The Federal Association
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, Kdö.R., Berlin - on the one hand - and the GKV-Spitzenverband (National Association of Health Insurance Funds), Kdö.R., Berlin - on the other hand - agree the following:53. Change to the agreement on forms for statutory health care from April 1, 1995 (Annex 2 BMV-Ä)
Article 1
Changes to the form agreement
Number 2.61 changes as follows:
" Sample 61: Part A: Advice on medical rehabilitation / Examination of the responsible rehabilitation provider Part B to D: Ordinance on medical rehabilitation (status: 04.2020) “
Article 2
Changes to the explanations of the form
1. The explanation of the form for sample 19 changes under No. 2 as follows:
" 2. Template 19b is to be signed by the attending physician and sent to the attending physician as notification. The rest of the copy (sample 19c) remains with the representing doctor. “
2. The form explanation for sample 61 changes as follows:
" Sample 61 Part A: Advice on medical rehabilitation / examination of the responsible rehabilitation provider
Under Part A of Model 61, contract physicians can arrange for additional advice from the health insurance company (e.g. in the case of equal responsibility for child rehabilitation services or oncological rehabilitation for old-age pensioners or relatives of insured persons or pensioners) or the Let the health insurance company determine the responsible rehabilitation provider if this cannot be conclusively assessed by the contract doctor (e.g. with regard to the statutory requirements of the pension insurance). In this case, only part A has to be completed and sent to the health insurance company. The health insurance company informs the contract doctor about the responsible rehabilitation provider. If the health insurance company is responsible, the contract doctors are asked to also fill in part B-D of sample 61 and send it to the health insurance company. In order to make it easier for the prescribing contract physicians to delimit the responsible rehabilitation provider, corresponding criteria are listed in Part A of the template. If there is clarity about the responsibility of the health insurance company, you can dispense with filling in Part A and fill out Part B-D and send it to the health insurance company.
The form is divided into three sections. The Federal Association Announcements
53. Change to the agreement on forms for statutory health care from April 1, 1995 (Annex 2 BMV-Ä)
Article 1
Changes to the form agreement
Number 2.61 changes as follows:
" Sample 61: Part A: Advice on medical rehabilitation / Examination of the responsible rehabilitation provider Part B to D: Ordinance on medical rehabilitation (status: 04.2020) “
Article 2
Changes to the explanations of the form
1. The explanation of the form for sample 19 changes under No. 2 as follows:
" 2. Template 19b is to be signed by the attending physician and sent to the attending physician as notification. The rest of the copy (sample 19c) remains with the representing doctor. “
2. The form explanation for sample 61 changes as follows:
" Sample 61 Part A: Advice on medical rehabilitation / examination of the responsible rehabilitation provider
Under Part A of Model 61, contract physicians can arrange for additional advice from the health insurance company (e.g. in the case of equal responsibility for child rehabilitation services or oncological rehabilitation for old-age pensioners or relatives of insured persons or pensioners) or the Let the health insurance company determine the responsible rehabilitation provider if this cannot be conclusively assessed by the contract doctor (e.g. with regard to the statutory requirements of the pension insurance). In this case, only part A has to be completed and sent to the health insurance company. The health insurance company informs the contract doctor about the responsible rehabilitation provider. If the health insurance company is responsible, the contract doctors are asked to also fill in part B-D of sample 61 and send it to the health insurance company. In order to make it easier for the prescribing contract physicians to delimit the responsible rehabilitation provider, corresponding criteria are listed in Part A of the template. If there is clarity about the responsibility of the health insurance company, you can dispense with filling in Part A and fill out Part B-D and send it to the health insurance company.
The form is divided into three sections.When filling the fields, please note the following:
I. Diagnoses justifying rehabilitation and other diagnoses
II. Note / request to the health insurance company
The box can be ticked if the insured person is advising the insured person about medical rehabilitation benefits from the health insurance company or another rehabilitation provider is ed. This can e.g. This may be the case, for example, with equal responsibility for child rehabilitation services or with oncological rehabilitation for retirees or relatives of insured persons or pensioners. In addition, the box can be filled in if advice on other health insurance benefits (e.g. preventive medical care in recognized health resorts) is indicated. If this is the case, only part A of the form needs to be sent to the health insurance company. Part BD of the form then does not have to be completed.
If There is or is threat of reduction in earning capacity due to illness / disability and z. If, for example, the statutory requirements of the pension insurance cannot be clearly assessed, an examination of the responsible rehabilitation institution can be requested. If this is the case, only part A of the form needs to be sent to the health insurance company. Part BD of the form then does not have to be filled out.
Here further information can be provided by the contract doctor such as B. the request for callback can be made by the health insurance company.When filling the fields, please note the following:
I. Diagnoses justifying rehabilitation and other diagnoses
II. Note / request to the health insurance company
The box can be ticked if the insured person is advising the insured person about medical rehabilitation benefits from the health insurance company or another rehabilitation provider is ed. This can e.g. This may be the case, for example, with equal responsibility for child rehabilitation services or with oncological rehabilitation for retirees or relatives of insured persons or pensioners. In addition, the box can be filled in if advice on other health insurance benefits (e.g. preventive medical care in recognized health resorts) is indicated. If this is the case, only part A of the form needs to be sent to the health insurance company. Part BD of the form then does not have to be completed.
If There is or is threat of reduction in earning capacity due to illness / disability and z. If, for example, the statutory requirements of the pension insurance cannot be clearly assessed, an examination of the responsible rehabilitation institution can be requested. If this is the case, only part A of the form needs to be sent to the health insurance company. Part BD of the form then does not have to be filled out.
Here further information can be provided by the contract doctor such as B. the request for callback can be made by the health insurance company.If there are indications that other or further needs for participation benefits (e.g. benefits for social participation or participation in working life) exist for the insured person, these can be named here. The health insurance company picks up on this to identify needs at an early stage.
III. Return the original to the contract doctor
Sample 61 Part B to D: Ordinance on medical rehabilitation
Under Part BD, contract doctors can prescribe medical rehabilitation services and medical rehabilitation for mothers and fathers. The sample is kept in the contracted doctor's practice.
When using sample 61 part BD, it should be noted that the health insurance company will only provide medical rehabilitation benefits if
- curative individual services of outpatient treatment are not sufficient and
- complex service for medical rehabilitation is medically indicated and no other rehabilitation provider is responsible.
The form is divided into seven sections. Please note the following when filling in the fields:
Regulation from medical rehabilitation
- does not concern reduction / significant risk to the ability to work and
- also does not concern the consequences of an accident at work / an occupational disease,
III. Return the original to the contract doctor
Sample 61 Part B to D: Ordinance on medical rehabilitation
Under Part BD, contract doctors can prescribe medical rehabilitation services and medical rehabilitation for mothers and fathers. The sample is kept in the contracted doctor's practice.
When using sample 61 part BD, it should be noted that the health insurance company will only provide medical rehabilitation benefits if
- curative individual services of outpatient treatment are not sufficient and
- complex service for medical rehabilitation is medically indicated and no other rehabilitation provider is responsible.
The form is divided into seven sections. Please note the following when filling in the fields:
Regulation from medical rehabilitation
- does not concern reduction / significant risk to the ability to work and
- also does not concern the consequences of an accident at work / an occupational disease,
The box only needs to be ticked if the insured person, after prior consultation (see sample 61 Part A), wishes the service to be carried out by the health insurance company.
I. Diagnoses justifying rehabilitation and other diagnoses
II. Information on the need for rehabilitation and the course of the patient's treatment
In addition to the anamnesis and the damage, this section also queries the impairments in defined activity and participation areas in the sense of rehabilitation medical assessment.
There is need for rehabilitation if, due to physical, mental or emotional damage, there are likely to be more than temporary everyday impairments to activities that threaten participation in the foreseeable future or impairment of participation already exists and over curative care in addition to the multi-dimensional and interdisciplinary approach of medical rehabilitation is required.
This subsection serves to document the clinical anamnesis and the previous course the medical treatment of the insured person including their complaints. In particular, the beginning and the course of the patient's treatment must be documented, as well as information on treatments in the hospital and by specialists.
The damage to the body functions and structures that are necessary for the under II.
The box only needs to be ticked if the insured person, after prior consultation (see sample 61 Part A), wishes the service to be carried out by the health insurance company.
I. Diagnoses justifying rehabilitation and other diagnoses
II. Information on the need for rehabilitation and the course of the patient's treatment
In addition to the anamnesis and the damage, this section also queries the impairments in defined activity and participation areas in the sense of rehabilitation medical assessment.
There is need for rehabilitation if, due to physical, mental or emotional damage, there are likely to be more than temporary everyday impairments to activities that threaten participation in the foreseeable future or impairment of participation already exists and over curative care in addition to the multi-dimensional and interdisciplinary approach of medical rehabilitation is required.
This subsection serves to document the clinical anamnesis and the previous course the medical treatment of the insured person including their complaints. In particular, the beginning and the course of the patient's treatment must be documented, as well as information on treatments in the hospital and by specialists.
The damage to the body functions and structures that are necessary for the under II.G listed rehabilitation-relevant impairments are responsible.
Example: medially accentuated gonarthrosis (= structural damage) with painful restriction of mobility - extension / flexion: 0/10/90 pain after 50 m walking distance (= Functional damage).
The information can be substantiated with appropriate assessments, for example the Barthel index.
In subsections C to F, the previous medical treatment services, such as medical / psychotherapeutic interventions, Use of remedies and aids and other measures such as B., patient training or medical preventive services requested.
If known, information about the previously prescribed individual services and their frequency within the last six months should also be provided with regard to therapeutic agent therapy. If the treatment goal cannot be achieved with (further) therapeutic agent treatment, this must be indicated by the checkbox. The information in the free text field can then be dispensed with.
This documentation is intended to emphasize once again that the treatment goals cannot be achieved with individual services of the patient treatment or combination of these.
This is where long-term everyday impairments to activities and participation (> 6 months) in different areas of life of the insured as well as the need for support with regard to self-determined and as independent life as possible. If impairments are seen in the individual areas of life, these are to be assessed accordingly.
The categories mobility and self-sufficiency are broken down. Here there is the option of placing higher-level cross if there are no impairments.
Context factors represent the entire living conditions of person. They include all influences relevant to rehabilitation from the patient's background on his / her activities and participation in the sense of support factors or barriers that are both in the Environment as well as person can be justified. In each individual case, environmental and person-related factors contribute to an understanding of the effects of health problem caused by illness or disability.G listed rehabilitation-relevant impairments are responsible.
Example: medially accentuated gonarthrosis (= structural damage) with painful restriction of mobility - extension / flexion: 0/10/90 pain after 50 m walking distance (= Functional damage).
The information can be substantiated with appropriate assessments, for example the Barthel index.
In subsections C to F, the previous medical treatment services, such as medical / psychotherapeutic interventions, Use of remedies and aids and other measures such as B., patient training or medical preventive services requested.
If known, information about the previously prescribed individual services and their frequency within the last six months should also be provided with regard to therapeutic agent therapy. If the treatment goal cannot be achieved with (further) therapeutic agent treatment, this must be indicated by the checkbox. The information in the free text field can then be dispensed with.
This documentation is intended to emphasize once again that the treatment goals cannot be achieved with individual services of the patient treatment or combination of these.
This is where long-term everyday impairments to activities and participation (> 6 months) in different areas of life of the insured as well as the need for support with regard to self-determined and as independent life as possible. If impairments are seen in the individual areas of life, these are to be assessed accordingly.
The categories mobility and self-sufficiency are broken down. Here there is the option of placing higher-level cross if there are no impairments.
Context factors represent the entire living conditions of person. They include all influences relevant to rehabilitation from the patient's background on his / her activities and participation in the sense of support factors or barriers that are both in the Environment as well as person can be justified. In each individual case, environmental and person-related factors contribute to an understanding of the effects of health problem caused by illness or disability.For example, both the conditions in the social space and one's own skills in connection with coping with the health problem and its effects are important. Risk factors that may endanger the success of the rehabilitation are also to be named at this point.
III. Information on rehabilitation ability
IV. Rehabilitation goals
A. - B. Rehabilitation goals
In this subsection, the contract doctor should position himself / herself which goals he / she is considering who considers context or risk factors to be realistic - both in terms of functional impairment and impairment of activities and participation.
The rehabilitation goals refer to the above-mentioned functional impairments in ers the line on the resulting impairments. They should be described as specifically as possible (e.g. reaching transfer, walking short distances). The everyday-relevant rehabilitation goals formulated with the patient and especially with those in need of care, also with the relatives, must be documented. Deviations between the rehabilitation goals formulated by the patient and those of the contract doctor must also be documented, as this can have an impact on the prognosis.
V. Rehabilitation prognosis
III. Information on rehabilitation ability
IV. Rehabilitation goals
A. - B. Rehabilitation goals
In this subsection, the contract doctor should position himself / herself which goals he / she is considering who considers context or risk factors to be realistic - both in terms of functional impairment and impairment of activities and participation.
The rehabilitation goals refer to the above-mentioned functional impairments in ers the line on the resulting impairments. They should be described as specifically as possible (e.g. reaching transfer, walking short distances). The everyday-relevant rehabilitation goals formulated with the patient and especially with those in need of care, also with the relatives, must be documented. Deviations between the rehabilitation goals formulated by the patient and those of the contract doctor must also be documented, as this can have an impact on the prognosis.
V. Rehabilitation prognosis
The rehabilitation prognosis is medically based probability statement for the success of the medical rehabilitation based on the illness or disability, the previous course, the compensation potential or the ability to regress. The positive and negative influence of the social and personal background (environmental and person-related factors) must be taken into account. Particular attention is paid to the patient's motivation with view to strengthening resources (e.g. attitudes to the effects of illness and disability, coping strategies) as well as possible reduction in negative context factors (e.g. risk factors).
VI. Referral recommendations
This subsection contains information on the recommended form of rehabilitation, i.e. whether the performance z. B. outpatient, inpatient or as mother / father service should be provided. When prescribing mother / father benefit or mother / father / child benefit, the context factors relevant to these must be specifically presented in Section II. H. For the prescription of medical preventive benefit (not rehabilitation) for mothers or fathers according to § 24 SGB V, the model 61 part B-D is not to be used. A separate regulation form, sample 64, is provided for this purpose. In addition, under B the information on the main focuses / indications of the rehabilitation, such as B. to be specified orthopedically or geriatrically. In addition, the contract doctor should provide information on which requirements the rehabilitation facility in which the medical rehabilitation service is to take place should meet.
If the person concerned is the insured person is caring relative, this must be stated under C in order, among other things, to justify the performance of the medical rehabilitation service in inpatient form.
VII. Other information
In this subsection the question about answer whether the requested medical rehabilitation benefit is medically necessary before the statutory waiting period of 4 years between two rehabilitation services has expired. This can be the case if another illness justifies the rehabilitation or if the rehabilitation illness has worsened in the meantime, medical rehabilitation benefits are indicated again.
The rehabilitation prognosis is medically based probability statement for the success of the medical rehabilitation based on the illness or disability, the previous course, the compensation potential or the ability to regress. The positive and negative influence of the social and personal background (environmental and person-related factors) must be taken into account. Particular attention is paid to the patient's motivation with view to strengthening resources (e.g. attitudes to the effects of illness and disability, coping strategies) as well as possible reduction in negative context factors (e.g. risk factors).
VI. Referral recommendations
This subsection contains information on the recommended form of rehabilitation, i.e. whether the performance z. B. outpatient, inpatient or as mother / father service should be provided. When prescribing mother / father benefit or mother / father / child benefit, the context factors relevant to these must be specifically presented in Section II. H. For the prescription of medical preventive benefit (not rehabilitation) for mothers or fathers according to § 24 SGB V, the model 61 part B-D is not to be used. A separate regulation form, sample 64, is provided for this purpose. In addition, under B the information on the main focuses / indications of the rehabilitation, such as B. to be specified orthopedically or geriatrically. In addition, the contract doctor should provide information on which requirements the rehabilitation facility in which the medical rehabilitation service is to take place should meet.
If the person concerned is the insured person is caring relative, this must be stated under C in order, among other things, to justify the performance of the medical rehabilitation service in inpatient form.
VII. Other information
In this subsection the question about answer whether the requested medical rehabilitation benefit is medically necessary before the statutory waiting period of 4 years between two rehabilitation services has expired. This can be the case if another illness justifies the rehabilitation or if the rehabilitation illness has worsened in the meantime, medical rehabilitation benefits are indicated again.In any case, such measure and its urgency must be justified separately.
This subsection must be ticked if home care is ensured in the case of outpatient rehabilitation.
This question records the patient's ability to travel. Can e.g. B. be used public transport with which the patient can reach the facility? Do you need car and / or an accompanying person?
In this subsection information is to be given about the possible care of the person in need of care during the inpatient rehabilitation of the caring relative. Provided that the person in need of care is included in the same facility, i.e. the rehabilitation facility or the coordination of care for the person in need of care in another facility (e.g. short-term care) by the health insurance company and long-term care insurance company is required, this must be stated. If there are medical reasons against taking the person in need of care into the rehab facility, these must be stated under "Other". This can be the case, for example, in the case of severe exhaustion syndromes or depressive disorders of the caring relatives, in which spatial / local distancing from the social environment appears necessary for positive rehabilitation prognosis.
In this subsection, special information can be given, such as B. on the ability to travel, the existence of pregnancy or if there are indications of the insured person that there are further needs for participation benefits that go beyond medical rehabilitation (e.g. benefits for social participation or benefits for participation in working life). The health insurance company picks up on this to identify needs early on. In addition, the contract doctor has the opportunity to ask the health insurance company to call you back. “
Article 3
Entry into force
The changes will take effect with effect from April 1st, 2020. Old sample 61 are no longer valid.
Berlin, December 2nd, 2019
National Association of Statutory Health Insurance Physicians, Kdö.R., Berlin
GKV-Spitzenverband, Kdö .R.In any case, such measure and its urgency must be justified separately.
This subsection must be ticked if home care is ensured in the case of outpatient rehabilitation.
This question records the patient's ability to travel. Can e.g. B. be used public transport with which the patient can reach the facility? Do you need car and / or an accompanying person?
In this subsection information is to be given about the possible care of the person in need of care during the inpatient rehabilitation of the caring relative. Provided that the person in need of care is included in the same facility, i.e. the rehabilitation facility or the coordination of care for the person in need of care in another facility (e.g. short-term care) by the health insurance company and long-term care insurance company is required, this must be stated. If there are medical reasons against taking the person in need of care into the rehab facility, these must be stated under "Other". This can be the case, for example, in the case of severe exhaustion syndromes or depressive disorders of the caring relatives, in which spatial / local distancing from the social environment appears necessary for positive rehabilitation prognosis.
In this subsection, special information can be given, such as B. on the ability to travel, the existence of pregnancy or if there are indications of the insured person that there are further needs for participation benefits that go beyond medical rehabilitation (e.g. benefits for social participation or benefits for participation in working life). The health insurance company picks up on this to identify needs early on. In addition, the contract doctor has the opportunity to ask the health insurance company to call you back. “
Article 3
Entry into force
The changes will take effect with effect from April 1st, 2020. Old sample 61 are no longer valid.
Berlin, December 2nd, 2019
National Association of Statutory Health Insurance Physicians, Kdö.R., Berlin
GKV-Spitzenverband, Kdö .R., Berlin
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