Guide to Reimbursement
by Public Health Insurance
In my private practice, I offer psychotherapy (1) for self-paying clients as well as for (2) patients with private health insurance. Additionally, (3) it is also possible for statutory/public health insurance (GKV) providers to cover the costs of psychotherapy through the so-called reimbursement procedure ("Kostenerstattungsverfahren").
What's the 'Reimbursement' Procedure?
The reimbursement procedure applies if you can demonstrate what is known as a "system failure" ("Systemversagen") —that is, if you were unable to find a therapy place with a contract psychotherapist covered by statutory health insurance within a reasonable time frame or within an acceptable distance. In such a case, you can apply to your health insurance provider to cover the costs of treatment in my private practice.
To do so, you will need to gather some supporting documentation (see below). We should also schedule an initial consultation in my practice — this session must be paid privately — so that we can then, if we both decide to proceed together, prepare and submit the reimbursement application together.
>>> Please note: Services provided before your health insurance approval are not eligible for reimbursement. Reimbursement applies only once the approval has been granted.
What Do You Need for the Reimbursement Procedure?
Here is a list of documents you need to gather on your own. Once you have collected everything and if we decide to move forward together, I will provide you with additional documents needed to complete the application. We can then submit the application to your insurance provider and wait for their response, which may take several days or weeks. >>> If your application is rejected, DON'T BE DISCOURAGED — we will carefully review the rejection and file an appeal (Widerspruch) on your behalf.
1. Call your insurance provider
Contact your health insurance provider to find out which documents and steps are required for the reimbursement process. >>> Please note: Some health insurance providers may try to discourage you from initiating this procedure. However, you have a legal right to reimbursement for psychotherapy with a licensed psychotherapist in private practice (for example, in my practice), according to § 13 paragraph 3 of the German Social Code, Book V (SGB V), provided that a so-called "system failure" has occurred. >>> A "system failure" occurs when you are unable to secure a therapy place with a contracted psychotherapist covered by public health insurance within a reasonable timeframe—typically no longer than six weeks. In this case, your health insurance provider is legally required to cover the costs of treatment in a private practice—provided there is a valid indication for therapy.
This step is essential to obtain the PTV-11 form. Call 116 117 (the KV Berlin hotline) or visit their website (www.116117.de) to schedule a psychotherapeutic consultation ("psychotherapeutische Sprechstunde") with a contract psychotherapist ("Vertragstherapeut:in") who works with public health insurance. You should gather at least two psychotherapeutic consultations and two completed PTV-11 forms.
2.2. Two PTV-11 Forms
You should gather at least two psychotherapeutic consultations and two completed PTV-11 forms. >>> Make sure that each PTV-11 form explicitly states: 1> that the treatment is urgently required (“dringlich erforderlich”), 2> that the recommended treatment is Psychodynamic Psychotherapy ("Psychodynamische Psychotherapie"). 3> Also, try to obtain an urgency certificate ("Dringlichkeitsbescheid"), which further supports your application.
3. Medical Certificate
Obtain a certificate from your general practitioner or psychiatrist confirming the necessity of psychotherapeutic treatment—this is known as a “Konsiliarbericht”. It is a required document for starting psychotherapy and part of the reimbursement application process.
4. Proof of Unsuccessful Therapist Search
Gather a list of 10–20 psychotherapists who are approved by statutory health insurance (Vertragspsychotherapeut) and whom you have contacted in your search for treatment. These written records serve as proof that you were unable to access timely care within the statutory system. For each inquiry, document the following in writing: 1> Name of the therapist 2> Date of your contact attempt 3> Response received (e.g., rejection, waiting time longer than 6 weeks, no availability, no response) >>> At the end of the page, you'll find a Template that you can use for this part.
5. Informal Application for Insurance
Prepare an informal application to your health insurance provider explaining why timely treatment is necessary and stating that you were unable to find a therapy spot with statutory health insurance therapists.
Remember:
Stay patient and don’t get discouraged—
the reimbursement process takes time and some effort, but it’s worth it.