approvED

approvED

International Process Guidelines

Sickness

S_BUC_07 – Scheduled Treatment - Information on Coverage of Specific Benefit in Kind

Date: 11/09/2018

Version of guidelines document: v4.1.0

Based on: S_BUC_07 version 4.1.0

Common Data Model version 4.1.0

TABLE OF CONTENTS

S_BUC_07 – Scheduled Treatment - Information on Coverage of Specific Benefit in Kind 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 start the international exchange as Case Owner? 6

CO.4 What should I do if I have received SED S015 as Case Owner? 6

CP.1 What should I do if I have received SED S014 as Counterparty? 6

BPMN diagram for S_BUC_07 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

23/05/2017

Secretariat

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

v0.2

02/08/2017

Secretariat

Second version of the document after review from AHG. Version submitted for AC review.

v0.3

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

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_07 – Scheduled Treatment - Information on Coverage of Specific Benefit in Kind

Description: When an insured person (claimant) applies for an authorisation to receive an appropriate (scheduled) treatment outside the Member State of residence / competent Member State, the competent institution (prior to issuing a portable document S2) requests the institution in the Member State where the insured person is to undergo the treatment whether the particular treatment is among the benefits in kind covered in that Member State of stay. This BUC models the request for information issued by the competent institution of the competent Member State and the reply by the institution in the Member State of stay.

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.

SEDs

Basic Regulation (883/04)

Implementing Regulation (987/09)

20

26

S014 - Request for information if treatment is provided for by Member State of stay - scheduled treatment

S015 - Information if treatment is provided for by Member State of stay - scheduled treatment

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)

S014 - Request for information if treatment is provided for by Member State of stay - scheduled treatment

S015 - Information if treatment is provided for by Member State of stay - scheduled treatment

Glossary of relevant terms used in S_BUC_07:

Term used

Description

Case Owner

In this BUC the Case Owner is Institution of the competent Member State where the insured person asks an authorisation to receive an appropriate (scheduled) treatment outside the Member State of residence / competent Member State.

Counterparty

In this BUC the Counterparty is the Institution of the Member State of stay where the insured person is going to receive the treatment.

How to start this BUC?

In order to help you understand S_BUC_07 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 Competent Member State where the insured person asks an authorisation to receive an appropriate (scheduled) treatment outside the Member State of Residence / Competent Member State and you need to request information on coverage of a specific benefit in kind from the institution in the Member State of stay, then your role will be defined as the Case Owner.

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

If you represent the institution of the Member State of stay where the insured person is going to receive the treatment and you are requested to provide information on the coverage of a specific benefit in kind, 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 where the person is to receive treatment. The second step is to identify the relevant institution in this Member State that you need to exchange information with. 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 start the international exchange as Case Owner?

As a Case Owner you have decided that there is a need to gather information regarding the process of a sickness case. You need to request for information on the scheduled treatment by filling out and sending a

'Request for information if treatment is provided for by Member State of stay - scheduled treatment' SED S014 to the identified Counterparty. Fill in information on the nature of the request (if treatment is provided for by legislation of the Member State, how much it is cost, etc.).

The Counterparty will reply with information by filling out and sending 'Information if treatment is provided for by Member State of stay - scheduled treatment' SED S015 back to you.

I have received SED S015 from the Counterparty. (step CO.4)

CO.4 What should I do if I have received SED S015 as Case Owner?

You have received 'Information if treatment is provided for by Member State of stay - scheduled treatment' SED S015 from one Counterparty.

If all information is provided, the Business Use Case ends here.

If you need further information, you can request them using the sub- process H_BUC_01

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).

CP.1 What should I do if I have received SED S014 as Counterparty?

You have received the Request for information 'Request for information if treatment is provided for by Member State of stay - scheduled treatment' SED S014 from the Case Owner.

If you do not need further information, provide the requested information by filling out and sending the 'Information if treatment is provided for by Member State of stay - scheduled treatment' SED S015 to the Case Owner. The Business Use Case ends here.

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 Forward Case the case to another Competent Institution (AD_BUC_05).

BPMN diagram for S_BUC_07

Click here to open the BPMN diagram(s) for S_BUC_07.

Structured Electronic Documents (SEDs) used in the process

The following SEDs are used in S_BUC_07:

SED S014 – Request for information if treatment is provided for by Member State of stay - scheduled treatment;

SED S015 – Information if treatment is provided for by Member State of stay - scheduled treatment.

Administrative sub-processes

The following administrative sub-processes are used in S_BUC_07:

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_07:

H_BUC_01_Subprocess – Ad hoc Exchange of Information