MS CHRISTA VAN STADEN

PO BOX 101091
MORELETAPARK
0044

22 November 2018

Dear MS CHRISTA VAN STADEN

Approval/Partial Approval of Request

This Authorisation is only valid for the specified beneficiary, accommodation level and codes and is dependent on active membership (this
excludes suspended membership) and the available benefits. When approving the authorisation GEMS first checks the sub-limits and benefits
that are available at the point of request. An approved authorisation is not a guarantee that GEMS will settle the bill in full. It is important to
contact the GEMS Hospital Authorisation department in the event of changes; i.e. The date of service/ admission date, length of stay/ required
to stay longer, level of care or if there is additional treatment required after the original authorization was approved. Please note that should the
patient's stay be extended, GEMS requires an appropriate clinical motivation from the treating service provider, should these not be received
the Scheme may decline funding/ paying of the change or additional treatments done after the authorization was approved. Items appearing on
the "Medscheme Health Risk Solutions In-Hospital Restricted and Non-Covered Services" list are not covered by this authorisation.

Patient name: MS CHRISTA VAN STADEN

Member number / Dependant code: 001392549/00
Scheme and Option: GEMS, EMERALD
Authorisation number: 79538830
Admisson number: N/A
Reason for admission: SHOULDER ARTHROSCOPY/SURGERY; DEBRIDEMENT, EXTENSIVE
Treating provider: DR A JULYAN
Place of treatment: PRETORIA EAST HOSPITAL
Length of stay: 1 Days
Admission date: 27/11/2018
Expected discharge date: 28/11/2018

Accommodation required From: To:

General Ward 27/11/2018 AM 28/11/2018 AM

Code Outcome Description

29823 CPT Approve SHOULDER ARTHROSCOPY/SURGERY; DEBRIDEMENT, EXTENSIVE
M75.4 ICD IMPINGEMENT SYNDROME OF SHOULDER
0667 NRPL Approve ARTHROSCOPY (EXCLUDING AFTER-CARE), MODIFIERS 0005 AND 0013
NOT APPLICABLE.
0745 NRPL Approve MUSCLE AND TENDON REPAIR : BICEPS HUMERI.
0748 NRPL Approve MUSCLE AND TENDON REPAIR: DEBRIDEMENT ROTATOR CUFF
24341 CPT Approve REPAIR ARM TENDON/MUSCLE
0615 NRPL Approve ARTHROPLASTY : EXCISION MEDIAL OR LATERAL END OF CLAVICLE.
29827 CPT Approve ARTHROSCOP ROTATOR CUFF REPAIR
23120 CPT Approve PARTIAL REMOVAL, COLLAR BONE
Patient MS CHRISTA VAN STADEN Medical Aid GEMS

Medical Aid Number 001392549 Option EMERALD

Disclaimer:
Every effort has been made to ensure that all information provided to you is factual and accurate.However, in the event of a dispute, the
Scheme Rules shall apply. You can view the Scheme Ruleson our website at www.gems.gov.za under the ´About Us´ section on the Menu.
The information provided on this correspondence is for information purposes only and cannot replace medical advice from your professional
healthcare provider. Please note that GEMS is not a financial service provider and is prohibited by law from giving any financial advice.
Patient MS CHRISTA VAN STADEN Medical Aid GEMS

Medical Aid Number 001392549 Option EMERALD

MANAGED CARE NOTES

CEREBRAL OXIMETER (e.g. SOMASENSOR). Funding will be considered for the beach-chair position dependent on specific criteria.
MENISCAL TRANSPLANTATION OR IMPLANTS. Prosthesis subject to prosthesis limits. Meniscal allograft transplant will be considered for funding
against specific criteria, subject to clinical motivation. No benefits for a Collagen Meniscal Implant (CMI) or the implantation of a polyurethane
meniscal scaffold.
SHOULDER ANCHORS: Anchors for rotator cuff repair will be funded from the overall annual limit.

SCHEME BENEFIT NOTES

**TAKE NOTE: This authorisation is only valid for the specified member, accommodation level and code/s, based on the information provided at
time of request. Authorisation is dependent on active membership, benefit sub-limits and available benefits at date of service. It is not a guarantee of
payment. It is essential to contact the managed healthcare agent in the event of changes to the date of service, length of stay, level of care or
scope of this authorisation request. Please note that should the treatment extend beyond the scope of authorisation and an appropriate clinical
motivation is not received, the Scheme/Fund may decline further funding. All benefits, including consultations will be reimbursed at Scheme Rate or
Negotiated Tariff.
2019 Benefits: If your authorisation falls in the new benefit year, effective 01 January 2019, it will be subject to 2019 scheme rules and benefits.
Please familiarise yourself with your 2019 benefits as these may differ or contact your client service department.
ADVANCED RADIOLOGY: 100% Scheme Rate, subject to PMBs. Shared limit for in and out-of-hospital: R21 166 per family per annum. A specific
pre-authorisation (in addition to hospital authorisation), subject to managed care protocols and processes, is required for a list of approved radiology
services: Angiography, CT scans, MDCT, Coronary Angiography, MUGA / PET /MRI scans and Radio-Isotope studies.
ALCOHOL AND DRUG DEPENDANCIES: 100% of cost, subject to PMB legislation. DSP (State) applies, subject to pre-authorisation, managed
care protocols and processes. Call 0860 00 4367 for a list of DSP's.
ALLIED HEALTH SERVICES: 100% Scheme Rate, subject to PMBs. In and out of Hospital: Shared limit of R1 517 per family per annum. Shared
sub limit of R759 per family for Social Workers and Registered Counsellors. Managed care protocols and processes apply.
ALTERNATIVES TO HOSPITALISATION: (Sub Acute Facilities and Private Nurse). 100% of Scheme Rate, Unlimited. Pre-authorisation, managed
care protocols and processes apply. Includes physical rehabilitation for approved conditions and home nursing. Excludes frail care and recuperative
holidays. Hospice: 100% of cost; Unlimited but subject to PMB legislation. Pre-authorisation, managed care protocols and processes apply.
AMBULANCE / EMERGENCY ASSISTANCE (Road and Air): 100% of cost, subject to PMB legislation. Unlimited subject to use of emergency
services Network Providers (DSP), managed care protocols and processes. Call 0860 00 4367 or 0800 44 4367 for all your ambulance/emergency
assistance services to avoid co-payments.
APPEALS: Hospital Benefit Management: To appeal a decline / partial decline decision, a letter of motivation may be submitted via e-mail to
hospitalauths@gems.gov.za or via fax to 0861 00 4367.
AUXILIARY SERVICES IN HOSPITAL: (E.g. dietician, occupational therapy, audiology, biokinetist etc.) NOTE that for funding consideration,
auxiliary provider claims must be submitted with the referring doctor details. No additional authorisation is required, except for physiotherapy
BLOOD TRANSFUSION: 100% of Scheme Rate. Unlimited, subject to PMB legislation. Pre-authorisation, managed care protocols and processes
apply. Includes erythropoietin, cost of blood, blood equivalents, blood products and transport of thereof.
BREAST REDUCTION BENEFIT: 100% Scheme Rate, Unlimited. Pre-authorisation is required, subject to managed care protocols and processes.
CHRONIC DISEASE MANAGEMENT: All benefits for chronic diseases require registration on the Disease Management Programme.
CIRCUMCISION: 100% of Scheme Rate, subject to pre-authorisation, managed protocols and processes. Global fee (out of hospital only) of R1 421
per beneficiary which includes all post-op care within a month of procedure. Limit applies to all related costs (consult, medication etc.)
COSMETIC SURGERY: Not covered by Scheme.
Patient MS CHRISTA VAN STADEN Medical Aid GEMS

Medical Aid Number 001392549 Option EMERALD

DENTISTRY: Conservative, Restorative and Specialised Dentistry. 100% of Scheme Rate, limited to professional fees. Shared in and out of hospital
benefit of R4 918 per beneficiary per year; subject to pre-authorisation, list of approved services and use of Day Theatres. Lingual and labial
frenectomies under general anaesthesia is allowed for beneficiaries under the age of 8 years, subjected to managed healthcare programme and
pre-authorisation. General anaesthetic and conscious sedation for dentistry (in and out of hospital) is subject to pre-authorisation, managed care
protocols and processes; only applicable to beneficiaries under the age of 6 years, severe trauma and impacted third molars. Treatment of bony
impactions of third molars under conscious sedation in doctors rooms will be reimbursed at 200% Scheme Rate. Osseo-integrated implants,
implant-related procedures and orthognathic surgery are excluded from benefits.
DESIGNATED SERVICE PROVIDER: For in-hospital Prescribed Minimum Benefits (PMBs), the designated service provider (DSP) is the State. Use
of non-DSP will attract a co-payment. Where PMBs services are not available from a DSP, the member should call the GEMS call centre number
0860 00 4367 to discuss alternatives for approval by the Scheme.
EMERGENCY SERVICES (CASUALTY): Emergency medical condition as defined in the rules. Limited to Prescribed Minimum Benefits (PMBs). A
registered emergency facility must be used. Authorisation is required within 24 hours of admission. Managed care protocols & processes apply.
Unauthorised events will be paid from the available Day to day Block Benefit. Any shortfalls will be the responsibility of the member.
FAMILY BENEFITS: All benefits and sub limits are calculated per family per year unless otherwise specified.
FAMILY PRACTITIONER NETWORK EXTENDED BENEFIT: Extended benefit for beneficiaries with chronic conditions registered on Disease
Management Programme. Two additional Family Practitioner consultation at a Network Family Practitioner once Block Benefit is exhausted.
Payable from risk. The additional family practioner consultation at Nominated Network family practioner is subject to pre-authorisation, managed
care protocols and processes apply.
FOLATENG WARDS: Please note these are considered as Private Wards available for use at selected Provincial Hospitals. Please contact the
Client Service Centre for more detail, 0860 00 4367.
HEADACHE CLINICS/STRESS RELIEF CLINICS. No benefits. Call 0860 00 4367 if more information is needed.
HIV INFECTION, ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS): 100% of cost, subject to PMB legislation. Beneficiaries subject to
managed care protocols and processes. Call 0860 00 4367 to register on the HIV Management Programme.
INFERTILITY: 100% of cost, subject to PMB legislation. Pre-authorisation, managed care protocols, processes and use of DSP applies. Call 0860
00 4367 if more information is needed.
MATERNITY (Hospital, home birth or accredited birthing unit) Includes midwife services: Unlimited, 100% of cost, subject to PMB legislation.
Registration on the Scheme's Maternity Management Programme prior to admission is required, subject to managed care protocols and processes.
Authorisation must be obtained from the Scheme at least 48 hours before a beneficiary is admitted to hospital (except in the event of emergency
medical condition, includes complication for mother and new-born, in which case authorisation must be received within 24 hours of admission)
failing which a co-payment of R1 000 per admission shall apply. Elective Caesarean Sections (meaning the C-section is not for medical or clinical
reasons) may be subjected to second opinion and managed care protocols and processes and may therefore not be paid in full.
MEDICAL TECHNOLOGIST: 100% of Scheme Rate. Unlimited, subject to event pre-authorisation and management. Call 0860 00 4367 if more
information is needed.
MEDICAL and SURGICAL APPLIANCES and EXTERNAL PROSTHESIS: Includes Bilateral (both ears) Hearing Aids every 36 months (3 years),
Wheelchairs, Mobility Scooters, Oxygen Cylinders, Nebulizers, Glucometers, Colostomy Kits, Diabetic Equipment, Foot Orthotics and External
Prosthesis applicable in and out -of -hospital. Shared limit with in-hospital internal prostheses of R40 010 per family per annum. Sub-limit of R15 611
for medical and surgical appliances per family per annum. Shared sub-limit with in hospital prosthetics of R4 394 per beneficiary for foot orthotics
and prosthetics formulary applies, with a sub limit of R1 255 for orthotic shoes: foot inserts and levellers; R500 for crutches; R5 500 for wheelchairs;
R8 000 for hearing aids per beneficiary per annum. (Bilateral hearing aids every 36 months) Paid at 100% of Scheme Rate, in line with Prescribed
Minimum Benefits (PMBs) and managed care protocols.
Patient MS CHRISTA VAN STADEN Medical Aid GEMS

Medical Aid Number 001392549 Option EMERALD

MENTAL HEALTH. Accommodation, hospital equipment, professional fees of Family Practitioners, Psychiatrist and Psychologists: 100% of Scheme
Rate, subject to PMBs. Shared limit (in and out of hospital) of R17 639 per family per annum; limited to one individual psychologist consultation and
one group psychologist consultation per day. Psychologist services exclude educational and industrial psychologist services. Use of a registered
facility, pre-authorisation, managed care protocols and processes apply. A maximum of 3 days hospitalisation by a Family Practitioner. Family
Practitioners Nomination Rules apply. Out-of-hospital: Shared limit with in-hospital mental health of R17 639 per family per annum with sub-limit of
R5 231 for out-of-hospital Psychologist consultations.
NEW BORN REGISTRATION: Please note that all new born babies have to be registered within 60 days of birth to enjoy benefits from date of birth.
Failing this, benefits will only be applicable from the first day of the first month after registration. Accounts for babies not registered on the scheme,
will not be reimbursed even if the maternity event was authorised. Call 0860 00 4367 if more information is needed.
NON-COVERED LIST: Certain items, including medicine, are excluded from benefits unless specifically pre-authorised. This includes certain high
cost items. Please check with the hospital / treating provider that specialised items have been authorised before use. Call 0860 00 4367 if more
information is needed.
NON-DISCLOSURE: In line with GEMS underwriting policy (i.e. application of waiting periods), a request can be kept on hold to investigate the
possibility of non-disclosure (e.g. not declaring an existing illness or condition when joining the Scheme). Feedback based on the outcome of the
investigation will be communicated to you. If it is found at a later stage that there was non-disclosure (once claim has been settled), the Scheme will
require a member to pay a portion equal to the value of the claims paid to service providers to recover these amounts.
ONCOLOGY (Chemo and Radiotherapy): In and out-of-hospital and includes medicine and materials. 100% Scheme Rate, subject to PMBs. Limit of
R352 801 per family per annum with sub-limit of R240 004 per family for biological and similar specialised medicine. Pre-authorisation, managed
care protocols and processes, use of a registered facility and Medicine Price List (MPL) applies. This benefit includes the cost of pathology, related
basic radiology, advanced radiology, medical technologists and oncology medicines.
ORGAN and TISSUE TRANSPLANT: 100% of Scheme Rate, subject to PMBs. Limit of R587 996 per beneficiary per annum. Sub-limit of R19 960
per beneficiary per annum for corneal grafts (imported corneal grafts subject to managed care protocols). Limit Includes all costs associated with the
transplant including immunosuppressants. Organ harvesting is limited to the Republic of South Africa, except for cornea tissue. Pre-authorisation
and clinical guidelines used in Public facilities apply. Call 0860 00 4367 if more information is needed.
OVERALL LIMIT: Hospitalisation benefit is unlimited but sub-limits apply as specified
PHYSIOTHERAPY: In-Hospital: 100% of Scheme Rate in-Hospital, subject to PMBs. Limited to R4 757 per beneficiary per annum.
Pre-authorisation is required subject to managed care protocols and processes. Post Hip, Knee & Shoulder replacement or revision surgery: 10
post-surgery physiotherapy visits will be funded (shared out of hospital visits) up to a limit of R5 021 per beneficiary, per event utilised within 60 days
of surgery. Out-of-Hospital: Shared benefit with Specialist Services; sublimit of R2 147 per beneficiary and R4 287 per family per annum.
POST CATARACT SURGERY: 100% of Scheme Rate. Optical Prescribed Minimum Benefit (PMB) entitlement shall be limited to the cost of bifocal
lens, not exceeding R1 061 for both lens and frame with a sub-limit of R210 for the frame. Optical managed care protocols and processes apply.
PRE-AUTHORISATION for Renal Dialysis: All benefits for renal dialysis require pre-authorisation at least 48 hours before initial dialysis session for
planned dialysis visits and within one working day for emergency treatment sessions. Failure to get such pre-authorisation may results in a
co-payment of R1000 being applied.
PRE-AUTHORISATION: All benefits require pre-authorisation at least 48 hours before to admission to hospital for planned admissions and within
one working day after emergency admissions. Failure to get such pre-authorisation may result in a co-payment of R1 000 per admission being
applied. Clinical protocols still apply even if pre-authorisation is requested late. Call us on 0860 00 4367 for more information on which protocols
apply to your authorisation. Benefits are only available if membership is active on the date of service and no waiting periods apply.
PRESCRIBED MINIMUM BENEFITS (PMBs): 100% of cost in public hospitals and/or Designated Service Provider (DSP) in line with managed care
protocols. Call 0860 00 4367 if more information is needed.
PRESCRIBED MINIMUM BENEFITS: 100% of costs, unlimited subject to PMBs. If your condition is classified as a Prescribed Minimum Benefit
(PMB), you must be treated by a Designated Service Provider (DSP). The DSP is the State or government health facilities. If the DSP is not
available or accessible, please contact the GEMS call centre at 0860 00 4367 to discuss alternatives. Voluntary use of a non-DSP may result in a
co-payment for both provider and hospital claims. The co-payment will be the difference between the rate that the DSP would charge and what the
non-DSP hospital and/or provider charges.
Patient MS CHRISTA VAN STADEN Medical Aid GEMS

Medical Aid Number 001392549 Option EMERALD

PREVENTATIVE CARE SERVICES: Paid from risk, not from your benefits. Paid at 100% of Scheme Rate. Bone Density Scan (1 per year), Pap
Smear including liquid based cytology (1 per year), Prostate Specific Antigen (1 per year), Glaucoma screening (1 per year), Serum Glucose (1 per
year), Serum Cholesterol (1 per year), Mammogram and other screenings and other screening according to evidence standard practice (1 per year)
and Occult Blood Tests (1 per year), Thyrotrophic (TSH) tariff 4507 only for Neonatal Hypothyroidism screening test, Influenza Vaccinations (1 per
year) for beneficiaries at risk, Human Papillomavirus (HPV) vaccination for female beneficiaries, Pneumococcal Vaccination for members with
asthma and Chronic Obstructive Disease (every 5 years).
PRO-RATA: All benefits and sub-limits are calculated pro-rata from date of joining. For example: If you join on 1 July, you would only qualify for 6
months' benefits (July to December). As 6 months equal half of the year, you would only have half the benefits available for the rest of the year.
PROSTHESES: 100% of Scheme Rate, subject to PMBs. Limit of 40 010 per family per annum; shared limit with medical and surgical appliances
and external prostheses of R15 611 with the following further sub-limits R4 394 for foot orthotics and prosthetics with a sub-limit of R1 255 for
orthotic shoes, foot inserts and levellers; R500 for crutches; R5 500 for wheelchairs; R8 000 per hearing aid per beneficiary per annum.
Pre-authorisation, managed care protocols and processes apply. The Scheme reserves the right to obtain comparative quotes, or arrange supply of
prosthesis. The benefit covers prosthesis and internal devices (surgically implanted), including all temporary or permanent devices used to assist
with the guidance, alignment or delivery of these internal prostheses devices. Bone Cement paid from in hospital benefit, subject to authorisation.
Call 0860 00 4367 if more information is needed.
PROSTHESIS. If any operation during your admission requires internal prosthesis it is important for you to be aware of the cost that you will need to
cover outside of your medical aid benefits. Find out from your doctor whether you require prosthesis and confirm the type and cost of the intended
prosthesis. You will then need to check your member guide or contact the client service department to confirm the amount of money your scheme
will fund, as any shortfall will be for your own account. Internal prosthesis are costly and your medical aid benefits available might not cover this cost
in full.
RADIOLOGY (BASIC) and PATHOLOGY : 100% of Scheme Rate. Unlimited, subject to managed care rules. Pathology tests must relate to
admission diagnosis.
RENAL DIALYSIS (Chronic): 100% of Scheme Rate, subject to PMB legislation. Limit of R251 993 per beneficiary per annum for chronic dialysis,
subject to the use of Renal Dialysis Network DSP, failing which a co-payment of 15% per event shall apply in accordance with network rules.
Pre-authorisation, managed care protocols and processes apply. Includes costs of pathology, radiology, medical technologist, material and
immunosuppressants. Call 0860 00 4367 if more information is needed.
RENAL DIALYSIS: (Acute/In Hospital): 100% of Scheme Rate, subject to PMBs , included in Hospital benefits (cost of pathology, radiology, medical
technologist, material and immunosuppressants included). Pre-authorisation, managed care protocols and processes apply. Call 0860 00 4367 if
more information is needed.
SCHEME RATE: All benefits including consultations will be reimbursed at the current Scheme rate. If healthcare providers charge more than the
Scheme rate you will be responsible for the additional amount. Please verify if the services will be charged at the scheme rate before receiving
treatment or service. Call 0860 00 4367 if more information is needed.
SELF-MEDICATION (Over-the-Counter medicine) (OTC): 100% of Scheme Rate, subject to acute medicine benefit limit. Limit of R237 per event for
over the counter medicines with annual limit of R889 per beneficiary per annum and a family limit of R1 1421 per annum. Managed care protocols
and formulary apply.
SPECIALIST SERVICES: IN HOSPITAL 100% of Scheme Rate, subject to PMBs. Consultations and Visits: Unlimited, 100% of Scheme Rate for
non-network provider and 130% of Scheme Rate for established Network specialists. Out-of-hospital: Reimbursement of 200% of Scheme Rate for
procedures specified by managed care done in doctors' room instead of in-hospital and cataract procedure performed by Ophthalmologists in their
rooms.
SURGICAL PROCEDURES (including Maxillo-Facial Surgery): 100% Scheme rate Unlimited, subject to pre-authorisation, managed care protocols
and processes. Includes hospital procedures performed in the practitioners rooms as approved by the scheme. Excludes Osseo-integrated
Implants, all implant related procedures and Orthognathic Surgery. Call 0860 00 4367 if more information is needed.
TTO's (Prescribed Medicine from Hospital stay): 100% of Scheme Rate. Limited to 7 days supply, subject to acute medicine benefits. Payable from
risk once acute medication benefit limit is exhausted.
Patient MS CHRISTA VAN STADEN Medical Aid GEMS

Medical Aid Number 001392549 Option EMERALD

WAITING PERIODS: For new beneficiaries joining GEMS, the scheme may impose a three (3) month general waiting period and or twelve (12)
month condition specific waiting period in line with the scheme rules. If your condition is classified as a prescribed minimum benefit and if you
(beneficiary) are eligible, then the designated service provider is the State or government health facility. Services received in a private facility that
qualify as a prescribed minimum benefit will be reimbursed at the rate applicable to a state facility. The member/beneficiary will be responsible for
paying the shortfall. Please refer to the scheme rules on waiting period and prescribed minimum benefits.
WILLFULL SELF INFLICTED ILLNESS OR INJURY: Limited to Prescribed Minimum Benefits (two nights, three days) only.