PRIOR AUTHORISATION
- THERAPEUTIC TREATMENT - AUTOMATIC GRANTING
- THERAPIES FOR WHICH NO PRIOR AUTHORISATION IS NECESSARY
- APPLICATION FOR PRIOR AUTHORISATION
- SUMMARY LIST OF TREATMENTS REQUIRING PRIOR AUTHORISATION
Form "application for prior authorisation" 
- THERAPEUTIC TREATMENT - AUTOMATIC GRANTING
1.1. Introduction
As part of the simplification of the working procedures of the Sickness Fund, the Management Committee of the Joint Sickness Insurance Scheme agreed that the prior authorisation required for therapeutic treatment under Annex IV.B of the Rules could be granted automatically.
Consequently:
- Like the treatments listed in Annex IV.A (kinesitherapy, physiotherapy, etc.), those listed in Annex IV.B may be reimbursed without any requirement for prior authorisation up to the maximum number of sessions provided for in the Rules in any calendar year, i.e. from 1 January to 31 December (see the complete list of treatments for which no prior authorisation is necessary in the table below).
- A medical prescription - in cases where the treatment is administered by medical auxiliaries or persons other than doctors - will still be required for all treatment listed in sections A and B of Annex IV. All applications for reimbursement of such treatment must be accompanied by a medical prescription mentioning the reason for the treatment and the number of sessions prescribed.
- Once the aggregate number of sessions in a year exceeds the maximum laid down by the Rules, prior authorisation must be sought for the reimbursement of any further sessions before the end of the year.
1.2. Application and transitional provisions
- These measures will be applicable immediately
- Any requests for prior authorisation that have already been sent to the Settlements Office will be dealt with in the normal way. Authorisation already granted on the date of publication of these measures will remain valid until the final date specified in the authorisation, even where that date is later than the end of the current calendar year.
- Counting of the number of sessions per year will begin with immediate effect, including those for 2001. Thereafter the calculation of the number of sessions will automatically start again from 1 January of each year.
1.3. Reimbursement of expenses
- Fees for the treatment listed in sections A and B of Annex IV will be reimbursed at a rate of 80 % on condition the treatment is dispensed by a person legally authorised to exercise the relevant profession. The Rules set a maximum reimbursement for acupuncture (EUR 22.31) and psychotherapy (EUR 45.19).
It is advisable as far as possible to apply for reimbursement of fees at the end of the treatment, corresponding to the number of sessions indicated on the medical prescription.
- Section XV.3 of Annex I of the Rules should be borne in mind:
- "Expenses in respect of treatment considered non-functional or unnecessary by the office responsible for settling claims after consultation of the medical officer shall not be reimbursed." In this context, treatment for purely cosmetic purposes is in principle not refundable (unless prior authorisation has been granted) and any reimbursement may be recovered or set against future reimbursements after subsequent verification.
- "That part of expenses considered excessive by the office responsible for settling claims after consultation of the medical officer shall not be reimbursed." This refers to all treatment for which the Rules do not lay down a maximum reimbursement.
- For certain treatments (e.g. acupuncture, laser therapy, osteopathy, chiropractic treatment and mesodermal microinjection therapy), fees comprising a consultation as well as the treatment proper will not be covered . The consultation fee will be covered by the reimbursement for the treatment session.
- THERAPIES FOR WHICH NO PRIOR AUTHORISATION IS NECESSARY
For the types of treatment in the table below, covered by sections A and B of Annex IV, prior authorisation is not necessary as long as the aggregate number of sessions in the calendar year, for all conditions, does not exceed the maximum number laid down in the Rules. The limit may be reached by combining various treatments from the same group of items (e.g. kinesitherapy: 30 sessions of therapeutic massage and 30 sessions of mechanotherapy).
Important: A medical prescription stating reasons for the treatment and specifying the number of sessions prescribed must be attached to the claim form except where the treatment is dispensed by a doctor.
Therapeutic treatment and number of sessions per calendar year (*) authorised without prior application
| Type of treatment | (*) | Special remarks:
A medical prescription stating reasons for the treatment and specifying the number of sessions prescribed must be attached to the claim form except where the treatment is dispensed by a doctor. |
| Kinesitherapy (therapeutic massage, remedial gymnastics, mobilisation, rehabilitation, mechanotherapy, traction, mud baths, hydromassage, hydrotherapy, any combination of the above) | 60 | Sessions of antenatal and postnatal exercises are not counted in this type of treatment, but reimbursed separately on the basis of a medical prescription. |
| Physiotherapy (electrotherapy, diadynamic currents, microwave therapy, ionisation, short-wave therapy, special forms of electrotherapy, any combination of the above) | 60 | - |
| Aerosol therapy (inhalation, insufflation, irrigation, nebulisation or spray treatment, any combination of the above) | 30 | - |
| Infra-red radiation, ultrasound theraphy | 40 | - |
| Radiotherapy | | This treatment is reimbursed, but only if dispensed in hospital or by a doctor. |
| Acupuncture | 30 | Following the Medical Council's opinion, acupuncture may be reimbursed by the Joint Sickness Insurance Scheme only if the treatment has been dispensed by a doctor. |
| Laser therapy | 20 | The prior opinion of the medical officer must be sought if the treatment is dispensed by a dermatologist (since the reasons may be cosmetic) or an ophthalmologist (lasik).
Treatment for purely cosmetic reasons is not reimbursed. |
| Ultraviolet radiation | 40 | May be reimbursed only if dispensed in hospital or by a doctor. |
| Chiropractic treatment | 24 | A medical prescription is required. For the countries where the profession of chiropractor is not legally recognised, the medical prescription must state the name of the chiropractor dispensing the treatment (at present the profession is recognised in Denmark, Finland, Ireland, the United Kingdom and Sweden).
Following the Medical Council's opinion, prior authorisation is still required for children under 12, even in the countries where the profession of chiropractor is legally recognised. The medical prescription must clearly state the reasons for the treatment. |
| Osteopathy | 20 | A medical prescription is required. For the countries where the profession of osteopath is not legally recognised, the medical prescription must state the name of the osteopath dispensing the treatment (at present the profession is recognised in Finland, Ireland and the United Kingdom)
Following the Medical Council's opinion, prior authorisation is still required for children under 12, even in the countries where the profession of chiropractor is legally recognised. The medical prescription must clearly state the reasons for the treatment. |
| Medical chiropody - Podology | 12 | Treatment for purely cosmetic reasons is not reimbursed. |
| Mesodermal microinjection therapy | 30 | These treatments are reimbursed only if they are dispensed by a doctor.
Treatment for purely cosmetic reasons is not reimbursed. |
| Psychotherapy | 60 | A medical prescription issued by a psychiatrist, a neurologist or a paediatrician mentioning the name of the psychotherapist who will dispense the treatment is still compulsory if the treatment is not dispensed by a psychiatrist. |
| Speech therapy | 60 | A medical prescription drawn up by a school doctor (e.g. the model application form for therapy issued by the European Schools) in the context of school inspection duties is acceptable only if it is endorsed by another doctor.
The Medical Council has decided that prior authorisation is still required for children over 12. The medical prescription must in this case be accompanied by a detailed logopaedic report setting out the test results. |
| Graphomotor therapy | 60 | A medical prescription drawn up by a school doctor is not acceptable (see remark in connection with speech therapy). |
| Psychomotor therapy | 60 | A medical prescription drawn up by a school doctor is not acceptable (see remark in connection with speech therapy). |
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- APPLICATION FOR PRIOR AUTHORISATION
- In cases of serious illness requiring more sessions in the course of a calendar year than are allowed under the Rules and specified in the above table, an application for prior authorisation for the number of sessions required by the end of the year must be submitted when the ceiling is reached, indicating clearly that the maximum number of sessions allowed has been exceeded.
In exceptional circumstances, authorisation may be granted, in accordance with the opinion of the medical officer, for reimbursement of sessions in excess of the maximum number laid down, in particular in the case of conditions recognised as serious illness, in certain cases of chronic illness and in cases of severe trauma, e.g. due to accidental injury.
- Applications for prior authorisation must include:
- the member's surname, forename and personnel number
- the patient's surname and forename
- the type of treatment requiring prior authorisation
- the number of sessions requested
- the probable duration of treatment.
- Applications must always be accompanied by a medical prescription drawn up by a doctor, stating:
- the patient's name and forename
- the type of treatment and the number and, where applicable, the frequency of sessions
- a diagnosis of the illness requiring treatment
- in certain cases (see table) the name of the person dispensing the treatment
- the date of the prescription, which must be before the start of the treatment
- the issuing practitioner must be clearly identified by means of a letterhead or stamp.
- Applications for prior authorisation must be submitted when the treatment is prescribed and, except on duly substantiated medical grounds, may not cover treatment already given.
- The answer will indicate whether the application has been approved or refused by the Settlements Office, the scheme's code for the treatment, the number of sessions approved, a comment in certain cases, and the period for which the authorisation is valid.
Below is a summary list of the treatments which always require prior authorisation (application for prior authorisation, medical officer's opinion, estimate).
SUMMARY LIST OF TREATMENTS REQUIRING PRIOR AUTHORISATION 4.1. Treatments for which prior authorisation must always be sought
- Plastic surgery
- Appliances for medical treatments, e.g. purchase of sprays, respirators, glucometers, blood pressure gauges, etc.
- Nursing attendance
- Convalescence cures, thermal cures, cures for delicate children
- Purchase of orthopaedic shoes
- Purchase of wheelchairs and similar appliances
- Travelling expenses to receive treatment away from the place of employment or residence
- Therapeutic treatment sessions in excess of the maximum number laid down for the calendar year, as indicated in the above table, for the treatment referred to in sections A and B of Annex IV of the Rules.
- Chiropractic and osteopathy treatments for children under 12
- Speech therapy for children over 12.
4.2. Treatments for which the opinion of the medical officer must be sought
To obtain prior notification from the Settlements Office of the favourable or unfavourable opinion of the medical officer, you are urged to make prior application for certain treatments:
- Cosmetic treatments
- Stays in nursing or convalescent homes
- Cost of a stay in hospital by a family member accompanying the patient (unless the patient is a child under 12)
- The patient's transport costs or travelling expenses
- Items not mentioned in the Rules (Point XV.2 of Annex I), such as lymph drainage, orthoptic rehabilitation, dorsal gymnastics ("école du dos"), in vitro fertilisation, etc.
- Certain pharmaceutical products that have no real curative properties, e.g. Xenical, Nicorette and other products to help smokers give up tobacco, Rilatine, Ritaline, etc. (see list of medicines on Europaplus), special diet products essential to survival.
4.3. Dental treatment requiring an estimate
- The cost of peridontal treatment
- The cost of orthodontic treatment (authorised only for children whose treatment begins before the age of 18)
- Fixed and mobile dental prostheses, including the cost of repair.
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