approvED
approvED
International Process Guidelines
Sickness
S_BUC_05 - Necessary Treatment in Member State of Stay - Request for Entitlement Document
Date: 11/09/2018
Version of guidelines document: v4.1.0
Based on: S_BUC_05 version 4.1.0
Common Data Model version 4.1.0
TABLE OF CONTENTS
S_BUC_05 - Necessary Treatment in Member State of Stay - Request for Entitlement Document 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 What should I do if I have received the S045 ‘Entitlement Document – Temporary Stay' SED? 6
CP.1 What should I do if I have received the ‘Request for entitlement document’ SED S044? 6
CP.2 What should I do if I am responsible for the business process? 6
CP.3 What should I do if I am not responsible for the business process? 7
BPMN diagram for S_BUC_05 8
Structured Electronic Documents (SEDs) used in the process 8
Administrative sub-processes 8
Horizontal sub-processes 8
Document history:
Revision
Date
Created by
Short Description of Changes
V0.1
05/05/2017
Secretariat
First draft of the document submitted for review to the Sickness Ad Hoc group
V0.2
02/08/2017
Secretariat
Implement changes and updates following the AHG comments. Version submitted for AC review.
V0.3
22/09/2017
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
11/12/2017
Secretariat
AC approved version.
V4.1.0
11/09/2018
Secretariat
Performed patch changes to reference the new CDM version 4.1.0
S_BUC_05 - Necessary Treatment in Member State of Stay - Request for Entitlement Document
Description: As the regulation dictates (Art. 25 of 987/09, Art. 19, 27 (1) of 883/04) the insured person and/or family members of the insured person located in a Member State other than the Competent Member State are entitled to benefits in kind which become necessary on medical grounds during their stay, taking into account the nature of the benefits and the expected length of stay. These benefits shall be provided by the Institution of the Place of Stay on behalf of the Competent Institution.
To receive benefits in kind in the Member State of Stay, the insured person shall present to the health care provider in the Member State of Stay a document issued by the competent institution indicating the insured person's entitlement to health benefits in kind. If the insured person does not have such a document, the Institution of the Place of Stay, upon request shall contact the Competent Institution in order to obtain one.
This BUC addresses the situation when an insured person or his/her family member needs necessary treatment during their temporary stay in another Member State other than the Competent one without being able to present the appropriate entitlement document for health benefits in kind to the health care provider. The Member State of Stay requests the confirmation of entitlement from the Competent Member State. The institution of the Member State of Stay is requested to contact the Institution in the Competent Member State of the insured person to obtain an entitlement document for health benefits in kind in the situation of a temporary stay. The request is performed using the SED
S044 ‘Request for Entitlement Document – Temporary Stay’.
The Competent Institution provides a confirmation of entitlement for temporary stay to the Institution of the MS of Stay. The confirmation indicates the entitlement to health benefits in kind for the insured person or his/her family member. If the person is not entitled to benefits in kind, the Competent Institution states the reason for no- entitlement. The reply is performed using the SED S045 ‘Entitlement Document – Temporary Stay’.
The BUC is individualized, meaning the case concerns 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.
SED
Basic Regulation (883/04)
Implementing Regulation (987/09)
19
27(1)
25 (1)
25 (2)
25 (3)
S044 Request for Entitlement Document – Temporary Stay
S045 Entitlement Document – Temporary Stay
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)
S044 Request for Entitlement Document – Temporary Stay
S045 Entitlement Document – Temporary Stay
Glossary of relevant terms used in the BUC:
Term used
Description
Case Owner
In this BUC the Case Owner is the Member State of Stay which, contacts the institution in the Competent Member State to obtain the confirmation of entitlement to health benefits in kind during a temporary stay.
Counterparty
In this BUC the Counterparty is the Institution of the Competent Member State which has to provide the entitlement document or information of no entitlement for health benefits in kind during the temporary stay in another Member State.
How to start this BUC?
In order to help you understand this BUC 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 represent the institution of the Member State of Stay which contacts the institution in the Competent Member State to obtain the confirmation of entitlement to health benefits in kind for a temporary stay, then your role will be defined as the Case Owner in this BUC.
I am the Case Owner. (step CO.1)
If you are the Institution of the Competent Member State which has to provide the confirmation of entitlement document or information of no entitlement for health benefits in kind when an insured person needs necessary treatment during his/her temporary stay in another Member State, your role will be defined as the Counterparty in this BUC.
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 of information 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?
You need to fill in the S044 ‘Request for Entitlement Document – Temporary Stay’ SED by entering the requested information and send it to the Counterparty. Please note the "starting / ending date of entitlement" information is required.
As an answer, you should receive the S045 ‘Entitlement Document – Temporary Stay’ SED with a reply from the competent institution.
I have received S045 ‘Entitlement Document – Temporary Stay’ SED (step CO.4)
Sub-process steps available to the Case Owner at this stage:
I want to request ad-hoc Information from the Counterparty (H_BUC_01).
I want to remind a Counterparty of a SED or information that it needs to send to me (AD_BUC_07).
You can do these multiple times.
CO.4 What should I do if I have received the S045 ‘Entitlement Document – Temporary Stay' SED?
You have received the S045 ‘Entitlement Document – Temporary Stay’ SED this SED may provide either a confirmation of a right or an information on no entitlement from the competent Member State.
If the rights to benefits in kind are confirmed on S045 this document will be the basis for the future request for reimbursement from the competent Member State for the cost of provided benefits in kind.
If the Counterparty chose in S045 “Info on non-entitlement” and as a reason:
“unknown in this situation” in order to get the confirmation of a right you need to send a new S044 with a request;
“other reason” with information that Counterparty is not competent to review the request and he could not forward the case to another institution.
You need to send a new S044 to correctly identified institution.
Unless you want to request for additional information, this business use case ends here.
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’ SED S044?
You receive the S044 ‘Request for Entitlement Document – Temporary Stay’ SED from the Case Owner. S044 is a request from the institution in the Member State of Stay for an entitlement document for a person who is claiming to be insured in your institution.
First check if if you are responsible to process the received request.
I am responsible for the business process (CP.2)
I am not responsible for the business process (CP.3)
CP.2 What should I do if I am responsible for the business process?
If you have confirmed that you are responsible for handling this case you need to review the request and provide a reply on the entitlement document or the reason for non-entitlement by filling in the S045 – Entitlement Document – Temporary Stay SED and then send it back to the Case Owner.
Before you send a reply on S045 you can ask for any additional information which are necessary for you to provide a reply.
Unless you want to request for additional information, this business use case ends here.
Sub-process steps available to the Counterparty at this stage:
I want to request ad-hoc Information from the Case Owner (H_BUC_01).
I want to remind the Case Owner of previously requested ad-hoc information that I expected, but did not yet receive (AD_BUC_07).
CP.3 What should I do if I am not responsible for the business process?
You have two options:
If you are not responsible to handle the received SED 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 to handle the received SED but you do not know which other institution in your country is the competent one, you
can reply on S045 with information about non-entitlement and reason about the lack of competence.
Before you forward the case you can ask for any additional information which is required to provide a reply.
I want to send S045 – Entitlement Document – Temporary Stay SED (Step CP.2)
Sub-process steps available to the Counterparty at this stage:
I want to forward the case to another Competent Institution in my Member State because I am not or no longer competent to treat it (AD_BUC_05).
I want to request ad-hoc Information from the Case Owner (H_BUC_01).
I want to remind the Case Owner of previously requested ad-hoc information that I expected, but did not yet receive (AD_BUC_07).
You can Forward the Case only once, the rest you can perform multiple times.
BPMN diagram for S_BUC_05
Click here to open the BPMN diagram(s) for S_BUC_05.
Structured Electronic Documents (SEDs) used in the process
The following SEDs are used in this BUC:
S044 – Request for Entitlement Document – Temporary Stay
S045 – Entitlement Document – Temporary Stay
Administrative sub-processes
The following administrative sub-processes are used in S_BUC_05:
AD_BUC_05_Subprocess – Forward Case
AD_BUC_07_Subprocess – Send 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_05:
H_BUC_01_Subprocess – Ad-hoc Exchange of Information