A radiology formulary has been applied as part of the scheme rules. This formulary aims to guide the practitioner as to the investigations funded by GEMS for these two options. It also provides information on the radiological investigations that require pre-authorisation.
Certain radiological investigations have been rejected for payment on the basis that no pre-authorisation was obtained. The majority of these rejections are due to additional views conducted for plain X-rays that would have required a pre-authorisation.
Only basic radiological investigations can be accommodated within the Sapphire and Beryl benefits. GEMS will fund additional views should they be clinically indicated but these tests are subject to pre-authorisation.
Please contact 0860 00 4367 for pre-authorisation. You will be asked to provide the membership number and the tariff code for the required investigation.
We will be working with the Radiological Society to review this formulary and explore ways to streamline the claims process in order to reduce rejections.
Attached herewith, please find the formulary for your perusal.