This article explains what a pre-existing condition inquiry is, under what circumstances Personio Payroll automatically submits a request to the health insurance provider, and how you can view it in the Compliance tab.

What is a pre-existing condition inquiry?

If an employee falls ill, the employer is required under § 3 (1) of the EFZG to continue paying wages for up to six weeks. However, if the illness is the same as that which caused a previous period of incapacity for work, those periods may be combined under certain circumstances. As a result, the entitlement to continued pay for the relevant period may be reduced. 

Since the employee is not required to disclose the diagnosis of the illness to the employer, the employer is generally unable to review whether previous absences should be counted as pre-existing conditions toward the actual inability to work. In this case, the employer may request information from the applicable statutory health insurance provider to determine whether there are any periods of pre-existing conditions that can be taken into account. This process is referred to as a pre-existing condition inquiry and is conducted electronically via the EEL reporting procedure using submission reason 41.

Note
The health insurance provider only provides information on whether and to what extent periods of pre-existing conditions are to be taken into account. The diagnosis is not reported to the employer.

When can periods of pre-existing conditions be taken into account?

Previous periods of sick leave may be counted toward the actual period of continued pay only if the employee has not accrued a new entitlement to continued pay. A new entitlement arises when

• the employee was able to work for at least six months prior to becoming unable to work again due to the same illness, or
• a period of twelve months has elapsed since the onset of the first period of incapacity for work resulting from the same illness. 

If none of the above applies, previous periods of incapacity for work due to the same illness may be taken into account when calculating the actual continued pay. 

Only periods of incapacity for work attributable to the same underlying medical condition may be credited. Since the employer is not aware of the diagnosis, they cannot conduct this examination on their own and must therefore contact the health insurance provider.

Manage Pre-existing Conditions in Personio Payroll

Requirements for an Automatic Pre-existing Condition Inquiry

Personio Payroll automatically sends a pre-existing condition request to the health insurance provider if all of the following conditions are met:

1. The employee has statutory health insurance. People with private health insurance and those in marginal employment are exempt from the electronic EEL procedure. 
2. An (electronic) certificate of incapacity for work has been submitted for the actual absence.
3. During the six months prior to the onset of the actual work disability, there was at least one certified pre-existing condition. 
4. The cumulative number of calendar days for all potential pre-existing conditions over the past twelve months, combined with the actual period of incapacity for work, totals at least 42 calendar days.

This request can be made regardless of the reason for the absence (illness, accident, rehabilitation, etc.). The key factor is whether a connection to a previous illness can be considered. 

A request may be made only after the necessity has been assessed on a custom basis. Personio Payroll automatically checks authorization before sending.

Processing Pre-Existing Condition Inquiries in Personio Payroll

Personio Payroll automatically handles the entire process of requesting information on pre-existing conditions: 

1. As soon as an absence is recorded under the "Sickness" category and the above requirements are met, Personio automatically checks whether an EEL contribution statement needs to be created. 
2. Personio Payroll sends the request to the employee's health insurance provider.
3. The health insurance provider reviews the submitted sick leave certificates and diagnoses to determine whether past absences were due to the same underlying condition.
4. The health insurance provider sends its results back to Personio Payroll within 14 days.
5. You can view the results under Payroll > Compliance.

Health Insurance Review

To review whether periods of incapacity for work are related or not, the health insurance provider needs the diagnoses for all affected periods of incapacity for work. If not all sick leave certificates are existing, the health insurance provider may request them directly from the insured person or the treating physician's office.

Once all the certificates have been submitted, the health insurance provider reviews the diagnoses to determine whether the pre-existing conditions are attributable to the same underlying condition. This assessment cannot be performed automatically, since identical diagnoses do not necessarily correspond to the same underlying condition.

Response from the health insurance company

For each pre-existing condition that has been reviewed, the reported data set contains the following information:

• Whether a sick leave certificate is available for the period prior to the onset of the illness, and if so, for what specific period 
• Whether the reviewed sick leave period is eligible, ineligible, or only partially eligible.

Note
Due to data protection regulations, health insurance companies may only respond to inquiries about pre-existing conditions electronically via a certified payroll accounting program or the Social Security Reporting Portal. 

View inquiries about pre-existing conditions in the "Compliance" tab

All EEL notifications sent and received, including requests for prior medical history and responses from the health insurance provider, can be viewed in the "Compliance" tab in Personio Payroll. This involves the following steps:

1. Go to the Payroll > Compliance section.
2. Filter by income replacement benefits.

In the Compliance tab, you can view the following EEL contribution statements: 

• Pre-existing condition inquiries sent
• Responses from health insurance companies with the results of the review
• Canceled requests, provided that the underlying absence has been modified or deleted and no response has yet been received from the health insurance provider.

Manually Linking Pre-existing Conditions

In addition to the automatic pre-existing condition query, you can manually link two or more absences in Personio Payroll. This is useful for preventing overpayments, if necessary. 

A manual link is a good option when, 

• the health insurance provider has already confirmed the connection between the illnesses in a previous EEL-41 report, and you are now recording a subsequent absence,
• the employee has explained the connection between the medical conditions to you, and you do not wish to request the review again through your health insurance provider, or
• You want to ensure that the system correctly combines absences when calculating continued pay.

To manually link absences, follow these steps: 

1. Go to the Payroll > Compliance section.
2. Filter by income replacement benefits.
3. Click on "Check for Diseases."
4. Select the periods you want to link
5. Click on Confirm.

Note
Manual linking is available within the first 30 days of absence and does not trigger a pre-existing condition inquiry. Starting with the 43rd... On the day of absence, Personio Payroll automatically sends a pre-existing condition request to the health insurance provider—regardless of whether a manual link has been created. The pre-existing condition inquiry cannot be canceled. Once bookmarks have been saved, they cannot be changed or deleted later. If there is a variance in the health insurance provider's response compared to your manual link, the health insurance provider's response takes precedence, as it is the authoritative data source.

FAQ

For whom does Personio Payroll automatically submit a pre-existing condition inquiry?

Personio Payroll automatically submits a pre-existing condition request for employees with statutory health insurance who are not in marginal employment, provided that all requirements (certificate of sick leave, potential pre-existing condition within the past six months, at least 42 cumulative days of absence) are met.

When does an employee have a full entitlement to 6 weeks of continued pay despite previous illnesses?

An employee is once again entitled to full continued pay for six weeks if he or she was able to work for at least six months prior to the actual period of incapacity for work, or if twelve months have passed since the start of the first period of incapacity for work resulting from the same illness. In these cases, it is not possible to count periods of prior illness toward the total.

What happens when an absence is modified or deleted?

If an absence for which a pre-existing condition request has already been submitted is modified or deleted, Personio Payroll automatically cancels the associated request, provided that the health insurance provider has not yet responded. This cancellation is visible under Payroll > Compliance.

Does manually linking absences always trigger a new pre-existing condition request?

No. Manually linking the team calendar does not trigger a pre-existing condition request (EEL-41). The EEL-41 contribution statement is generated automatically starting on the 43rd day, regardless of whether a manual link has been created. Sick leave notice sent to the health insurance company. If there is a variance in the health insurance provider's response compared to the manual link, the health insurance provider's response takes precedence.

How long does it take for the health insurance company to provide a response?

The health insurance provider's time to respond is beyond Personio Payroll's control. This is usually between 14 days and 3 weeks. 

Does that also apply to the Core product or DATEV?

No. The automatic pre-existing condition query is a feature exclusive to Personio Payroll and is not available for preliminary payroll or DATEV customers.