The Medical Adviser is an impartial medical doctor responsible for determining which treatments may or may not be authorized for reimbursement. All submissions are treated with strict confidentiality, and the Medical Adviser is the sole authority in making medical decisions. Each case is evaluated exclusively from a medical perspective.
The Medical Adviser reviews your medical documents, quotations, and other relevant documentation to assess a given treatment you wish to undergo, particularly regarding its efficiency and duration, as well as the cost share that could be covered by UNSMIS.
Decisions are based on the criteria of effectiveness, appropriateness and usual, reasonable and customary charges (URC) of the treatment.
Although most treatments do not require prior authorization, there are specific cases where it is mandatory. These include long-term hospitalization, long-term nursing care, dependency benefits, laser procedures, detoxification, weight loss, and infertility treatments. For a comprehensive list, please consult Annex III of the Internal Rules for further guidance.
If a benefit is marked with ‘Yes’ in the “prior authorization” column, then prior authorization must be obtained before proceeding. You can request this by submitting a detailed medical report along with the proposed treatment plan to medrepunsmis@un.org.
As stipulated in Annex III of the UNSMIS Internal Rules, authorization must be secured in advance for any treatment requiring it. Failure to do so may result in the expense not being reimbursed.
Prior to any medical treatment, surgery or purchase that, pursuant to our Internal Rules, is subject to prior authorization, it is essential to send us all relevant documentation (a prescription or referral, medical report, quotation, medical imagery, etc.) at least two weeks in advance. This obligation applies, among other things, in the cases of in-vitro fertilization (IVF), genetic tests, and any expensive treatment. In the USA, most planned treatments and examinations are subject to prior authorization. For details, consult 'Treatments in the USA'.
If any of the above is applicable in your case, the request for prior authorization must be sent to our Medical Adviser at medrepunsmis@un.org.
To prevent excessive billing and safeguard the financial solvency of the Fund, if the total cost of a treatment exceeds its average price in a wider comparison, it is advised to request a second opinion and quotation from another provider. Any lack of documentation risks delaying the final decision; therefore, it is essential to send all available, relevant documents to the Medical Adviser and for these to be clear and detailed.
The Medical Adviser will review your case and issue a final decision. The reimbursement of your treatment will be based on the amount authorized and the conditions specified by the Medical Adviser. The decision is made, and approval may be granted based on the documentation and information received beforehand.
In general, approvals are granted for a maximum duration of one year. However, based on the treatment and the medical condition, the length is often adjusted to a shorter period. For instance, the approved duration is determined on the basis of the doctor’s recommendation but does not fully align with it, as the Medical Adviser wants to first assess the effectiveness of a given medication. In such cases, it is possible that the Medical Adviser does not approve the prescribed duration, only a shorter trial period.
For IVF treatments, authorization is issued for two years. Additionally, IVF treatment must start before the age of 45.
When submitting your claim, it is important to attach the approval of the Medical Adviser, as well as all supporting documentation (including the prescription). Regardless of the duration of the prior authorization’s validity, it is essential to ensure that your prescription is still valid. Should your prescription expire while the prior authorization is still valid, a new prescription must be issued.
Should you decide to proceed with an unapproved treatment, all expenses must be covered by you. Similarly, if a treatment is approved but capped at a certain amount by the Medical Adviser, all additional costs will be borne by you.