GEMS pathology formulary. Please
refer to Annexure C of this guide.
• All additional tests not listed in the formulary will require pre-authorisation.
• Please also refer to the Pathology Request form included in this guide.
Who can refer the member • Members must be referred by the DSP/FP or a Specialist, subject to authorisation of the
specialist visit, in order for tests to qualify for payment.
How to obtain authorisation • Tests not included in the pathology formulary, are subject to pre-authorisation. Please contact
the GEMS Call Centre on 0860 436 777 to obtain authorisations.
• The authorisation number must be included in the Pathology Request form. Failure to do so
will result in the laboratory being unable to perform the test.
10 Day-to-day benefits
Allied Health Services
Details Sapphire Beryl
Benefit includes:
• Chiropractors • Benefits are subject to PMBs. • In-hospital services limited to R2 187
• Dieticians • Only on referral from the Network FP as per beneficiary and R3 291 per family
• Homeopaths per the referral management process. per annum, subject to PMBs.
• Podiatrists • Out-of-hospital services limited to R2 126
• Phytotherapists per beneficiary and R3 197 per family per
• Social Workers annum, subject to PMBs.
• Registered Counsellors • There is a sub-limit of R1 599 per family
• Chinese Medicine Practitioners for Social Workers and Registered
• Physiotherapists Counsellors.
• Occupational Therapists
• Speech Therapists
• Audiologists
Who can refer a member Subject to referral from a Network FP and the Network FP obtaining authorisation.
How to obtain authorisation Authorisation is obtained by contacting the GEMS Call Centre on 0860 436 777.
14 GEMS 2019 Sapphire & Beryl Family Practitioner Guide11 Hospitalisation
Details Sapphire Beryl
Benefit Annual limit of R219 482 per family, per annum Annual limit of R1 097 425 per family, per
subject to pre-authorisation and managed annum subject to pre-authorisation and
care protocols. managed care protocols.
Which hospitals Access to public hospitals only, except Public hospitals as well as a network of
for maternity and certain admission types: private hospitals.
Circumcisions, myringotomies, tonsillectomies,
retinal procedures, cataract procedures,
hip replacements, knee replacements,
schizophrenia, anxiety, bipolar mood disorder,
major depression, normal vaginal delivery,
abortion, ante-natal admissions, caesarean
sections, hysterectomies, cholecystectomies,
hernias, spinal fusions and myomectomies,
where a network of private hospitals can
be accessed and subject to authorisation.
Hospital network The GEMS hospital network for Sapphire and Beryl can be accessed on the GEMS website
at www.gems.gov.za.
How to obtain pre-authorisation • Email: hospitalauths@gems.gov.za
• Fax: 0861 00 4367
• Phone: 0860 436 777
12 Prescribed Minimum
Benefits (PMBs)
• Benefits for both Sapphire and Beryl are as per the GEMS PMB treatment protocols for each disease.
• Registration for chronic diseases is compulsory.
• All PMB services to be delivered by the GEMS designated provider networks for Sapphire and Beryl.
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 1513 HIV/AIDS registration
Benefit Benefits for both Sapphire and Beryl are subject to PMBs
Reimbursement for completing the HIV/ AIDS Disease Management Doctors will be reimbursed at the Scheme rate upon submission of the
Programme registration form completed HIV/AIDS Disease Management Programme registration
form and the successful registration of the beneficiary on the HIV/
AIDS Disease Management Programme (DMP).
How to access the form The registration form can be accessed on the GEMS website at
www.gems.gov.za.
Return the completed form • Fax (toll-free): 0800 436 732
• Email: hiv@gems.gov.za
Queries, clinical advice and script updates • Phone: 0860 436 736
• Please call me: 083 843 6764
14 Circumcision
Benefit Codes that apply How to obtain
authorisation
• Limited to a global fee of R1 498 which • Network FPs will be reimbursed up to the
includes all post-procedure care, global fee upon submission of the claim. • Email: hospitalauths@gems.gov.za
consultations and medicine within a • The GEMS tariff code 2133 or 2137 • Fax: 0861 00 4367
month of the procedure. or 2139 or 9901 to be used for the • Phone: 0860 436 777
• The benefit is subject to pre- procedure.
authorisation, managed care protocols • Please include the correct and applicable
and the use of a GEMS Network ICD-10 code.
provider.
• Out-of-hospital only.
16 GEMS 2019 Sapphire & Beryl Family Practitioner Guide15 Disease management
Details Sapphire Beryl
Benefit includes: • The State is the DSP. • Oncology: Subject to the GEMS Oncology
• Oncology (chemotherapy and • Organ transplants are limited to PMBs. managed care protocols, annual hospital
radiotherapy) limit and a sub-limit of R219 481 per
• Organ transplants and renal dialysis family per annum.
• Mental health • Organ transplants are limited to PMBs.
• Alcoholism and drug dependency • Renal Dialysis: Subject to the
annual hospital limit and a sub-limit of
R 219 481 per family per annum
and PMBs.
• Mental health: Limited to PMBs and have
a combined in- and out-of-hospital sub-
limit of R9 971 per family per annum and
limited to PMBs.
• Alcoholism and drug dependency: The
State healthcare sector is the DSP.
Authorisation of care All benefits are subject to managed care protocols and the patient being registered on the
relevant Disease Management Programme (DMP).
Registration on the Disease Management Registration on the relevant DMP can be done by contacting the GEMS Call Centre on
Programme (DMP) 0860 436 777.
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 1716 Preventative care and
screening services
Details Benefits for Sapphire and Beryl
Benefit includes investigations for:
• Bone Density scan • Bone Density scan, Mammogram, Occult Blood Test, Pap Smear
• Glaucoma screening (including liquid based cytology) Prostate Specific Antigen,
• Mammogram Glaucoma screening, TB, Syphilis, Chlamydia, Gonorrhoea,
• Occult Blood Test Childhood Hearing screening, Childhood Optometry screening,
• Pap smear (including liquid based cytology) Serum Cholesterol, Serum Glucose investigations, Thyrotropin
• Prostate Specific Antigen (TSH) for Neonatal Hypothyroidism, Influenza-, HPV- and
• Serum Cholesterol Pneumococcal vaccinations are according to managed care
• Serum Glucose principles and processes.
• Thyrotropin (TSH) for Neonatal Hypothyroidism • Only on referral of a Network FP or on referral from a Specialist
• Influenza vaccination where the specialist visit was authorised by a Network FP.
• HPV vaccination
• Pneumococcal vaccination
• TB
• Syphilis
• Chlamydia
• Gonorrhoea
• Childhood Hearing and Childhood Optometry screening
18 GEMS 2019 Sapphire & Beryl Family Practitioner Guide17 Chronic Back and Neck
Rehabilitation Programme
GEMS implemented a Chronic Back and Neck Rehabilitation (CBNR) The focus of the CBNR programme is on back and neck rehabilitation
programme which provides GEMS beneficiaries with appropriate with the major components being controlled exercises, biopsychosocial
treatment to manage their chronic back and neck pain. This programme support and pain education. Clinical measurements are taken and
is offered by identified centres, where the Family Practitioner (FP) recorded and these are used to evaluate the progress of treatment
is the coordinator of the spinal care and he/she is supported by a over time.
multidisciplinary team (including a Physiotherapist and Biokineticist).
Positive outcomes include improved flexibility and reduced pain and
The CBNR programme has been developed on a scientific basis stiffness which lead to a more productive life.
and consists of carefully planned exercises and guidance on how
to deal with the back problem and so live a normal life.
The services provided by the CBNR Programme are in accordance with the standards of professional conduct and include, amongst others:
• Initial assessment of patients referred to the centre.
• Identifying patients for whom the treatment is contra-indicated and referring such patients to the appropriate healthcare provider.
• Where the treatment is clinically indicated, the design of an appropriate treatment programme.
• Implementation of such a treatment programme in the inter-disciplinary environment and maintaining appropriate records.
• Providing the referring doctor with clinical feedback on services performed.
Identified members will have their claims paid from the overall annual limit with no financial impact on their day-to-day benefit or savings.
Should your GEMS patient require a referral to a CBNR network facility, kindly send an e-mail to enquiries@gems.gov.za. For an updated
CBNR network list please visit the GEMS website or call the GEMS Call Centre on 0860 436 777.
We look forward to your support in making this programme a success.
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 1918 The referral management
process for Sapphire and
Beryl
Authorisation needs to be obtained by the Network FP before the event for the
following benefit categories:
• All specialist visits, including ante-natal visits at a gynaecologist and selected admissions.
• Allied health visits.
• Certain special procedures that can be performed by the FP as indicated in this guide.
• Radiology and pathology investigations not indicated on the GEMS pathology and radiology formularies in this guide.
Please contact the GEMS Call Centre on 0860 436 777 and follow the prompts to the Provider Network enquiries option to
obtain authorisation.
19 Any other enquiries
For all GEMS Sapphire and Beryl queries (benefit and claims enquiries, pre-authorisation requests and chronic medicine authorisation
requests) or other network related queries, please make use of our interactive voice recognition (IVR) call centre number on 0860 436 777
and follow the voice prompts.
20 GEMS 2019 Sapphire & Beryl Family Practitioner Guide20 Submitting claims
For all GEMS Sapphire and Beryl queries (benefit and claims enquiries, pre-authorisation requests and chronic medicine authorisation
requests) or other network related queries, please make use of our interactive voice recognition (IVR) call centre number on 0860 436 777
and follow the voice prompts.
Submit all paper claims and Submit electronic claims using
hospital claims to: the following codes:
GEMS: Private Bag X782 Cape Town 8000 DHS Switch: QEDI - 875P | Mediswitch: GEMS0001
Firstnet or Gateway Other clearinghouses
Communications mailboxes: or hubs:
6004930008673 TUN Number A843 Please contact your relevant clearinghouses or hubs on
the respective submission codes
Scheme Name Routing Code
GEMS 875P
Should you have any queries, kindly contact the GEMS Call Centre on 0860 436 777.
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 21Annexure A
GEMS Network Radiology
Formulary
All codes not listed require authorisation.
MEDICAL PRACTITIONER RADIOLOGIST RADIOGRAPHY CODE DESCRIPTION
General
Non-chargable Non-chargable 39300 X-Ray films
Skull and Brain
3349 10100 39039 X-Ray of the skull
Facial and nasal bones
3353 11100 39043 X-Ray of the facial bones
3357 11120 39047 X-Ray of the nasal bones
Orbits and Paranasal sinuses
3353 12100 39043 X-ray orbits
3351 13100 39041 X-ray of the paranasal sinuses, single view
Non-chargable 13110 Non-chargable X-ray of the paranasal sinuses, two or more view
Mandible, teeth and maxilla
3355 14100 39045 X-ray of the mandible
3361 14130 39051 X-ray of the teeth single quadrant
3363 14140 39053 X-ray of the teeth more than one quadrant
3365 14150 39055 X-ray of the teeth full mouth
3361 15100 39059 X-ray tempero-mandibular joint, left
3361 15110 39059 X-ray tempero-mandibular joint, right
3359 16100 39049 X-ray of the mastoids, unilateral - Left
3359 16100 39049 X-ray of the mastoids, unilateral - Right
3359 16110 39049 X-ray of the mastoids, bilateral
Thorax
3445 30100 39107 X-ray of the chest, single view - PA
3445 30100 39107 X-ray of the chest, single view - Lateral
Non-chargable 30110 39107 X-ray of the chest two views, PA and lateral
3449 30150 39107 X-ray of the ribs
Abdomen and Pelvis
3477 40100 39125 X-ray of the abdomen
Non-chargable 40110 Non-chargable X-ray of the abdomen multiple views including chest
Non-chargable 40105 39125 X-ray of the abdomen supine and erect, or decubitus
Spine
3321 39017 Skeleton: Spinal column - Per region, e.g. cervical, sacral, lumbar
coccygeal, one region thoracic
Non-chargable 50100 39025 X-ray of the spine scoliosis view AP only
3321 51110 39017 X-ray of the cervical spine, one or two views - AP
22 GEMS 2019 Sapphire & Beryl Family Practitioner GuideMEDICAL PRACTITIONER RADIOLOGIST RADIOGRAPHY CODE DESCRIPTION
3321 51110 39017 X-ray of the cervical spine, one or two views - Lateral
3321 52100 39017 X-ray of the thoracic spine, one or two views - AP
3321 52100 39017 X-ray of the thoracic spine, one or two views - Lateral
3321 53110 39017 X-ray of the lumbar spine, one or two views - AP
3321 53110 39017 X-ray of the lumbar spine, one or two views - Lateral
3321 54100 39017 X-ray of the sacrum and coccyx
Non-chargable 54110 39027 X-ray of the sacro-iliac joints
Pelvis and Hips
3331 55100 39027 X-ray of the pelvis
6518 56100 39017 X-ray of the left hip
6518 56110 39017 X-ray of the right hip
Non-chargable 56120 Non-chargable X-ray pelvis and hips
Upper Limb
6509 61100 39003 X-ray of the left clavicle
6509 61105 39003 X-ray of the right clavicle
6510 61110 39003 X-ray of the left scapula
6510 61115 39003 X-ray of the right scapula
6508 61120 39003 X-ray of the left acromio-clavicular joint
6508 61125 39003 X-ray of the right acromio-clavicular joint
6507 61130 39003 X-ray of the left shoulder
6507 61135 39003 X-ray of the right shoulder
6506 62100 39003 X-ray of the left humerus
6506 62105 39003 X-ray of the right humerus
6505 63100 39003 X-ray of the left elbow
6505 63105 39003 X-ray of the right elbow
6504 64100 39003 X-ray of the left forearm
6504 64105 39003 X-ray of the right forearm
6500 65100 39003 X-ray of the left hand
6500 65105 39003 X-ray of the right hand
3305 65120 39001 X-ray of a finger
6501 65130 39003 X-ray of the left wrist
6501 65135 39003 X-ray of the right wrist
6503 65140 39003 X-ray of the left scaphoid
6503 65145 39003 X-ray of the right scaphoid
Lower Limb
6514 73100 39003 X-ray of the left lower leg
6514 73105 39003 X-ray of the right lower leg
6512 74100 39003 X-ray of the left ankle
6512 74105 39003 X-ray of the right ankle
6511 74120 39003 X-ray of the left foot
6511 74125 39003 X-ray of the right foot
6513 74130 39003 X-ray of the left calcaneus
6513 74135 39003 X-ray of the right calcaneus
6511 74140 39003 X-ray of both feet – standing – single view
3305 74145 39001 X-ray of a toe
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 23MEDICAL PRACTITIONER RADIOLOGIST RADIOGRAPHY CODE DESCRIPTION
6517 71100 39003 X-ray of the left femur
6517 71105 39003 X-ray of the right femur
6515 72100 39003 X-ray of the left knee one or two views - AP
6515 72100 39003 X-ray of the left knee one or two views - Lateral
6515 72105 39003 X-ray of the right knee one or two views - AP
6515 72105 39003 X-ray of the right knee one or two views - Lateral
Non-chargable 72120 39003 X-ray of the left knee including patella
Non-chargable 72125 39003 X-ray of the right knee including patella
6516 72140 39003 X-ray of left patella
6516 72145 39003 X-ray of right patella
Non-chargable 72150 39003 X-ray both knees standing – single view
6519 74150 39003 X-ray of the sesamoid bones one or both sides - Left
6519 74150 39003 X-ray of the sesamoid bones one or both sides - Right
Ultrasound abdomen and Pelvis
5102 61200 Non-chargable Ultrasound of the left shoulder joint
5102 61210 Non-chargable Ultrasound of the right shoulder joint
Non-chargable 41200 Non-chargable Ultrasound study of the upper abdomen
3627 40210 Non-chargable Ultrasound study of the whole abdomen including the pelvis
3618 43200 39147 Ultrasound study of the pelvis transabdominal
3615 43250 39145 Ultrasound study of the pregnant uterus, first trimester
Non-chargable 43270 39145 Ultrasound study of the pregnant uterus, third trimester, first visit
Non-chargable 43273 39145 Ultrasound study of the pregnant uterus, third trimester, follow-up
visit
3615 43277 39145 Ultrasound study of the pregnant uterus, multiple gestation, second
or third trimester, first visit
3617 43260 39145 Routine obstetric ultrasound at 20 to 24 weeks to include detailed
anatomical assessment
24 GEMS 2019 Sapphire & Beryl Family Practitioner GuideAnnexure B
GEMS Radiology Request Form
GEMS Radiology Request Form
Sapphire • Beryl
Referring General Practitioner Details:
Doctor’s Name: _____________________________________________________________________ Practice Number: nnnnnnnnnnn
Tel: nnnnnnnnnn Fax: nnnnnnnnnn Email: ___________________________________________________________
Signature: _____________________________
Patient Details:
Patient date of birth: nnnnnnnn Gender: nM nF
Patient Surname: ___________________________________________ Patient Name: ______________________________________________________
Medical Scheme Name: _____________________________________________ Medical Scheme Option: ___________________________________
Membership Number: nnnnnnnnnn Dependant Code: nn
I certify that the above information is correct and give specific consent for selected test(s) to be done. I authorise the disclosure of these results to my doctor, medical aid administrators and/or insurance company. I undertake
to pay all outstanding monies not covered by medical aid. I fully understand the implication of the test and have received adequate pre-test counselling.
Patient Signature: _____________________________
Clinical Information:
ICD-10 Codes: ________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Please choose from the following investigations below. For certain tests, please specify the view and site.
Skull and brain Request Pelvis and hips Request Lower limb cont. Request
Skull Pelvis Knee: right ap
Facial bones and nasal bones Hip: left Knee: right lateral
Facial bones Hip: right Knee including patella: left
Nasal bones Pelvis and hips Knee including patella: right
Orbits and paranasal sinuses Upper limb Patella: left
Orbits Clavicle: left Patella: right
Paranasal sinuses Clavicle: right Both knees standing: single view
Paranasal sinuses: 2 views Scapula: left Sesamoid bones: left
Mandible, teeth and maxilla Scapula: right Sesamoid bones: right
Mandible Acromio-clavicular joint: left Ultrasound
Teeth: single quadrant Acromio-clavicular joint: right Ultrasound: left shoulder joint
Specify quadrants: Shoulder: left Ultrasound: right shoulder joint
Teeth: more than one quadrant Shoulder: right Ultrasound study: upper abdomen
Specify quadrants: Humerus: left Ultrasound: abdomen and pelvis
Teeth: full mouth Humerus: right Ultrasound: pelvis transabdominal
Tempero-mandibular joint: left Elbow: left Ultrasound: pregnant uterus
Tempero-mandibular joint: right Elbow: right For advanced radiology tests not included on this form,
Mastoids: left Forearm: left please contact 0860 436 777 and request an a
Mastoids: right Forearm: right uthorisation number.
Mastoids: right and left Hand: left
Thorax Hand: right List additional test required
Chest: pa Finger: specify
Chest: lateral Wrist: left
Chest : pa and lateral Wrist: right
Ribs Scaphoid: left
Abdomen Scaphoid: right
Abdomen Lower limb
Abdomen: multiple views incl chest Lower leg: left
Specify views: Lower leg: right
Abdomen: supine and erect or decubitus Ankle: left
Spine Ankle: right Authorisation number
Spine scoliosis view: ap only Foot: left
Cervical spine: ap Foot: right
Cervical spine: lateral Calcaneus: left Clinical information
Thoracic spine: ap Calcaneus: right
Thoracic spine: lateral Both feet standing: single view
Lumbar spine: ap Toe: specify
Lumbar spine: lateral Femur: left
Saccrum and coccyx Femur: right
Sacro-iliac joints Knee: left ap
Knee: left lateral
Tel 0860 436 777 • Fax 0861 00 4367 • enquiries@gems.gov.za • HIV Aids Helpline 0860 436 736 • www.gems.gov.za
Visit www.gems.gov.za to download this form.
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 25Annexure C GEMS Network Pathology Formulary All codes not listed require authorisation. RPL DESCRIPTION SUBJECT TO AUTHORISATION A. Chemistry Cardia / Muscle 4152 CK-MB: Mass determination: Quantitative (Automated) No 4161 Troponin isoforms: Each No Diabetes 4057 Glucose: Quantitative No 4064 HbA1C No 4221 Creatinine No 4261 Micro Albuminurea (Quantitative) No Inflammation / Immune 3947 C-reactive protein No Lipids 4027 Cholesterol total No 4026 LDL cholesterol No 4028 HDL cholesterol No 4147 Triglyceride No 4132 Creatinine Kinase (CK) No Liver / Pancreas 3999 Albumin No 4001 Alkaline phosphatase No 4006 Amylase No 4009 Bilirubin: Total No 4010 Bilirubin: Conjugated No 4117 Protein: Total No 4130 Aspartate aminotransferase (AST) No 4131 Alanine aminotransferase (ALT) No 4133 Lactate dehidrogenase (LD) No 4134 Gamma glutamyl transferase (GGT) No Renal / Electrolytes / Bone 4017 Calcium: Spectrophotometric No 4032 Creatinine No 4086 Lactate No 4094 Magnesium: Spectrophotometric No 4109 Phosphate No 4113 Potassium No 26 GEMS 2019 Sapphire & Beryl Family Practitioner Guide
RPL DESCRIPTION SUBJECT TO AUTHORISATION
4114 Sodium No
4155 Uric acid No
4151 Urea No
Cerebrospinal fluid
B. Haematology
3709 Antiglobulin test (Coombs' or trypsinzied red cells) No
3716 Mean cell volume No
3743 Erythrocyte sedimentation rate No
3739 Erythrocyte Count No
3783 Leucocyte Differential Count No
3785 Leucocytes - Total Count No
3791 Packed Cell Volume: Haematocrit No
3755 Full blood count (including items 3739, 3762, 3783, 3785, 3791) No
3762 Haemoglobin estimation No
3764 Grouping: A B and O antigens No
3765 Grouping: Rh antigen No
3797 Platelet count No
3805 Prothrombin index No
3809 Reticulocyte count No
3865 Parasites in blood smear No
4071 Iron No
4144 Transferrin No
4491 Vitamin B12 No
4528 Ferritin No
4533 Folic acid No
C. Endocrine - Reproductive
4450 HCG: Monoclonal immunological: Qualitative No
4537 Prolactin No
Endocrine - Thyroid
4482 Free thyroxine (FT4) No
4507 Thyrotropin (TSH) No
Other Endocrine
4519 Prostate specific antigen No
D. Serology
Auto immune
3934 Auto antibodies by labelled antibodies: FOR ANF ONLY No
3939 Agglutination test per antigen No
4155 Uric acid No
4182 Quantitative protein estimation: Nephelometer or Turbidometeric method: FOR RHEUMATOID FACTOR ONLY No
Hepatitis tests
4531 Hepatitis: Per antigen or antibody No
4531 Acute hepatitis A (IgM) No
4531 Chronic Hepatitis A (IgG) No
4531 Acute Hepatitis B (BsAG) No
4531 Hepatitis B: carrier/ immunity (BsAB) No
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 27RPL DESCRIPTION SUBJECT TO AUTHORISATION HIV tests 3816 T and B-cells EAC markers (limited to ONE marker only for CD4/8 counts) No 3932 Antibodies to human immunodeficiency virus (HIV): ELISA No 3974 Qualitative PCR (only for children < age 6 months) No 4429 Quantitative PCR (DNA/RNA) No 4614 HIV Rapid Test No Infectious Diseases and Others 3946 IgM: Specific antibody titer: ELISA/EMIT: RUBELLA No 3948 IgG: Specific antibody titer: ELISA/EMIT: RUBELLA No 3949 Qualitative Kahn, VDRL or other flocculation No 3951 Quantatative Kahn, VDRL or other flocculation No E. Cytology 4566 Vaginal or cervical smears, each No F. Histology 4567 Histology per sample No G. Miscellaneous 4352 Faecal occult blood test (FOB) No H. Microbiology MCHS 3909 Anaerobe culture: Limited procedure No 3901 Fungal culture No 3918 Mycoplasma culture: Comprehensive No 4401 Cell count No 4188 Urine dipstick, per stick (irrespective of the number of tests on stick) No 3928 Antimicrobic substances No 3893 Bacteriological culture: Miscellaneous No 3867 Miscellaneous (body fluids, urine, exudate, fungi, puss, scrapings, etc.) No 3922 Viable cell count No 3879 Campylobacter in stool: Fastidious culture No 3895 Bacteriological culture: Fastidious organisms No 3928 Antimicrobic substances No 3887 Antibiotic susceptibility test: Per organism No 3924 Biochemical identification of bacterium: Extended No 3869 Faeces (including parasites) No 3868 Fungus identification No 3881 Mycobacteria No 3901 Fungal culture No 3868 Fungus identification No AFB flurochrome auramine (ZN) only 3885 Cytochemical stain No 3881 Antigen detection with monoclonal antibodies No TB culture 0221 Mantoux-Tuberculin PPD test No 3881 Antigen detection with monoclonal antibodies No 4433 Bacteriological DNA identification (LCR) No 3916 Radiometric tuberculosis culture No 28 GEMS 2019 Sapphire & Beryl Family Practitioner Guide
RPL DESCRIPTION SUBJECT TO AUTHORISATION
3867 Miscellaneous (body fluids, urine, exudate, fungi, puss, scrapings, etc.) No
3895 Bacteriological culture: Fastidious organisms No
TB sensitivity
3887 Antibiotic susceptibility test: Per organism No
3974 Polymerase chain reaction Yes
Extrapulmonary TB
4139 Adenosine deaminase (CSF, Peritoneal or Pleural) No
Parasites
3869 Faeces (including parasites) No
3883 Concentration techniques for parasites No
3865 Parasites in blood smear No
Bilharzia micro
3980 Bilharzia Ag Serum/Urine No
3867 Miscellaneous (body fluids, urine, exudate, fungi, puss, scrapings, etc.) No
3946 IgM: Specific antibody titer:ELISA/EMIT: Per Ag No
3883 Concentration techniques for parasites No
GEMS 2019 Sapphire & Beryl Family Practitioner Guide 29Annexure D
GEMS Pathology Request Form
GEMS Pathology Clinical Request Form
Sapphire • Beryl
Copies to Doctors: _____________________________________________________________________________________________________
n Urgent Contact Person: ________________________________________________________________________________________________________
n Routine Test Laboratory: ________________________________________________________________________________________________________
Referring General Practitioner Details:
Doctor’s Name: __________________________________________________________________________________ Practice Number: nnnnnnnnnnn
Tel: nnnnnnnnnn Fax: nnnnnnnnnn Email: ________________________________________________________________
Signature: _____________________________
Patient Details (Patient to complete) Person responsible for payment of account:
n Male nFemale Date of birth: nnnnnnnn ID Number: nnnnnnnnnnnnn
Surname: ___________________________________________________________ Surname: _____________________________________________________________
First Name: ___________________________________________________________ First name: ___________________________________________________________
Medical Scheme Name: ________________________________________________ Tel: nnnnnnnnnn
Medical Scheme Option: ________________________________________________ Postal Address: _______________________________________________________
Membership number: nnnnnnnnnnnn _____________________________________________________________________
Dependent Code: nn _____________________________________________________________________
I certify that the above information is correct and give specific consent for selected test(s) to be done. I authorise the disclosure of these results to doctor, my medical aid administrators
and/or insurance company. I fully understand the implication of the test and have received adequate pre-test counselling.
ICD 10 Codes: ________________________________________________________
Patient Signature _____________________________________________________________________
Clinical Information: __________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
Please note that the prices listed below, are reference prices only. GEMS has specific arrangements in place with various laboratories.
Chemistry Endocrinology Inflammation/ immunology
Renal / electrolytes / bone Request Endocrine – thyroid Request Auto-immune Request
Creatinine TSH CRP
Calcium (serum - no cuff) Free T4 ESR
Magnesium Endocrine – reproductive Uric acid
Phosphate (serum) b-HCG screen Rheumatoid factor
Sodium Prolactin (rest 15 minutes) ANF
Agglutination test per antigen
Potassium Diabetes Infectious diseases
Urea Glucose fasting VDRL (Qualitative)
Lactate Glucose random VDRL (Quantitative)
Liver / pancreas HBA1C Rubella immunity (IgG only)
Albumin Creatinne Hepatitis tests: specify
Total protein Microalbunurea (quanititative) Acute hepatitis A (IgM)
ALP Ante-natal screen Chronic hepatitis A (IgG)
ALT Haemoglobin estimation Acute hepatitis B (Bs AG)
AST Platelet count Hepatitis B (carrier/immunity : BsAB)
Bilirubin (total, conjugated) - fee ± Blood group: A B and O antigen HIV tests
GGT Coombs test HIV 1+2 Ab + P24 Ag
Lactate dehydrogenase Grouping: Rh antigen HIV Ab - Rapid Test
Amylase HEP B s Ag CD4 count
Cardiac / muscle HIV 1+2 Ab + P24 Ag HIV PCR Testing
Troponin VDRL HIV PCR viral load
CK-MB mass Rubella igg, IgM - fee ± HIV PCR qualitative (diagnostic only)
Lipids / CAD risk Tumour markers Microbiology
Cholesterol PSA Micro specimen type and site
HDL and LDL Haematology MCS
Triglycerides (fasting) Grouping: A B and O antigens AFB fluorochrome auramine (ZN) only
Creatinine kinase (ck) Grouping: Rh antigen Parasites
Histology Full blood count Bilharzia microscopy
Histology per sample Platelet count TB tests
Clinical data (please supply): Haemoglobin estimation TB culture
Reticulocyte count TB sensitivity
ESR Adenosine deaminase (CSF)
Specimen type: Iron Adenosine deaminase (Peritoneal)
Transferrin Adenosine deaminase (Pleural)
Ferritin Mantoux-Tuberculin PPD test
Cytology Folate (serum) The following TB related tests require an authorisation
Cervical /vaginal smear Vit B12 TB PCR Testing
Specimen type: Coombs test For advanced pathology tests not included on this form, please
contact 0860 436 777 and request an authorisation number.
Parasites in blood smear Other tests requested:
Collection Date: ____________________________ Coagulation Pre-authorisation number:
Collected by: _______________________________ INR/PI
Collection Time: ____________________________ Miscellaneous
Faecal occult blood test (FOB)
Tel 0860 436 777 • Fax 0861 00 4367 • enquiries@gems.gov.za • HIV Aids Helpline 0860 436 736 • www.gems.gov.za
Visit www.gems.gov.za to download this form.
30 GEMS 2019 Sapphire & Beryl Family Practitioner GuideYou can also read
