Approved
Approved
International Process Guidelines
Sickness
S_BUC_08 – Scheduled treatment -Request Entitlement Document in Member State of Stay (Residence not in competent Member State)
Date: 11/09/2018
Version of guidelines document: v4.1.0
Based on: S_BUC_08 version 4.1.0
Common Data Model version 4.1.0
TABLE OF CONTENTS
S_BUC_08 – Scheduled treatment -Request Entitlement Document in Member State of Stay (Residence not in competent Member State) 4
How to start this BUC? 5
What is my role in the social security exchange of information I have to complete? 5
CO.1 Who do I need to exchange information with? 5
CO.2 How do I identify the correct institution to exchange information with? 5
CO.3 How do I proceed after having identified the Counterparty? 5
CO.4 How do I proceed after having received the ‘Request for Medical Information' SED 120? 6
CO.5 How do I proceed after having received the ‘Reply to request for Entitlement Document - scheduled treatment outside Member State of residence ' SED S010? 6
CP.1 What should I do if I have received the ‘Request for entitlement document - scheduled treatment outside Member State of residence’ SED S009? 6
BPMN diagram for S_BUC_08 8
Structured Electronic Documents (SEDs) used in the process 8
Portable Documents 8
Administrative sub-processes 8
Horizontal sub-processes 8
Document history:
Revision
Date
Created by
Short Description of Changes
V0.1
23/05/2017
Secretariat
First draft of the document submitted for review to the Sickness Ad Hoc group
V0.2
27/06/2017
Secretariat
Second version of document with comments from AHG integrated
V0.3
02/08/2017
Secretariat
Modifications to take into account:
-The change request EESSI-1849: S075 and S076 are replaced by Horizontal SEDs
-The change request EESSI-1798: Added sub-process AD_BUC_07 'Reminder'.
Version submitted for AC review.
V0.4
20/09/2017
Secretariat
Implemented changes and updates following the AC comments.
V0.99
05/10/2017
Secretariat
Implemented changes and updates following the AC review. Version submitted for AC approval.
V1.0
14/11/2017
Secretariat
Version approved by AC.
Including the comment received from Finland about the description of the Case Owner role.
V4.1.0
11/09/2018
Secretariat
Performed patch changes to reference the new CDM version 4.1.0
S_BUC_08 – Scheduled treatment -Request Entitlement Document in Member State of Stay (Residence not in competent Member State)
Description:
An insured person/pensioner (claimant) who does not reside in the competent Member State requests for an authorisation for a scheduled treatment outside the Member State of residence from the institution of his/her place of residence. If this institution determines it is not competent to issue the authorisation, it uses this BUC as a Case Owner to forward the authorisation request to the competent institution (Counterparty). This competent institution subsequently decides whether the authorisation is granted or not, it issues a portable document S2 to the person concerned and informs the institution of the Member State of residence of its decision.
The conditions for applying this BUC are:
The insured person stays outside the residence Member State and outside the competent Member State;
The competent Member State is mentioned in ANNEX IV of Regulation (EC) 883/2004 (the Member States currently listed there are: Belgium, Bulgaria, Czech Republic, Germany, Greece, Spain, France, Cyprus, Luxemburg, Hungary, Netherlands, Austria, Poland, Slovenia and Sweden, as well as Iceland, Liechtenstein and Switzerland);
The institution of the Member State of residence is not competent for issuing an authorisation (i.e. the Member State of residence is not mentioned in ANNEX 3 of Regulation (EC) 987/2009).
As the request is individualised, this business use case can concern only one person.
Legal Base: This Business Use Case document's legal base is described in the following Regulations
Basic Regulation (EC) No 883/2004
Implementing Regulation (EC) No 987/2009
The following matrix specifies the SEDs that are used in this Business Use Case and documents the articles that provide the legal basis for each SED.
Basic Regulation No 883/2004
Implementing Regulation No 987/2009
SED
20
26
S009 - Request for entitlement document - scheduled treatment outside Member State of residence
S010 - Reply to request for Entitlement Document - scheduled treatment outside Member State of residence
Request – Reply SEDs:
The following table specifies the SEDs that have a logical pairing to one another, usually this is known as a request-reply pair.
REQUEST SED
REPLY SED(s)
S009 - Request for entitlement document - scheduled treatment outside Member State of residence
S010 - Reply to request for Entitlement Document - scheduled treatment outside Member State of residence
Glossary of relevant terms used in S_BUC_08:
Term used
Description
Case Owner
In this BUC the Case Owner is Institution of the Member State of Residence to which the insured person/pensioner is requesting the authorisation.
Counterparty
In this BUC The Counterparty is the Institution of the competent Member State entitled to grant an authorisation to receive an appropriate treatment.
How to start this BUC?
In order to help you understand S_BUC_08 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 the Member State of residence and the insured person or his/her care provider requests you for entitlement document (portable document S2) to receive the treatment, your role will be defined as Case Owner.
I am the Case Owner. (step CO.1)
If you are the institution that receives a 'Request for entitlement document – scheduled treatment’ SED S009 from an institution of another Member State of stay where the insured person is receiving an appropriate (scheduled) treatment, in order to inform that institution on the decision to grant an authorisation to receive an appropriate treatment, 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 in any new request for entitlement document – scheduled treatment will be to identify the responsible Member State that you need to exchange information with. The second step is to identify the relevant institution in this Member State that is responsible for the information you require. In this Business Use Case, the institution can be chosen only among the institutions responsible for health insurance. This activity will define the Counterparty you will be working with in the gathering of information. There can only be one Counterparty in this Business Use Case.
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 another Member State 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)
CO.3 How do I proceed after having
identified the Counterparty?
Request the authorisation of the scheduled treatment outside the Member State of residence by filling out and sending the ‘Request for entitlement document - scheduled treatment outside Member State of residence’ SED S009 to the identified Counterparty.
Make sure to enter in the SED the information supporting the request and attach all the relevant medical data files (medical report, treatment options, medical evaluation/examination by a medical officer, etc.).
This will determine the Counterparty to consider the request, decide on the authorisation and reply with the decision by filling out the ‘Reply to request for Entitlement Document - scheduled treatment outside Member State of residence’ SED S010 and sending it back to you.
Optionally, the Counterparty may use the sub-process H_BUC_08 'Medical Information' and a H120 Request for Medical Information to you, before replying with a SED S010.
I have received SED S010 from the Counterparty. (step CO.5)
I have received SED H120 from the Counterparty. (step CO.4)
Sub-process steps available to the Case Owner at this stage:
I want to send reminder in order to receive Information expected and not yet received (AD_BUC_07).
CO.4 How do I proceed after having received the ‘Request for Medical Information' SED 120?
After you have received SED H120 from the Counterparty, you need to
fill in the H121 'Reply/Notification for Medical Information' SED by entering the requested additional information, and send the SED H121 to the Counterparty.
Upon receiving the SEDH121, the Counterparty can continue to answer your request in SED S009 by filling in the S010 and send it to you.
I have received SED S010 from the Counterparty. (step CO.5)
CO.5 How do I proceed after having received the ‘Reply to request for Entitlement Document - scheduled treatment outside Member State of residence ' SED S010?
After you have received the SED S010 from the Counterparty, you are informed of the decision of the Counterparty. The international Business Use Case ends here.
You will have to inform the insured person, or the care provider of the decision according to your national procedures.
Sub-process steps available to the Case Owner at this stage:
I want to request ad-hoc information from the Counterparty (H_BUC_01).
CP.1 What should I do if I have received the ‘Request for entitlement document - scheduled treatment outside Member State of residence’ SED S009?
If you have received a SED S009 from the Case Owner, please verify if it is possible for you to take a decision on the request for authorisation for a scheduled treatment outside the Member State of residence.
If you have sufficient information to make the decision and after the decision was taken, you need to reply to the request by filling out and sending a ‘Reply to request for Entitlement Document - scheduled treatment outside Member State of residence’ SED S010 to the Case Owner. You need to specify details of the decision taken, whether the authorisation was granted or not, together with the information supporting the decision. You can optionally attach the entitlement document.
If you need additional information on the scheduled treatment, you have to use the sub-process H_BUC_08 'Medical Information' fill in H120 Request for Medical Information to request the medical report, and send the SED H120 to the Case Owner.
In response to your SED H120, you expect to receive a H121 Reply/ Notification for Medical Information from the Case Owner.
Once you received the additional information, you can reply with completing SED S010. The business use case ends here.
Sub-process steps available to the Counterparty at this stage:
I want to forward the case to another Competent Institution in my Member State (AD_BUC_05).
I want to request ad-hoc Information from the Case Owner (H_BUC_01).
I want to request Medical Information from the Case Owner (H_BUC_08).
I want to send reminder in order to receive Information expected and not yet received (AD_BUC_07).
BPMN diagram for S_BUC_08
Click here to open the BPMN diagram(s) for S_BUC_08.
Structured Electronic Documents (SEDs) used in the process
The following SEDs are used in S_BUC_08:
S009 - Request for entitlement document - scheduled treatment outside Member State of residence
S010 - Reply to request for Entitlement Document - scheduled treatment outside Member State of residence
Portable Documents
The following Portable Document (PD) is relevant for S_BUC_08:
PD S2 – Entitlement to scheduled treatment
Administrative sub-processes
The following administrative sub-processes are used in S_BUC_08:
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
Horizontal sub-processes
The following horizontal sub-process is used in S_BUC_08:
H_BUC_01_Subprocess – Ad-hoc Exchange of Information
H_BUC_08_Subprocess – Ad-hoc Medical Information