Abuse in reimbursement requests

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Reimbursement requests from service providers must be submitted to the insured person for review, in the form of “patient information”, before reimbursement.

The insured person has the right not to approve the reimbursement request transcribed into the “patient information” – if it does not correspond to their recollection – before clarification.

If approval is refused – with comment – or if there are indications of inaccuracies, in particular in connection with collected or used data (including tracking data), no reimbursement may be made until the matter has been clarified.

If a service provider violates the provisions of Art. 117 para. 2 of the Federal Constitution in the context of their reimbursement requests, their right to cooperate with the EKK shall be withdrawn for a period of one year.

After this period, the service provider is subject to a probation period of three years.

If the service provider commits another violation during the probation period in accordance with paragraph 4, they shall be permanently excluded from cooperation with the EKK.

MEDIFACT decides

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