The ZVK does not enter into a contract with every care provider. If no contract has been concluded with a care provider, the following applies.
If an insured person intends to receive care from a non-contracted care provider, he/she must request permission from the ZVK. This means that, if you yourself choose a care provider other than the one to whom your general practitioner, specialist or dentist has referred you, then Article 10 paragraph 4 of the BES Healthcare Insurance Decree applies.
Article 10 paragraph 4 of the BES Healthcare Insurance Decree states that if the insured person has received permission and receives care from a non-contracted care provider, then, rather than entitlement to the healthcare service, the insured person is entitled to full or partial reimbursement of the medical expenses incurred for this care.
If there are sufficient other care providers available that provide the same type of care and, on the basis of indicators such as quality and effectiveness, do have a contract with us, the ZVK may deny this request.
The insured person may submit the care provider’s invoice to the ZVK. The invoice will be checked by the ZVK, after which a full or partial payment by way of reimbursement will be made to the insured person.
The ZVK will no longer process invoices from non-contracted parties, but requires insured persons to pay these themselves and then submit them to the ZVK.
By testing care providers for specific quality indicators, insight into the quality and effectiveness of the care provided can be obtained. These insights are included in the purchase of care, by which selective purchasing is not excluded.
To be able to submit a complete application through the doctor or specialist, the following documents must be supplied:
- referrer's medical statement (general practitioner or specialist),
- offer from the non-contracted care provider with exact description of the treatment and the total costs thereof,
- signed statement of approval by the insured
Incomplete applications will not be processed.
The legal framework
The legal framework is formed by the BES Healthcare Insurance Decree and the BES Healthcare Insurance Claims Regulation. On this basis, insured persons can apply their entitlement to care in kind, insofar as that care can reasonably be offered on the islands. To that end, the ZVK concludes contracts with eligible care providers.
The assumption is that the insured persons will turn to care providers that have entered into a contract with the ZVK (Article 10 paragraph 2 of the Decree).
The Decree has also determined that it is possible for insured persons to turn to non-contracted care providers, both on and off the islands, pursuant to Article 10 paragraph 4 of the Decree.
Generally, if prior permission has been acquired from the ZVK, the insured person may turn to a non-contracted care provider and be entitled to full or partial reimbursement of the medical expenses incurred for this care.