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Prior authorization

Under the Patient Mobility Directive 2011/24/EU the basic principle holds that cost reimbursements shall be rendered without prior authorisation and at that, in the amount of the costs which the insurance system had incurred were the relevant service provided in Austria. The prior authorisation concept is thus regarded as an exception to this general rule.
Likewise must be ensured that the prior authorisation concept for cost reimbursement will not result in discrimination or unjustified obstacles to patient mobility in regard to cross-border healthcare.

Treatments requiring prior authorization

In respect to Austria, prior authorisation provided for by the EU Patient Mobility Directive is required for certain therapies in order to be entitled to the special reimbursement that is governed by this act. No demand for reimbursement can be made, if the service was received, although authorisation had been rejected. More information on the mentioned variants in regard to reimbursement can be found in the fact sheet “Reimbursement”.

As a result of the so-called  "cross-divisional service", the application can be submitted to any social insurance carrier.

Prior authorisation is required for the following treatments:

  • Inpatient treatment and examinations (at least one overnight stay is required),
  • Outpatient treatment and examinations requiring the use of highly specialised and cost-intensive medical infrastructure or medical equipment; these are
    • diagnostic and therapeutic applications using radiation or particles such as CT, MRT, magnetic resonance imaging, proton therapy and particle therapy;
    • outpatient treatment and examinations using high technology equipment that would be covered by the Austrian Major Equipment Plan;
    • cosmetic treatments, for which cover is granted in accordance with § 133 section 3 ASVG;
    • human genetic studies;
    • surgical procedures that must be performed in a sterile setting;

  • treatments that are associated with a particular risk for the patient or the population; or
  • treatments that are provided by healthcare providers, which in the individual case may raise serious and specific concerns in terms of the quality or safety of care, with the exception of healthcare provision governed by the European Union legislation on the assurance of a minimum level of safety and a minimum quality throughout the European Union.

The insured person must present documents to the relevant social insurance carrier on

  • the type of treatment;
  • the therapeutic goal sought;
  • the treatment date;
  • the healthcare provider, where the treatment will be received; and
  • records about the medical condition that will permit an evaluation of the urgency of the treatment.

Commitment to approve

Prior authorisation must be granted by the social insurance carrier responsible at all events, if the patient is entitled to the particular service in Austria and if this cannot be provided within a reasonable time. In terms of the assessment, what timeframe shall be regarded as “reasona-ble”, an assessment on a case-by-case basis must be conducted, including the patient’s subjective and objective health status as well as disease progression up to now and the anticipated future development.

Exceptions

Medical emergencies are excluded from the prior authorisation requirement, if proven that prior authorisation cannot be obtained in time or not at all. In these cases, the actual costs incurred by the insured person will be refunded.
Detailed regulations can be found under the Health services regulations of the social insurance carriers or at www.sozialversicherung.at.

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