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Does GEMS Pay for Implants

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Does GEMS cover implants

Based on the GEMS Dental Provider Guide, GEMS has limited coverage for dental implants:

What’s Covered ✅

GEMS covers Phase 3 implant procedures only on the Ruby, Emerald Value, Emerald, and Onyx options. This includes:

  • Implant supported crowns
  • Implant supported bridges
  • Implant supported dentures

These are paid from the shared dental sublimit and require pre-authorisation.

What’s NOT Covered ❌

  • Phase 1 procedures (surgical placement of implants)
  • Phase 2 procedures (abutment placement)
  • All implant-related clinical and laboratory fees for Phases 1 and 2

Specific Covered Codes

The following implant denture codes are funded (with pre-authorisation):

  • 8533 – Implant supported removable complete overdenture
  • 8534 – Implant supported removable partial overdenture
  • 8654 – Implant supported fixed-detachable complete overdenture
  • 8655 – Implant supported fixed-detachable partial overdenture
  • 8660 – Additional fee per implant for fixed-detachable dentures

In summary: You would need to pay out-of-pocket for the actual implant surgery and placement, but GEMS can help cover the final crowns, bridges, or dentures that attach to those implants on certain options.

 

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Here are GEMS’s contact details:

GEMS Contact Centre

For Provider Queries:
📞 0860 436 777

For Member Queries:
📞 0860 004 367

Email:
📧 enquiries@gems.gov.za

Fax:
📠 0861 00 4367

Operating Hours

  • Monday – Friday: 08h00 – 17h00
  • Saturday: 08h00 – 12h00
  • Sundays and Public Holidays: Closed

Online Access

  • Website: www.gems.gov.za
  • Provider Portal: hcp.gems.gov.za
  • Mobile App: Download the GEMS Provider App from Google Play or the App Store

 

Brought to you courtesy of Dental Tariffs Bundle

Tooth Extraction ICD-10

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Tooth Extraction ICD-10

Accurate coding is essential for successful dental claims

For South African dentists submitting claims for tooth extraction, the correct use of diagnosis codes (ICD‑10) paired with clear documentation and the medical aid scheme’s procedure codes determines whether a claim will be paid. This article explains practical guidance for “tooth extraction ICD 10” so you can reduce rejections and speed reimbursements.

Why ICD‑10 matters for tooth extraction claims ICD‑10 codes are diagnosis codes – they tell the medical aid why a procedure (like an extraction) was clinically necessary. Medical aid schemes review the ICD‑10 diagnosis together with the dental procedure code, clinical notes, and radiographs. Using a diagnosis code that accurately reflects the reason for extraction (caries, infection, impaction, trauma, etc.) helps claims processors accept the clinical necessity of the procedure.

Common ICD‑10 diagnosis groups used for extractions ICD‑10 classifies oral disease under the K00–K14 range. For tooth extraction claims you’ll commonly select one of these diagnosis categories based on the clinical finding:

  • K02 – Dental caries: Use when extraction is due to extensive decay that cannot be restored.
  • K04 – Diseases of pulp and periapical tissues: Use for extractions driven by pulpal necrosis, acute apical periodontitis, or periapical abscess.
  • K01 – Disorders of tooth development and eruption: Use when extracting impacted or malerupted teeth.
  • K08 – Other disorders of teeth and supporting structures: Use for retained roots, fracture, or other conditions leading to extraction.

Note: Use the most specific ICD‑10 subcategory available in your system (e.g., K04.x) if you can confidently document the precise diagnosis. Specificity reduces queries from medical aids.

What medical aids typically expect on a tooth extraction claim

To avoid denials, include the following on every extraction claim:

  1. Correct ICD‑10 diagnosis code(s) – match the reason for extraction to the K00–K14 group.
  2. Procedure code(s) – use the dental tariff or procedure coding system required by the medical aid (e.g., the insurer’s preferred code set). ICD‑10 is not a substitute for a procedure code.
  3. Tooth notation – indicate the tooth number using FDI notation (recommended) or the notation requested by the payer.
  4. Clinical notes – succinct rationale: symptoms, diagnosis, alternatives considered, and reason extraction was necessary.
  5. Radiographs – current pre‑operative images supporting the diagnosis (e.g., periapical radiograph showing periapical pathology or impaction).
  6. Anaesthesia and surgical details – type of anaesthesia, surgical vs. simple extraction, extra time or complexity if applicable.
  7. Pre‑authorization when required – for some major or surgical extractions, insurers require pre‑authorisation. Obtain written approval where needed.

Best practice workflow for an unambiguous claim

  • Diagnose and document: note clinical findings, pulp/periapical status, mobility, swelling, sinus tract, prior treatment attempts.
  • Match the diagnosis to the correct ICD‑10 category (K02, K04, K01, K08, etc.). Use the most specific subcode you can support clinically.
  • Use the medical aids’s procedure/tariff code for the extraction type and list the tooth number.
  • Attach the radiograph and brief clinical narrative.
  • Submit pre‑authorisation if required, especially for surgical or complicated removals.
  • Follow up promptly if the medical aid requests additional information.

Common reasons extractions claims are queried or denied

  • Vague or incorrect ICD‑10 code that doesn’t support extraction (e.g., using a generic code rather than specifying infection or impaction).
  • Missing radiographs or inadequate clinical justification.
  • Wrong tooth notation or mismatch between procedure tooth and radiograph.
  • Failure to obtain pre‑authorisation for surgical extractions.
  • Use of procedure codes the payer does not accept without mapping to their tariff.

Practical tips to reduce rejections

  • Keep a short diagnosis template in the clinical notes that aligns with ICD‑10 language (e.g., “Periapical radiolucency at tooth 36 consistent with chronic apical periodontitis – extraction indicated” – then use the K04.x code).
  • Confirm the medical aid’s preferred coding format and whether they require additional codes (e.g., Z codes for history).
  • Train staff to verify tooth numbering, attach radiographs, and check authorisation rules before submission.
  • When in doubt, contact the medical aid’s provider helpdesk before performing non‑emergency extractions.

Final checklist before you submit

  • Specific ICD‑10 diagnosis code matching the clinical reason (K02 / K04 / K01 / K08).
  • Correct procedure/tariff code and tooth number.
  • Radiograph(s) attached.
  • Short clinical rationale and operative details.
  • Pre‑authorisation if required.

Courtesy of Dental Tariffs Pack

GEMS Medical Aid Options

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GEMS Medical Aid Options: A Clear Guide to Dental Cover

Choosing the right medical plan means more than just hospital cover – dental care can have a big impact on your health and your budget. If you’re researching GEMS medical aid options, this guide explains how dental benefits typically work, what to look for, and practical tips to get the most from your cover.

What dental cover usually includes

Under most gems medical aid options, dental benefits are offered in different forms and levels depending on the option you select. Common elements include:

  • Preventive care: routine check-ups, cleanings, and fluoride treatment.
  • Basic restorative care: fillings and extractions.
  • Major restorative procedures: crowns, root canals, and dentures (often subject to limits).
  • Emergency dental treatment: urgent care for acute pain or injury.
  • Orthodontics: sometimes included for children, often as a separate benefit or waiting period applies.

Benefits and limits vary between options, so it’s important to compare what each GEMS medical aid option provides for dentistry.

How dental benefits are structured

Dental cover under gems medical aid options is typically structured in one or more of the following ways:

  • Annual limits: a set monetary amount per beneficiary or family for dental procedures per year.
  • Sub-limits: specific caps for categories like restorative or orthodontic care.
  • Network vs. non-network providers: using an approved dental network may reduce your out-of-pocket costs.
  • Co-payments and authorisations: some procedures require pre-authorization and a co-payment may apply.

Understanding these structures will help you avoid surprise bills and make informed choices about care.

Choosing the right GEMS medical aid option for dental needs

When comparing GEMS medical aid options for dental cover, focus on these key questions:

  1. What is covered under preventative care and how often?
  2. Are major restorative procedures included or excluded?
  3. Is there a separate limit for orthodontics or prosthetics?
  4. Do I need to use network dentists to get full benefits?
  5. What are the waiting periods before specific dental benefits kick in?

If you or your dependents need routine dental care and occasional restorative procedures, look for options with strong day-to-day benefits and reasonable annual limits. If you anticipate major work (crowns, implants, orthodontics), prioritise options that include higher dental sub-limits or supplementary cover.

How to maximize your dental benefits

Make your dental budget go further by applying these practical tips:

  • Prioritize preventive care: regular check-ups and cleanings prevent costly treatments later.
  • Use network providers: they often bill the scheme directly and charge negotiated rates.
  • Get treatment plans authorised: for major procedures, an authorization avoids rejected claims.
  • Keep accurate records: receipts, treatment plans, and referral notes streamline claims.
  • Plan treatments across benefit years: if you’re approaching an annual limit, discuss timing with your dentist.

Common pitfalls to avoid

A few frequent mistakes members make when assessing GEMS medical aid options:

  • Overlooking waiting periods for major dental work.
  • Assuming all dentists are treated equally — non-network prices can be higher.
  • Ignoring sub-limits for specific procedures (e.g., crowns or orthodontics).
  • Not confirming whether emergency dental treatment is covered outside normal hours or when traveling.

Read the option-specific rules and the scheme’s dental benefit schedule carefully before committing.

Final checklist before you decide

  • Confirm what dental services are included and the annual limit.
  • Ask about network providers and whether your current dentist is in-network.
  • Check for waiting periods on major treatments.
  • Understand pre-authorisation and co-payment requirements.
  • Compare premium differences versus expected dental needs.

If dental cover is important for you or your family, weigh the value of stronger day-to-day and dental benefits against any additional premium. For many members, a slightly higher monthly contribution can save money over time by reducing out-of-pocket spending for routine and restorative care.

Next steps

To compare GEMS medical aid options accurately:

  • Review the scheme’s latest benefit guides for exact dental limits.
  • Request a written benefits comparison or speak to a GEMS representative.
  • Consider consulting a financial advisor if you’re balancing cover across multiple dependents.

 

Courtesy of Dental Tariffs Pack

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