approved
International Process Guidelines Accidents at Work and Occupational Diseases AW_BUC_01a - Certification right benefits in Kind - Member State of stay/residence requests confirmation of rights
Date: 12/09/2018 Version of guidelines document: v4.1.0 Based on: AW_BUC_01a version 4.1.0 Common Data Model version: 4.1.0
TABLE OF CONTENTS
AW_BUC_01a – Certification right benefits in Kind – Member State of stay/residence requests confirmation of rights.............................................................................................................................. 4 How to start this BUC? ............................................................................................................................ 6 What is my role in the social security exchange of information I have to complete?............. 6 CO.1 Who do I need to exchange information with? .............................................................. 6 CO.2 How do I identify the correct institution to exchange information with? ...................... 6 CO.3 How do I send the ‘Request for certification of the right to benefits in kind’ SED DA001? ..................................................................................................................................... 7 CO.4 What should I do if I have received the ‘Certification of the right to benefits in kind’ SED DA002?.............................................................................................................................. 7 CO.5 What should I do if the ‘Certification of the right to benefits in kind’ SED DA002 denies the right to benefits in kind?.................................................................................................... 7 CO.6 What should I do if the ‘Certification of the right to benefits in kind’ SED DA002 confirms the right to benefits in kind? .................................................................................... 7 CO.7 What should I do if I have received SED DA003? ............................................................ 8 CP.1 What should I do if I received a ‘Request for certification of the right to benefits in kind’ SED DA001? ..................................................................................................................... 8 CP.2 What should I do if I am not responsible for the business process? ............................... 8 CP.3 What should I do if I am responsible for the business process? ..................................... 8 CP.4 What should I do when it turns out that I must cancel the former decision made in the `Certification of the Right to Benefits in Kind´ SED DA002? .................................................... 9 BPMN diagram for AW_BUC_01a ......................................................................................................... 10 Structured Electronic Documents (SEDs) used in the process .............................................................. 10 Portable Documents .............................................................................................................................. 10 Horizontal sub-processes ...................................................................................................................... 10 Administrative sub-processes ............................................................................................................... 10
Guidelines for EESSI Business Use Case AW_BUC_01a – Certification right benefits in Kind - Member State of Date: September 2018 Document version: 4.1.0 2
Document history:
Revision Date Created by Short Description of Changes v0.1 07/04/2017 Secretariat First draft of the document submitted for review to the AWOD Ad Hoc group v0.2 09/05/2017 Secretariat Implement changes and updates following the AHG comments. Version submitted for AC review. v0.99 14/06/2017 Secretariat Implement changes and updates following the AC comments. Version submitted for AC approval. v1.0 12/07/2017 Secretariat AC approved version With minor formatting and clarification corrections v4.1.0 12/09/2018 Secretariat Performed patch changes to reference the new CDM version 4.1.0
Guidelines for EESSI Business Use Case AW_BUC_01a – Certification right benefits in Kind - Member State of Date: September 2018 Document version: 4.1.0 3
AW_BUC_01a – Certification right benefits in Kind – Member State of stay/residence requests confirmation of rights.
Description: The role of the AW_BUC_01a is to allow institutions in Member States to exchange information about the Claimant (person who is claiming the benefits) such as the insurance situation, and other details that the Institution in the Member State of Stay or Residence needs in order to decide about a claim for benefits in kind in respect of an accident at work or an occupational disease. The BUC can be used when: an insured person had an accident at work in Member State of stay or residence and it is necessary to confirm the rights of the person to benefits in kind; an insured person who stays in the Member State requires medical care with connection to an accident at work or an occupational disease, but the person does not have an entitlement document; an insured person who has a right to benefits in kind in respect of an accident at work or an occupational disease decided to reside in another Member State, but the person does not have an entitlement document. When the Business Use Case is successfully completed, the Institution of the Member State of stay or residence is informed whether the rights are granted and benefits will be reimbursed by the competent institution or not. Legal base: The legal basis of the AW_BUC_01a lies in Regulation No 883/2004 and in the Implementing Regulation No 987/2009. The following table specifies SEDs used in this BUC and documents the articles that provide the legal basis for each SED: SED Basic Reg (883/04) Implementing Reg (987/09) 17 19 20 36 36 36 24 24 25 26 33 33 (1) (1) (1) (2) (2a) (1) (2) (1) (1) (1) (2) DA001 Request for Certification of the Right to Benefits in Kind DA002 Certification of the Right to Benefits in Kind DA002 Certification of the Right to Benefits in Kind
Request-reply SEDs: REQUEST SED REPLY SED(s) DA001 - Request for certification of the right to DA002 - Certification of the right to benefits in kind benefits in kind
Glossary of relevant terms used in AW_BUC_01a: Term used Description Case Owner Institution of a Member State of stay or residence that requests for a document confirming the right of a person to benefits in kind in case of an accident at work or an occupational disease. Counterparty Competent Institution of the Member State that holds information about the claimant’s insurance situation and the person’s right to benefits in kind in case of an accident at work or an occupational disease. The Competent Institution of the Member State is entitled to confirm or deny the person’s Guidelines for EESSI Business Use Case AW_BUC_01a – Certification right benefits in Kind - Member State of Date: September 2018 Document version: 4.1.0 4
right to benefits in kind in case of an accident at work or an occupational disease. The Competent Institution of the Member State is allowed to send a cancellation document to the Case Owner if the person's right to benefits in kind has been cancelled. Claimant The Claimant is the insured person who stays or resides outside the competent Member State and claims for the benefits in kind in case of an accident at work or an occupational disease.
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How to start this BUC?
In order to help you understand the AW_BUC_01a we have created a set of questions that will guide you through the main scenario of the process as well as possible sub-scenarios or options available at each step along the way. Ask yourself each question and click on one of the hyperlinks that will guide you to the answer. You will notice that in some of the steps where it is allowed to use the additional horizontal and administrative sub-processes they will be listed under the step description. What is my role in the social security exchange of information I have to complete?
If you are the Institution of a Member State of stay or residence that is being requested to determine the proper right to benefits in kind in case of an accident at work or an occupational disease. In order to do so, you require information from another institution within another Member State. Your role will be defined as the Case Owner. I am the Case Owner. (step CO.1)
If you are the Competent Institution that receives a request for information from another Member State to assist in the processing of their national case, your role will be defined as the Counterparty. I am the Counterparty. (step CP.1)
CO.1 Who do I need to exchange information with?
As the Case Owner, your first step will be to identify the Counterparty by identifying the responsible Member State that you need to exchange information with. Then you have to identify the relevant Competent Institution in the Member State that is responsible for the information you wish to exchange. The institution can be chosen only among the institutions responsible for the accident at work and occupational disease sector. It is not possible to choose more than one institution. This activity will define the Counterparty you will be working with in the exchange of information. I need to identify the Counterparty. (step CO.2) I have identified the Counterparty I need to contact. (step CO.3)
CO.2 How do I identify the correct institution to exchange information with?
In order to determine the relevant Competent Institution from other Member State(s) you will need to consult the Institution Repository (IR). The IR provides an electronic record of all current and previous Competent Institutions and Liaison Bodies that have been responsible for the cross border coordination of social security information for each of the relevant Member States. Please note that the Liaison Body should be chosen only if it is impossible to identify the correct Competent Institution in the respective Member State or if the case is handled by the Liaison Body. To access the IR please use the following link. I have now identified the Competent Institution from the Member State I need to contact. (step CO.3)
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CO.3 How do I send the ‘Request for certification of the right to benefits in kind’ SED DA001?
Fill out the ‘Request for certification of the right to benefits in kind’ SED DA001 by entering all the required information. Afterwards, you send the SED DA001 to the Counterparty. As the request is individualized the case can concern only one person. SED DA001 is a request from your institution for a document confirming the right of a person to benefits in kind in case of an accident at work or an occupational disease. The SED DA001 is always sent from the Institution in the Member State of stay or residence to the Competent Institution of the Member State of the insured person. As an answer you should receive the ‘Certification of the right to benefits in kind’ SED DA002 from the Counterparty. I have received the SED DA002 from the Counterparty. (step CO.4)
Sub-process steps available to the Case Owner at this stage: I want to exchange additional information not foreseen in SED DA001 (H_BUC_01). I want to remind a Counterparty of a SED or information that it needs to send to me (AD_BUC_07).
CO.4 What should I do if I have received the ‘Certification of the right to benefits in kind’ SED DA002?
You have received the ‘Certification of the right to benefits in kind’ SED DA002, which is issued by the Competent Institution of the Member State with the required information about the insurance situation of the person in question. The SED DA002 can be sent either to confirm or to deny the right to benefits in kind. I have received SED DA002 and the person´s rights to benefits in kind in case of an accident at work or an occupational disease have been approved.(step CO.6) I have received SED DA002 and the person`s rights to benefits in kind in case of an accident at work or an occupational disease have been denied.(step CO.5)
Sub-process steps available to the Case Owner at this stage: I want to exchange additional information not foreseen in SED DA002 (H_BUC_01). I want to remind a Counterparty of a SED or information that it needs to send to me (AD_BUC_07).
CO.5 What should I do if the ‘Certification of the right to benefits in kind’ SED DA002 denies the right to benefits in kind?
Since only the Competent Institution is capable of deciding upon the validity of the claim, once you have received the Competent Institution’s decision to deny the right to benefits in kind in ‘Certification of the right to benefits in kind’ SED DA002 the international part of the process is over. You may need to inform the Claimant about this outcome according to your national procedures. The Business Use Case ends here.
CO.6 What should I do if the ‘Certification of the right to benefits in kind’ SED DA002 confirms the right to benefits in kind?
Once you have obtained the Competent Institution’s confirmation of the right to benefits in kind in the Guidelines for EESSI Business Use Case AW_BUC_01a – Certification right benefits in Kind - Member State of Date: September 2018 Document version: 4.1.0 7
‘Certification of the right to benefits in kind’ SED DA002, there is no further obligatory international exchange of information. You may need to process the confirmation and inform the claimant according to your national procedures. If you receive no further message from the Counterparty, this Business Use Case ends here. You are enabled to grant benefits in kind on behalf of the competent institution. However, it is possible that the Competent Institution has to cancel the right to benefits in kind at a later point in time and sends you a SED DA003 for this purpose. I have received a SED DA003. (step CO.7)
Sub-process steps available to the Case Owner at this stage: I want to exchange additional information not foreseen in SED DA002 (H_BUC_01).
CO.7 What should I do if I have received SED DA003?
If the person’s rights to benefits in kind in case of an accident at work or an occupational disease have been cancelled, you receive SED DA003. You are informed that benefits in case of an accident at work or an occupational disease cannot be granted any longer on behalf of the competent institution. The effective date of cancellation is the date I received SED DA003. The Business Use Case ends here.
CP.1 What should I do if I received a ‘Request for certification of the right to benefits in kind’ SED DA001?
The process is initiated by receiving the ‘Request for certification of the right to benefits in kind’ SED DA001 from the Case Owner. SED DA001 is a request from the Institution of the Member State of stay or residence for a document confirming the right of a person to benefits in kind in case of an accident at work or an occupational disease. First, you check if you are responsible for the business process in accordance with your national procedures. I am not responsible for the business process. (step CP.2) I am responsible for the business process. (step CP.3)
CP.2 What should I do if I am not responsible for the business process?
You have to forward the case to the competent Institution in your Member State using the 'Forward Case' sub-process AD_BUC_05
CP.3 What should I do if I am responsible for the business process? I received the ‘Request for certification of the right to benefits in kind’ SED DA001 from the Case Owner and I am responsible for the business process. You have to fill out the ‘Certification of the right to benefits in kind’ SED DA002, which is always issued by the Competent Institution of the Member State with information about the insurance situation of the person in question.
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You have to note that SED DA002 can be sent either to confirm or to deny a right to benefits in kind. You send SED DA002 as a reply to the Case Owner. Usually, the Business Use Case ends here. However, in some cases it may turn out later that you need to revoke an earlier decision to confirm a right to benefits in kind. If you have doubts if the legislation related to an accident at work or an occupational disease should apply in this case, you can dispute the application of this legislation by starting process AW_BUC_08 - Contestation of the application of the legislation related to accidents at work or occupational diseases. I want to cancel a former decision confirming a right to benefits in kind I want to dispute the application of the legislation related to an accident at work or and occupational disease, see AW_BUC_08 - Contestation of the application of the legislation related to accidents at work or occupational diseases
Sub-process steps available to the Counterparty at this stage: I want to exchange additional information not foreseen in the case-specific SEDs (H_BUC_01).
CP.4 What should I do when it turns out that I must cancel the former decision made in the `Certification of the Right to Benefits in Kind´ SED DA002?
If you have granted the person’s right to benefits in kind with the `Certification of the Right to Benefits in Kind´ SED DA002, but later the person insurance situation has changed and you have to revoke the right to benefits in kind, you need to send a cancellation. The `Cancellation of Certification of the Right to Benefits in Kind´ SED DA003 cancels the earlier SED DA002 confirming the person’s right to benefits in kind in case of an accident at work or an occupational disease. Only you can send a SED DA003 with regard to your prior decision. You fill out SED DA003 and send it to the Case Owner. In general, you do not receive a specific reply from the Case Owner. After revoking your earlier decision in this way, there is no need for further international exchange of information. The Business Use Case ends here.
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BPMN diagram for AW_BUC_01a
Click here to open the BPMN diagram(s) for AW_BUC_01a.
Structured Electronic Documents (SEDs) used in the process
The following SEDs are used in AW_BUC_01a:
• SED DA001 - Request for certification of the right to benefits in kind • SED DA002 - Certification of the right to benefits in kind • SED DA003 - Cancellation of certification of the right to benefits in kind
Portable Documents
The following Portable Document is used in AW_BUC_01a:
• DA1 – Entitlement to health care cover under insurance against accidents at work and occupational diseases
Horizontal sub-processes
The following horizontal sub-process is used in AW_BUC_01a:
• H_BUC_01_Subprocess: Ad hoc exchange of information
Administrative sub-processes
The following administrative sub-processes are used in AW_BUC_01a: • AD_BUC_05_Subprocess – Forward Case • AD_BUC_07_Subprocess - Reminder The following sub-processes are used for the handling of exceptional business scenarios that arise due to the exchange of social security information in an electronic environment and can be used at any point in the process: • AD_BUC_11_Subprocess – Business Exception • AD_BUC_12_Subprocess – Change of Participant
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