A patient insured by a German health insurance fund may undergo dental treatment in Poland and then apply for reimbursement of the costs incurred. This also applies to conservative dental treatment, meaning services aimed at diagnosis, the treatment of dental caries, pain relief and the preservation of natural teeth.
In the case of typical outpatient conservative dental treatment, prior approval from the German health insurance fund is generally not required. However, this does not mean that after submitting any invoice, the patient will automatically receive reimbursement equal to the amount paid.
The greatest differences in reimbursement usually result not from the treatment itself being rejected, but from an incorrect description of the services provided, a lack of detailed documentation or failure to take into account the rules of the German reimbursement system.
Does a German health insurance fund reimburse conservative dental treatment carried out in Poland?
As a general rule, a patient may receive dental treatment in another European Union country and apply for reimbursement if the service is included within the scope of treatment financed by their German statutory health insurance. This also applies to dental care provided in a private dental practice in Poland.
However, the German health insurance fund reimburses costs only up to the amount it would have paid for a comparable service provided in Germany. Statutory co-payments and administrative costs, amounting under German law to a maximum of 5% of the calculated reimbursement amount, may be deducted.
This means that the amount paid by the patient at a Polish dental practice and the amount reimbursed by the German health insurance fund do not have to be the same.
Which procedures are classified as conservative dental treatment?
Conservative dental treatment primarily includes services intended to preserve teeth and treat dental diseases. Depending on the clinical condition, these may include:
- dental consultation and examination,
- caries diagnosis,
- treatment of cavities,
- preparation of the tooth,
- placement of a filling,
- replacement of a leaking filling,
- treatment of tooth sensitivity,
- placement of a medicated dressing,
- protection of the dental pulp,
- treatment of inflammatory conditions,
- pain treatment,
- radiological diagnostics related to the treatment,
- certain endodontic procedures, provided they meet the reimbursement requirements applicable in the German system.
The German Federal Joint Committee, G-BA, includes among the dental services financed by statutory health insurance, among others, diagnostics, conservative treatment of caries and inflammation of the dental pulp, as well as certain surgical and radiological services.
Is approval from AOK, TK, BARMER or another health insurance fund required before conservative dental treatment?
In the case of standard outpatient conservative dental treatment, prior approval of the treatment plan is usually not required.
The patient may therefore generally undergo a consultation, an X-ray, caries treatment or a standard filling in Poland and then submit the documentation to the German health insurance fund.
However, conservative treatment must be distinguished from procedures that only appear to be a standard tooth restoration. If a post and core, a glass-fibre post, a core build-up for a crown or a prosthetic crown is actually being performed, the service may already fall within prosthetic treatment and be subject to different rules.
Incorrectly classifying prosthetic treatment as an ordinary “filling” may result in reduced reimbursement or the documentation being questioned.
Why does the patient pay more in Poland than the German health insurance fund reimburses?
This is one of the most common questions raised after receiving a reimbursement decision.
For example, a patient may pay PLN 800 for an extensive tooth reconstruction, while the German health insurance fund reimburses only part of this amount. This does not necessarily mean that the insurer has made an error.
The difference primarily results from the fact that a Polish dental practice sets its prices according to its own price list, while a German statutory health insurance fund calculates reimbursement according to the value of services specified in the German system.
The basis for settling dental services financed by German statutory health insurance is the BEMA catalogue. It contains separate items, among others, for conservative treatment, surgery and radiological diagnostics.
The health insurance fund therefore does not usually convert the entire Polish invoice according to the euro exchange rate. It first determines which specific German services correspond to the procedures performed and then values each of them according to its own rules.
The cost of treatment in Poland versus the value of the service in Germany
The price of a procedure in Poland may include elements that, in the German system:
- are not financed by statutory health insurance,
- are financed only partially,
- constitute above-standard services,
- are already included in another billing item,
- cannot be billed separately,
- require additional medical justification,
- correspond to a more expensive material selected by the patient.
For example, the cost of a filling may depend on:
- the size of the cavity,
- the number of tooth surfaces involved,
- the material used,
- reconstruction of the tooth walls,
- the need to use a liner,
- anaesthesia,
- the use of a rubber dam,
- the dentist’s working time,
- the standard of the dental practice,
- additional diagnostic procedures.
However, the German health insurance fund may recognise only the part of the service corresponding to the statutory standard of treatment. The cost of an aesthetic material, an above-standard technique or an extensive private restoration may remain wholly or partly payable by the patient.
The most common mistake – submitting only a general invoice
The most common mistake is submitting an invoice to the German health insurance fund containing only general descriptions such as:
- “dental treatment”,
- “conservative treatment”,
- “composite filling”,
- “tooth restoration”,
- “treatment of several teeth”,
- “dental package”.
Such a document may be sufficient for the patient and correct from an accounting perspective, but it often does not allow the German health insurance fund to determine precisely which services were actually provided.
If the insurer cannot assign the procedure to the appropriate item in the German catalogue, it may:
- recognise only the basic procedure,
- apply the lowest possible rate,
- omit part of the services,
- request additional explanations from the patient,
- suspend the reimbursement process,
- refuse reimbursement for the insufficiently documented part of the treatment.
Proper preparation of the documentation may therefore determine a difference of several dozen or even several hundred euros for a single stage of treatment.
Each tooth and each procedure should be described separately
For the correct reimbursement of conservative dental treatment, the German health insurance fund should receive information allowing it to determine:
- which tooth was treated,
- what the diagnosis was,
- what type of cavity was identified,
- how many tooth surfaces were restored,
- what procedure was performed,
- whether anaesthesia was used,
- whether an X-ray was taken,
- whether a dressing or liner was placed,
- whether the restoration was permanent or temporary,
- what material was used,
- whether the treatment concerned caries, trauma, leakage of a previous filling or an inflammatory condition.
For example, the description “filling of tooth 16” may be insufficient. It is much more useful to state that a carious cavity was prepared and a specified number of surfaces of tooth 16 were restored using composite material, together with the diagnosis, date, price and information about any anaesthesia.
Missing tooth numbers
An invoice for the “treatment of three teeth” without specifying their numbers may prevent the health insurance fund from verifying the number and type of procedures performed.
The documentation should use consistent tooth numbering, preferably in accordance with the international FDI system, which is used in both Poland and Germany.
There should not be a situation in which:
- the invoice indicates tooth 16,
- the treatment description indicates tooth 15,
- the X-ray is described as relating to tooth 14,
- and the dentist’s certificate does not indicate any tooth number.
Such discrepancies often lead to additional questions, delayed payment or the omission of part of the costs.
Missing information about the number of filling surfaces
In the German system, the value of a filling may depend on its extent. A small restoration involving one surface is assessed differently from an extensive filling involving several tooth surfaces.
If the Polish invoice states only “composite filling”, the health insurance fund may not know whether it was a minor procedure or an extensive reconstruction.
In such a situation, it may apply the basic, lower value of the service.
Combining several procedures into one item
Another common mistake is issuing one consolidated item:
“Comprehensive treatment of one tooth – PLN 1,200.”
However, this amount may have included:
- consultation,
- anaesthesia,
- X-ray,
- removal of caries,
- protection of the dental pulp,
- placement of a liner,
- restoration of several surfaces,
- occlusal adjustment,
- a follow-up visit.
Each of these procedures may have a different reimbursement significance. If they are not separated and described, the health insurance fund may recognise only one basic item.
As a result, the patient paid for several procedures, but the reimbursement was calculated as though only one had been performed.
Incorrectly presenting a prosthetic restoration as conservative treatment
Not every tooth restoration is an ordinary filling.
If the tooth was restored using:
- a post and core,
- a glass-fibre post,
- a metal post,
- a crown,
- a prosthetic onlay,
- a partial crown,
- a laboratory-made restoration,
the treatment may fall within the field of prosthetics.
Submitting such a service as an ordinary invoice for a “filling” may result in reimbursement of only a small amount corresponding to conservative treatment, whereas properly prepared documentation could allow the prosthetic part to be assessed under separate rules.
Endodontic treatment is not always reimbursed in full
Root canal treatment is often presented as one consolidated service. However, its cost may include:
- diagnostics,
- X-rays,
- anaesthesia,
- preparation of the pulp chamber,
- preparation of individual root canals,
- disinfection,
- temporary protection,
- root canal filling,
- restoration of the tooth crown,
- follow-up visits.
The German health insurance fund assesses not only the price, but also whether the treatment meets the requirements applicable to statutory benefits. Not every private method, material used or additional technique must be financed by statutory health insurance.
If the invoice does not indicate the number of canals, the tooth number, the diagnosis and the individual stages of treatment, the reimbursement may be significantly reduced.
Missing medical diagnosis
Indicating the procedure performed is not always sufficient. The documentation should also explain why the treatment was necessary.
The following may be helpful:
- a description of the diagnosis in Polish and German,
- the appropriate ICD-10 code, where applicable,
- information about caries, pulp inflammation, necrosis, hypersensitivity or tooth damage,
- a description of symptoms and the clinical condition,
- medical justification for the procedure.
The diagnosis must correspond to the patient’s actual condition and the remaining documentation. It should not be selected solely for the purpose of obtaining higher reimbursement.
Missing translation of the documentation
The German health insurance fund may require documentation in German or at least a description that allows the services provided to be clearly understood.
A literal, automatic translation of procedure names is not always sufficient. A Polish term used by the dental practice may not correspond to a German reimbursement item or may have a broader meaning.
The specification should therefore be prepared in a way that allows the insurer to compare the Polish treatment with the corresponding service financed in Germany.
What should a correct invoice for conservative dental treatment look like?
A properly prepared invoice or an attached specification should include:
- the patient’s details,
- the dental practice’s details,
- the dates on which the services were provided,
- the numbers of the treated teeth,
- the exact names of the procedures,
- the extent of the restoration performed,
- the number of filling surfaces,
- information about the material used,
- unit prices,
- the number of individual services,
- the value of each item,
- the total cost of treatment.
A separate certificate or medical treatment specification should also be attached to the invoice, containing:
- diagnoses,
- a description of the condition before treatment,
- the medical indication,
- the course of treatment,
- the anaesthesia used,
- radiological examinations,
- the procedures performed,
- the treatment outcome,
- the dentist’s signature and stamp.
The documentation should be complete, logical and mutually consistent.
Why can two people with similar invoices receive different reimbursement amounts?
Differences in reimbursement may result, among other things, from:
- a different scope of treatment,
- the number of teeth treated,
- the extent of the fillings,
- the type of materials used,
- the classification of procedures,
- the scope of services financed by the specific health insurance fund,
- the deduction of administrative costs,
- applicable co-payments,
- the way in which the treatment is described,
- the completeness of the documentation,
- additional dental insurance,
- errors made during the initial reimbursement process.
Even people insured by the same health insurance fund may receive different amounts if one person’s documentation describes all services in detail, while the other person submits only a consolidated invoice.
Does a higher price in Poland mean a higher reimbursement?
No. The German health insurance fund does not automatically reimburse a fixed percentage of the Polish invoice.
The price set by the dental practice does not determine the amount payable under German insurance. The health insurance fund determines which procedure was performed and how much it would have paid for the equivalent service in Germany.
If the patient selected a more expensive material, a more advanced technique or a service exceeding the standard of statutory health insurance, the difference may remain payable by the patient.
On the other hand, an invoice described too generally may result in the health insurance fund failing to recognise all eligible items. In such a case, the reimbursement will be lower not because the services were not eligible for financing, but because they were not properly documented.
What should be done if the health insurance fund reimbursed too little?
After receiving the reimbursement statement, it is necessary to check:
- which procedures were recognised,
- which items were omitted,
- the basis on which the reimbursement was calculated,
- whether an administrative deduction was applied,
- whether the insurer requested additional documents,
- whether the treatment was classified correctly,
- whether it is possible to supplement the invoice or submit an appeal.
In many cases, it is possible to submit:
- a corrected specification,
- a dentist’s certificate,
- a detailed description of the procedures,
- a translation,
- diagnoses,
- radiological documentation,
- proof of payment.
However, the scope of the treatment actually performed must not be changed, and procedures that were not carried out must not be added. The documentation must accurately reflect the course of treatment.
MedicalAdvisor.pl – assistance with the reimbursement of conservative dental treatment invoices
For more than eight years, we have been helping patients obtain reimbursement from German health insurance funds for dental treatment carried out in Poland.
We verify invoices, medical documentation and the classification of individual services. We prepare detailed treatment specifications, translations, procedure descriptions and letters to AOK, TK, BARMER, DAK, IKK, BKK and other insurers.
We also provide assistance when:
- the patient received a significantly lower reimbursement than expected,
- the health insurance fund reimbursed only part of the invoice,
- the documentation was considered insufficient,
- the insurer requested additional explanations,
- the classification of the treatment needs to be corrected,
- an appeal against the decision is required.
Correct reimbursement does not consist solely of translating the invoice. Every procedure performed should be described and presented in a way that allows the German health insurance fund to assign it to the appropriate service.
MedicalAdvisor.pl Sp. z o.o.
Telephone: +48 607 871 284
E-mail: kontakt@medicaladvisor.pl
