What Is a Kostengutsprache (Prior Authorization)?

What is a Kostengutsprache?

Kostengutsprache (literally "cost approval") is a formal written commitment from your health insurer confirming that they will cover (or partially cover) a specific treatment. It is requested before the treatment takes place so that everyone — patient, doctor, and insurer — knows in advance who pays what.

The term is used across KVG (basic insurance) and VVG (supplementary insurance). In French-speaking Switzerland, it is called "garantie de prise en charge."

When is a Kostengutsprache required?

Not every treatment needs prior authorization. It is typically required for:

• Expensive medications (especially biologics, cancer drugs, or off-label prescriptions)
• Certain surgeries (especially elective or complex procedures)
• Rehabilitation and inpatient psychiatric stays
• Long-term physiotherapy beyond the initial 36 sessions
• Out-of-canton hospital stays (when not an emergency)
• Dental treatment covered by KVG (rare, specific exceptions)
• Some specialist referrals in gated insurance models

Who submits the request?

Your doctor or hospital submits the Kostengutsprache request to your insurer — not you. They include the medical justification, proposed treatment plan, and estimated costs. You may need to sign a consent form, but the administrative work is done by your healthcare provider.

How long does it take?

Insurers typically respond within a few business days to two weeks, depending on complexity. For urgent cases, an expedited process exists. If your insurer does not respond within a reasonable time, the treatment may proceed and the insurer is considered to have tacitly approved.

What happens if it is denied?

If the Kostengutsprache is denied:

• The treatment may still happen — but you risk paying the full cost out of pocket
• Your doctor can submit additional medical justification and request a review
• You can appeal the denial through your insurer's internal process
• If the internal appeal fails, you can escalate to the cantonal insurance court (Versicherungsgericht / Tribunal des assurances) at no cost for claims under CHF 20,000

Common situations requiring Kostengutsprache

• Long-term physiotherapy: KVG covers 36 sessions per prescription. Beyond that, your physiotherapist must request a Kostengutsprache for continued treatment
• Psychiatric inpatient stays: Especially for stays longer than a few weeks
• Expensive biologics: Medications costing thousands of francs per dose often require pre-approval
• Out-of-canton hospitals: If you choose a hospital outside your canton for non-emergency reasons, prior authorization is often needed
• Rehabilitation: Post-surgery or post-accident rehab programs typically need a Kostengutsprache