Why CPAM refuses reimbursements
Every refusal has a specific coded reason — visible on your relevé de remboursement on ameli.fr. The most common codes:
- "Hors parcours de soins coordonnés" — you saw a specialist without a referral from your médecin traitant
- "Médecin non conventionné" — the doctor you saw doesn't have a social security agreement (secteur 3)
- "Acte non remboursable" — the treatment isn't covered (cosmetic procedures, certain alternative medicine)
- "Prescription périmée" — you used a prescription more than 3 months old
- "Médecin traitant non déclaré" — you don't have a declared GP
When a refusal can be successfully challenged
Not all refusals are final. Strong grounds for challenge include:
- You were in a genuine medical emergency (documented)
- Your médecin traitant was unavailable and you can prove you tried to reach them
- You saw a "direct access" specialist (ophthalmologist, gynaecologist, psychiatrist for under-26s, dentist) — these never require referral
- You've just arrived in France and couldn't yet declare a médecin traitant
- CPAM made a calculation or coding error
How to file your appeal
Send a letter to your CPAM within 2 months of the refusal notice. Be factual and specific:
- State the date and details of the consultation
- Explain exactly why you couldn't follow the normal care pathway
- Attach any supporting evidence (attempted call to your GP, emergency documentation)
- Request reconsideration with specific reference to the circumstances
The Commission de Recours Amiable (CRA)
If your initial letter doesn't resolve the issue, escalate to the Commission de Recours Amiable — an internal review body at your CPAM. Request referral by recorded letter within 2 months of the initial refusal (or within 2 months of a rejected first appeal). The CRA has 2 months to decide.
Going to the social affairs tribunal
If the CRA upholds the refusal, you can take the case to the tribunal judiciaire (social affairs division) within 2 months. This is rarely necessary for individual consultation reimbursements, but for significant treatment costs it may be worthwhile.
💡 Prevention: Declare a médecin traitant on ameli.fr. Always ask your GP for a letter of referral (ordonnance de médecin traitant) before seeing a non-direct-access specialist. If your GP is unavailable, note the date and time — this is your documented justification for going directly.