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February 2024

GEMS Claims for Network Dental Providers

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Good afternoon,

The GEMS Dental Management team monitor monthly claims data of dental service providers who form part of the GEMS Dental Network. This is to ensure that the correct rates are charged for applicable dental procedure codes.

Common procedure codes charged above the GEMS Dental Network contract tariff amounts.

We have noted that most dental providers who use your EDI system charge above the contracted rates for mostly restorative procedure codes on the low benefit options. Kindly note the following for members belonging to Tanzanite One for 2024:

Restorative codes for Tanzanite One members are covered as below:

Procedure codes Descriptions Limitations How GEMS covers the procedure codes
8367 Resin restoration, one surface posterior Any four resin fillings per beneficiary per year (posterior); limited to four restorations overall Procedure codes covered on the benefit option but at the same rand value as surface amalgam filling.
8368 Resin restoration, two surfaces posterior
8369 Resin restoration, three surfaces posterior
8370 Resin restoration, four and more surfaces

Please note the tariff amounts quoted below is from the tariff list for Contracted Dental Practitioners only, please refer to the attached list for the tariff amounts for the other Practice types.

The above procedure codes for Tanzanite One members will therefore pay as per below:

Procedure codes Descriptions Tariff amounts
8341 Amalgam – one surface R 354.80
8342 Amalgam – two surfaces R 436.70
8343 Amalgam – three surfaces R 532.70
8344 Amalgam – four or more surfaces R 593.50

Instead of the below tariff amounts confirmed in the 2024 tariff schedule.

Procedure codes Descriptions Tariff amounts
8367 Resin – one surface, posterior R 422.00
8368 Resin – two surfaces, posterior R 521.90
8369 Resin – three surfaces, posterior R 630.80
8370 Resin – four or more surfaces, posterior R 678.40

I have attached the 2024 GEMS Tariff Lists for ease of reference. Please feel free to contact me should you need any additional information.

Kind Regards

GEMS Dental Management

 

Tel: Member +27 860 004 367

Tel: Service Provider +27 860 436 777

Fax: +27 861 004 367

enquiries@gems.gov.za | www.gems.gov.za

NHI Pending Impact on Healthcare IT

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Here are 8 salient points from the provided information about South Africa’s National Digital Health Strategy and National Health Insurance implementation:

  1. Digital health is a significant driver in transforming South Africa’s health system, especially with the National Digital Health Strategy and National Health Insurance implementation.
  2. A Health Patient Registration System (HPRS) project has been initiated as a step toward developing a patient Electronic Health Record (EHR) template.
  3. EHRs are described as portable, interactive digital health records that contain a patient’s medical information to assist healthcare providers in managing care.
  4. EHRs provide crucial patient information like medical history, test results, prescriptions, procedures, X-rays, and allergies for improved patient care.
  5. EHRs can help in closing healthcare gaps by enhancing access to healthcare, reducing disparities, and improving population health management.
  6. Adoption of EHRs in South Africa is low but expected to increase with the NHI Bill, aiming to boost care coordination, population health management, efficiency, and cost savings.
  7. EHRs contribute to improved efficiency, reduced duplicates in records, better patient outcomes, and streamlined care processes.
  8. EHRs offer benefits such as enhanced patient safety, care coordination, population health management, efficiency, decision-making, claims processing, and early detection of chronic conditions in the NHI program implementation.

These points emphasize the significance of EHRs in advancing healthcare outcomes in South Africa and suggest their potential role in the success of the National Health Insurance program.

Better Practice Management