Application and Reimbursement Procedures

Application and Reimbursement Procedures

The information below outlines the:

application procedure for prior authorisation for inpatient care

and how to claim reimbursement for inpatient/outpatient/daycase healthcare you have attended and paid for.

 Please note that prior authorisation is only required for inpatient care.  (However, not securing prior authorisation may not of itself preclude a claim for reimbursement being processed but it will ensure you as the patient have full information to enable you to make an informed decision on whether to proceed with the healthcare abroad.)  The most significant barrier for patients seeking to access healthcare abroad is the ability to be able to make an informed decision based on knowledge of the reimbursement rate and the cost the provider will invoice.  Furthermore by applying for the healthcare in advance of availing of it the patient ensures the following:

  • The patient can make an informed decision based on knowledge of the reimbursement rate that applies to the procedure specified on the application form.
  • It allows the patient a little time to consider whether he/she wishes to proceed with the treatment abroad (cooling off period) as opposed to having to make a decision there and then in a consultant’s office.
  • It ensures the patient proceeds in the knowledge that the healthcare will qualify for reimbursement under two specific area

              i.     that the treatment is provided for under the public healthcare system in Ireland and is therefore eligible for reimbursement and
             ii.     that the patient has followed public patient pathways and will qualify for reimbursement.  In the case of the latter it allows the patient the opportunity to fulfill this requirement so that reimbursement can ultimately be achieved.

The application procedure for prior authorisation is outlined.

The procedure for claiming reimbursement for inpatient/outpatient/daycase attendances is outlined here.

Application

Prior approval will be required for all hospital care involving overnight accommodation, healthcare that involves treatments presenting a particular risk for the patient or the population, or healthcare which would be provided which could raise serious concerns with regard to the quality or safety of the care.

The Application formfor prior authorisation must be assessed and a determination given prior to the patient availing of the treatment abroad. Valid applications will be processed within 15 to 20 working days and a decision will be issued via letter.  Appointments should not be scheduled prior to a decision being reached on an application. Appointments that are made prior to decision will have no bearing on the review process or its expedition.

 N.B. Treatments that qualify for funding under the  E112 Treatment Abroad Scheme are excluded for reimbursement under the CBD.  If you require any advice on the provisions of access to care under the Treatment Abroad Scheme versus the Cross Border Directive please contact the Treatment Abroad Scheme office on 056 778 4551 or the Cross Border Directive Office on 056 778 4547 or 056 778 4546 or 056 778 4556

The referral process and assessments that are required to avail of any element of public health care in Ireland will apply to any and all applications for approval and subsequent reimbursement under the CBD e.g. if there is eligibility criteria (medical, or financial, or etc) applicable in Ireland that same criteria will be applied under the CBD. Please note, under no circumstance will an outpatient appointment in a private capacity in Ireland be accepted for the purpose of accessing healthcare abroad under the Cross Border Directive. Public referral pathways as applicable in Ireland must be adhered to. Public consultant appointments can only be accepted. 

 Applications for prior authorisation may be declined where the HSE considers that it is justified by overriding reasons of general interest, such as planning requirements related to the aim of ensuring sufficient and permanent access to a balanced range of high quality treatment in the State, or the wish to control costs or to avoid, as far as possible, any waste of financial, technical and human resources.


 Reimbursement

The Pro-forma Invoiceshould be completed by your healthcare provider abroad in order to facilitate your claim for reimbursement. The pro-forma invoice was developed to assist the patient in securing a timely reimbursement.  The pro-forma invoice captures all the information the HSE (Ireland) requires in order to process a payment in an efficient manner.

While the completion and submission of the pro-forma is optional, it is recommended that it is completed and submitted as:

  • It facilitates timely processing of reimbursements for the patient as it contains all the information we require to make a reimbursement.
  • It ensures a patient gets all the necessary information prior to discharge rather than returning home and trying to clarify issues from a foreign base.
  • It ensures the patient does not incur the additional expense of certified medical translations of documents which are in a language other than English.
  • It ensures the patient is reimbursed the correct amount for the treatment he/she has had.
  • The completed pro-forma invoice should be submitted with the original invoice and original receipt for the healthcare provided.  Reimbursements will be made in line with the governing legislation and criteria for this scheme. 

 Payments will only be made to the patient or in the case of a child his/her parent of guardian. No payments will be made to third parties, except in the case of patient’s death, and this will be subject to the executor of the estate providing evidence of the outstanding liability. The HSE will only accept court appointed/approved power of attorney for the purpose of CBD reimbursements.

 The maximum cost of reimbrusement for a consultation abroad is €130. Further, Reimbursement rates can be accessed via this link , if the reimbursement rate you are seeking does not appear to be on this link please contact the National Contact Point office 056 778 4547 or 056 778 4546 or 056 778 4556 or  crossborderdirective@hse.ie and the staff will assist you. The ready reckoner accessible on this link is coded via ICD 10. Your referring doctor will be familiar with these codes and identify the correct code and corresponding reimbursement rate for you.

 Terms and conditions for reimbursement of costs:

 In order to be entitled to seek reimbursement of the healthcare costs please ensure the following:

If the healthcare involved an overnight stay in hospital ensure you have prior authorisation for same.

Ensure the clinician you attended abroad has provided you with an invoice, a receipt for your payment and it is strongly recommended that they have completed the HSE pro-forma. The pro-forma should be completed in English. Please complete and return the Vendor Set Up form to allow payment to issue to you

Reimbursement will be at the cost of the treatment you availed of abroad or the cost of providing the healthcare in Ireland whichever is the lesser. Please note that in the case of inpatient care abroad the HSE will deduct €80 per night, to a maximum of €800, from the total to be reimbursed being the overnight charge for inpatient care in Ireland unless you are a medical card holder or have already reached the maximum in the preceding 12 months. Healthcare in Ireland is funded through general taxation so the cost of the provision of the care is that funded through general taxation plus the statutory payment the patient would have made here in Ireland.

Payments will only be made to the patient or in the case of a child his/her parent of guardian. No payments will be made to third parties, except in the case of a patient’s death, and this will be subject to the executor of the estate providing evidence of the outstanding liability and evidence of the settlement of that liability upon which the reimbursement will be processed and made to the legal representative of the deceased patient. The HSE will only accept court appointed/approved power of attorney for the purpose of CBD reimbursements.

HSE National Contact Point for the Cross Border Directive Policy

on

Overpayments

and

Catastrophic Complications and Co-Morbidities (CCC) Codes.

 

Overpayments

 

The Cross Border Healthcare Directive is very specific a patient is only entitled to be reimbursed in respect of the treatment he/she receives for which he/she has demonstrated necessary care and public patient pathways.

 

In cases where an overpayment is made to a patient the HSE reserves the right to recoup that overpayment in its entirety. In such instances the National Contact Point (NCP) will write to the patient informing him/her of the overpayment. The letter will request that the patient refunds to the HSE without delay the entire amount of the overpayment. The patient may seek to organise instalment payments with the NCP to be agreed between the parties.

 

In instances where an overpayment has been made in respect of one or more treatments and the patient has outstanding reimbursement claims with the NCP all such claims will be put on hold pending the repayment of the overpayment to the HSE. In such cases if the patient does not respond to the letter from the HSE outlining the overpayment as described above the overpayment will become a first charge on any subsequent reimbursements so that the HSE can bring the matter to a conclusion.

 

The use of CCC (catastrophic complications and co-morbidities) DRG codes.

 

The National Contact Point has become aware of the inappropriate use of CCC DRG codes for the purpose of accessing higher value reimbursements than justified in individual cases. As a result of this inappropriate coding the NCP has adopted a policy of referring CCC coded reimbursements for independent assessment. Any issue with regard to an expectation of a higher value reimbursement on the basis of an incorrect CCC coding will be a matter for the patient and his/her treating consultant and not the HSE.

Travel and subsistence costs are not reimbursable.

Certain healthcare which is provided over extended periods of time may be subject to staged payments with a final payment at the end of the care. The staff of the National Contact Point will advise you in relation to this.

 The National Contact Points in the other member states abroad are available via this  link

 The HSE accepts no liability for healthcare availed of abroad which fails to meet the governing legislation, criteria and the HSE’s administration requirements.