86,345
YOUR GEMS
OPTOMETRY
PROVIDER
GUIDE 2023
Introduction
Welcome to the GEMS Optometry Management Programme. GEMS always strives to provide members with access
to excellent, comprehensive and affordable healthcare. To achieve this, GEMS understands that Optometrists
play an essential role in the provision of quality Optometry care to our members. Our enhancement to the
optometry benefits demonstrates our commitment to improve members’ access to the excellent healthcare
to which they have become accustomed.
Summary of Optometry
Benefits
The following are applicable to the GEMS Tanzanite One and Beryl
options for 2023:
• One eye examination per beneficiary per 12 month period calculated from the month within
which same was last rendered to the affected beneficiary (“Eye Examination Cycle”); and
• Examination includes visual, binocular stability and pathology evaluation (including tonometry)
and diagnosis.
• One pair of spectacles (frame plus lenses) at the applicable package tariff per beneficiary per 24
month period calculated from the date services were last rendered to the beneficiary, subject to
the benefit limit.
GEMS 2023 Optometry Provider Guide 1
The below table indicates the limits applicable per option:
Benefit Option Limit Available
Tanzanite One Limit of R1 380 per beneficiary/dependant every two (2) years
Beryl Limit of R1 748 per beneficiary/dependant every two (2) years
• Frame choice is from a provider-designated range. Lenses are standard-quality lenses, single vision
or bifocal (where appropriate).
• Should the beneficiary select a frame from outside the designated range, R266 must be credited
towards this frame in lieu of the ‘package’ frame and the member will be liable for the difference.
• Benefits are for either spectacles or contact lenses, not both.
• No cash refund or credit is available in lieu of the optometry benefit.
• All providers to use the GEMS Optometry Network tariff codes.
• Accounts from non-network Optometrists will be rejected.
• Upgrades or services outside of the benefit option will not be covered by the Scheme
and will be for the patient’s account.
• The prescribed minimum benefit entitlement for post cataract surgery has been enhanced for the
2023 benefit year. Prescribed minimum benefit entitlement for post-cataract surgery: Bifocal lenses
and frame up to the value of R1 585 with a sub-limit of R266 for the frame will apply where the
Optometry benefit is exhausted.
The following are applicable to the GEMS Emerald Value, Emerald and
Onyx options for 2023:
• One Optometric examination per beneficiary per 12-month period (subject to clinical necessity),
calculated from the date which services were last rendered to the beneficiary.
• A comprehensive examination (11001) includes visual, binocular stability and pathology evaluation
(including tonometry) and diagnosis.
• One pair of spectacles (frame plus lenses) per beneficiary per 24-month period, calculated from the
date which services were last rendered to the beneficiary, subject to the applicable limits and Scheme
rate.
The below table indicates the limits applicable per option:
BENEFIT OPTION LIMIT AVAILABLE
Emerald Value Annual family limit available of R5 400
Limit of R2 817 per beneficiary/dependant every two (2) years
Frame is limited to R 1 497. Fitting (nylon or rimless, etc.) will not be covered.
Emerald Annual family limit available of R5 400
Limit of R2 817 per beneficiary/dependant every two (2) years
Frame is limited to R 1 497. Fitting (nylon or rimless, etc.) will not be covered.
Onyx Annual family limit available of R6 392
Limit of R3 325 per beneficiary/dependant every two (2) years.
Frame is limited to R2 404. Fitting (nylon or rimless, etc.) will not be covered.
GEMS 2023 Optometry Provider Guide 2
• Benefits are for either spectacles or contact lenses, not both.
• All providers to use the GEMS Optometry Network tariff codes.
• Accounts from non-network optometrists will be considered for refund to the member per the
Scheme refund process that the member must adhere to. Refunds to the member, when approved
will be paid according to the Scheme rules and funding protocols.
• Upgrades or services outside the benefit option will not be covered by the Scheme but are for the
patient’s account.
• Spectacles with accommodative single vision lenses or intermediate-to-near multifocal lenses will be
covered up to the relevant clinically appropriate benefit per clinical criteria.
• The prescribed minimum benefit entitlement for post cataract surgery has been enhanced for the
2023 benefit year. Prescribed minimum benefit entitlement for post cataract surgery: Bifocal lenses
and frame up to the value of R1 585 with a sub-limit of R266 for the frame will apply where the
Optometry benefit is exhausted.
The following is applicable to the GEMS Ruby option for 2023:
• One Optometric examination per beneficiary per financial year, starting on 01 January and ending on
31 December of the same year.
• A comprehensive examination (11001) includes visual, binocular stability and pathology evaluation
(including tonometry) and diagnosis.
• One pair of spectacles (frame plus lenses) per beneficiary per financial year, limited to available
benefit in either the personal medical savings account or block benefit, subject to prescribed
minimum benefits
The below table indicates the limits applicable on the Ruby option:
Ruby Option Limited to PMSA and Block Benefit
Frame is limited to R 1 497
Fitting (nylon or rimless, etc.) will not be covered.
• Benefits are for either spectacles or contact lenses, not both.
• All providers to use the GEMS Optometry Network tariff codes.
• Accounts from non-network optometrists will be considered for refund to the member per the
Scheme refund process that the member must adhere to. Refunds to the member, when approved
will be paid according to the Scheme rules and funding protocols.
• Upgrades or services outside the benefit option will not be covered by the Scheme but are for the
patient’s account.
• Spectacles with accommodative single vision lenses or intermediate to near multifocal lenses will be
covered up to the relevant clinically appropriate benefit per clinical criteria.
• The prescribed minimum benefit entitlement for post cataract surgery has been enhanced for the
2023 benefit year. Prescribed Minimum Benefit (PMB) entitlement for post cataract surgery: Bifocal
lenses and frame up to the value of R1 585 with a sub-limit of R266 for the frame will apply where the
Optometry benefit is exhausted.
GEMS 2023 Optometry Provider Guide 3
Childhood screening (all options) for 2023:
• Preventative health screening is one of the most important healthcare strategies to facilitate early
diagnosis and treatment of disease as well as to improve quality of life.
• GEMS offers comprehensive childhood screening for children.
• This screening is a once in a lifetime childhood Optometry screening benefit across all options for
beneficiaries up to and including age seven.
• Optometrists are encouraged to utilize the screening benefit available.
• Screening benefits when billed cannot be billed in combination with other codes as this is a stand-
alone event.
Tariff code Code description Tariff amount Service
94000 Individual Child Screening R 99.90 Screening only
Signed consent must be obtained from the child’s parent/guardian before screening takes place (this consent
and the patient report must be produced on request).
During a child screening event, per industry norms, the following usually
is noted:
• Unaided visual acuity: Assessment of the habitual acuity at distance and near
• Acuity through a +1.50 dioptre sphere lens: To eliminate the possibility of the patient accommodating
during the assessment of his/her habitual visual acuity test
• Colour vision: To determine the presence of colour
blindness or deficiency
• Stereo acuity (depth perception): To
ascertain that depth can be seen in
binocular views
• Ocular motilities, cover test and
near point of convergence
(NPC): Assessment of
ocular movements,
alignment of the eyes,
and to determine any
convergence weakness
• Ophthalmoscopy: To
detect and evaluate
various retinal vascular
diseases or eye
diseases and pupil
response.
Any deviation from clinically accepted
industry norms, will require a comprehensive
eye examination (the screening will then be void
and only an eye examination must be charged).
GEMS 2023 Optometry Provider Guide 4
Optometry tariffs for 2023
The GEMS Optometry Network tariffs for 2023 are available on the GEMS website (www.gems.gov.za).
The following tariffs will apply to both the Tanzanite One and Beryl options:
Tariff code Code description Tariff amount Service
90011 Vision Exam (when no Material R 261.20 Consultation only
Supplied)
93200 Combined V/Exam+Frame+S/Vision R 922.20 Consultation, frame and single vision
Standard standard lenses
93201 Combined V/Exam+Frame+S/Vision R 989.50 Consultation, frame and single vision
Surfaced surfaced lenses
93300 Combined V/Exam+Frame+Bifocal R 1 573.10 Consultation, frame and bifocal lenses
• Benefits will not be paid if these codes are not reflected in your claim.
• For a single vision or bifocal package, your claim must reflect only the package tariff code and not
the individual consultation and other tariff codes, e.g., for the bifocal package only claim for 93300
and do not include 90011.
• Disposable or permanent contact lenses
for the Tanzanite One and Beryl
options are to be billed by using the
appropriate product tariff code
and rate per the approved
GEMS tariff file for
Optometry services.
The GEMS
Optometry Network
tariffs for 2023 will apply
to the Ruby, Emerald
Value, Emerald and
Onyx options.
GEMS 2023 Optometry Provider Guide 5
Qualifying Criteria
The optometry benefit is subject to qualifying norms, including family or beneficiary limits where applicable.
Benefits will be subject to the Optometry Benefit Management Programme:
The following are applicable to the GEMS Tanzanite One and Beryl options for 2023:
• Unaided visual acuity of worse than 6/9 (Snellen rating) for distance or near (where appropriate).
• Refractive error of minimum 0.75 Dioptre sphere or 0.75 Dioptre cylinder, or reading Rx (Add) of
at least +1.50 Dioptre sphere.
• For bifocals, both distance and near norms must be satisfied.
The following are applicable to the GEMS Ruby, Emerald, Emerald Value and Onyx options
for 2023:
• Unaided visual acuity of 6/9 (Snellen rating) or worse for distance or near (where appropriate).
• Refractive error of minimum of 0.50 Dioptre sphere or 0.50 Dioptre cylinder, or reading Rx (Add)
of +1.00 Dioptre sphere.
• For bifocals and multifocals, both distance and near norms must be satisfied.
Claims for spectacles and lenses that do not meet the qualifying
criteria for benefits will be rejected.
Out-of-benefit upgrades
• Out-of-benefit upgrades are payable by members, directly to the participating Optometrist at no more
than the relevant GEMS Optometry network tariff.
• The Scheme will not fund claims received for items excluded from benefits as per the Scheme rules.
• Should members on the Tanzanite One and Beryl options select a non-designated frame, the claim
must reflect the package code tariff as well as the selected frame at the marked price, less R266.
Only R266 will be paid towards the frame. The balance is for the member’s account.
• All additional out-of-benefit items are to be reflected on the claim, but they will not be funded. Please
discuss this with the member. Split billing is prohibited on all claims.
• No sunglasses or lenses with a tint over 35% will be covered (spectacles including frames, will be
rejected) except for in cases with albinism and proven photophobia, subject to pre-authorisation.
GEMS 2023 Optometry Provider Guide 6
Disclaimer applicable on benefit confirmations:
Benefits listed are subject to the 2023 registered Scheme rules, Optometry Management Programme and in
the event of a dispute the Registered Scheme rules takes precedence.
Benefits may also be subject to a beneficiary limit every two (2) financial years, calculated from 1 January of the
year within which any optical service was first rendered to any beneficiary following the end of such previous
two-year period (if any) ended on 31 December. The family limit is calculated per option either annually as of
1 January. Benefits on the Ruby option are subject to one (1) financial year.
Insured benefit confirmations ideally will not change,
provided that the member has no the membership is active, and the claim is in line with the
outstanding accounts which will requirements of Optometry
impact the benefit limits, Management Programme.
Optometrists are encouraged to educate members on the different treatment options and what is available
per the member’s benefit option. Where members may change options, optometry benefits may be affected.
Providers are encouraged to check the benefit option at each visit to be able to discuss treatment vs available
benefits and potential shortfalls with the member accordingly. Benefit limits and tariff rates may vary from option
to option and are subject to available limits (per family, or per beneficiary) and in line with the option structure.
The Scheme does not cover optometry devices that are not regarded as
clinically essential or desirable.
GEMS 2023 Optometry Provider Guide 7
Contact details
Monday – Friday: 08h00 – 17h00
Saturday: 08h00 – 12h00
Closed on Sundays and public holidays
GEMS Contact Centre
0860 436 777 for provider queries
0860 00 4367 for member queries
Fax
0861 00 4367
Web
www.gems.gov.za
Email
[email protected]
Postal address
GEMS, Private Bag X782, Cape Town, 8000
GEMS Emergency Services
0800 444 367
GEMS Fraud hotline
0800 212 202
[email protected]Make use of the Use the QR Code
to download the
multi-function GEMS GEMS Member App
Member App to interact
with the Scheme at
home or on the go to
make your life easier.
