51ºÚÁÏÍø

How does the claims process work?

In addition to premium medical benefits, private health insurance (PKV) operates on the reimbursement principle. While public insurers pay doctors directly, as a private patient, you receive the invoice yourself. You then submit this claim to your insurer, who reimburses the costs according to your plan.

The best part: You often don't have to pay upfront out of your own pocket. Since doctors usually give you several weeks to settle an invoice, you can simply submit it to ottonova first and receive the money before the payment is even due.

Step-by-Step: Submitting your invoice

Once you have received medical treatment, here is how the reimbursement process works with ottonova:

1. Receive & Review: Your doctor will send the invoice directly to you. Take a moment to check it for accuracy.
2. Check the Deadline: Unless a different timeframe is stated, you typically have 30 days from the date of receipt to settle the payment.
3. Submit Digitally: No paperwork required. Simply open the ottonova app, snap a photo of your original invoice, and submit it instantly.
4. Fast Reimbursement: We process your claim within just a few business days. The money is transferred to your account according to your tariff (considering any agreed deductible). You can find all the details in your digital benefit statement within the app.
5. Settle the Bill: Once the reimbursement has arrived in your bank account, verify the amount and pay your doctor or therapist.

What does private health insurance cover?

Private health insurance generally reimburses medical bills whenever treatment is medically necessary. The scope of benefits covered by private health insurance can exceed that of statutory health insurance. For some services, such as vision aids or dental treatment, the amount reimbursed depends on the type of insurance you have: PKV usually reimburses more for high-performance plans than for low-cost plans.

However, PKV does not cover anything that is not included in the plan. Before signing up, check carefully what is and is not included in your plan and whether the benefits are sufficient for you or whether you should choose a higher-performance plan.

How to ensure that your costs are reimbursed

For complex treatments, you can request a cost estimate (Heil- und Kostenplan) and clarify with your private health isurance provider whether the costs will be covered.

In order for private patients' invoices to be reimbursed by private health insurance providers, they must be issued correctly and the services must be verifiable. A free online tool for invoice verification can be found, for example, at the .

You do not have to submit a private health insurance invoice immediatley - but you should not let the deadline pass. You can find out how long you have at the end of this article.

For certain treatments, you should check in good time what reimbursement your tariff provides for. This applies, for example, to dental prostheses, orthodontics, spa treatments, or psychotherapeutic treatments.

Civil servants must submit their invoices not only to their private health insurance company but also to the benefits office (Beihilfe) in order for their costs to be covered.

What's covered? Examples of what you can and can't claim

Exception from the reimbursement principle: hospital bills

After a hospital stay, the bills are often significantly higher than for outpatient services. Don't worry, you don't have to take out a loan after inpatient treatment. Instead, privately insured individuals can sign a declaration of assignment when they are admitted to the clinic. This allows the hospital to bill your private health insurance directly for standard services.

A seperate bill is usually isssued for optional services such as a single or double room or treatment by the chief physician.

How long does it take to receive my reimbursement?

Once your invoice has been submitted and reviewed, private health insurers usually issue the payment within a few a business days. In many cases, the reimbursement will arrive in your bank account before you even have to pay the doctor's bill.

While processing times vary across the industry, 51ºÚÁÏÍø is built for speed. Thanks to our digital-first approach, most claims are processed and reimbursed within just a few business days after a quick digital review.

When is the deadline for submitting invoices to your private health insurance company?

The deadline for submitting a private health insurance invoice is set by law at three years and begins at the end of the year in which you received the medical bill. When should you take your time with this?

If you have taken out private health insurance with an absolute deductible, it may be advisable to submit invoices collectively.

Let's assume your deductible is €500 per year and you have only received one bill for €320 this year. If you submit it, you won't get any money back. If you have to pay another €470 a few months later, you can submit both bills together and receive €290 (€790 total amount of the submitted bills minus €500 deductible).

With ottonova, however, it does not make sense to postpone submission. This is because, with our private health insurance rates, we do not reimburse you for invoices once you have reached a certain invoice amount, but rather the percentage (according to the rate) of each of your invoices immediately after taking out the insurance. 

Why is my invoice being reviewed? 

Unlike Germany's statutory health insurance system, where treatments are billed directly to the insurer using standardized case rates, private health insurance operates on the reimbursement principle. This means that you receive an individual invoice directly from your doctor, physician, or other healthcare provider and then submit it to us for reimbursement. 

Once submitted, every invoice is reviewed. This is an important part of our claims assessment process and one of our legal and contractual obligations as an insurer. The review ensures that benefits are reimbursed fairly and correctly while helping to keep premiums stable for all policyholders over the long term. 

What private health insurance reviews before reimbursement 

Before we make a payment, we verify: 

• whether your invoice is complete 

• whether the treatment and the billed fee are covered under your insurance plan 

• whether the services billed are medically necessary* 

• whether the invoice complies with the applicable German fee schedules (e.g., GOÄ, GOZ, or ³Ò±ð²úü±á) 

• whether the submitted documents are sufficient to process your reimbursement 

What this means for you 

• Most invoices are reimbursed according to your policy without any further questions. 

• Only in a small number of cases do we require additional information or documentation. 

• You do not need to do anything unless we contact you. 

When does private health insurance request additional documents after you submit an invoice? 

Not every invoice requires additional information. However, if your doctor has issued a referral, prescription, medical order, or similar document, we may need it to review and verify your invoice. We recommend uploading these documents together with your invoice. 

Examples of relevant documents include: 

• a referral for an MRI, CT scan, or other diagnostic imaging procedure 

• a referral to a specialist (for plans that require a primary care physician referral) 

• a prescription or medical order for medications, therapeutic treatments, or medical aids 

• proof of vaccine-related expenses if the vaccine was not obtained from a pharmacy via prescription 

Our goal is to process your invoice as quickly and efficiently as possible. If we require additional information, processing may take a little longer. However, we will make every effort to resolve the matter as quickly as possible. 

You can help shorten the processing time by ensuring that your invoices are complete and by submitting any requested documents promptly. 
 

Why might private health insurance have questions about my invoice? 

In some cases, we need to determine whether there is generally an entitlement to reimbursement. This may happen if an invoice indicates that a diagnosis or pre-existing medical condition may have existed before your insurance coverage began. 

When you applied for your private health insurance policy, you answered questions about your health. This information is important because it allows us to determine your insurance coverage and calculate your premium correctly. 

To assess your claim accurately and completely, we must also consider any possible connection to previous medical conditions. For example, this may be relevant if a current diagnosis has a medical history or has developed over a longer period of time. 

This review is part of our responsibility as a private health insurer and is based on legal and contractual requirements, including the German Insurance Contract Act (Versicherungsvertragsgesetz). It ensures that we can make fair and consistent decisions about benefit entitlement for all policyholders. 

The purpose of the review is to make decisions based on reliable and transparent information while helping to maintain fair and stable premiums for everyone insured. 

What specific information might be requested regarding your invoice? 

We will usually begin by asking you to provide a self-disclosure so that we can better understand your situation. 

Depending on the circumstances, we may also require additional documents, such as: 

• access to your medical records to review your medical history 

• medical reports and treatment records 

• radiology reports 

• records from your previous health insurance provider 

These medical findings and physicians' records help us better understand your medical history and enable us to make a final decision. 

How long does the review take? 

We strive to complete every review as quickly as possible. 

The duration depends on: 

• how complex the case is 

• which documents are required 

• how quickly the requested information is provided 

You can help speed up the process by submitting any requested documents as soon as possible. If you are unable to meet a deadline, please let us know in good time. 

What happens to your invoice during the review? 

While the review is ongoing, reimbursement of individual invoices may be temporarily put on hold. 

As soon as the review has been completed and no further clarification is required, all eligible benefits will, of course, be reimbursed in accordance with the terms of your insurance plan. 

You can continue uploading additional invoices through the app and view the current processing status at any time. 

Could the review affect my insurance policy? 

In most cases, the matter can be fully clarified without any changes to your insurance policy. 

However, if it becomes apparent that relevant health information was omitted when the policy was taken out, contractual adjustments may become necessary. For example, a risk surcharge may be applied retrospectively. 

In particularly serious cases, the policy may also be terminated if it is proven that false health information was deliberately provided. 

For this reason, it is important to answer all health-related questions completely and truthfully when applying for private health insurance. If you later realize that you forgot to disclose important medical information, please contact us as soon as possible so that we can work with you to find an appropriate solution.