Patient transport without prior approval: when the health insurer still pays

The approval requirement sits in section 60 (1) sentence 4 SGB V and is drafted more narrowly than it is usually read. It applies exclusively to trips to outpatient treatment, and there in two groups of cases. First, the special exceptional cases that the Federal Joint Committee has set out in the Krankentransport-Richtlinie. Second, a Krankentransport within the meaning of section 60 (2) sentence 1 no. 3 SGB V.

Everything else is free of the approval requirement. Section 7 (6) of the directive states this expressly for Krankenfahrten. The following can be driven without prior consent from the insurer:

• trips to services provided on an inpatient basis (section 60 (2) sentence 1 no. 1 SGB V, section 7 (2) (a) of the directive),
• trips to pre- or post-inpatient treatment under section 115a SGB V where this shortens or avoids an inpatient stay,
• trips to outpatient surgery under section 115b SGB V or to outpatient surgery in a contracted medical practice, including the associated preparatory or follow-up treatment,
• emergency trips to hospital, even if no inpatient treatment turns out to be necessary,
• Krankenfahrten prescribed by a hospital as part of day-inpatient treatment under section 115e SGB V; section 8a of the directive permits this for insured people who meet the conditions of section 8 (3),
• a Krankentransport to inpatient services (section 6 (3) sentence 3 of the directive).

That leaves two constellations that still require approval. The Krankenfahrt to outpatient treatment in an exceptional case under section 8 (6) of the directive, and the Krankentransport in an ambulance-type vehicle to outpatient treatment under section 6 (3) sentence 1. For the first, the statutory deeming rule may apply. For the second, it never does.

Waiting for a response from the insurer as a precaution in the approval-free cases delays trips with no legal reason to do so.

For Krankenfahrten to outpatient treatment, approval counts as granted under section 60 (1) sentence 5 SGB V where one of the following applies:

• a Schwerbehindertenausweis bearing the Merkzeichen aG (exceptional walking impairment), Bl (blind) or H (helpless),
• a classification under section 15 SGB XI in Pflegegrad 4 or 5,
• a classification in Pflegegrad 3 where a permanent mobility impairment exists in addition,
• as a transitional rule, a classification in the former Pflegestufe 2 up to 31 December 2016 and at least Pflegegrad 3 since 1 January 2017.

Merkzeichen G on its own is not enough. Pflegegrad 2 is not enough. At Pflegegrad 3 the prescribing practice has to establish the permanent mobility impairment, and no transport operator can supply that finding after the fact.

Alongside this, section 8 (4) of the directive allows a prescription even without a Merkzeichen and without a Pflegegrad decision, provided there is a comparable mobility impairment and the outpatient treatment is required over an extended period. The PraxisInfo Krankenbeförderung published by the Kassenärztliche Bundesvereinigung (the national association of statutory health insurance physicians) puts a treatment duration of at least six months on this case, together with tick box „e) dauerhafte Mobilitätsbeeinträchtigung vergleichbar mit b)" on Formular 4, the prescription form. Such trips can be prescribed, but they are not free of the approval requirement. The deeming rule in section 8 (6) sentence 2 covers only the cases in subsection 3.

Merkzeichen and Pflegegrad therefore belong in the passenger master data as checked fields. A note in a tour comment will not carry that weight. Passes expire, care levels get raised, and the transport operator is usually the last to hear about it. At the same time both are health data within the meaning of article 9 GDPR and need a legal basis, a deletion concept and tightly scoped role permissions, as set out in our article on health data in transport operations.

The prescription evidences the compelling medical reason that section 3 (1) of the directive requires on the form. The health insurer decides on reimbursement, either in advance or during billing. For approval-free trips to outpatient treatment, the practice ticks letter „b) ambulante Behandlung" on Formular 4 under „1. Grund der Beförderung" in the block for approval-free trips; for an ambulance-type vehicle it ticks „f) anderer Grund für Fahrt mit KTW" in the block that does require approval.

Section 3 (2) draws a second line. As a rule, only trips on the direct route between the place where the person is staying and the nearest suitable treatment option are necessary, and necessity has to be assessed separately for the outward and the return leg. If a passenger prefers the familiar practice at the far end of the district, the insurer does not carry the risk for the extra distance.

Two rules from section 2 of the directive are useful in dispatch. The prescription should be issued before the journey; issuing it afterwards is permitted only in exceptional cases, in particular in an emergency. And no prescription at all is needed for trips in a private car or on public transport.

The ruling of the Bundessozialgericht of 20 February 2025 (case B 1 KR 7/24 R) is often read as a general all-clear where approval is missing. The decision is more precise than that, and considerably narrower in reach.

The claimant was the widow of an insured man with Pflegegrad 3, a degree of disability of 100 and the Merkzeichen G and aG. From 30 July 2020 he was transported to chemotherapy twice a week, prescribed and carried out as a Krankentransport in an ambulance-type vehicle, with a carrying chair and an oxygen inhalation unit. The application for reimbursement only arrived on 23 November 2020, and the insurer refused for the preceding period. The appeal still concerned 650 euros in reimbursement and 4,195.50 euros in release from costs.

The court first made clear that the deeming rule in section 60 (1) sentence 5 SGB V applies only „for Krankenfahrten" and cannot be extended to a Krankentransport. Merkzeichen aG and Pflegegrad 3 were therefore of no help to the insured man here. The senate then applied a teleological reduction to the approval requirement. Where the insurer cannot provide the necessary Krankentransport as a benefit in kind it organises itself because overriding public law provisions stand in the way, in the decided case the rescue service of a district in North Rhine-Westphalia organised under state law, the missing prior approval cannot be held against the insured person, provided all other conditions are met.

Where a trip takes place without prior approval, the evidence decides the outcome weeks later. The reason then has to be documented as well. Which prescription existed, what condition of the passenger required which mode of transport, who called the insurer and when, and what came of it.

The exception sits in section 8 (2) of the Krankentransport-Richtlinie and demands two conditions cumulatively. First, a therapy schedule dictated by the underlying illness with a high treatment frequency over an extended period. Second, an impairment caused by the treatment or by the course of illness leading to it that makes transport indispensable in order to avoid harm to life and limb. High frequency on its own does not suffice.

Annex 2 of the directive names three cases in which both conditions are as a rule met: dialysis, oncological radiotherapy, and parenteral antineoplastic drug therapy or parenteral oncological chemotherapy. This list is expressly not exhaustive. Other therapy schedules need a solid justification on the prescription.

In this segment the expensive part is usually the period. Under section 9 of the directive, prescriptions that require approval must be submitted to the health insurer in good time; the insurer then sets the duration and scope of the approval, including whether the outward and return legs are both covered. A recurring tour that runs past the end of the approval period silently produces uncovered trips.

1. 1Hold the approval period as a data fieldAs a from-to date on the passenger record that tour planning can read. A PDF in a shared folder does not do this job.
2. 2Check the recurring tour against the end of the approvalRecurring appointments end with the approval, not with the calendar year. A warning two to three weeks before expiry gives the practice time for the follow-up prescription.
3. 3Reconcile the scope with the actual tripIf only the outward leg is approved, the return leg is not automatically covered. Section 3 (2) of the directive requires both directions to be assessed separately.
4. 4Flag shared trips correctlyWhere several passengers travel to the same destination at the same time, section 7 (5) of the directive requires a shared trip to be prescribed stating the number of people travelling. That number belongs in your trip data as well.

The dividing line runs along the level of care needed during the journey. Under section 7 (1) of the directive, Krankenfahrten are trips by public transport, private car, hire car or taxi, expressly including vehicles fitted out to carry wheelchair users; no professional medical care takes place on board. A Krankentransport under section 6 (1) presupposes that the passenger needs professional care during the journey or the special equipment of the ambulance-type vehicle, or that this is to be expected given their condition.

The distinction reaches all the way into the operating licence. Under section 1 (2) no. 2 PBefG, the German Passenger Transport Act, transport in an ambulance-type vehicle falls outside that act where the passenger needs professional care or the special equipment of the vehicle. The rescue service acts of the federal states govern instead. A Krankenfahrt by taxi or hire car stays within the Passenger Transport Act.

Section 60 (3) SGB V recognises four categories of travel costs, and it ranks them: public transport, using any available fare reductions; taxi or hire car where public transport cannot be used; an ambulance or rescue vehicle where taxi and hire car are ruled out as well; and the private car at the maximum mileage allowance under section 5 Bundesreisekostengesetz, the Federal Travel Expenses Act.

• Vehicle classification: a wheelchair vehicle without professional care on board counts as a hire car within the meaning of the directive. The journey is therefore a Krankenfahrt and not a Krankentransport service.
• Pricing: the amount chargeable under section 133 SGB V is what gets recognised. Where state or municipal law sets charges for the rescue service, those take precedence; otherwise the contracts between health insurers and providers apply, and the agreed prices are maximum prices.
• Regional variation: because section 133 SGB V refers to state and municipal law, remuneration and billing routes differ considerably by federal state. There is no nationwide figure to quote.

Annex 1 of the Krankentransport-Richtlinie sets out what has to appear on the prescription. Outward leg, return leg or both, the reason for the transport, the treatment date or treatment frequency, the nearest suitable treatment facility and the medically necessary mode of transport. What stands there has to be traceable in your trip data.

• Prescription reference: date of prescription, prescribing practice, prescribed mode of transport
• Approval status: approved, deemed granted under section 60 (1) sentence 5 SGB V, or approval-free, each with the reason
• Approval period and scope (outward and/or return leg)
• Passenger attributes relevant to the deeming rule: Merkzeichen, Pflegegrad, status of the check
• Distance actually driven and destination, reconcilable with the nearest suitable treatment facility
• Departure and arrival times plus confirmation that the trip took place
• For shared trips: number of people travelling per trip
• Co-payment status: collected, exempt under section 62 SGB V, or open

What matters is the moment this evidence comes into being. On the day of the trip it is an observation, at month end it is a reconstruction, and reconstructions rarely survive an audit. Capturing trip data in dispatch and handing it to billing without a break in the media chain closes exactly the gaps that get cut later. How payers attack proof of service is broken down in our article on rejected proof of service.

Passengers are given wrong information about the Zuzahlung, the statutory co-payment, more often than about anything else. Section 10 of the Krankentransport-Richtlinie summarises the position. The co-payment under section 61 sentence 1 SGB V is in principle ten per cent of the cost per trip, but at least five euros and at most ten euros, and never more than the cost of the trip itself.

Two details get overlooked regularly. First, for travel costs the co-payment applies to children and young people too, as the GKV-Spitzenverband (the national association of statutory health insurers) confirms for the payer side; the exemption for minors that applies elsewhere does not bite here. Second, trips to outpatient treatment that avoid or shorten full or partial inpatient hospital treatment that would otherwise be indicated, or that stand in where such treatment cannot be carried out, are covered „as for inpatient hospital treatment" under section 60 (2) sentence 1 no. 4 SGB V. In its February 2025 decision the Federal Social Court recalled that the co-payment is then limited, across the whole series of treatments, to the first and the last trip.

Whatever the amount, the Belastungsgrenze, the annual co-payment cap under section 62 SGB V, stays in place. Anyone who has exceeded it is exempt from further co-payments for the rest of the calendar year once they present the certificate from their health insurer. That certificate belongs in the passenger master record together with its year of validity, otherwise drivers keep collecting and the operator refunds later.