GEMS Claims for Network Dental Providers
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 |