Reimbursement for Psychotherapy: The Reimbursement Procedure When No Therapy Spot Covered by Statutory Health Insurance Is Available

The consultation is over, you have the written recommendation for psychotherapy right in front of you, and yet there is no therapy spot available.

The reimbursement procedure is the legal emergency exit from an overcrowded healthcare system. If you cannot find a therapy spot with a contracted psychotherapist, that does not mean you have run out of options. People with statutory health insurance can, under certain conditions, also receive treatment from therapists without a statutory health insurance license and are reimbursed for the resulting costs by their health insurance provider. The legal basis for this is Section 13(3) of SGB V.

The text of the law is brief. If the health insurance provider was unable to provide an urgent service in a timely manner, the costs of the service the insured person obtained on their own must be reimbursed, to the extent the service was necessary. Legal experts refer to this as system failure. This refers to the mandate to provide care that a statutory health insurance provider has but cannot fulfill in an individual case.

The entitlement remains unchanged. What has changed is how readily health insurance providers recognize it.

Three conditions must be met: psychotherapy is necessary and required promptly, the search in the statutory health insurance system was unsuccessful, and the selected practice meets the professional requirements.

The psychotherapy consultation documents the first condition. During this consultation, it is determined whether outpatient psychotherapy is indicated and how urgent it is. You document the second condition yourself, with a record of your inquiries. You ask about the third at the practice you are considering.

Who Is Authorized to Provide Psychotherapy

This condition is stated verbatim in the law and is overlooked in most guides: the costs are reimbursable provided the psychotherapist meets the requirements of Section 95c of SGB V. This means a license to practice psychotherapy and a specialist qualification in an approach recognized by the Federal Joint Committee. The following are recognized under Section 15 of the Psychotherapy Guidelines: the psychoanalytically based approaches, namely depth psychology-based and analytical psychotherapy, as well as behavioral therapy and systemic therapy.

The PTV 11 form is an important document, but it is not yet a complete application for reimbursement. It documents the preliminary findings, the treatment recommendation, and whether the treatment is available at the issuing practice.

The reimbursement application also includes, in particular, the search log, the attempt to arrange placement through 116117, and the documents from the private practice.

No law prescribes a fixed number. That is the honest answer to the question most frequently asked in the reimbursement procedure. What has to be documented is something else: that you were unable to get psychotherapy in the statutory health insurance system.

kassenwatch.de, operated by the DGVT professional association, now advises people with statutory health insurance to make about ten to twenty calls to practices with a statutory health insurance license, noting each inquiry individually. There is no prescribed number; what matters is that the record clearly shows that no suitable therapy spot is available within a reasonable time and distance.

The German Association of Psychotherapists describes a system failure as follows: Insured individuals are unable, through the efforts that can reasonably be expected of them individually, to find a practice with a statutory health insurance license that is willing to provide treatment within a reasonable time and distance, and the health insurance provider is unable to successfully assist them in this regard. Distance therefore counts as well, not the waiting time alone.

What Belongs in the Log

Practice name, date/time, result, for each individual call. Also record the attempt to arrange placement through the appointment service center 116117.

A log that starts tracking from the first rejection costs you three notes per phone call.

These calls are more than just a series of rejections. They're an opportunity to get to know psychotherapists who will have an opening in a few months.

If you are offered a therapy spot at a practice with a statutory health insurance license, accept it. You are only entitled to reimbursement as long as no spot is available in the statutory health insurance system. kassenwatch.de puts it this way: Such an offer should be declined only in rare and well-justified exceptional cases. If you feel absolutely uncomfortable with the psychotherapist during the initial consultation, that is, of course, a good reason not to begin therapy there.

There is no uniform application procedure nationwide. The following procedure has worked well in practice and keeps the financial risk as low as possible.

The exact requirements vary from one health insurance provider to another. Therefore, if possible, ask them to tell you in writing which documents are initially needed for the trial sessions.

The applicant is the patient. The application typically includes the PTV 11 form, the record of the search for a therapy spot, and proof of an attempt to arrange placement through 116117. Depending on the health insurance provider, a medical certificate of urgency or even a consultation report can also be required.

The private practice includes a cover letter. In it, the practice confirms that it can provide trial sessions on short notice and, if indicated, subsequent therapy as well. It also provides information on qualifications, treatment approach, and estimated costs.

You generally submit the application for reimbursement of the trial sessions. The practice can send the complete package with your consent.

After the trial sessions, the practice will prepare the application for short-term or long-term therapy and typically submit it to the health insurance provider. Keep a copy of all submitted documents and proof of the date they were received.

As a general rule, the health insurance provider must be given the opportunity to arrange a therapy spot on its own before the first session for which the patient is responsible for the cost. Anyone who begins treatment first and only applies for reimbursement afterward generally loses their right to reimbursement.

This also applies to trial sessions: Apply explicitly for coverage of these costs before your first appointment and, if possible, wait for the insurer’s decision. Exceptions may apply, particularly in cases where treatment cannot be postponed.

As long as full coverage of the costs has not been confirmed, the practice must inform you in writing of the estimated costs before treatment begins (Section 630c(3) of the German Civil Code (BGB)). If this does not happen, caution is advised.

When the Patient Pays Upfront

In the reimbursement procedure, the practice bills the patient for its services. Typically, you pay the bill yourself first and then submit it to your health insurance provider. You bear the risk that the insurer may reimburse less than the amount billed. In certain cases, instead of a retroactive reimbursement, you may request to be relieved of the outstanding bill.

In the reimbursement procedure, the patient enters into the treatment agreement with the practice, not the insurer. That is the difference from treatment at a contracted practice, and it explains why the bill is sent to you.

If your health insurance provider has denied your claim for reimbursement, you have one month to file an appeal, starting from the date of notification (Section 84 SGG). The one-month period applies if the information regarding the right to appeal is provided in the proper manner. If this information is missing or contains errors, a longer period may apply.

Request a written and reasoned decision that includes information on your right to appeal. Even a rejection communicated verbally can already constitute a decision; however, a written decision provides clear evidence of its content, the reasons for it, and the applicable deadlines.

The Three Most Common Reasons

The same reasons come up again and again. They say there is the appointment service center, after all. They claim the search wasn’t sufficiently documented. They argue that the urgency wasn’t substantiated. Objective arguments can be made against each of these three points, and that is precisely what the log you’ve been keeping since the first rejection is for.

If the appeal is unsuccessful, the next step is to file a lawsuit in social court. The proceedings are free of court costs for insured persons (Section 183 SGG). It’s still not pleasant, but the hurdle is lower than most people think.

There is support available for this, and it’s free. The Independent Patient Counseling Foundation of Germany has been providing free, nationwide advice on health and health law issues since May 2024. Through the free portal widerspruch.online, an appeal can be filed automatically. And the VdK social welfare association offers its members its own legal counseling service.

An appeal is not a dispute. It is the established procedure for having a decision regarding your psychotherapy reviewed, and the office expects you to file one.

An approved reimbursement does not necessarily mean full reimbursement. In its decision, the health insurance provider often agrees to cover only the amount that a practice with a statutory health insurance license could bill based on the Uniform Assessment Standard. However, a private practice bills according to the fee schedule, and that amount is sometimes higher. You would be responsible for the difference.

The chambers of psychotherapists consider this cap to be unlawful. Section 13(3) of SGB V refers to reimbursement in the amount incurred, which is determined by the treatment contract. The assessment standard is binding only on contracted practices.

You handle this appeal yourself; the practice can provide you with the figures to back it up. Before you argue about it, however, make sure there actually is a discrepancy. There are practices for which the statutory rate is acceptable, and in those cases, the issue can be resolved with a phone call.

The most recent publicly available figure comes from the German Association of Psychotherapists: an online survey among its members in private practice, published in February 2022 and conducted in October 2021, with 503 participating psychotherapists. The rejection rate for initial applications rose from 43 percent in 2019 to 48 percent in 2021.

Filing an appeal pays off more often than the rejection rate would suggest. In 2021, 44.8 percent of patients filed an appeal, and only 29.8 percent of those appeals were rejected. In 38 percent of practices, the first appeal is in fact always successful. That is the encouraging figure from this survey.

The health insurance provider’s reasons come up again and again, and the survey measures them: 79 percent of practices report that the insurer pointed to the appointment service center, 64 percent report being told that there are enough contracted psychotherapists, and 59 percent report that the insurer claimed reimbursement is no longer permitted.

For three years, I supported these applications from a private practice because, without a statutory health insurance license, there was no other route to billing. The reimbursement procedure is bureaucratic. That’s the most honest way to describe it. Still, the effort involved remains manageable; there are only a few steps, and the key is to complete them correctly.

Today I work as a psychologist via video for self-pay clients. My service is online individual psychological counseling: It is neither psychotherapy nor treatment, so it is not covered by statutory health insurance. For psychotherapy, the path leads through a practice with a statutory health insurance license and, if no spot is available there, through reimbursement.

Keep a record starting with the first rejection, even if you’re still hoping you won’t need to apply for reimbursement. It doesn’t take long to write three lines after each phone call, but reconstructing the details from memory does.

And if someone tells you that this procedure no longer exists, that’s not true. This information comes strikingly often from the health insurance provider itself, not from the practices, as the figures above show. The entitlement under Section 13(3) of SGB V remains unchanged in the law, and it applies to any psychotherapy that is necessary and for which no spot can be found in the statutory health insurance system.