S_BUC_06 | Lexipedia

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International Process Guidelines

Sickness

S_BUC_06 – Necessary or Scheduled Treatment - Reimbursement Rates

Date: 11/09/2018

Version of guidelines document: v4.1.0

Based on: S_BUC_06 version 4.1.0

Common Data Model version 4.1.0

TABLE OF CONTENTS

S_BUC_06 – Necessary or Scheduled Treatment - Reimbursement Rates 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 transmit information to? 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? 6

CP.1 What should I do if I have received the ‘Request for reimbursement rates - stay’ SED S067? 6

BPMN diagram for S_BUC_06 7

Structured Electronic Documents (SEDs) used in the process 7

Administrative sub-processes 7

Horizontal sub-processes 7

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_06 – Necessary or Scheduled Treatment - Reimbursement Rates

Description: This BUC allows the Competent Institution to request from

a Member State of Stay the reimbursement rates information to be reimbursed to an insured person. The BUC is used in the following context: An insured person has received necessary or scheduled treatment in another Member State other than the Competent Member State and the insured person has incurred there the costs for the received treatment.

The insured person requested the Competent Member State for reimbursement of the costs incurred (all or part of benefits in kind). The Competent Institution thus requests from the Member State of Stay the reimbursement rates information, using the S067 - Request for reimbursement rates - stay SED. The institution in the Member State of Stay provides the requested information using the S068 - Reply reimbursement rates - stay SED.

The BUC is individualized, meaning the case concerns only one person. A case should concern only one stay. The invoices related to different treatments during this stay should be included in the same request.

Legal Base - is captured in the following:

Basic Regulation (EC) No. 883/2004;

Implementing Regulation (EC) No. 987/2009.

The matrix specifies the articles providing the legal basis for the SEDs used in this BUC:

SED

Basic Regulation (883/04)

Implementing Regulation (987/09)

S067 Request for reimbursement rates - stay

S068 Reply reimbursement rates - stay

Request – Reply SEDs:

REQUEST SED

REPLY SED(s)

S067 - Request for reimbursement rates - stay

S068 - Reply reimbursement rates - stay

Glossary of relevant terms used in the BUC:

Term used

Description

Case Owner

In this BUC the Case Owner is in most cases the Competent Member State who receives the claim from the insured person to reimburse the costs that he/she incurred for a necessary or scheduled treatment in a Member State other than the Competent Member State. In a minority of cases, the case owner will be the country of residence. The institution of place of residence is considered to be the competent institution only for

cases when insured person lives in MS listed in Annex 3 of Reg.987/2009 and only for scheduled treatment.

Counterparty

In this BUC the Counterparty is the Member State of the place of treatment where the insured person received necessary or scheduled treatment. This Member State can only be the Member State of Stay.

How to start this BUC?

In order to help you understand the 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 Competent Member State who received the claim from the insured person to reimburse the costs that he/she incurred for a necessary or scheduled treatment in a Member State other than the Competent Member State, OR if you represent the country of residence (only for cases when insured person lives in MS listed in Annex 3 of

Reg.987/2009 and only for scheduled treatment), 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 Member State of the place of treatment where the insured person received necessary or scheduled treatment, then your role will be defined as the Counterparty.

I am the Counterparty. (step CP.1)

CO.1 Who do I need to transmit information to?

As the Case Owner, your first step in any new exchange 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 need to exchange. 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. There can be only one Counterparty.

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?

Once you determined the correct Counterparty institution, you prepare the request by filling the SED S067 ‘Request for reimbursement rates – stay’ and making sure you enter all the required information. The nature of the treatment should be indicated by selecting the appropriate checkbox in the section '2.2 Type of treatment (necessary or scheduled treatment)'

The receipt(s) concerning the necessary or scheduled treatment should be provided as an attachment to the request.

You start the BUC for each case for which you require information on reimbursement rates. The S067 SED request can concern a family member and not necessarily the insured person.

You then send the SED (including any attachments if necessary) to the

Counterparty.

You expect to receive the corresponding reply in SED S068 ‘Reply reimbursement rates – stay’ from the Counterparty that you process (along with any provided attachments) and then close the case. This BUC ends here.

Sub-process steps available to the Case Owner at this stage:

I want to remind a Counterparty of a SED or information that it needs to send to me (AD_BUC_07).

After receiving the SED S068, I want to request ad-hoc information or to remind about information that I expected but did not yet receive (H_BUC_01).

CP.1 What should I do if I have received the ‘Request for reimbursement rates - stay’ SED S067?

You have received a request SED S067 ‘Request for reimbursement rates - stay’ from the Case Owner which you need to process (along with any provided attachments).

You then have to fill in the reply SED S068 ‘Reply reimbursement rates - stay’, making sure you enter all the information required by the Competent Member State concerning the applicable reimbursements and adding the corresponding attachments. The Information about the total amount to be reimbursed can be indicated. Additional information in respect of reimbursement rates can be provided in section 2.4. You may also indicate the amount for which no reimbursement is foreseen as Additional Information.

You then send the SED along with attachments to the Case Owner. The use case ends here.

Sub-process steps available to the Counterparty at this stage:

I want to request ad-hoc information or to remind about information that I expected but did not yet receive (H_BUC_01).

I want to forward the case to another Institution in my Member State AD_BUC_05).

I want to remind a Counterparty/Case Owner of a SED or information that it needs to send to me (AD_BUC_07).

BPMN diagram for S_BUC_06

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

Structured Electronic Documents (SEDs) used in the process

The following SEDs are used in this BUC:

S067 - Request for reimbursement rates - stay (Case Owner);

S068 - Reply reimbursement rates - stay (Counterparty).

Administrative sub-processes

The following administrative sub-processes are used in this BUC:

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 this BUC:

H_BUC_01_Subprocess – Ad-hoc Exchange of Information