Third -party payment: definition, conditions and procedures

The third -party third party is a system implemented by health insurance and mutuals. It allows the insured not to make the advance of certain health care. How does it work? Who has the right to third party paying in France? Can a doctor refuse it? Principle, procedures, request, reimbursement … Lighting on this important principle in the French health system.

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What does that mean third-party paid?

Third -party payment: definition

The purpose of the third party paying aims to avoid the insured to make the advance of the health expenses which will be reimbursed by his health insurance fund. The healthcare professional is paid directly by this share by social security. In some cases, the patient must settle the amount remaining at his expense, which is called the moderator ticket.

There are two types of third -party payment: the third -party full or partial paid.

The full third party

As part of the full third party, the beneficiary has no costs to pay and therefore has nothing to pay with the healthcare professional. Only lump sum participation and medical deductibles can remain in charge. Health insurance will hold him on future reimbursements or ask him for reimbursement.

The partial paid third party

As part of the partial paid third party, the insured pays the costs not covered by health insurance. They include the moderator ticket, as well as excess fees. This share of care can be taken care of for all or part by the mutual insurance company.

How does the third -party third party work?

The third -party third party is a two -level direct management system.

Third -party payment of social security

Health insurance directly pays the price of the consultation or the medical procedure to the professional on the basis of the conventional rate. Only the moderator ticket remains the responsibility of the patient, any fee overruns and, in the event of hospitalization, the daily hospital package. To benefit from the third -party third party, the patient must present to the health professional his vital card up to date.

Third -party payment of the mutual

The patient’s complementary health mutual insurance company supports all or part of the sums not settled by Social Security, depending on the guarantees taken out in the contract. The presentation of the mutual card is essential.

Provide your vital and/or mutual card to healthcare professional

During the consultation, the doctor, via the Vitale card reader, has access to the information necessary for the reimbursement of health care. It can then fill the electronic care sheet (FSE), transmitted directly to the CPAM. This is the remote transmission. As part of the payment third party of the mutual insurance company, the card issued to the person takes care of the moderating ticket within the limit of the guarantees appearing in the contract.

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How do I know if I benefit from third -party payment?

Automatic beneficiaries

The third -party payment applies automatically for people:

• beneficiaries of complementary solidarity health (CSS);
• beneficiaries of the soul;
• beneficiaries of prevention acts in the context of organized screening (mammography, cervical cancer …);
• beneficiaries of maternity insurance;
• victims of an accident at work or an occupational disease;
• hospitalized in an establishment under agreement with health insurance;
• wishing to have recourse to a voluntary termination of pregnancy;
• under 26 who consult for their contraception:
• damage to a long -term condition (ALD);
• beneficiaries of care related to a terrorism act.

These people are also, for the most part, exempt from lump sum participation and medical franchises.

Beneficiaries at the initiative of the health professional

The healthcare professional may decide to grant the third party to the patient then:

• issuing the pharmacist for medicines reimbursed by health insurance;
• examinations, care, provided by radiology or medical analysis firms;
• consultation with the attending physician (for people faced with financial difficulties).

Who has the right to third party paying pharmacy?

The drugs prescribed by a doctor, a midwife, a dental surgeon, a director or deputy director of analysis laboratory, are taken care of, in part or in whole, by health insurance. The vital card makes it possible not to advance the part of health insurance. Medicines must appear on the “list of refundable drugs to social insured”, fixed by ministerial decree. The reimbursement rates vary between 15 and 100%. The share of unsu -refunded drugs can be covered by the mutual.

What are the steps to benefit from third -party payment?

To benefit from the third -party third party, it is essential to present your vital card up to date and/or a third party certificate paying to the healthcare professional. The first request for a vital card can be made from the age of 15, online on its Ameli account. It is then necessary to update it each year or each change of situation, in pharmacy.

The certificate of paid third parties or mutual card makes it possible not to adjust the additional share of medical costs. It is provided by the insurer at the time of the contract. It is possible to download it from your account. It will be necessary to present it at the time of consultation and at the pharmacy.

Can a doctor refuse a third-party third party?

If the generalized third -party paid is essential to professionals in certain situations (for people benefiting from the full third party), the third party may however be refused to the patient in certain situations:

• If the patient refuses the generic drug proposed by the pharmacist;
• If the patient consulted a specialist doctor without prior consultation of his general practitioner (therefore without respecting the coordinated care pathway);
• In cases where care is not taken care of by health insurance (for example consultation of a doctor unheeped).

To know : If the majority of health professionals offer third-party payment on the compulsory share incumbent on health insurance, you should know that this is not an obligation (except in the framework of the full third party).

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What differences between paying third party certificate, mutual insurance card and paid third party card?

Certificate of paid third parties, mutual insurance card and paid third party card actually designates the same document which is issued by the additional health insurance (addressed by mail or downloadable on the customer area). It contains, in addition to the name of the patient and the contract number, the names of the covered (beneficial) and the details of the guarantees.

The certificate of paid third parties is to be presented to the healthcare professional to justify his rights and avoid putting forward on the part of the costs covered by the mutual.