Applying for prior authorization for planned treatment

To finance planned treatment abroad, it is possible to apply for PRIOR AUTHORIZATION from the Health Insurance Fund on the basis 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 service applied for or alternatives to such health service cannot be provided to the insured person in Estonia;

2.     Provision of the health 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 the aim of the health service applied for being achieved is at least 50 per cent.

1.     Provision of the health service applied for is indicated for the insured person;

2.     The health service applied for is provided in Estonia and it is a service compensated for by the Health Insurance Fund (Estonian Health Insurance Fund’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 with all the data fields filled to the Health Insurance Fund before travelling abroad for treatment or tests. It is possible to start processing an incomplete application only when you have provided all the missing information.

If possible, please add the decision of a council of Estonian doctors to your application, as the Estonian Health Insurance Fund makes its decision on referral for treatment to another state on the basis of the decision by the council of Estonian specialist doctors.

To receive a decision of the council, you must contact your doctor (the specialist doctor, not the general practitioner) who will then prepare the decision of the council of at least two participating specialist doctors, who shall evaluate the conformity of the service applied for with the criteria presented in the table above.

It is possible to submit applications at customer service offices of the Estonian Health Insurance Fund or via regular mail at the address Eesti Haigekassa, Lembitu 10, Tallinn 10114. As the application includes delicate 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 valissuhted [at] haigekassa.ee.

If the Health Insurance Fund receives your application without the decision of the council, the Health Insurance Fund will contact the specialist doctor of the person who submitted the application 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 the decision of the council. The processing of applications submitted with the decision of a council takes about up to 30 days on average. The processing of applications sent without the decision of a council takes 2 months on average.

In case of a positive decision:

1.     The Health Insurance Fund 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 service has been provided on the basis of the submitted original invoice (receipt) and the epicrisis (case summary).

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 concluded between you and the Health Insurance Fund. The amount of your prepayment according to the contract with the Estonian Health Insurance Fund is agreed between the parties, but does not exceed 50% of the estimated total cost. The amount is stated in the contract of payment for planned health services abroad concluded with the Health Insurance Fund. After the contract has been signed by both parties, the Health Insurance Fund shall transfer the agreed portion of the estimated total costs to your bank account at the agreed time. You will pay the total cost of the health services to the foreign medical institution yourself. To verify that the health services were provided and paid for, you must submit the original invoice (receipt) and the epicrisis (case summary) to the Health Insurance Fund within 30 calendar days from the provision of the health services, after which the Health Insurance Fund will reimburse for the remaining amount of the actual cost of health services. If the health service is not provided or its cost is lower than the sum transferred to your bank account by the Health Insurance Fund, you are obliged to return the remaining amount to the Health Insurance Fund.

2.     If the medical institution of another European Union member state does not accept a letter of guarantee but will accept the form E112 or S2, the corresponding form shall be provided for you. You must personally deliver the form E112 to the foreign medical institution.

NB! The letter of guarantee, contract and form E112 do not extend to possible non-medical expenses (patient’s co-payment, 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, a written notice is sent to the insured person along with the statement of grounds of denial of referral to treatment.