Cost reimbursement under § 13 (3) SGB V: what you can certify as a psychotherapist
If a statutorily insured patient wants a health fund to reimburse treatment in your private practice, you can contribute a therapeutic statement. It contains only your professional details: treatment data, indication, urgency and the documented search for a treatment place. Legal assessments do not belong in it.
Not legal advice. This guide describes which details you can give from your own professional expertise. Whether a claim to reimbursement exists, whether an objection succeeds and which deadline applies are legal questions that you do not need to, and should not, assess for the patient. Advice services exist for that (see below).
What § 13 (3) SGB V is about
Under § 13 (3) SGB V, the health fund must reimburse the costs of a service the insured person procured themselves if the fund could not provide an urgent service in time or wrongly refused a service, to the extent the service was necessary. In psychotherapy practice the discussion often centres on whether a treatment place with accredited providers was available in time and how urgent treatment was. The fund, and in a dispute the courts, answer both questions. The patient is the applicant.
Who does what
| Who | Role |
|---|---|
| Patient | Files the application with the health fund, receives the decision, files an objection if needed and decides whether to take advice |
| Health fund | Decides the application and issues the notice with instructions on remedies |
| You as psychotherapist | Give your professional details on the treatment and certify them by signature |
| Advice services | A lawyer, a social association or the independent patient advice service clarify legal questions |
What a therapeutic statement can contain
- Treatment data: start of treatment, dates of the initial consultation and probatory sessions, method used, sessions held and planned.
- Indication and treatment need: your own professional account, in your words, of why psychotherapy is indicated.
- Urgency: your own professional estimate of how urgent the start of treatment was, also in your words.
- Documented attempts to find a treatment place: a table of facts the patient reported to you, with date, body contacted and result (for example refusal, no reply, appointment only on a stated date), including a contact with the appointment service office (Terminservicestelle) and its date.
- Signature: you sign personally.
Put a clear label at the top, for example “Therapeutic details. No legal assessment.” The table of attempts only lists what is documented; you draw no conclusions from it, which is left to the fund and, in a dispute, the court.
What does not belong in it
- Statements on whether the fund's refusal was lawful or unlawful
- Statements on whether a claim exists or care has “failed”
- References to case law or prospects of success
- Wording for the patient's objection
- Treatment recommendations beyond your own treatment plan
Confidentiality and handover
As a psychotherapist you are bound by professional secrecy (§ 203 of the German Criminal Code). You therefore normally hand the statement to the patient, who encloses it with their application. The patient is entitled to information and copies of their own treatment records (§ 630g BGB). If you wish to send the statement directly to the fund, you first need the patient's written confidentiality release naming the recipient, content and purpose.
If the fund refuses
The patient can file an objection (Widerspruch) against a refusal notice. That is their own matter. The deadline is stated in the notice's instructions on remedies and is decisive there. Point that out and refer to independent advice, such as a lawyer, a social association or the independent patient advice service (UPD). The patient can attach your statement to their own letter.
How software can help
Treatment data and documented attempts can be taken from a case file as a table. Indication and urgency are your own text; the software proposes nothing, assesses nothing and sends nothing. The Application Copilot creates letters from the case file with sources, which you check and sign. To the waitlist; an example report is in the sample report.
Frequently asked questions
May I help the patient with the objection?
Legal advice and drafting the objection are not part of your role as a psychotherapist. You can provide your professional statement and refer to independent advice services.
Does the statement have to go to the health fund?
No. You usually hand it to the patient, who submits it personally. Direct transmission requires a written confidentiality release.
Does the statement say anything about prospects of success?
No. It contains your professional details and documented facts. Statements on entitlement, lawfulness or prospects of success are legal questions and are not in it.
Sources
- § 13 (3) SGB V, gesetze-im-internet.de
- § 203 StGB (breach of private secrets) and § 630g BGB (access to patient records), gesetze-im-internet.de
- Bundespsychotherapeutenkammer (BPtK): information on cost reimbursement and professional code, bptk.de (individual references not cross-checked by us: unverified)
- Unabhängige Patientenberatung Deutschland (UPD): advice on patient rights, patientenberatung.de (scope of services unverified)
- On the objection deadline: instructions on remedies in the respective notice; § 84 SGG (not cross-checked by us: unverified)