Estimate for the health insurance: Your path to cost coverage
13 Jun 2025
5
Minutes
Katrin Straub
CEO at nextsure
A cost estimate from the health insurance provider is often the first step toward important medical services. Many policyholders are unsure how to proceed, what deadlines apply, or what to do in case of a rejection. This article safely guides you through the process.
The topic in brief and concise terms
A cost estimate is a pre-calculation of medical costs that often needs to be approved by the health insurance company before the service is provided, especially for aids.
Health insurance companies have statutory deadlines (usually three to six weeks) for decisions on benefit applications; if there is an unjustified delay, the benefit may be considered approved.
An objection to a rejected cost estimate can be filed in writing within one month; many objections are successful.
Understanding a Quote: The Basis for Your Commitment to Service
A cost estimate is a commercial preliminary calculation. It provides you and your health insurance company with a detailed overview of the expected costs of a medical treatment or an aid. As a patient, the cost estimate is generally non-binding for you. It only becomes the basis for service provision with your signature and the approval of the health insurance company. Many treatments, particularly for aids, necessarily require a pre-approved cost estimate. The need often arises from the health insurance companies' supply contracts with service providers. Without this approval, you risk being left with the costs. The exact regulations may vary depending on the health insurance company and the type of service. Therefore, it is important to be familiar with the process.
The road to an approved estimate: A step-by-step guide
The process for approving a cost estimate, particularly for aids, usually follows a clear pattern. Often, the starting point is a medical prescription that certifies the medical necessity. With this prescription, you contact an approved service provider, such as a medical supply store or hearing aid specialist. After selecting the appropriate aid, this provider prepares the cost estimate. This is then submitted – often directly by the provider – to your health insurance company. Since the first of February 2023, electronic submission for aids has been mandatory. This speeds up the process and saves administrative costs. For certain aids like visual aids or hearing aids, there are fixed amounts that cap the maximum cost coverage by the statutory health insurance. Your co-payment is legally ten percent of the costs, but at least five euros and a maximum of ten euros. For aids intended for consumption, it is ten percent per package, but no more than ten euros per month. A careful review of all documents before submission can significantly increase the chances of success. Inform yourself about additional insurance for dental prostheses, as cost estimates are often necessary here.
Deadlines at a Glance: What Policyholders Need to Know
Health insurance companies must process benefit applications promptly. The Social Code stipulates clear deadlines. In principle, your health insurance company must decide on your application no later than three weeks after receipt. This deadline is regulated in § 13, paragraph 3a SGB V. If an expert opinion from the Medical Service (MD) is required, the deadline is extended to five weeks. The health insurance company is obliged to inform you of the necessity of an expert opinion. For dental treatments requiring an expert opinion, the deadline is six weeks. If the health insurance company cannot meet these deadlines, it must inform you in writing or electronically in a timely manner and state the reasons. Our expert tip: Always send important applications by registered mail to prove receipt. Knowledge of deadlines is also relevant for a private health insurance, although the exact regulations may vary.
If the health insurance company fails to adequately justify a delay, there is an important regulation: the service is deemed approved once the deadline has passed. If you then procure the required service yourself, the health insurance company is obliged to reimburse the costs incurred. This underscores the importance of documenting deadlines precisely and following up on any overruns.
Rejection of the Quote: How to Defend Yourself Successfully
A rejection of the cost estimate is frustrating, but not a reason to give up. You have the right to appeal. You have one month to lodge an appeal after receiving the rejection notice. The appeal must be in writing and should ideally be sent by registered mail to your health insurance provider. It is advisable to carefully examine the insurance company's reasoning and substantiate your appeal thoroughly. Include medical opinions or other relevant documents that prove the necessity of the service. The health insurance provider then has three months to decide on your appeal. If the appeal is also rejected, you can file a lawsuit with the social court, for which there is again a one-month deadline. Many appeals are successful, so this step is often worthwhile. You can find support from social associations or specialized lawyers. Even for services such as a naturopathic psychotherapy, an appeal might be necessary.
Here are the steps for an appeal:
Carefully review the rejection notice and the instructions on legal remedies.
Formulate your appeal in writing within one month.
Provide a detailed explanation of why the service is medically necessary.
Attach supporting documents (e.g., medical reports).
Send the appeal in a verifiable way (e.g., by registered mail) to the health insurance provider.
If rejected again, you can file a lawsuit with the social court.
Reimbursement: An Alternative to Direct Billing
Publicly insured individuals can choose reimbursement instead of the usual goods or services. This means you initially pay for the service yourself and then submit it for reimbursement to your health insurance provider. However, the reimbursement claim is limited to the amount that the insurer would have covered for an in-kind service. Additionally, the insurer may deduct administrative costs of up to five percent. The decision to opt for reimbursement should be carefully considered and commits you for at least one calendar quarter. This can be relevant for services such as a new pair of glasses from the statutory health insurance. Always discuss the details with your health insurance company beforehand. Some insurers also offer special optional tariffs for reimbursement that may allow for higher reimbursements but come at an additional premium and a minimum commitment of one year.
Special Case Private Health Insurance (PKV): This applies to cost estimates
In private health insurance (PKV), submitting cost estimates, especially for more expensive treatments, is often a contractual requirement for reimbursement. From an anticipated invoice amount of two thousand euros, private insured individuals have a legal right to a binding statement on the refundability. For those eligible for aid, this applies from one thousand euros. The PKV must provide this information within four weeks, or in urgent cases, within two weeks. If this deadline is missed, the treatment is deemed medically necessary, which facilitates the assertion of claims, even if reimbursement continues in accordance with the tariff. Submitting a cost estimate can speed up the process and provide you with financial security before treatment begins. This is particularly important for planned procedures or high-quality dental prostheses. Also, consider a hospital supplementary insurance to secure optional services.
Expert tips for a smooth process
To ensure a smooth process for obtaining a cost estimate, here are some tried-and-true tips. Our expert tip: Beforehand, confirm with your health insurance whether a cost estimate is necessary for the planned service and which documents are specifically required. A correct and complete medical prescription is often the key to success. Ensure that the diagnosis, number, and type of service are precisely stated. For aids, the aid number and product type should be specified. A detailed description of the purpose of the aid is also helpful. Document all steps and keep copies of all submitted documents and correspondence with the health insurance meticulously. This is particularly important in case of queries or an appeals process. If there are any uncertainties, hearing aid insurance can offer additional security.
Checklist for submission:
Obtain a medical prescription (prescription).
Select a provider with health insurance approval.
Have a suitable aid/treatment selected.
Have a detailed cost estimate prepared.
Submit the cost estimate (possibly with prescription) to the health insurance (electronically for aids).
Await written confirmation of cost coverage.
Observe the deadlines for the insurance's decision.
If rejected, file an appeal within the deadline.
Conclusion and Your Next Step to Optimal Protection
More useful links
Gesetze im Internet provides the full text of § 13 SGB V, which contains the regulations on reimbursement in statutory health insurance.
Federal Ministry of Health explains in detail the term reimbursement in statutory health insurance (GKV) and its framework conditions.
GKV-Spitzenverband provides information about the fundamental principles and organization of all statutory health insurance funds in Germany.
Federal Ministry of Health offers comprehensive information on the functions and structure of statutory health insurance (GKV).
Federal Statistical Office (Destatis) provides official data and statistics on healthcare expenditures in Germany.
German Medical Association offers a publication on patient rights, which contains important information for insured individuals.
Federal Government Commissioner for Patients' Affairs informs about the rights of patients in the German healthcare system.
Gesund.bund.de offers comprehensive information on various aids and their provision.
National Association of Statutory Health Insurance Physicians (KBV) provides information on relevant topics for panel doctors and psychotherapists, which may also be of interest to insured individuals.
FAQ
Is an estimate for the health insurance binding?
For the service provider (e.g., doctor, medical supply store), the cost estimate is usually binding, with deviations only possible to a limited extent and under certain circumstances. For you as a patient, it is initially information; only through your consent and the approval of the insurance company does it become the basis for billing.
What documents does the health insurance need for a cost estimate?
Typically, the health insurance company requires the medical prescription and the detailed cost estimate from the service provider. Depending on the service, further medical justifications or findings may be necessary.
How do I submit an estimate electronically to the health insurance company?
Since February 2023, electronic submission has been mandatory for aids. This is usually done through specialized portals or software solutions used by service providers (such as medical supply stores). As a patient, you generally do not need to take care of this yourself.
Does the health insurance always cover the full costs according to the cost estimate?
Not necessarily. The health insurance company assesses the medical necessity and cost-effectiveness. There are often fixed amounts for certain aids or contractually agreed prices. Co-payments and personal contributions may apply. In the case of dental prostheses, for example, a fixed subsidy is granted.
Are there deadlines for submitting a cost estimate?
The cost estimate should always be submitted and approved *before* the start of the treatment or the acquisition of the aid. There is no set deadline for submission after the prescription is issued, but a timely submission is recommended.
What is the difference between a cost estimate and a treatment and cost plan?
A treatment and cost plan (HKP) is specific to dental treatments. It is more detailed than a simple cost estimate and includes not only the costs but also the exact dental plan and standard care. Both serve to clarify upfront the cost coverage by the health insurance provider.
