APPROVED
International Process Guidelines Accidents at Work and Occupational Diseases AW_BUC_04b Information about supplement scheduled treatment
Date: 12/09/2018 Version of guidelines document: v4.1.0 Based on: AW_BUC_07c version v4.1.0 Common Data Model version: 4.1.0
TABLE OF CONTENTS
AW_BUC_04b – Information about Supplement Scheduled Treatment ................................................ 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 send the SED ‘Information on medically appropriate supplement to authorised scheduled treatment’ DA008?............................................................................... 6 CO.4 What should I do if I have received the ‘Authorisation to receive scheduled treatment in a Member State other than the competent Member State and the Member State of Residence’ SED DA007? ........................................................................................................... 6 CO.5 What should I do when it turns out that I must invalidate the request ‘Information on medically appropriate supplement to authorised scheduled treatment’ SED DA008? .......... 6 CP.1 What should I do if I received a ‘Information on medically appropriate supplement to authorised scheduled treatment’ SED DA008? ....................................................................... 7 CP.2 What should I do if I am responsible for the business process? ..................................... 7 CP.3 What should I do if I am not responsible for the business process? ............................... 7 BPMN diagram for AW_BUC_04b ........................................................................................................... 8 Structured Electronic Documents (SEDs) used in the process ................................................................ 8 Horizontal sub-processes ........................................................................................................................ 8 Administrative sub-processes ................................................................................................................. 8
Guidelines for EESSI Business Use Case AW_BUC_04b – Information about supplement scheduled treatment Date: September 2018 Document version: 4.1.0 2
Document history:
Revision Date Created by Short Description of Changes v0.1 12/07/2017 Secretariat First draft of the document submitted for review to the AWOD Ad Hoc group v0.2 24/08/2017 Secretariat Comments from AHG integrated. Version submitted for AC review. v0.99 09/10/2017 Secretariat Comments from AC integrated. Version submitted for AC approval. v1.0 27/10/2017 Secretariat AC approved version. 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_04b – Information about supplement scheduled treatment Date: September 2018 Document version: 4.1.0 3
AW_BUC_04b – Information about Supplement Scheduled Treatment
Description: This case deals with situation when a person who has received an authorisation for scheduled treatment outside the Member State of residence and competent Member State and it appears that it is medically appropriate to supplement the treatment covered by an existing authorisation. In this situation, the institution of the place of stay shall inform the competent institution that it is medically appropriate to supplement of the treatment. The competent institution informs the institution of the place of stay of its decision. The DA007 is the basis for the future request for reimbursement from the competent Member State for supplementary scheduled treatment provided. An insured person who is authorised by the competent institution to go to another Member State with the purpose of receiving the treatment appropriate to his condition should receive only the benefits in kind provided by the institution of the place of stay in relation with an accident at work or an occupational disease. Legal base: The legal basis of the AW_BUC_04b 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 Regulation Implementing Regulation (883/04) (987/09) 20 36 26(5) 33(1) 33(2) DA007 - Authorisation to receive scheduled treatment in a Member State other than the competent Member State and the Member State of Residence DA008 - Information on medically appropriate supplement to authorised scheduled treatment Request-reply SEDs: REQUEST SED REPLY SED(s) DA008 - Information on medically appropriate DA007 - Authorisation to receive scheduled treatment in supplement to authorised scheduled a Member State other than the competent Member State treatment and the Member State of Residence Glossary of relevant terms used in AW_BUC_04b: Term used Description Case Owner In this BUC the Case Owner is the institution in the Member State of stay which sends information to the institution in the competent Member State about the medically appropriate supplement to the treatment covered by an existing authorisation. Counterparty In this BUC the Counterparty is the institution in the competent Member State which has previously authorised the treatment and receive the information about the medically appropriate supplement to the treatment requested by Member State of stay.
Guidelines for EESSI Business Use Case AW_BUC_04b – Information about supplement scheduled treatment Date: September 2018 Document version: 4.1.0 4
How to start this BUC?
In order to help you understand the AW_BUC_04b 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 in the Member State of stay which sends information to the institution in the competent Member State about the medically appropriate supplement to the treatment covered by an existing authorisation your role will be defined as the Case Owner. I am the Case Owner. (step CO.1)
If you are the Institution in the competent Member State which has previously authorised the treatment and receives the information about the medically appropriate supplement to the treatment requested by Member State of stay 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 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. Please note that in this BUC you should select from the IR the institution that has previously authorised the treatment and issued the PD DA1 – Entitlement to health care cover under insurance against accidents at work and occupational diseases. 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)
Guidelines for EESSI Business Use Case AW_BUC_04b – Information about supplement scheduled treatment Date: September 2018 Document version: 4.1.0 5
CO.3 How do I send the SED ‘Information on medically appropriate supplement to authorised scheduled treatment’ DA008?
Fill out the ‘Information on medically appropriate supplement to authorised scheduled treatment’ SED DA008 by entering all the required information. Afterwards, you send the SED DA008 to the Counterparty. As the request is individualised the case can concern only one person. The SED DA008 is providing information from your institution to inform the counterparty that it was medically appropriate to supplement the treatment covered by the existing authorisation and request their approval; The supplement to the treatment on SED DA008 covered by the existing authorisation apply only for the benefits in kind provided in relation to an accident at work or an occupational disease; You may optionally attach a Medical Report to SED DA008 As an answer, you should receive the ‘Authorisation to receive scheduled treatment in a Member State other than the competent Member State and the Member State of Residence’ SED DA007 from the Counterparty. What should I do when it turns out that I must invalidate the request ‘Information on medically appropriate supplement to authorised scheduled treatment’ SED DA008?(step CO.5) I have received the SED DA007 from the Counterparty.(step CO.4)
Sub-process steps available to the Case Owner at this stage: I want to send a Reminder for the return of information I am expecting (AD_BUC_07)
CO.4 What should I do if I have received the ‘Authorisation to receive scheduled treatment in a Member State other than the competent Member State and the Member State of Residence’ SED DA007?
You have received the ‘Authorisation to receive scheduled treatment in a Member State other than the competent Member State and the Member State of Residence’ SED DA007; this SED may provide either an approval or a refusal from the competent Member State for supplementary treatment. If the DA007 was sent with the approval, it will be the support for the future request for reimbursement from the competent Member State for the supplement to the scheduled treatment. The Business Use Case ends here. Sub-process steps available to the Case Owner at this stage: I want to exchange Ad Hoc information not covered by the main process (H_BUC_01) I want to send a Reminder for the return of information I am expecting (AD_BUC_07) I want to Clarify the Content of a received SED (AD_BUC_08)
CO.5 What should I do when it turns out that I must invalidate the request ‘Information on medically appropriate supplement to authorised scheduled treatment’ SED DA008?
You may optionally choose to invalidate the request you have sent when issuing SED DA008 however this must be done before the Counterparty replies on SED DA007. You have to use the Invalidate a sent SED sub-process (AD_BUC_06). Once the SED DA008 has been invalidated, you may optionally choose to send a new SED DA008. Send another ‘Information on medically appropriate supplement to authorised scheduled treatment’ DA008. (step CO.3)
Guidelines for EESSI Business Use Case AW_BUC_04b – Information about supplement scheduled treatment Date: September 2018 Document version: 4.1.0 6
CP.1 What should I do if I received a ‘Information on medically appropriate supplement to authorised scheduled treatment’ SED DA008?
The process is initiated by receiving the ‘Information on medically appropriate supplement to authorised scheduled treatment’ SED DA008 from the Case Owner.
The SED DA008 is a request to your institution for an insured person residing outside of the competent Member State, and for whom an existing authorisation treatment exists, to receive supplementary, medically appropriate, treatment.
First, you check if you are responsible for the business process in accordance with your national procedures.
I am responsible for the business process. (step CP.2) I am not responsible for the business process.(step CP.3)
CP.2 What should I do if I am responsible for the business process?
I received the ‘Information on medically appropriate supplement to authorised scheduled treatment’ SED DA008 from the Case Owner and I am responsible for the business process.
You have to fill out the ‘Authorisation to receive scheduled treatment in a Member State other than the competent Member State and the Member State of residence’ SED DA007, where you must describe the treatment and provide either an approval or a refusal for the requested supplementary treatment.
You send the SED DA007 as a reply to the Case Owner. Usually, the Business Use Case ends here.
In some cases it may turn out later that you need to update the information you provided on SED DA007
I want to Update information contained in a sent SED (AD_BUC_10)
Sub-process steps available to the Counterparty at this stage: I want to exchange Ad Hoc information not covered by the main process (H_BUC_01) I want to send a Reminder for the return of information I am expecting (AD_BUC_07) I want to Clarify the Content of a received SED (AD_BUC_08)
CP.3 What should I do if I am not responsible for the business process? If you are not responsible for the reply but another institution in your country is, you forward the case to the competent Institution in your Member State using the 'Forward Case' sub-process AD_BUC_05. This can be used only once and it interrupts the main process. If you are not responsible for the reply and the other institution is not in you country, do not grant the authorization with reason “Other”: Case sent mistakenly to our Member State.
Guidelines for EESSI Business Use Case AW_BUC_04b – Information about supplement scheduled treatment Date: September 2018 Document version: 4.1.0 7
BPMN diagram for AW_BUC_04b
Click here to open the BPMN diagram(s) for AW_BUC_04b.
Structured Electronic Documents (SEDs) used in the process
The following SEDs are used in AW_BUC_04b: • SED DA007 - Authorisation to receive scheduled treatment in a Member State other than the competent Member State and the Member State of Residence’ • SED DA008 - Information on medically appropriate supplement to authorised scheduled treatment’
Horizontal sub-processes
The following horizontal sub-process is used in AW_BUC_04b: • H_BUC_01_Subprocess: Ad hoc exchange of information
Administrative sub-processes
The following administrative sub-processes are used in AW_BUC_04b: • AD_BUC_05_Subprocess – Forward Case • AD_BUC_06_Subprocess – Invalidate SED • AD_BUC_07_Subprocess - Reminder • AD_BUC_08_Subprocess – Clarify Content • AD_BUC_10_Subprocess – Update SED 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
Guidelines for EESSI Business Use Case AW_BUC_04b – Information about supplement scheduled treatment Date: September 2018 Document version: 4.1.0 8