GEMS Dental Benefits 2024: Emerald, Beryl, Tanzanite-One 

Dental Management 

The GEMS dental benefit ensures that members have access to cost-effective, quality dental healthcare.  

Network providers GEMS recommends that you visit your dentist or dental therapist every six months for a dental check-up and oral preventative care. Please consider visiting a dental service provider who is a member of the GEMS dental network to avoid unexpected out-of-pocket expenses.

GEMS dental network providers charge the agreed-upon Scheme tariffs, while non-network providers may charge above the Scheme rate, creating a shortfall which you would be liable for. You may not have to pay any out-of-pocket expense at a network provider if GEMS covers the service rendered and you have benefits available for the treatment.

If any dental work is required that is not covered by GEMS, the network provider will first obtain your permission before proceeding with the treatment, with a cost discussion between yourself and the provider. This way, you will always know what dental bills to expect.  

If you are on the Tanzanite One or Beryl benefit option, your dental services must be provided by a dentist, dental therapist, or oral hygienist who is part of the GEMS dental network, in line with the Scheme Rule expectation.

You can find a network provider for your option here or by calling 0860 00 4367. Choose option 4, your preferred language, then option 2 for Dental and option 3 for General Enquiries. Emergency out-of-network visits for members on the Tanzanite One and Beryl options. 

Benefits on the Tanzanite One and Beryl options are subject to the use of a GEMS dental network provider. Members are allowed one emergency out-of-network visit per year for pain and sepsis treatment. If there is no network provider in your area, call GEMS at 0860 00 4367 before visiting the dentist or dental therapist to ensure that the visit is covered.

This will help you avoid unexpected shortfalls when the claim is received at GEMS. Choose option 4, your preferred language, then option 2 for Dental and option 3 for General Enquiries. 

Dental fissure sealants 

• Dental fissure sealants are included on the list of approved services at your dental network provider on the Tanzanite One and Beryl options. 

• Dental fissure sealants are covered by the Preventative Care Services benefit on the Ruby, Emerald Value, Emerald, and Onyx options if they are obtained from a network provider. 

• Enquire with your dentist, dental therapist or oral hygienist about fissure sealants for your child’s permanent teeth. 

Root canal treatment 

• For Beryl and Tanzanite One members, this benefit is limited to one root canal treatment per beneficiary per year. For the claim to be payable, the services must be provided by a dentist who is part of the GEMS dental network. 

• This benefit is subject to the available shared dental sub-limit for all other options. This means that the claim will be paid if there are available benefits. Otherwise, this will likely be a shortfall to be funded by the member. 

Pre-authorisation for specialised dentistry
Members and dependants need pre-authorisation for the following treatment types:
 

• Conscious sedation. 

• Crown and bridge treatment. 

• Maxillofacial surgery. 

• Orthodontics. 

• Periodontal treatment (see also Registering on the Periodontal Programme). 

• Plastic dentures (Tanzanite One and Beryl options). 

To request pre-authorisation, ask your dental provider to complete and submit the ‘Periodontal’ form (for Periodontal treatment) or the ‘Dental Report’ form for all other treatments. The forms are available here.

Dental treatment under conscious sedation in the dental provider’s rooms
Your dental provider may inform you that your dental procedure will be performed under conscious sedation in certain circumstances or for specific procedures. Conscious sedation means that you are awake but relaxed during the procedure. This procedure is carried out in the dental chair in the provider’s consulting rooms. All procedures performed under conscious sedation require pre-authorisation.  

Benefits for treatment under conscious sedation in the dentist’s rooms are available for patients up to and including the age of nine years or if they have impacted teeth, subject to pre-authorisation and managed care protocols. Dental treatment under general anaesthesia in hospital Dental hospitalisation is only permitted for: 

• Impacted teeth. 

• Severe trauma (PMBs).  

All procedures performed under general anaesthesia require pre-authorisation. You will be asleep throughout the procedure if you are given general anaesthesia. This is usually done in a hospital or day clinic setting.   

For admission to a private facility (including facilities on the GEMS Hospital Network list and one-day admissions for elective procedures), please contact us at least 48 hours before the treatment to request pre-authorisation for hospitalisation. Unless it is an emergency, a co-payment of R1 000 per admission will apply if the pre-authorisation is not obtained. If a patient is admitted to a private facility for an emergency dental condition, the Scheme must be notified within one working day of the admission. Otherwise, a co-payment of R1 000 per admission will apply.  

If you are on the Tanzanite One or Emerald Value option, you are required to use a State or GEMS Network facility; failing this, the Scheme shall not be liable to fund the first R15 000 of the non-network facility’s bill. Use a GEMS network facility to avoid any out-of-pocket expenses. View the Hospital Network list here, or call GEMS at 0860 00 4367. 

Registering on the Periodontal Programme Periodontal (gum) disease treatment is limited to local anaesthesia, with no coverage for in-hospital care. 

To be eligible for periodontal treatment benefits, members on Tanzanite One and Beryl must be enrolled by their GEMS dental network provider on the Periodontal Programme. The Periodontal Programme is a disease management programme for patients with mild periodontitis. Once the treatment plan is approved for out-of-hospital care, the enhanced benefits for dental cleaning and specialised treatment (such as root planning) will help prevent tooth loss. Your GEMS dental network provider must complete the periodontal pre-authorisation form and forward it to GEMS, together with the supporting documentation, to enquiries@gems.gov.za or fax to 086 100 4367. The Periodontal form is available here. 

Orthodontic treatment 

The benefit for orthodontic treatment is available to GEMS beneficiaries under the age of 21 on the Ruby, Emerald Value, Emerald and Onyx options only. GEMS does not have a separate benefit limit for orthodontic treatment. This means that all orthodontic claims are payable from the available shared dental sub-limit. 

A treatment plan for orthodontic care is required, and the approval is subject to prior evaluation according to the Index of Complexity, Outcome and Treatment Need (ICON) criteria. Your dental practitioner is familiar with the ICON criteria, and GEMS uses the records submitted by your dental practitioner to determine your orthodontic treatment need.    

Fixed orthodontic treatment ranges from 9 to 36 months, depending on the complexity, as explained in the treatment plan. The approval for the orthodontic treatment plan is valid for one year. An updated authorisation is required on an annual basis for the remainder of the treatment. Members must please take note that should they change options, the benefits for the continued service may also change depending on the new option selected.  

Valid claims will only be covered if the beneficiary’s GEMS membership is active and valid on the treatment date. Once approved, GEMS will pay the provider an initial amount and the balance will be paid in monthly installments, subject to the beneficiary’s shared dental sub-limit funds. If a case is transferred to another provider, only the remaining balance under the original treatment plan is covered.  When transferring to another provider, e.g. the member relocated or is seeking a second opinion, kindly request records from the applicable provider to avoid a duplication of costs or possible overexposure to radiation from repeated X-rays.   

Orthodontic treatment is a once-in-a-lifetime benefit per beneficiary, and the retreatment is not funded. 

Dentures 

Tanzanite One and Beryl options: 

• GEMS covers fissure sealants, subject to managed care protocols. Dental fissure sealants are a simple and effective way to prevent tooth decay 

• Only members and beneficiaries over the age of 21 qualify for this benefit. 

• The benefit is subject to pre-authorisation, the use of a GEMS dental network provider, and is limited to the approved 2024 Scheme tariff. 

• No benefit is available for metal frame dentures. 

Ruby Emerald Value, Emerald and Onyx options: 

• GEMS covers fissure sealants, subject to managed care protocols. Dental fissure sealants are a simple and effective way to prevent tooth decay 

• Members are allowed one set* of plastic dentures per beneficiary every four years, with rebase and relines of the soft base every two years. Metal frames for partial dentures are limited to one per jaw, once every five years. 

• A set of dentures is defined as follows: 

• A complete upper and/or a complete lower denture.  

• A partial upper and/or partial lower denture.  

Appeals process
If your application for pre-authorisation has been declined for a planned procedure, an appeal may be lodged at enquiries@gems.gov.za. The appeal process can take up to five working days before a decision is sent to you. Kindly await the outcome of the decision before proceeding with the treatment. 

Dental providers: for more info click here