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Applying for preventive medical benefits for persons insured with statutory health insurance


When it comes to preventive medical services, the principle is: outpatient before inpatient.

Outpatient preventive services

Upon application and under certain conditions, your statutory health insurance will cover the costs of medical services and spa remedies in the case of outpatient preventive care. You pay for accommodation and meals as an insured person.

Outpatient preventive medical services are medical and therapeutic treatments, such as spas or physiotherapy, which are carried out by therapy centres in state-recognised health resorts. You can choose the health resort and therapy centre together with your doctor. You can organise your own accommodation and meals.

Inpatient preventive care services

If outpatient preventive care in a state-approved health resort is not sufficient, for example because you are severely physically impaired or require intensive medical care, your health insurance company must grant you an inpatient preventive care service upon application. In addition to treatment, this also includes accommodation and meals in the spa clinic.

Medical Necessity

Your health insurance company can only grant you an outpatient or inpatient preventive care service if you have previously exhausted all therapy offers at your place of residence. In the application, your doctor must justify the necessity of the preventive care to your health insurance company.

A cure can be considered medically necessary if:

  • they can prevent an imminent illness or prevent it from getting worse, or
  • the need for long-term care is avoided, or
  • a risk to a child's health development can be counteracted.

Duration

The duration of outpatient preventive services should be provided for a maximum of 3 weeks. An extension can only be considered if it is urgently necessary for medical reasons in order to achieve the prevention goal.

Inpatient preventive services should be provided for a maximum of 3 weeks – unless an extension of the service is urgently required for medical reasons.

In individual cases, spa stays abroad are also possible, please contact your health insurance company for more information.
 

Process flow

For a pension benefit, proceed as follows:

  • In a consultation, your doctor will prescribe a preventive medical service.
  • For outpatient preventive care: Your doctor will fill out the application form (sample 25) together with you and explain the necessity of the measure.
  • For inpatient preventive care: Your doctor will fill out the application form of your health insurance company together with you and explain the necessity of the measure.
  • You send the completed application to your statutory health insurance company. You can submit the application by post and – with many health insurance companies – also online or hand it in at the office.
  • The health insurance company will check whether you are entitled to a preventive service and inform you of the result.
  • In the case of outpatient preventive services: Together with your doctor, you will select a suitable state-approved health resort from a medical point of view.
  • In the case of inpatient preventive services: You are welcome to tell your health insurance company what you would like to see in a particular pension fund. Your health insurance company will check whether these wishes can be met.
     

Requirements

Your doctor will prescribe the cure and explain the medical necessity to your health insurance company.

Which documents are required?

In individual cases, medical documentation may be required. You can find out what these are from your doctor or your health insurance company.

What are the fees?

Under certain conditions, your statutory health insurance will cover the costs of spa treatment and proportionately the costs of spa remedies in the case of outpatient preventive care. You pay for accommodation and meals. For this purpose, a subsidy from the health insurance company is possible.
In the case of inpatient care, the health insurance company covers the costs of treatment, accommodation and food. You pay the usual deductible.  
 

What deadlines do I have to pay attention to?

In order for your health insurance company to approve the application, your last outpatient treatment must usually be at least 3 years ago.

As a rule, your last inpatient treatment must have been at least 4 years ago.

In case of urgent medical necessity, shorter time intervals are also possible in both cases.
 

Processing duration

For outpatient preventive services, the processing time is usually 5 to 18 working days.

For inpatient preventive services, the processing time is usually 5 to 20 working days.

In order to process and make a decision quickly, your health insurance company must have the necessary information and, if necessary, documents complete and meaningful.
The health insurance company decides on applications promptly, whereby the statutory processing deadline is observed in order to protect patients' rights.
Please note that the stated processing time is an average value for all health insurance companies. It may vary in individual cases.
The exact processing time also depends on the complexity of the individual case and can be extended accordingly. The same applies if documents or records are sent to you or your health insurance company by post.

If necessary, the medical service must be involved. This will take up to an additional 5 weeks to process your request.
 

Appeal

  • Contradiction
  • Appeal to the Social Court
     

Technically approved by

Federal Ministry of Health

Professionally released on

02.12.2021

Author

The text was automatically translated based on the German content.

Source: Serviceportal Niedersachsen (Portalverbund des Bundes und der Länder)