Approval Process
Whether it's health insurance, long-term care insurance, prescriptions, care levels, cost estimates, or inquiries: The path to obtaining medical aids involves several steps. ADAM helps sort documents, prepare the appropriate supply process, and coordinate communication with cost bearers.
Two supply routes
Whether health insurance or long-term care insurance is responsible does not only depend on the product name. The purpose, everyday situation, documents, and supply chain are decisive.
often for medically necessary assistive devices
often for nursing aids and home care
Coordination by ADAM
ADAM does not make decisions on cost coverage. However, we coordinate service-related communication with cost bearers and help to meticulously prepare documents, needs, and next steps.
The final decision rests with the respective cost unit. ADAM cannot guarantee approval or replace legal advice.
We check which information is relevant for the next step: prescription, care level, product area, measurements, photos or everyday situation.
A clearer need for care emerges from a description: Mobility, Bath & Toilet, Nursing Bed, Transfer, Sleep & Breathing, or Care Box.
If a cost estimate is required, we will professionally and organizationally prepare the supply.
ADAM coordinates communication with health insurance companies, long-term care insurance companies, or other payers in the context of healthcare provision.
If documents are missing or questions arise, we help make the next step clear.
After clarification, delivery, customization, instruction, or further coordination will be prepared.
Detect process inhibitors
Many delays are not caused by the tool itself, but by missing information, unclear responsibilities, or outstanding queries.
Product area is mentioned, but need, execution, or supply objective are not clear enough.
Health insurance, long-term care insurance, self-payment, or other payers are mixed.
It is not described why the aid is specifically needed.
Particularly relevant for bathrooms, transfers, nursing beds, ramps, lifts, or the living environment.
The supply must match the contracts and specifications of the cost unit.
The health insurance, long-term care insurance, or ADAM still needs information before we can proceed.
The reason for rejection is not clearly read or deadlines are missed.
Categorize feedback
Provision of services does not always immediately follow the examination. Sometimes additional information is needed, sometimes approval is granted, sometimes a refusal is issued.
ADAM can classify the need for medical aids professionally, but it does not replace legal advice.
Realistic Expectations
The duration depends on the aid, cost bearer, contract partner, documents, and possible queries. It is important to start cleanly early and quickly clarify open information.
Depending on the aid, contract partner, health insurance fund and review, the process can take varying lengths of time. Some aids require prior approval, others do not.
For care aids, the long-term care insurance fund generally decides within three weeks; if the Medical Review Board or a care professional is involved, the deadline can be extended to five weeks. If it cannot meet the deadline, it must generally provide written reasons; without timely notification, an approval fiction may become relevant.
When applying for a care grade, the long-term care insurance fund must, in principle, decide on the care grade within 25 working days.
Missing documents, unclear responsibilities, measurements, photos, or additional evidence can delay the process.
Deadlines may be assessed differently depending on the service and individual case. For legal questions regarding deadlines, health insurance companies, long-term care insurance companies, or independent advisors are the right contacts.
Prepare practically
The clearer the needs, documents, and everyday situations are, the better the next step can be prepared.
Important for many medically necessary aids.
Relevant for long-term care insurance, care aids, care packages, or home environment topics.
Help with time-critical care after hospital, rehab, or new diagnosis.
The product can be categorized in the medical aids directory, but this alone does not determine its coverage.
Helpful for bath, bed, transfer, ramp, lift, or living environment.
What exactly is difficult: walking, showering, standing up, lying down, breathing, or personal care?
Name, health insurance company, long-term care insurance company, and contact details for queries.
Existing supplies can be important when something needs to be replaced, supplemented, or adapted.
Hospital discharge, fall risk, lack of nursing care, or short-term needs.
ADAM Process Support
From initial contact to feedback from the cost unit: ADAM helps to prepare needs, documents and communication around care in a structured way.
Request or prescription comes inYou send the prescription, requirement, or situation to ADAM.
Documents are being sortedWe are checking which information is relevant for care.
Supply route is being preparedA cost estimate, application, or next step will be professionally prepared.
Communication is coordinatedADAM coordinates care-related communication with payers.
Feedback is being categorizedFollow-up questions, approvals, rejections, or alternatives are sorted in a clear and understandable manner.
Provisioning will be implementedDelivery, customization, training, or further coordination will be prepared.
Choose an appropriate opening
Choose the entry that most closely matches your current situation.
Brief answers for guidance. The specific examination always depends on aids, documents, cost bearers, and the individual situation.
The decision is made by the responsible cost unit, for example, the health insurance company or long-term care insurance company. ADAM can prepare the care needs, sort documents, and coordinate communication within the scope of care.
ADAM helps categorize prescriptions, needs, documents, and product areas, prepares cost estimates or next steps as needed, and coordinates communication with cost bearers.
Not always. For many medical aids, prior approval is important, while for others, the health insurance company may waive it. This depends on the medical aid, the health insurance company, and the supply channel.
A prescription is often important, but it does not automatically replace every review. Depending on the aid, a cost estimate, approval, contractual partner, or other documents may be relevant.
A cost estimate describes the planned treatment and the expected costs. It can play an important role when reviewed by the cost bearer.
Then, documents often need to be supplemented, requirements described in more detail, or technical details clarified. ADAM helps to sort such queries within the scope of provision.
The notice should then be carefully reviewed. Insured persons can generally appeal; the deadline is often one month after the notice has been issued. ADAM can professionally assess the need for aids but does not replace legal advice.
ADAM cannot replace legal representation or legal advice. However, we can help professionally sort out care needs and potentially missing information.
That depends on the medical aid, health insurance, documents, and further inquiries. For nursing aids, deadlines of three weeks or five weeks generally apply when nursing professionals or the Medical Service are involved.
The Medical Service can be involved when there is a need to professionally assess necessity, care requirements, or the care situation. This is particularly possible in more complex cases.
The health insurance company is often responsible for medically necessary aids. The long-term care insurance company may be relevant for care levels, home care, care aids or consumables.
A prescription or order, care level assessment, discharge letter, medical aid number, photos, measurements, insurance data, and a brief description of the daily situation can help.
Personal Support
Send a prescription, requirement, or current query to ADAM. We help prepare documents, the supply chain, and communication with the cost bearer in a structured manner.
Coordinated. Understandable. Without promises of approval.
