Applying for prior authorization for planned treatment abroad

You can submit your application:

• valisravi [at] tervisekassa.ee (by e-mail) to info [at] tervisekassa.ee;
• at the Health Insurance Fund’s customer service offices.

The documents contain health data, so please encrypt them using the Estonian Health Insurance Fund’s certificate when sending them via e-mail.

Before submitting your application, please make sure:

• in consultation with your treating physician, that there is a need for planned treatment abroad;
• in consultation with your treating physician, that the foreign healthcare facility has expressed its willingness to provide the requested healthcare service;
• in consultation with your treating physician, that the foreign healthcare facility accepts the letter of guarantee or Form S2 issued by the EHIF;
• that a price quote is available.

Requirements for a council report

• The criteria for prior authorization for planned treatment abroad are assessed by at least three specialists, one of whom is the specialist providing healthcare services to the insured person.
• Specialists must have competence in the relevant specialty or in treating the medical condition.
• The specialists must be from at least two different medical institutions, unless no other medical institution in Estonia provides services in the same specialty.
• The consultation protocol must be signed by all participants in the consultation.
• All fields in the protocol must be completed. An incompletely filled-out consultation protocol will result in a request to provide the missing information, and therefore the pre-authorization process may be delayed.

Clinical Trials and Experimental Treatment

Prior authorization for planned treatment abroad cannot be requested for participation in a clinical trial, for the provision of pre- and post-trial examinations, or for other healthcare services.

Pursuant to the law, a healthcare service covered by the Health Insurance Fund must have proven medical efficacy. The evidence regarding the efficacy and safety of medicines, healthcare services, and health technologies is assessed based on the results of clinical trials published in scientific literature.

Treatment Complications Abroad and Further Management

When receiving healthcare services abroad, the patient’s point of contact in Estonia is the referring physician who referred them for treatment, who cooperates fully with the foreign healthcare provider and remains informed of the patient’s condition.

This also applies if complications have arisen as a result of healthcare services provided abroad and/or a change in the treatment plan is necessary (including a review of the terms of the payment guarantee). The assessment of the patient’s medical condition may be conducted by a physician who has reviewed the situation (i.e., the information provided by the foreign healthcare facility), based on which a decision regarding further steps can be made. Additionally, the treating physician and/or the relevant Estonian healthcare facility coordinates medical transport as needed.

Please notify the EHIF of any changes to the treatment plan as soon as possible.

Positive decision

Ff the criteria for prior authorization for planned treatment abroad are met, the Health Insurance Fund will issue you a corresponding decision and a guarantee letter or Form S2.

Both the guarantee letter and Form S2 are issued to the healthcare facility abroad providing the requested healthcare service and sent to the applicant via email or, if necessary, by registered mail. A copy of the issued document is sent to the patient’s treating physician in Estonia via e-mail.

The guarantee letter or Form S2 must be taken along by the patient when traveling for treatment and presented to the medical institution in the foreign country.

Expenses incurred in a foreign country that are not reimbursed by the Health Insurance Fund

• The Health Insurance Fund assumes the obligation to pay for medical expenses incurred in a foreign country. The issued guarantee letter or Form S2 does not cover potential non-medical expenses (patient copayment, consultation fee, transportation costs, translation costs, administrative or office costs, insurance, non-hospital accommodation, etc.). These costs must be paid to the foreign healthcare facility by the patient or their legal representative.

The Health Insurance Fund does not reimburse non-hospital accommodation costs for family members accompanying the patient. The Health Insurance Fund assumes the obligation to pay for one caregiver’s bed-day fee accompanying a minor patient to the same extent as when receiving healthcare services in Estonia in accordance with the Health Insurance Act (see calculation of bed-days in a hospital).

Transport when going abroad for medical treatment

In general, the Health Insurance Fund does not reimburse transport costs for planned treatment in a foreign country.

In exceptional cases, the Health Insurance Fund covers the cost of medical air transport if the patient’s health condition makes it impossible to use other means of transport. The need for medical air transport is agreed upon by the foreign and Estonian healthcare institutions. The Estonian healthcare institution settles the costs directly with the Health Insurance Fund.

As of January 1, 2021, the Health Insurance Fund also covers medical ground transport by ambulance and ferry.

Medical transport for a patient requiring treatment in a foreign country with prior authorization to a medical institution in that country, or medical transport for a patient undergoing treatment in a foreign country with prior authorization back to a medical institution in Estonia, is arranged through cooperation between the Estonian medical institution and the foreign medical institution.

Before arranging transport, the following must be clarified:

• what is the patient’s health condition and what type of transport is required (ambulance or air transport);
• whether and under what conditions the patient can be transported;
• whether the patient’s treatment can be continued in Estonia (in the case of transport from a foreign country to Estonia);
• whether the foreign healthcare facility has given its consent to admit the patient (in the case of transport from Estonia to a foreign country);

Medical transport is not arranged by the Health Insurance Fund, the Ministry of Foreign Affairs, or the patient, but is carried out in cooperation between the sending and receiving medical institutions.

Refusal 

The Health Insurance Fund explains and justifies in writing why it is not possible to finance the requested healthcare service through planned treatment abroad in the denial decision. In the event of a denial decision, the applicant is issued a written notice to that effect along with the decision.

Timely manner for the pre-approval procedure for planned medical treatment abroad

The application and medical report must be submitted together.

Processing the received documents takes up to 30 days. The procedure may be extended if additional information is requested or if incomplete documents are submitted.

In cases requiring urgent intervention, the pre-authorization documents are processed on an expedited basis.

Issue of a prior authorization for planned medical treatment abroad as a matter of urgency

The time resources available for emergency work are limited and reserved for handling truly urgent medical cases. Documents for a pre-authorization for planned outpatient treatment are processed on an expedited basis if treatment must be provided within a specified number of hours or days. The patient’s treating physician in Estonia sends a confirmation to the Health Insurance Fund, indicating when treatment is necessary. The prerequisite for expedited processing of the prior authorization is a correctly completed application for prior authorization for planned treatment abroad submitted to the Health Insurance Fund, along with the consultation protocol. Additionally, the consent of the foreign healthcare facility to provide the necessary healthcare services to the patient is required.

Documents are not processed on weekends or national holidays.

The following reasons preclude expedited processing of a prior authorization for planned treatment abroad:

• the date for surgery or consultation at the foreign medical facility has already been agreed upon, and the documents were not submitted with sufficient lead time;
• travel tickets have been booked, and the documents were not submitted with sufficient lead time;
• the patient’s health condition does not require emergency intervention.