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KCE Reports 133 Special Solidarity Fund 43
5.2.4.2 Administrative handling of application files
Once a demand for reimbursement is submitted to the services of the SSF, the
application is subject to administrative control procedures.
Administrative staff SSF
The administrative staff of the SSF counts 3 collaborators and 1 person for the handling
of mail representing 3,6 FTE. Two of the staff members treat the more difficult
applications. The applications are divided between these two staff members according
to the language of the patient requesting for reimbursement.
Registration and handling of SSF applications
The applications are registered into the SSF administrative database. At the same time
they are separated in two groups: the applications to be decided by the ‘College of
medical directors’ and the ones to be decided ‘by delegation’. (one member of the
‘College of medical directors’ – in reality the medical doctor in charge of the SSF).
As previously explained, if the request for reimbursement is a prolongation of a medical
treatment or cost that previously was reimbursed, the request for reimbursement will
be decided upon by the SSF medical director (leading officer of the SSF) ‘by delegation’.
The SSF administrative staff checks the files on completeness. If elements are missing,
(for example the prescription of a treatment or the motivation of the medical doctor
issuing the prescription, the ‘declaration on honour’, the invoices), the staff will contact
the national sickness fund and ask for the missing documents or return the file for
completion.
The administrative staff of the SSF prepares the file for decision by the ‘College of
medical directors’ or by the member of the college (delegation procedure) They enter
the data from the application file into the SSF database.
The information included in the database is described in table 1 in section 4.1.3.
At the same time a paper sheet is completed. This sheet contains all information initially
registered in the database and is used to register all elements that are important for the
decision to be taken on the request for reimbursement. The administrative staff
examines the case and formulates a draft decision as well as a draft motivation based on
the criteria as foreseen in the SSF regulation.
If a non-reimbursement decision is suggested, the administrative staff will mention the
criteria upon which the suggested rejection is based.
Preparing a draft decision, the administrative staff of the SSF adds information to the file
on previous decisions of similar cases taken by the College of medical directors. They
document the case and add relevant information to the file (for example on the
prevalence of the illness, the drug prescribed…).
The administrative services of the SSF keep a track of all decisions taken at SSF level. All
decisions of the ‘College of medical directors’ and the decisions taken ‘by delegation’ on
reimbursement are stored in a file (text file) by the administrative staff.
For each application for reimbursement the administrative staff also calculates the cost
of an eventual reimbursement over a one year period, in order to check if the criterion
“the treatment or the medical device is expensive” is met.