Reasons for refusal to grant prior authorisation

The competent health authority may refuse to grant prior authorisation in the following cases:

a) Where the benefit in question is not included in the National Health System's common portfolio of services or, as appropriate, in the corresponding regional authority's complementary portfolio or the conditions under which it is meant to be provided have not been met.

b) Where the patient will, according to a clinical evaluation, be exposed with reasonable certainty to a patient-safety risk that cannot be regarded as acceptable, taking into account evidence of the potential benefit for the patient of the sought cross-border healthcare.

c) Where the general public will be exposed with reasonable certainty to a substantial safety hazard as a result of the cross-border healthcare in question.

d) Where the benefit is provided by a healthcare provider that raises serious and specific concerns with respect of the standards and guidelines on quality of care and patient safety.

e) Where the healthcare can be provided on national territory within a time limit that can be justified on medical grounds.

In order to decide which time limit can be considered as justifiable on medical grounds, an individualised clinical evaluation shall be conducted taking into account each patient's state of health, the possible development of his disease, the degree of the his pain or the nature of his disability at the time when the request for authorisation is made.

In addition, the time limits set forth in Royal Decree 1039/2011 of 15 July establishing the framework criteria to ensure maximum time limits to gain access to the National Health System's healthcare benefits and the rules guaranteeing current waiting times in each regional authority shall be taken into account.

Prior Authorisation                                                                               Health benefits subject to prior authorisation

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