Applying for prior authorization for planned treatment
To finance planned treatment abroad, it is possible to apply for PRIOR AUTHORIZATION from EHIF based on two different principles:
1. Under §271, subsection 1 of the Health Insurance Act
2. Under article 20 of Regulation (EC) No 883/2004 of the European Parliament and of the Council
1. The health care service applied for or alternatives to such health care service cannot be provided to the insured person in Estonia.
2. The health care service applied for is indicated for the insured person;
3. The medical efficacy of the health service applied for has been proven;
4. The average probability of achieving the aim of requested health care service is at least 50 per cent.
1. The health care service applied for is indicated for the insured person;
2. The health care service applied for is provided in Estonia
and it is a service compensated for by EHIF (EHIF’s list of health care services).
3. The health service applied for cannot be provided to the patient
during a medically justified period of time, considering the patient’s state of health and the probable course of his/her illness;
4. The medical institution must be part of the national system of an EU member state.
In either case, you must submit an application for prior authorization (with all the data fields filled) to EHIF before travelling abroad for treatment or tests. An incomplete application can be processed only after you have provided all the missing information. The language of the application procedure is Estonian and EHIF has the right to request a translation of applications/statements submitted in a foreign language into Estonian.
If possible, please add the decision of a council of Estonian doctors to your application, as EHIF makes its decision on referral for treatment to another state on the basis of the decision by the council of Estonian medical specialists. To receive a decision of the council, you must contact your attending physician (a medical specialist, not your family physician) who will then prepare the decision of the council of at least two participating medical specialists, who shall evaluate the conformity of the service applied for with the criteria presented in the table above.
If EHIF receives your application without the decision of the council, EHIF will contact the attending physician of the applicant with a request to gather a council to determine the need for a health service and the possibility of receiving it in Estonia.
For faster processing of the case, we advise you to submit the application along with council’s decision. The processing of applications submitted with council’s decision takes about up to 30 days on average. The processing of applications sent without council’s decision takes 2 months on average.
Applications can be submitted:
- at EHIF’s customer service offices
- by regular mail, sending them to the address of the Estonian Health Insurance Fund, Lastekodu 48, Tallinn 10144.
- by e-mail. Please note! As the application includes sensitive personal data, we advise you to agree on the delivery of the application via e-mail and the data necessary for encryption in advance by e-mail at valisravi [at] haigekassa.ee
In case of a positive decision
- EHIF will issue a letter of guarantee, i.e. a document verifying that the Estonian Health Insurance Fund shall pay to the foreign medical institution after the health care service has been provided on the basis of the submitted original invoice (receipt) and the epicrisis (summary of medical history). If the medical institution does not accept the letter of guarantee, then a contract for a partial assumption of the obligation for prepayment shall be signed between the patient and EHIF. The amount of prepayment according to the contract with EHIF is agreed between the parties, but does not exceed 50% of the estimated total cost. The amount is stated in the contract on the payment for planned health care services abroad signed with EHIF.
After the contract has been signed by both parties, EHIF will transfer the agreed proportion of the estimated total costs to your bank account at the agreed time. The patient will pay the total cost of the health care services to the foreign medical institution themselves. To verify that the health services were provided and paid for, the patient must submit the original invoice (receipt) and the epicrisis (summary of medical history) to EHIF within 30 calendar days from the provision of the health care services, after which EHIF will reimburse for the remaining amount of the actual cost of health care services. If the health care service is not provided or its cost is lower than the sum transferred to the patient’s bank account by EHIF, the patient is obliged to return the remaining amount to EHIF.
- If the medical institution of another EU member state does not accept a letter of guarantee but will accept the form E112 or S2, the patient will be provided with corresponding form. The patient must personally deliver the form E112 to the foreign medical institution. Please note! The letter of guarantee, contract and form E112 do not extend to possible non-medical expenses (patient’s self-liability, transportation costs, translation services, administrative or office expenses, accommodation outside the hospital, etc.). These are paid for to the foreign medical institution by the patient or the patient’s legal representative.
In case of a negative response
In case of a negative response, a written notice is sent to the insured person along with the statement of grounds of denial of referral to treatment.
Please note! We recommend submitting your application as early as possible. EHIF can make a decision on the reimbursement for planned treatment abroad before the treatment takes place - we do not have the right to process applications submitted post-treatment!
For faster processing of the case, we advise you to submit the application along with council’s decision.
The processing of applications submitted with council’s decision takes about up to 30 days on average. The processing of applications sent without council’s decision takes 2-3 months on average.