Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

44 Special Solidarity Fund KCE Reports 133
Suspension of handling of the application
If the application has missing documents or is not complete, the administrative staff will
suggest suspending the period for handling of the application.
The decisions on suspension are always taken by the leading medical officer of the SSF.
If there is a suspension, the application will be returned to the correspondent sickness
fund (national level).
Formal reasons for suspending are:
• Prescription is not included
• No medical record
• No declaration ‘on honour’
If an invoice of medical costs is missing, the application will not be suspended; a decision
on the request for reimbursement will be taken but under the condition that the
missing invoice is provided.
The number of cases that are suspended is limited. The sickness fund at national level
will have to complete the missing ‘formal’ elements of the request for reimbursement
and re-enter it to the SSF services. When arriving at the SSF, it will be treated as a new
request and registered as such in the SSF database.
5.2.4.3 Medical handling
After the administrative handling, the patient’s file is transferred to the leading officer
(medical doctor) of the SSF. The application and the draft decision as well as the
motivation are reviewed in the perspective of the SSF criteria that have to be met from
a medical point of view. The leading officer of the SSF will further document the case
from a medical point of view and if necessary collect additional information from
medical specialists and experts on the subject to be examined.
Using the file as prepared by the administrative staff, the leading officer of the SSF will
check if the medical criteria as foreseen in the regulation on the SSF reimbursement are
met.
If the conclusion of the SSF leading officer is to suggest to grant reimbursement, the
corresponding category of the criteria that are applicable considering the SSF regulation,
are mentioned on the paper sheet in the file. (sheet that has been prepared by the
administrative staff).
If the request for reimbursement does not meet the SSF criteria, all criteria that are not
met are mentioned (marked) on the back of the paper sheet.
This paper sheet is an important document since all elements for taking a final decision
are inventoried. This sheet also is the official document on which the final decision
(delegated decision or decision from the ‘College of medical directors) will be
mentioned and signed.
When the decision is a delegated decision, taken by one member of the ‘College of
medical directors’, positive decisions will be signed by the person taking the decision. At
this moment delegation is only given to the leading officer (medical doctor) of the SSF.
Delegated decisions to refuse reimbursement always will be contra signed by another
member of the ‘College of medical directors’. The current practice is, that the medical
director from the sickness fund to which the patient adhered to, will contra sign the
decision.