S_BUC_19 | Lexipedia

EESSI – CDM 4.3

S-Sickness

S_BUC_19-v4.3.4

Actual cost claim – Benefits in kind

BUC Guidelines

EESSI – CDM 4.3

S-Sickness

S_BUC_19-v4.3.4

Actual cost claim – Benefits in kind

BUC Guidelines

TABLE OF CONTENTS

S_BUC_19 – Actual cost claim - Benefits in kind 6

How to start this BUC? 8

What is my role in the social security exchange of information I have to complete? 8

CO.1 Who do I need to notify? 8

CO.2 How do I identify the correct institution(s) to exchange information with? 8

CO.3 How do I proceed after having identified the Counterparty? 8

CO.4 How do I proceed after receiving 'Acknowledgment of Claim for Reimbursement’- SED S081? 9

CO.5 How do I create 'Credit Note – SED S085' 9

CO.6 How do I proceed after receiving 'Contestation of Credit note'- SED S087? 10

CO.7 How do I proceed after receiving 'Information on payment of individual claim'' - SED S091? 10

CO.8 How do I proceed after receiving 'Information on down payments' - SED S089? 11

CO.9 How do I proceed after receiving 'Contestation of individual claim' - SED S082? 11

CP.1 What should I do if I have received the 'Claim for reimbursement'- SED S080? 12

CP.2 What should I do if I am responsible for the business process? 12

CP.3 What should I do if I am not responsible for the business process? 13

CP.4 How do I send 'Information on payment of individual claim' – SED S091? 13

CP.5 How do I send ‘Information on down payment – SED S089? 14

CP.6 How do I send ‘Contestation of individual claim’ - SED S082? 14

CP.7 What should I do if I have received the 'Reply to contestation of individual claim' - SED S084? 15

CP.8 What should I do if I have received the 'Credit note' - SED S085? 16

CP.9 How do I send 'Contestation of Credit note' – SED S087? 16

CP.10 What should I do if I have received the 'Reply to contestation of credit note' - SED S088? 16

Information on specific workaronds awaiting changes in the processes 18

BPMN diagram for S_BUC_19 18

Structured Electronic Documents (SEDs) used in the process 18

Administrative sub-processes 18

Sample scenarios 18

Document Control Information

Document Control

Value

Project Title

Electronic Exchange of Social Security Information (EESSI)

Document Name

S_BUC_19-v4.3.4

Document Category

BUC 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

v0.1

07/07/2017

First draft of the document submitted for review to the Sickness Ad Hoc group

v0.2

06/11/2017

Comments received from AHG integrated.

v0.99

04/12/2017

Implemented changes and updates following the AC review. Version submitted for AC approval

v1.0

20/12/2017

AC approved version.

Comments from Finland received by writing as follow up of AC meeting integrated

v4.1.0

11/09/2018

Performed patch changes to reference the new CDM version 4.1.0

v4.2.0

01/09/2019

Performed patch changes to reference the new CDM version 4.2.0

v4.3.0

31/08/2021

Performed patch changes to reference the new CDM version 4.3.0

v4.3.1

07/12/2021

Implementation of Change Request EESSI-6438: including the contestation rules.

Implementation of Change Request EESSI-6381: improvement of reimbursement process description

Links update

v4.3.4

30/04/2024

Implementation of change request EESSI-12076 by adding a paragraph related to the attachments to the CO.6, CP.2, CP.3, CP.6, CP.7, CP.8, CP.9 and CP.10 steps. Also, apply correction to CO.9 for the existing paragraph related to the attachments.

S_BUC_19 – Actual cost claim - Benefits in kind

Description: The Member State, which provided benefits in kind, related to sickness, maternity/paternity, accident non professional or long term care is entitled to request for reimbursement from the competent Member States.

Reimbursement shall be determined and effected in accordance with the arrangements set out in the Implementing Regulation and shall be made on the basis of actual expenditure.

The reimbursement process between two Member States is conducted:

by the Liaison Bodies (Creditor and Debtor Liaison Body);

as promptly as possible respecting applicable deadlines.

Member States or their competent authorities may provide for other methods of reimbursement or waive all reimbursement between the

institutions coming under their jurisdictions.

The process includes:

the main scenario with ‘Claim for reimbursement (CLA)’ S080 SED, ‘Acknowledgment of claim for Reimbursement (ACK_CLA)’ S081 SED, ‘Information on payment of individual claim (PAY)’ S091 SED and ‘Acknowledgement of payment of single claim’ S092 SED;

the alternative scenarios which allow to:

withdraw or adjust the claim – including: ‘Credit Note (CRN) S085 SED’, ‘Contestation of Credit Note (COC_CRN)’ S087 SED, ‘Reply on contestation of Credit note (RPY_COC_CRN)’ S088 SED;

contest the claims – including: ‘Contestation of individual claim (COC)’ S082 SED, ‘Acknowledgment of contestation of individual claim (ACK_COC) S083 SED; ‘Reply on contestation of individual claim (RPY_COC)’ S084 SED;

offer down payment – including: ‘Information on down payments (IDP)’ S089 SED and ‘Reply to information on down payments (RPY_IDP)’ S090 SED.

The reimbursement processes are created based on the bulk messages therefore one reimbursement claim can include a large number of individual claims.

Alternative scenarios for credit notes and contestations can be used more than once during the reimbursement process and even after the process is finalized with ‘Acknowledgement of payment of single claim’ S092 SED issued for all accepted claims with retrospective effect. However, the contestation scenario can be used only within the deadline specified in the regulations.

A dispute concerning a particular claim shall not hinder the reimbursement of another claim or other claims.

The purpose of the reference numbers in reimbursement SED:

Global references placed on the global part of SED, i.e. Global CLA

reference number, Global COC reference number, connects the SEDs on the global level, i.e. connects the S082 (contestation) with the S080 (claim);

Individual references placed on the individual part of SED, i.e. Individual CLA number, Individual COC number, connects the SEDs on individual level, i.e. connects individual contestation of S082 with individual claim of S080;

Global references placed on the individual part of SED, i.e. Global CLA reference number, Global COC reference number, connects the individual part with the global part of the SED, i.e. connects individual CLA of S080 with global part of S080 and connects the individual parts with the global part of the previous SEDs, i.e. connects individual COC (S082) not only with global part of S082 but also with the global part of the original claim (S080).

Legal Base: The 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.

SED

Basic Regulation

(883/04)

Implementing Regulation

(987/09)

S080 Claim for reimbursement (CLA)

S081 Acknowledgment of claim for reimbursement (ACK_CLA)

S082 Contestation of individual claim (COC)

S083 Acknowledgement of contestation of individual claim (ACK_COC)

S084 Reply on contestation of individual claim (RPY_COC)

S085 Credit note (CRN)

S087 Contestation of Credit note (COC_CRN)

S088 Reply on contestation of Credit note (RPY_COC_CRN)

S089 Information on down payments (IDP)

S090 Reply to information on down payments (RPY_IDP)

S091 Information on payment of individual claim (PAY)

S092 Acknowledgement of payment of single claim (ACK_PAY)

Glossary of relevant terms used in S_BUC_19:

Term used

Description

Case Owner

In this BUC the Case Owner is the Creditor Institution's Liaison Body of the Member State of Residence or Stay that claims reimbursement of benefits in kind on the basis of actual costs on behalf of a Creditor Institution.

Counterparty

In this BUC the Counterparty is the Debtor Institution's Liaison Body of the Competent Member State that replies for the claim of a reimbursement payment on the basis of actual cost on behalf of a Debtor Institution.

How to start this BUC?

In order to help you understand the S_BUC_19 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 in the next step within this document or to another separate file. 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 a Creditor Institution's Liaison Body of the Member State of Residence or Stay that claims reimbursement of benefits in kind on the basis of actual costs on behalf of a Creditor Institution, then your role will be defined as the Case Owner.

I am the Case Owner. (step CO.1)

If you are the Debtor Institution's Liaison Body of the Competent Member State that replies for the claim of a reimbursement on the basis of actual cost on behalf of a Debtor Institution, then your role will be defined as the Counterparty.

I am the Counterparty. (step CP.1)

CO.1 Who do I need to notify?

As the Case Owner, your first step in any new exchange of information will be to identify the Member State that you need to exchange information with. The second step is to identify the relevant institution (Liaison body of the competent Member State) in this Member State that is responsible to treat the information you sent. In this Business Use Case, the institution can be chosen only among the institutions (Liaison body of the competent Member) responsible for health insurance. This activity will define the Counterparty you will be working with.

Please note that 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(s) 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 reimbursement occur only between Liaison Bodies.

To access the IR please use the following link.

I have now identified the Competent Institution(s) from the Member State(s) I need to contact. (step CO.3)

CO.3 How do I proceed after having identified the Counterparty?

There will only be one Counterparty identified. You have to fill out the 'Claim for reimbursement' – SED S080 by entering all required global and individual claim information on the basis of actual cost, and send it to the Counterparty.

The Global Part of the Claim includes a complete set of information, which allows to identify the claim in the next steps of the exchange, and which gives information about the summarized amount and number of individual claims, bank details necessary for the payment and date of submission. It includes also the CLA reference number which is used in the next SEDs and other processes, i.e. S_BUC_22, S_BUC_23.

The individual part of the claim is repeatable and includes information and amounts for the individual claims for which the claim is introduced, with details about the person who received benefits in kind, references and details of the individual claim.

The Counterparty receives it and creates 'Acknowledgment of claim for

reimbursement' – SED S081, confirming the receipt of the request, then sends it to you.

Optionally, after sending SED S080, at any time in the process, you may fill out 'Credit note' – SED S085 whereby you inform the debtor institution about correction of the amount of initial claim in SED S080 that you sent.

Depending on the circumstances of the case, any of the following steps may occur / can be taken:

I have received 'Acknowledgement of Claim for Reimbursement '- SED S081 (step CO.4)

How do I create ‘Credit Note – Benefits in kind - SED S085’ (step CO.5)

CO.4 How do I proceed after receiving 'Acknowledgment of Claim for Reimbursement’- SED S081?

The Counterparty responds to the 'Claim for reimbursement' - SED S080 received from you with 'Acknowledgment of claim for reimbursement ' - SED S081. This is a confirmation that your claim has been received.

At this point, the Counterparty has to send to you ‘Information on payment of individual claim’ – SED S091 or optionally may start the alternative scenarios and inform you either about ‘Contestation of individual claim’ –SED S082 or 'Information on down payment’ – SED S089.

If necessary you can create a ‘Credit Note’ – SED S085.

Depending on the circumstances of the case, any of the following step may occur / can be taken:

How do I create 'Credit Note ‘ - SED S085 (step CO.5)

What should I do If I receive ‘Information on payment of individual claim’ – SED S091. (step CO.7) What should I do If I receive ‘Information on down payment’ – SED S089. (step CO. 8) What should I do If I receive ‘Contestation of individual claim’ –SED S082. (step CO. 9)

CO.5 How do I create 'Credit Note – SED S085'

Optionally, after sending SED S080, at any time in the process, you may fill out 'Credit note' – SED S085 whereby you inform the debtor liaison body about a correction of the amount of the initial claim in SED S080 that you sent. Each individual credit note must refer to a specific invoice. It is not possible to inform an institution of a credit note regarding two separate invoices.

Within one global Credit Note, you inform the Counterparty about the Credit Note related to one of more individual claims.

In the Global Part of the Credit Note, you fill in the global information regarding the Credit Note.

In the Individual Part of the Credit Note, you fill in the required information related to the individual credit note(s).

You do not issue S085 if the claims are already contested by the Counterparty on 'Contestation to individual claim' - SED S082. After the contestations are accepted the claims will be removed from the claim.

S085 can be issued more than once; therefore, you can issue several credit notes for the same global claim, each time for an individual claim or part of individual claim which was not contested or withdrawn with previous credit note.

Then you send 'Credit Note' - SED S085 to the Counterparty. You do not issue SED S085 if the claims are already contested by Counterparty. After the contestations are accepted, the individual claims will be

removed from the global claim.

If the Counterparty receives from you SED S085, they can optionally fill out 'Contestation of Credit note' - SED S087 and send it to you.

What should I do If I receive “'Contestation of Credit note' - SED S087" (Step CO.6)

CO.6 How do I proceed after receiving 'Contestation of Credit note'- SED S087?

If you have received 'Contestation of credit note' - SED S087, you have to fill out 'Reply to contestation of credit note' – SED S088, and give information about the reply to contestations of credit notes and send SED S088 to the Counterparty. The replies have to apply to the reasons of contestation chosen by the Counterparty in the S087. S088 can be issued more than once.

All attachments supporting the reply must be attached to the individual part of the S088. An attachment that is not correctly referenced to a specific individual part might not be handled properly.

The Counterparty receives 'Reply to contestation of credit note' - SED S088.

The credit note alternative scenario finishes here, except when the Counterparty makes again another credit note contestation. So, in this case you will receive another SED S087 (step CO.6). The main process continues.

Please note that in order to finalize the claim the Debtor Liaison Body must receive a reply for all of the contestations made for the issued Credit Note.

Depending on the circumstances of the case, any of the following step may occur / can be taken:

How do I create ‘'Credit Note - SED S085 (step CO.5)

What should I do If I receive “Information on payment of individual claim – SED S091. (step CO.7) What should I do If I receive “Information on down payment – SED S089. (step CO. 8) What should I do If I receive “Contestation of individual claim –SED S082. (step CO. 9)

CO.7 How do I proceed after receiving 'Information on payment of individual claim'' - SED S091?

You can receive 'Information on payment of individual claim' - SED S091, from the Counterparty whereby they inform you about the schedule for payment. A specific payment announcement always refers to a specific 'Claim for reimbursement' - SED S080.

Exceptionally, several payment notifications can be pooled into one single payment order. An actual transfer of the money is done outside the system.

The SED S091 only provides the information, which invoices will be paid.

After you have confirmed that payment has been received in your account you create 'Acknowledgment of payment of single claim' – SED S092 confirming the receipt of the payment for a claim and send it to the Counterparty. The date of the payment is the value date of the transaction as introduced by the banking institution of your Liaison Body. If it is the last payment related to the case, the case ends, otherwise, another information on payments can be received (step CO.7) or alternative scenarios can be executed to process the remaining individual claims.

If you have accepted a down payment or if the Counterparty didn’t offer any down payment, and you received the payment late, you can charge interests on late payment and request them via S_BUC_22 Claim for

interest on late payment.

Depending on the circumstances of the case, any of the following step may occur / can be taken:

What should I do if I receive another ‘Information on payment of individual claim – SED S091. (step CO.7)

What should I do If I receive “Contestation of individual claim –SED S082. (step CO. 9) How do I create ‘'Credit Note - SED S085 (step CO.5) What should I do If I receive “'Contestation of Credit note' - SED S087" (Step CO.6)

CO.8 How do I proceed after receiving 'Information on down payments' - SED S089?

You can receive 'Information on down payment' – SED S089 from the Counterparty to make a down payment on the claims submitted in 'Claim for reimbursement' - SED S080. The exact amount of the down payment is determined by the details in the global note claim of SED S080 and it has to reach at least 90 % of the total amount of the global claim and down payment should be made within 6 months of the end of the month during which the claim was introduced.

You aren’t obliged to accept this down payment However, if you decline such an offer, the creditor institution shall no longer be entitled to charge interest on late payments related to the claims other than those parts of the claim not covered by the down payment.

Then you have to fill out 'Reply to information on down payment' – SED S090, informing the Counterparty whether the offer is accepted or not.

If your Member State has made a general statement that it accepts down payments such payments are automatically considered to be accepted. The list of Member States that have stated they accept down payment is drawn up by the Audit Board.

If your Member State has not stated that down payments are generally accepted the reply has to be sent within 6 months of the end of the month during which the claim is introduced. In the absence of a reply within the given time frame the down payment are considered as accepted and shall be executed.

In both situations (general statement/no general statement) S090 may be issued.

If the offer is accepted, the amount agreed upon should be processed for payment. The SED S090 has to be sent to the Counterparty.

The Down Payment alternative scenario finishes here, it can occur only once. The main process continues.

Depending on the circumstances of the case, any of the following step may occur/can be taken:

What should I do If I receive “Information on payment of individual claim – SED S091. (step CO.7) What should I do If I receive “Contestation of individual claim –SED S082. (step CO. 9) How do I create ‘'Credit Note - SED S085 (step CO.5) What should I do If I receive “'Contestation of Credit note' - SED S087" (Step CO.6)

CO.9 How do I proceed after receiving 'Contestation of individual claim' - SED S082?

The Counterparty may optionally fill out 'Contestation of individual claim' – SED S082, where the debtor state notifies the amount to be contested and the reason for refusal.

If you receive SED S082, optionally with relevant attachments, you have to fill out 'Acknowledgment of contestation of individual claim' – SED S083, confirming the receipt of the contestation of a claim and send it to the Counterparty.

After having sent the SED S083, you have to fill out 'Reply to contestation of individual claim – S084' where you indicate if you accept or not the contestation.

After receiving a contestation, only one reply can be sent for that contestation. All attachments supporting the reply must be attached to the individual part of the S084. An attachment, that is not correctly referenced to a specific individual part, cannot be forwarded to the competent institution, and might not be handled properly.

After a contestation was received, no payment of the individual claim is allowed until the contestation has been settled by both parties.

When you accept the contestation, the process continues with the information about the payments SED S091, which must be sent for all the remaining and neither contested nor withdrawn claims or the use case ends.

When you dispute the contestation, the Counterparty may send another contestation for those claims with new attachments justifying the contestations.

If the contestation is issued for the claims which you have already withdrawn on ‘Credit note – Benefits in kind’ SED S085 you must refuse the individual contestations on S088. Those claims will be withdrawn from the claim.

Depending on the circumstances of the case, any of the following step may occur / can be taken:

CP.1 What should I do if I have received the 'Claim for reimbursement'- SED S080?

The Case Owner has created the 'Claim for reimbursement' – SED S080 by entering all required global and individual information claim on the basis of actual cost and sends it to the Counterparty.

You receive the 'Claim for Reimbursement - Benefits in Kind' – SED S080. 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?

The Case Owner creates the 'Claim for reimbursement' – SED S080 by entering all required global and individual information claim on the basis of actual cost and sends it to you.

You receive SED S080 and revise this document, then create the 'Acknowledgment of claim for reimbursement' - SED S081 to confirm the receipt of the request and send it to the Case Owner.

If you agree with the Claim for reimbursement you can send to the Case Owner ‘Information on payment of individual claim’ – SED S091 where you inform the Case Owner about the schedule for payment. A specific payment announcement always refers to a specific 'Claim for reimbursement' - SED S080. As a response you will receive the SED S092.

Or you may fill out 'Contestation of individual claim' – SED S082, where you as the debtor state notify the amount to be contested and the reason for refusal. As a response you will receive SED S083 and also SED S084.

All attachments supporting the reply must be attached to the individual

part of the S082. An attachment that is not correctly referenced to a specific individual part might not be handled properly.

Optionally, you can send to the Case Owner ‘Information on down payment' – SED S089' if you want to make a down payment on the claims submitted in Claim for reimbursement' - SED S080. The exact amount of the

down payment is determined by the details in the global note claim of SED S080. As a response you will receive SED S090.

Depending on the circumstances of the case, any of the following step may occur / can be taken:

I want to send 'Information on payment of individual claim' - SED S091 (step CP.4)

I want to send ‘Information on down payment - SED S089 (step CP.5)

I want to send ‘Contestation of individual claim’ SED S082 (step CP.6)

I have received ‘Credit note' SED S085 (step CP.8)

CP.3 What should I do if I am not responsible for the business process?

If your institution was chosen incorrectly as a recipient of SED S080, you have to reject the SED with following steps:

First you need to create the 'Acknowledgment of Claim for Reimbursement ' - SED S081 to confirm the receipt of the request and send it to the Case Owner.

Then you need to send contestation for all of the individual claim on ‘Contestation of individual claim’ - SED S082 choosing as a reason option “99-Other” with additional explanation in section “Other” stating that the chosen institution is not correct to handle the case.

All attachments supporting the reply must be attached to the individual part of the S082. An attachment that is not correctly referenced to a specific individual part might not be handled properly.

I want to send ‘Contestation of individual claim’ SED S082 (step CP.6)

CP.4 How do I send 'Information on payment of individual claim' – SED S091?

After you have reviewed the claim and you accept it you have to send ‘‘Information on payment of individual claim’ – SED S091 by entering all the required information in the global and individual part. S091 can be sent more than once.

S091 is just an information that a payment will be done. An actual transfer of the money is done outside the system.

The information about a payment on S091 should be sent for all individual claims from S080 which were not withdrawn by the Case owner with S085 (credit note) or contested by you with S082 (contestation). You may send the S091 several times, each time for a new batch of the individual claims which are to be paid. The case owner receives the SED S091.

Partial payment of an individual contested claim is not possible. If an individual claim is in contestation, it cannot be paid in parts in the meantime. The contestation of an individual claim needs to be negotiated and, in the end, when a settlement has been reached, the whole (or partial, if some amounts are rightfully contested) claim needs to be paid at once.

A payment of all individual claims that are not contested is possible: a global claim must be paid as soon as possible.

After the Case owner receives the information about payment and the money transfer is completed, the case owner sends 'Acknowledgment of payment of single claim' – SED S092. This is a confirmation that the

payment has been received and on what date.

Optionally, you may send new ‘Information on payment of individual claim’ – SED S091 (loop) (step CP.4).

Unless you want to send another information on payment or there are still other claims which are to be processed, the business use case ends here.

If the case owner accepted a down payment or if you didn’t propose any down payment, and you sent the payment late, the Case Owner can charge interests on late payment and request them via S_BUC_22 Claim for interest on late payment.

Depending on the circumstances of the case, any of the following step may occur / can be taken:

I want to send 'Information on payment of individual claim' - SED S091 (step CP.4)

I want to send ‘Contestation of individual claim’ SED S082 (step CP.6)

I have received ‘Credit note' SED S085 (step CP.8) I want to send ‘Contestation of credit note- SED S087 (step CP.9)

CP.5 How do I send ‘Information on down payment – SED S089?

Within six months of the end of the month during which the claim was introduced, you can make a down payment of at least 90 % of the total claim by entering all the required information in the 'Information on down payment' – SED S089.

The Case Owner is not obliged to accept this down payment However, if he declines such an offer, the creditor institution shall no longer be entitled to charge interest on late payments related to the claims other than those parts of the claim not covered by the down payment.

If the creditor Member State has made a general statement that it accepts down payments such payments are automatically considered to be accepted. The Audit Board draws up a list of Member States that have stated they accept down payment.

If the creditor Member State has not stated that down payments are generally accepted the Case Owner has to reply to the S089 within 6 months of the end of the month during which the claim is introduced. In the absence of a reply within the given time frame the down payment are considered as accepted and shall be executed.

In both situation (general statement or no general statement) the Case Owner may fill out and sends 'Reply to information on down payment' – SED S090‘, informing you whether the offer is accepted or not. If the offer is accepted, the amount agreed upon should be used for payment.

You receive 'Reply to information on down payment' – SED S090‘

The alternative scenario for Down Payment finishes here, it can occur only once. The main process continues.

Depending on the circumstances of the case, any of the following step may occur / can be taken:

I want to send 'Information on payment of individual claim' - SED S091 (step CP.4)

I want to send ‘Contestation of individual claim’ SED S082 (step CP.6)

I have received ‘Credit note' SED S085 (step CP.8) I want to send ‘Contestation of credit note- SED S087 (step CP.9) I have received 'Reply to contestation of credit note' SED S088. (step CP.10)

CP.6 How do I send ‘Contestation of individual claim’ - SED S082?

After you have reviewed the claim and you do not agree with some of

the individual claims which were included in S080 you can contest it by sending ‘Contestation of individual claim’ – SED S082 with all the required information entered in the global and individual part.

All attachments supporting the reply must be attached to the individual part of the S082. An attachment that is not correctly referenced to a specific individual part might not be handled properly.

The claim may be rejected and returned to the creditor if for example:

it is incomplete and/or incorrectly filled out

it 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.

The 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.

In the S082 you have to indicate which individual claims (amongst the ones in SED S080) are not accepted and for each individual claim the reason for the contestation must be provided. It is possible also to contest only part of the individual claim.

For both partial and full contestations, a new contestation can be submitted only after having received an answer for the first one.

After sending a contestation, only one reply can be received for that contestation

After a contestation was sent, no payment of the individual claim is allowed until the contestation has been settled by both parties

You cannot send S082 for claims which were already withdrawn by the Case Owner on S085 (Credit note);

S082 can be issued even after the process has been finalized and

information on payment has been sent, as long as it is done within the deadlines specified in the regulation.

If S082 is issued because your institution is not competent to handle it, you need to contest all of the individual claims on ‘Contestation of individual claim’ - SED S082 and choose as a reason option “99-Other” with additional explanation in section “Other” stating that the chosen institution is not correct to handle the case.

The Case Owner receives from you, 'Contestation of individual claim' – SED S082, optionally with relevant attachments. The Case Owner will send to you 'Acknowledgment of contestation of individual claim' - SED S083, where the Case Owner confirms the receipt of the contestation of a claim.

You receive from the Case Owner 'Reply on contestation of individual claim' - SED S084.

If you didn’t receive S084 within 12 months, the contestation is considered accepted.

Depending on the circumstances of the case, any of the following step may occur / can be taken:

I want to send 'Information on payment of individual claim' - SED S091 (step CP.4)

I want to send ‘Contestation of individual claim’ SED S082 (step CP.6)

I have received 'Reply on contestation of individual claim' - SED S084. (step CP.7)

I have received ‘Credit note' SED S085 (step CP.8) I want to send ‘Contestation of credit note- SED S087 (step CP.9) I have received 'Reply to contestation of credit note' SED S088. (step CP.10)

CP.7 What should I do if I have received the 'Reply to contestation of individual claim' -

SED S084?

You will receive 'Reply to contestation of individual claim' – SED S084, in which the Case owner either accepts or disputes your contestation. You may receive more than one S084, optionally with attachments.

If the Case owner rejects or disputes the contestation you may send a new 'Contestation of individual claim' – SED S082 for this individual claim with new supporting evidence attached to the S082.

All attachments supporting the reply must be attached to the individual part of the S082. An attachment that is not correctly referenced to a specific individual part might not be handled properly.

The Case Owner must provide the reply SED S084 within 12 months of the end of the month during which the contestation was received by the liaison body. If the deadline is not met the contestation are deemed to be accepted and the claim or its relevant part are definitely rejected.

Unless you receive another ‘'Reply to contestation of individual claim' – SED S084 the loop for the contestation finishes here and the main process continues.

Depending on the circumstances of the case, any of the following step may occur / can be taken:

I want to send another ‘Contestation of individual claim’ SED S082 (step CP.6)

I want to send 'Information on payment of individual claim' - SED S091 (step CP.4)

I have received ‘Credit note' SED S085 (step CP.8) I want to send ‘Contestation of credit note- SED S087 (step CP.9) I have received 'Reply to contestation of credit note' SED S088. (step CP.10)

CP.8 What should I do if I have received the

'Credit note' - SED S085?

The Case Owner issues ‘Credit note’ – SED S085 with information about the correction of its initial 'Claim for reimbursement' - SED S080.

The individual part of S085 should include only those individual claims which were mentioned in S080 and which were not already contested by you with S082.

If you agree with S085 then all mentioned individual claims are withdrawn or adjusted in the claim sent on S080 and no reply is required.

Optionally, if you do not agree with the credit note you can contest it by sending ‘Contestation of credit note' – SED S087

All attachments supporting the reply must be attached to the individual part of the S087. An attachment that is not correctly referenced to a specific individual part might not be handled properly.

Afterwards, the Case Owner will send 'Reply on contestation of Credit note' - SED S088 to you.

I want to send ‘Contestation of Credit note’ - SED S087 (step CP.9)

CP.9 How do I send 'Contestation of Credit note' – SED S087?

If you do not agree with the proposition to withdraw or adjust the claims sent by the Case owner on ‘Credit note’ SED S085 you can contest it.

You have to enter all required information in the ‘Contestation of credit note' – SED S087 and send it to the Case Owner. S087 must be issued if any new claims were added by the Case Owner on S085 or claims already contested by you were included in S085. You may attach

additional documents to the S087 in order to justify your contestation.

All attachments supporting the reply must be attached to the individual part of the S087. An attachment that is not correctly referenced to a specific individual part might not be handled properly.

Then you send SED S087 to the Case Owner which receives it. The Case Owner sends 'Reply on contestation of Credit note' - SED S088 to you.

I have received 'Reply to contestation of credit note' SED S088. (step CP.10)

CP.10 What should I do if I have received the 'Reply to contestation of credit note' - SED S088?

You receive from the Case Owner 'Reply to contestation of credit note' – SED S088 which gives information about the reply to your contestations of credit notes.

If you decide, that you do not agree with the reply provided by the Case owner you may send again ‘Contestation of credit note' – SED S087. If you agree with the explanations provided by the Case Owner then all mentioned individual claims are withdrawn or adjusted in the claim sent on S080 and no reply is required.

Unless you want to send another Contestation of the credit note the alternative scenario for the credit note ends here and the main process continues.

Optionally, you fill out 'Contestation of credit note' – SED S087, where you as the debtor State give information about the contestation of credit note. Then you send SED S087 to the Case Owner which receives it. The Case Owner will send 'Reply on contestation of Credit note' - SED S088 to you.

All attachments supporting the reply must be attached to the individual part of the S087. An attachment that is not correctly referenced to a specific individual part might not be handled properly.

Depending on the circumstances of the case, any of the following step may occur / can be taken:

I want to send another ‘Contestation of Credit note’ - SED S087 (step CP.9)

I want to send 'Information on payment of individual claim' - SED S091 (step CP.4)

I want to send ‘Contestation of individual claim’ SED S082 (step CP.6)

I have received ‘Credit note' SED S085 (step CP.8)

Information on specific workaronds awaiting changes in the processes

Problem: Most SEDs for cost reimbursement consist of two parts: (1) the global part with global IDs, total amounts and total numbers which qualifies the SED from a global perspective and (2) one or many individual part(s) which consist of individual positions which are qualified by IDs, amounts and other business specific data.

The individual part(s) within one SED are related to the global part and certain consistency rules need to be followed (throughout all SEDs) to create a correct SED. See description in the first section of the document.

Workaround:

When these consistency rules are not followed and SEDs are incorrectly filled in, a communication between institutions based on phone, e-mail or H_BUC_01 should be used to enable a correction. A subsequent correction requires both a validation at the receiver side before the SEDs are imported and processed in national systems and the possibility to correct and possibly resend SED references at the sender side.

BPMN diagram for S_BUC_19

Click here to open the BPMN diagram(s) for S_BUC_19.

Structured Electronic Documents (SEDs) used in the process

The following SED is used in S_BUC_19:

S080: Claim for reimbursement (CLA)

S081: Acknowledgment of claim for reimbursement (ACK_CLA)

S082: Contestation of individual claim (COC)

S083: Acknowledgement of contestation of individual claim (ACK_COC)

S084: Reply on contestation of individual claim (RPY_COC)

S085: Credit note (CRN)

S087: Contestation of Credit note (COC_CRN)

S088: Reply on contestation of Credit note (RPY_COC_CRN)

S089: Information on down payments (IDP)

S090: Reply to information on down payments (RPY_IDP)

S091: Information on payment of individual claim (PAY)

S092: Acknowledgement of payment of single claim (ACK_PAY)

Administrative sub-processes

The following technical administrative sub-processes can be used at any point in the process:

AD_BUC_11_Sub-process – Business Exception

AD_BUC_12_Subprocess – Change of Participant

Sample scenarios

For scenario samples please consult the additional files presented in the ‘Sample scenarios’ folder.