Prior agreement of the Health Insurance

Verified 27 May 2024 - Directorate for Legal and Administrative Information (Prime Minister)

What is theprior agreement health insurance? That's the agreement given, before execution the act or treatment, by the Health Insurance for its care. These are often costly, rare, or long-lasting acts. Your doctor, physiotherapist, dentist must first complete an application for certain procedures. It is then up to you to complete and send the form to the CPAM: titleContent. The cash register replies by post only in case of refusal. We're showing you the regulations.

The acts concerned by the prior agreement of the Health Insurance are: in particular the following:

  • Certain treatments provided by masseurs-kinesitherapists, speech therapists, orthoptists (for example: in case of a recent external ankle sprain, the agreement is necessary from the 11the sitting)
  • Dento-facial orthopedic treatments (DOF)
  • Certain unusual disorders
  • Certain drugs (expensive or being tested)
  • Certain medical devices
  • Certain laboratory tests and tests
  • Some transports. For example: long-distance transport (more than 150 km), mass transport, transport by plane or by regular boat, transport related to the care or treatment of children and adolescents in centers for early medical-social action (CAMSP) and medical-psycho-educational centers (CMPP), transport for pregnant women traveling to hospital hotel.

In principle, you are the one who sends the request for prior consent to the sick assembly. However, in some cases, it is up to the health care practitioner to do so.

General case

In practice, the health care professional consulted informs you of the need to make a request for prior agreement (also sometimes referred to as request for prior agreement).

They fill out a specific form based on the care prescribed and give it to you.

You must complete it and then send it to the medical department:

  • Of your CPAM: titleContent if you are dependent on the general diet
  • Of your MSA: titleContent if you are dependent on the farm plan.
Who shall I contact

You must obligatory attach the medical prescription or a copy thereof for the acts or treatments performed by:

  • Medical assistant (masseur-physiotherapist, speech therapist, orthoptist)
  • Sanitary carrier
  • Provider of laboratory analyzes or examinations
  • Medical equipment supplier.
Cholesterol medicines

For certain cholesterol medicines, your doctor will request prior approval from the medical department of your health insurance fund.

Physical therapy

In certain situations (examples: rehabilitation of the shoulder, elbow, wrist, hip, knee, ankle), the extension of the sessions involves a prior request to the Health Insurance.

It is the masseur-physiotherapist who carries out this procedure.

In case of emergency

The doctor or health care practitioner dispenses the procedure.

However, he must draw up a request for prior agreement, indicating in it the words "Act of emergency".

The lack of response from your CPAM: titleContent or your MSA: titleContent within the 15 days from the receipt of the request shall be deemed to be agreement.

FYI  

This period may be extended to a maximum of 21 days where the service in question justifies a longer period (e.g. complexity of the analysis of the request for agreement).

In case of refusal of care, you receive a written answer. In this case, the Health Insurance tells you the means and time available to you to challenge the decision.

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