SED guideline DA016 – Contestation of individual claim – benefits in kind (COC) v4.3.4

EESSI – CDM 4.3 AWOD-Accidents at Work and Occupational Diseases DA016-v4.3.4 Contestation of individual claim – benefits in kind (COC) SED Guidelines Document Control Information Document Control Value Project Title Electronic Exchange of Social Security Information (EESSI) Document Name DA016-v4.3.4 Document Category SED guidelines Revision CDM Package CDM 4.3.4 Last Update Project Milestone 30/04/2024 EESSI - 2024 Document Status Final Sensitivity (TLP) Distribution terms Traffic Light Protocol (TLP) = “GREEN” The distribution of this document is done strictly in line with the Traffic Light Protocol (TLP) established by the European Commission's note AC 790/15 REV for the EESSI project documentation. In line with the note AC 790/15 REV, this document is labelled as TLP = “Green”. Therefore, it can be circulated widely within the EESSI community. However, the document or the information herein may not be published or posted on the Internet, nor released outside of the EESSI community. Connected/Embedded Files None Authors European Commission, DG EMPL A4, EESSI BA Revised by European Commission, DG EMPL A4, EESSI BA Approved by European Commission, DG EMPL A4, EESSI PMO Document history Milestone / Component version Publication Date Changes/Corrections Description v4.3.4 30/04/2024 Implementation of change request EESSI-11699 by updating the 05 and 06 paragraphs for the scenario when the period of benefits is not (fully) covered by one single entitlement document but instead is fully covered by a subsequent entitlement document. Also corrected minor typos and added the Document history table. DA016 – Contestation of individual claim – benefits in kind (COC) Purpose of the SED: The SED DA016 is used to send a contestation for a claim. - DA016 cannot be sent for claims which were already withdrawn by the Creditor Liaison Body (Case Owner) with the 'Credit Note – benefits in kind (CRN)'- SED DA012; - DA016 cannot be sent after 18 months of the end of the end of the month during which the claims were introduced to the liaison body of the debtor Member State; - DA016 can be sent several times and it is possible also to contest only part of the individual claim,; - For both partial and full contestations, a new contestation for the same individual claim can be submitted only after having received an answer for the first one. And the answer should be sent only once. In the new contestation of the same individual claim a different benefit can be contested each time. Example: An individual claim can be contested partially: - A given benefit A contested cannot be contested again before receiving an answer to the contestation of benefit A; - A benefit B which was not contested in the same individual claim can be still contested after receiving the answer to the contestation of benefit A. - After a contestation was sent, no payment of the individual claim is allowed until the contestation has been settled by both parties; - DA016 can be issued even after the process has been finalized and information on payment has been received, however only within the deadlines specified in the regulations. A Claim may be rejected and returned to the creditor if for example: - It is incomplete and/or incorrectly filled out; - concerns benefits which have not been given within the validity period of the entitlement documents used by the recipient of the benefits; - there are reasonable grounds to suspect abuse. A claim may not be rejected on the grounds that the person has ceased to be insured with the institution which has issued the entitlement document, provided that the benefits were given within the validity period of the documents used. Acronyms used in DA016: - CLA – claim for reimbursement - COC – contestation of a claim Reimbursement SEDs includes 2 parts: global and individual. Global part of DA016 includes following mandatory fields: - Reference numbers: - “Global CLA reference Creditor Liaison Body” – a reference number of the claim specified in the DA010, which should be copied without any change; - “Global COC reference Debtor Liaison Body” – a reference number of the contestation for a claim which allows to identify the contestation in the next steps of the exchange and in any future communication (links the SEDs). It is a unique number for given contestation and is repeated subsequently in the following SEDs at the global and at the individual level of SED. - Total number of individual contestations – which summarizes the number of individual contestation and should be equal to the number of repeated (P) individual parts; - Total amount of contestations – which summarizes the amounts of the contested claim which are specified in each individual claim; - Date of submission – with a date on which DA016 is submitted by the Debtor Liaison Body (Counterparty). This information sets the deadline for the final settlement of the disputed claims – any disputes concerning a claim shall be settled at the latest within 36 months following the month in which the claim was introduced. Individual part of DA016, which can be repeated (P), allows to provide information about contestation for each individual claim and includes following mandatory fields: - ID Creditor / Debtor Institution – copied from DA010 – with identification data (Institution ID, institution name) either of the institution of the place of residence / stay which provided benefits and requested reimbursement (Creditor) or the competent institution which issued entitlement document and is responsible for covering the cost of the benefits (Debtor); - References – a set of references which allows to identify the COC on global and individual level and connect it with the previous SEDs, including: - “Global CLA Reference Creditor Liaison Body” – a reference number of the claim specified in the DA010, which allows to link individual COC with the original global claim (DA010) and should be copied without a change; - “Global COC Reference Debtor Liaison Body” – a reference number of the COC specified in the global part of DA016 which allows to link individual contestations with the global part of DA016 and should be copied without a change; - “Individual CLA Number Creditor Liaison Body” – a reference number of the individual claim specified in the individual part of DA010 which allows to link the individual COC (DA016) with individual claim (DA010) and should be copied without a change; - “Individual COC Number Debtor Liaison Body” - a reference number of the individual COC which allows to identify the contestation in the next steps of the exchange and in any future communication (links the SEDs). It is a unique number for given individual contestation and is repeated subsequently in the following SEDs at the individual level of SED. - Person receiving benefits – copied from DA010 – information about the person who received the benefits in kind; - Reasons for contestation – with a list of predefined reasons: - 01 – This document does not concern us – should be chosen if the claim is issued for the incorrect institution; - 02 – Institution code is incorrect. Please provide correct institution ID – should be chosen if the institution ID provided in the individual part of a claim does not allow to identify the competent institution; - 03 – Unable to identify the person from the information provided. Please check the data – should be chosen if, based on the personal data for the person who received the benefits in kind, the person cannot be identified; - 04 – Entitlement documents is unknown or not found. Please provide copy – should be chosen if the entitlement document mentioned in DA010 cannot be found by the competent institution; - 05 – The period of benefits in kind is not covered by the entitlement period – should be chosen if the entitlement document mentioned in DA010 does not cover the period of the provided benefits; Even if the contestations reason is fulfilled, the debtor institution should check the entitlement of the person concerned and, in case an entitlement document has been issued for the person concerned and covers the period of benefits, not contest the individual claim; - 06 – The period of benefits in kind is partially covered by the entitlement period - should be chosen if the entitlement document mentioned in DA010 does not cover the whole period of the benefits; Even if the contestations reason is fulfilled, the debtor institution should check the entitlement of the person concerned and, in case an entitlement document has been issued for the person concerned and covers the period of benefits, not contest the individual claim; - 07 – Person was not insured during benefits period. Please provide copy of entitlement document – should be chosen if the person was not insured in the time when benefits were provided and the benefits can be reimbursed only of if the person has presented a valid entitlement document in order to get benefits; - 08 – The person died on [date should be filled in] – should be chosen if the period of benefits for which reimbursement is requested exceeds date when person died. Date has to be provided; - 09 – The benefits do not concern an accident at work – should be chosen if the benefits provided are not related to an accident at work. Details of the contestation have to be provided if this reason was chosen; - 10 – The benefits do not concern an occupational disease – should be chosen if the benefits provided are not related to an accident at work. Details of the contestation have to be provided if this reason was chosen; - 11 – Total amount of claim different to the sum of individual claims – should be chosen if the total amount specified in global part of the DA010 does not correspond to the amounts specified in the individual parts; - 12 – Total amount of individual claim different to the sum of the benefits – should be chosen if the total amount of individual claim specified in individual part of the DA010 does not correspond to the sum of all mentioned benefits; - 13 – Double invoice – should be chosen if individual claim has been already requested to be reimbursed; - 14 – Overlapping of hospitalisation periods, please check – should be chosen if the periods of hospitalisation mentioned in individual part of DA010 are overlapping; - 15 – Lack of information about the other benefits provided. Please specify – should be chosen if description of the other benefits is missing or is insufficient. Reference number of the global CLA and individual CLA number of the duplicated claim have to be provided; - 16 – Cost of benefits have been refunded in full or partially to the insured person – should be chosen if the cost of benefits was paid by the person and already refunded. Details of the contestation have to be provided if this reason was chosen; - 17 – Claim introduced after deadline [date should be filled in] – should be chosen if the claims are introduced later than within 12 months of the end of the calendar half-year during which those claims were recorded in the accounts of the creditor institution. . Date on which claim was introduced has to be provided; - 99 - Other [field Other should be filled in] – should be chosen if none of the reasons available is applicable and it is a free text field. If this reply is chosen details about the other reason must be provided in the free text field; It is possible to choose only one reason among the ones available. - Amount of individual contestation - the amount of contested claim. This amount can be either equal to the amount of the individual claim specified in DA010 or only partial if the contestation is issued only for part of the claim. This amount is being summarized in the Total amount of contestations in the global part. It is possible to add attachments to DA016. Especially the proof to support the reasons for contestations. All attachments supporting the reply must be attached to the individual part of the SED. An attachment that is not correctly referenced to a specific individual part might not be handled properly. For general remarks applicable to all the AWOD SEDs click here. Note that: In order to see the content and explanatory notes of SED DA016 please click here.