A series of medical tests can be performed free of charge, based on a referral ticket issued by the family doctor or a specialist, at laboratories under contract with a health insurance company. The number and type of investigations are established following the consultation, depending on the patient’s situation, in compliance with the settlement conditions.
From preventive checkups to tracking chronic diseases, laboratory investigations are part of the services financed by health insurance. Access to them, however, requires compliance with some rules that differ depending on the purpose of the examination and the patient’s situation.
How many investigations can be entered on the referral ticket
The model provided in annex no. 1 to the Order of the Ministry of Health and CNAS no. 2.168/502/2023, as amended, contains 15 positions for recommended investigations. The same number of columns appears on the form dedicated to prevention.
They are completed by the doctor, based on an initial consultation and according to the recommendation. Their existence does not mean that they must all be occupied, nor that the patient can choose any 15 tests from the list of settled services.
For prevention, there are also recommendations that require separate documents: when both laboratory analyzes and radiological or imaging examinations are indicated, separate referrals are issued. The instructions call for a separate ticket for each imaging investigation.
Which medical tests can be settled by the health insurance company
The basic package for outpatient paraclinical services includes hematology, biochemistry, immunology and microbiology tests, as well as cell and tissue examinations. Investigations are granted under the conditions provided for each service, based on medical recommendation. Inclusion in the nomenclature does not mean that any patient can perform the entire list for free.
Blood count and coagulation tests
Included in the category of hematology tests are the complete blood count, reticulocyte count, cytological examination of the blood smear and ESR. The blood count includes several parameters, including hemoglobin, hematocrit, and the number of red blood cells, white blood cells, and platelets. The list also includes the determination of the ABO and Rh blood group in pregnant women, as well as the identification of specific anti-Rh antibodies.
Analyzes for blood glucose, cholesterol and assessment of renal function
Biochemical investigations include blood glucose, total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides. The oral glucose tolerance test, known as TTGO, can also be included, respectively glycated hemoglobin, HbA1c, for which there are specific conditions of recommendation and settlement.
For the assessment of renal function and substances eliminated through urine, the nomenclature provides urea and serum creatinine, the latter with an estimate of glomerular filtration rate, as well as serum uric acid.
Complete urinalysis consisting of sum and sediment, urinary protein dosage, urinary albumin, albumin/creatinine ratio, glucose and urinary creatinine can be settled. The same category includes total serum protein, protein electrophoresis, and serum albumin.
Enzymes, vitamins and iron determinations
The list of countable analyzes includes total and direct bilirubin, transaminases TGO and TGP, gamma GT and alkaline phosphatase. Included are creatine kinase (an essential enzyme the body uses to make energy in muscles and other tissues), serum alpha-amylase, serum lipase, and lactate dehydrogenase, also called LDH—an intracellular enzyme present in almost all tissues of the body, with high concentrations in the heart, liver, muscles, kidneys, brain, and lungs.
To investigate iron metabolism, sideremia, ferritin and serum transferrin are provided. The package also includes the dosage of vitamin B12 and folic acid.
Hormonal and immunological analyses
In the category of immunology and immunochemistry are TSH and FT4, used in the evaluation of the thyroid, as well as antibodies against thyroperoxidase, known as ATPO. Included are parathyroid hormone, FSH, LH, cortisol, testosterone, estradiol, progesterone, and prolactin.
The nomenclature also includes C-reactive protein, rheumatoid factor and immunoglobulins IgG, IgA, IgM and IgE. For the evaluation of the prostate, PSA and its free fraction, free PSA, are provided, in compliance with the specific recommendation conditions.
Tests for infections
Determination of IgM anti-HAV antibodies, HBs antigen and anti-HCV antibodies can be settled, as well as HIV testing in pregnant women, under the conditions established by the rules. The list includes ASLO, VDRL or RPR tests, TPHA confirmation and Helicobacter pylori antigen determination.
Microbiological examinations include bacteriological analysis of pharyngeal exudate for beta-hemolytic streptococci of groups A, C and G, pharyngeal fungal examination, urine culture, coproculture and coproparasitological examination.
Microscopic examinations and cultures of vaginal secretions, cultures of cervical secretions, as well as tests for Streptococcus agalactiae in pregnant women are provided. The same category includes examinations from urethral, otic and conjunctival secretions, nasal exudate and bacteriological or fungal analyzes from purulent collections.
Test for the detection of occult hemorrhages
The CNAS norms also provide for the quantitative immunological test for the detection of occult hemorrhages in faeces. The settlement of the service is linked to the reporting conditions established for colorectal cancer screening.
What conditions accompany the list of deductible analyses
Referral rights differ by investigation. Some examinations can be prescribed by the family doctor, while others require a certain specialty, a precise medical indication or the fulfillment of additional criteria.
For example, TPHA confirmation is settled in the case of a positive result at VDRL or RPR, and the blood smear has conditions related to the change in the parameters of the blood count.
For people already diagnosed with diabetes, the periodic evaluation by HbA1c also follows the rules of the national programs. These provisions must be checked together with the doctor’s recommendation and the services for which the laboratory has a contract.
Where the tests can be done free of charge
For insured persons, the referral must be issued by a family doctor or a specialist who works in a contractual relationship with the insurance company. In turn, the chosen laboratory must have a contract for the recommended examinations.
The patient can call on a provider under contract with any insurance company, regardless of the one with which the prescribing doctor works.
There are also situations in which uninsured people benefit from settled investigations, including prevention, confirmation of an oncological suspicion and certain tests for hepatitis B and C or HIV in pregnant women. Each category has its own access conditions.
How many times per year can a Romanian receive a referral ticket for free analyses
“The referral ticket is not given at the request of the patient, but following a medical evaluation. The moment a person comes to the office, a consultation is made, and the doctor finds that he needs medical tests. At that time, he receives a referral ticket specific to his needs.
Also, if the medical staff finds that a patient also needs other medical investigations (to establish a clear diagnosis), then the analyzes can be supplemented.
There are no limitations on the issuance of a referral ticket
If a doctor finds, for example, this month, that more investigations are needed to establish a disease (other symptoms appear in the meantime, after the first analyzes have been done), then he can issue another referral ticket next month as well,” doctor Sandra Alexiu, president of the Bucharest-Ilfov Association of Family Doctors, explained to Digi24.ro
What is the validity of a doctor’s referral ticket?
“The validity of the referral ticket depends, first of all, on its type. If we are talking about a referral ticket to diagnose an acute or subacute illness, the validity is 30 days.
If we are talking about a referral ticket to diagnose a chronic disease/monitor a chronic disease, the validity is 90 days,” the specialist doctor also specified
There are several types of tickets
“The family doctor can do it referral ticket for preventive analysesfor the usual ones to which each patient is entitled once a year. They are a specific number of analyzes depending on the age group, the type of patient (it differs from man to woman or children).
Another referral ticket that we (family doctors) can prescribe is when we suspect a disease and then specific tests are needed to help us with a diagnosis. This is one referral ticket for paraclinical investigations (here we can mention analyzes or x-rays, Papanicolaou test, or for the osteoporosis exam, ultrasounds, etc.).
And there is one more referral ticket in which we request an interdisciplinary consultationin which, in order to elucidate a diagnosis or to establish a degree of evolution, we can send the patient to a consultation with a specialist doctor (for example: a patient with hypertension must be sent to the cardiologist for further investigations)”, said the doctor Sandra Alexiu
Referral tickets for uninsured people in the health system
“There are provisions that allow us, family doctors, to issue a referral ticket for medical investigations and to people who are not insured in the health system (uninsured people).
More precisely, if we suspect the presence of viral hepatitis or if we suspect an oncological condition, we can issue a ticket to request an oncological examination or an infectious disease examination (the ticket has a special section for uninsured people)”, concludes the doctor.
What documents do you need to benefit from analyzes settled by CNAS
- Referral ticket for the recommended services (issued by the family doctor/specialist, as the case may be);
- Identity card. For the minor patient, younger than 14 years old, the birth certificate is required;
- Insurance card or, as the case may be, insurance certificate;
- Other documents, as appropriate, depending on the doctor’s recommendation (eg: recent analysis report).
