Requests for medical appliances and external prosthesis is dealt with by the appliance management team

1. Working towards a healthier you
MHRS (Managed Care Organisation - MCO)

2. Working towards a healthier you
Medical and Surgical Appliances and External Prosthesis

3. Objective
“Equip trainers to train, applicable content, in their own environment, on
the roles and functions of each service provider within the GEMS network,
demonstrating all the GEMS values.”

4. Learning Outcome
By the end of this InterSPN train-the-trainer session all trainers will be able to train their own
identified audience, within their own environment, on the roles and functions of each service
provider within the GEMS network, while demonstrating the GEMS values of excellence,
collaboration, integrity, member value and innovation.
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5. Topic overview
SPN overview – Who we are?
Scope of service – What we do?
Rationale for service – Why we do what we do?
Out-of-scope of service – What we don’t do?
SPN interface – Which SPN we collaborate with?
Contact details for referrals
Escalation information
Top four (4) FAQ’s
Five (5) assessment questions
Observed top knowledge and service delivery gaps
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6. Learning outcomes
By the end of this session the trainer will be able to:
Give a brief overview of all SPN’s within the network
Describe and list the scope of services, according to each SLA, for all SPN’s within the network
Explain the rationale behind the services each SPN, within the network, is required to provide
List the out-of-scope services for all SPN’s, within the network
Provide name of the SPN responsible for the identified out-of-scope service
Illustrate, with the use of an example, which collaborative SPN interfaces exist
List a set of contact details for referrals for each SPN
Explain the escalation process and provide a list of contact persons
Provide a list of the top four (4) frequently asked questions in each SPN environment
Provide a set of assessment questions for all SPN’s presentations
Provide a list of the knowledge and service delivery gaps for all SPN’s.
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7. Medical & Surgical Appliance Management
Requests for medical appliances and external prosthesis is dealt with by the appliance
management team.
These items are funded from the Medical and surgical appliances and external prosthesis benefit.
The appliances included on this benefit fall within 3 categories:
Auto-approve (APP) – meaning no pre-authorisation is required from MHRS, and the provider can submit the
claim for processing.
Referral (REF) – these items will only be funded if pre-authorized. A motivation and quotation needs to be
submitted to MHRS for review.
Exclusion (EXC) – these items will be declined as exclusions.
Authorisations generated by the appliance management team are sent via real-time interface to
the Administrator (MH) and PBM (Medikredit).
Members or providers may submit all pre-authorisation documents (motivations and quotations)
via enquiries@gems.gov.za or fax to 0861 004 367.
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8. What we don’t do
The appliance management department does not pre-authorize internal appliances, e.g. cochlear
implants, bone-anchored hearing aids, etc. This is done by the Hospital Benefit Management
(HBM) department.
We don’t deal with claims enquiries. This is dealt with by the Administrator (MH).
We don’t deal with the rental of appliances such as home oxygen. This is done by the Hospital
Benefit Management (HBM) department.
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9. Which SPN we collaborate with
The appliance team collaborates with the Administrator (MH) and PBM (Medikredit) in the
following ways:
On a quarterly basis (Dec, Mar, June, Sep) the MCO (MHRS) shares the medical and surgical appliance lists
with the Administrator and PBM.
Any authorisations or declines for medical and surgical appliances generated by the MCO (MHRS) is shared
with the Administrator (MH) and PBM (Medikredit) via a real-time interface.
The Administrator and PBM will refer requests for pre-authorisation documents related to queries which they
have received to the MCO for processing.
The PBM processes all appliance claims submitted by pharmacies and dispensing providers based on the
funding instruction received from the MCO.
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10. Contact details for referrals
SPN queries and referrals related to medical appliances and external prosthesis which require
pre-authorisation may be directed to GEMSapplmotivations@medscheme.co.za
All member and provider queries and requests related to medical appliances and external
prosthesis which require pre-authorisation may be directed to enquiries@gems.gov.za or fax to
0861 004 367.
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11. FAQs – the top four
How do I know what GEMS will pay for?
A list of appliances which do not require pre-authorisation is published on the GEMS website. The list may be
accessed via www.gems.gov.za -> healthcare provider TAB -> Tools -> Medical Appliance List.
Requests for items not included on the above list may be submitted via enquiries@gems.gov.za or fax to 0861
004 367.
What documents need to be submitted?
A current quotation from a supplier with a registered practice number.
The quotation must include the date, name, surname and date of birth of the beneficiary for whom the
request is being submitted.
The quotation must indicate the Nappi or tariff code of the item, as well as the description, quantity
requested, and cost of quotation.
A motivation for the use of the item/s and any supporting clinical information or test results, e.g. audiogram.
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12. Assessment questions
Identify the SPNs which the MCO (MHRS) appliance team collaborates with:
MMP, Administrator (MH) and PBM (Medikredit)
Administrator (MH) and PBM (Medikredit) √
Administrator (MH) and MMP
A member contacts the customer services call-centre regarding a funding request for a cochlear
implant. You will:
Refer the member to the Hospital Benefit Management team for further assistance. √
Request that the member submits a quotation and motivation which can be referred to the appliance team.
Refer the member to the ambulatory PMB department for further assistance.
If the member or provider asks how they will know what GEMS will pay for, you will:
Ask them to submit a quotation and motivation and an outcome will be communicated.
Advise them that a claim may be submitted for the item/appliance and they will receive a response.
Refer them to the GEMS website, www.gems.gov.za where the appliance list can be found under the
healthcare provider section. √
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13. Assessment questions (cont.)
A provider contacts the customer services department regarding a claim for an appliance which
was short-paid. The provider confirms that an authorisation was issued for the appliance. Which
SPN would you refer this query to:
The administrator (MH) √
The MCO (MHRS)
The PBM (Medikredit)
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14. Identified knowledge and service delivery gaps
Before referring an appliance request to the MCO (MHRS) or requesting a quotation from a
member / provider, check the quarterly list to ensure that the item requires pre-authorisation.
For items coded as APP, no pre-authorisation is required and these should not be routed to the
MCO.
Refer providers to the appliance list published on the GEMS website for items which do not
require pre-authorisation. Items not included on this list may be submitted for authorisation.
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15. Questions
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