Prior agreement of the Health Insurance

Verified 26 October 2023 - Legal and Administrative Information Directorate (Prime Minister)

What is Medicare Pre-Approval? This is the agreement given, before the execution of the act or treatment, by the Sickness Insurance for its care. This agreement is therefore a prerequisite. These are often costly, rare, or long-lasting acts. Your doctor, physical therapist, dentist must first fill out a request for some of his procedures. It is then up to you to complete and send the form to the CPAM: titleContent. The cash register replies by post only in case of refusal.

The prior agreement procedure shall consist of, before execution of certain medical procedures and treatments, to ask the Health Insurance if it agrees to take them over.

The acts concerned are in particular the following:

  • Certain treatments provided by masseurs-kinesitherapists, speech therapists, orthoptists (for example: in case of a recent external ankle sprain, the agreement is necessary from the 11the sitting)
  • Dento-facial orthopedic treatments (DOF)
  • Certain unusual disorders
  • Certain drugs (expensive or being tested)
  • Certain medical devices
  • Certain laboratory tests and tests
  • Certain transport services

Example :

Long-distance transport (more than 150 km), mass transport, transport by plane or regular boat, transport related to the care or treatment of children and adolescents in centers for early medical-social action (CAMSP) and medical-psycho-pedagogical centers (CMPP), transport for pregnant women traveling to a hospital hotel

General case

In practice, the health care professional consulted informs you of the need to make a request for prior agreement (also sometimes referred to as request for prior agreement).

They fill out a specific form based on the care prescribed and give it to you.

You must complete it and then send it:

  • At the medical service of your CPAM: titleContent if you are dependent on the general diet
  • By mail to the medical department of your MSA: titleContent to the attention of "M. the medical officer" if you are dependent on the agricultural plan.
Who shall I contact

You must obligatory attach the medical prescription or a copy thereof for the acts or treatments performed by:

  • Medical assistant (masseur-physiotherapist, speech therapist, orthoptist)
  • Sanitary carrier
  • Provider of laboratory analyzes or examinations
  • Medical equipment supplier.
Cholesterol medicines

For certain cholesterol medicines, your doctor will request prior approval from the medical department of your health insurance fund.

Physical therapy

In some situations (e.g., shoulder rehabilitation), extended sessions require prior application to the Health Insurance.

It is the masseur-physiotherapist who carries out this procedure.

In case of emergency

The doctor or health care practitioner dispenses the procedure.

However, he must draw up a request for prior agreement, indicating in it the words "Act of emergency".

The lack of response from your CPAM: titleContent or your MSA: titleContent within the 15 days from the receipt of the request shall be deemed to be agreement.

In case of refusal of care, you receive a written answer. In this case, the Health Insurance tells you the means of recourse you have to challenge the decision.