Prior authorisation

  1. What is the prior authorisation for seeking treatment abroad?

Prior authorisation constitutes a payment commitment through which your municipality or hospital district bears the costs of treatment provided abroad. Prior authorisation can be granted for treatment to be provided in another EU or EEA country.

The authorisation must be granted if the treatment in question is part of the Finnish health care system’s service selection and it is not possible to provide the patient with the treatment within a medically justified period of time taking into account the patient’s current health and the probable disease progression. In practice, the prior authorisation must be granted if the time limits under the care guarantee are not fulfilled. The dissatisfaction of a patient in treatment provided in Finland is not sufficient cause for granting prior authorisation.

As of 1 January 2014, Kela has made the decision on prior authorisations. The decisions can be appealed to the Administrative Court.

Advance authorisation can be applied for from Kela with the form SV 129.

  1. What are the grounds that Kela uses to decide on granting prior authorisation?

Kela will issue a negative or positive decision on the prior authorisation based on a statement from public health care. In the statement, public health care must address the fulfilment of the requirements for granting the authorisation. The public health care statement is binding with regard to Kela’s decision.

The statement is issued by the body responsible for the patient’s treatment. In basic health care, this can be the municipality or joint municipal authority instead of the hospital district.

The public health care statement on the prior authorisation must be provided to Kela within 21 days of receiving the statement request. If the statement is not submitted within the allotted time, Kela can grant the prior authorisation to the patient. In these cases, the treatment costs incurred based on the prior authorisation are the responsibility of the municipality or joint municipal authority that was responsible for issuing the statement.

Primarily, Kela does not take a stand on whether or not the treatment for which the person in question is requesting prior authorisation can be considered specialised medical care or basic health care. Kela delivers the statement request to the registry office of the hospital district that is responsible for specialised medical care in the person’s place of residence. If the treatment falls under the responsibility of basic health care, the hospital district must transfer the processing of the matter to basic health care. In this case, the time limit for issuing the statement is as defined in the statement request (21 days). Alternatively, the hospital district can return the matter to Kela, in which case Kela can request a new statement on the matter from basic health care. The time limit is counted from the time at which basic health care receives the statement request.

  1. Does the patient need to justify the decision to seek treatment abroad? When can prior authorisation be denied?

Patients do not need to state why they wish to be treated abroad. For prior authorisation, however, patients must provide an account of their current health.

Prior authorisation to another EU or EEA country or Switzerland does not need to be granted if public health care can organise the care required by the patient in Finland within a medically justified time span based on the patient’s health and likely disease progression. Prior authorisation is not granted for treatments that are not included in the choices of Finnish public health care services.

Prior authorisation can be granted on a discretionary basis even if the justifications set in the legislation are not met. For example, it may be necessary to grant a patient prior authorisation for reasons related to language, culture or service pricing. even if there is no obligation to grant the authorisation in the situation in question.

  1. Is it possible for a doctor to recommend prior authorisation but Kela to deny it?

This cannot happen. The doctor issuing the statement represents the public health care unit responsible for the patient’s treatment. The statement is binding with regard to Kela’s decision.

  1. Is there a separate form for the public health care statement concerning the prior authorisation?

No, there is not. The statement is provided in writing but does not need to adhere to any specific format. It can also be doctor’s statement B. The statement must indicate the treatment for which the authorisation is applied, the country where the treatment will be provided and an estimate of the treatment period. In addition to this, the statement must address the fulfilment of the requirements for granting the prior authorisation – adherence to the time limits under the care guarantee, for example. The statement is free of charge to the patient.

Kela has issued instructions (in Finnish) to public health care on issuing the statement and its content.

  1. What is the procedure if the party issuing the statement does not have access to the patient’s information (if the person has only used private health care services, for example)? Can Kela oblige the client to provide the information?

The patient must append to the prior authorisation application a doctor’s statement or other document issued by a health care professional, such as a copy of a medical history or a statement on the patient’s state of health.

If the patient has not appended the information on his/her sickness to the application form, the Kela will request it from the patient before submitting the statement request pertaining to the application to public health care. Kela will supply all documents related to the authorisation application to statement provider.

If the patient does not provide the information required for the application for prior authorisation, despite Kela’s request, and public health care is therefore unable to take a stance on the matter, Kela will provide the person in question with a decision not to process the application.

  1. Can patients freely choose the place of care if they have been granted prior authorisation to seek treatment abroad? Who will cover the travel expenses?

Prior authorisation is normally granted for a specific country and specific treatment. The authorisation remains valid for a fixed period. The public health care statement concerning prior authorisation must indicate the country and treatment for which authorisation should be granted. The patient can select the place of treatment within these limits.

If prior authorisation has been granted, Kela will retroactively reimburse the patient for the expenses of travel to the place of treatment. The hospital district is not responsible for the travel costs.

  1. Does a fee need to be paid for a statement requested for a prior authorisation decision?

No, a payment is not required. Issuing a statement is considered a statutory duty of public health care.

  1. How many prior authorisation applications are lodged?

Some 200 applications a year are submitted to Kela.