EESSI – CDM 4.3
S-Sickness
S082-v4.3.4
Contestation of individual claim (COC)
SED Guidelines
Document Control Information
Document Control
Value
Project Title
Electronic Exchange of Social Security Information (EESSI)
Document Name
S082-v4.3.4
Document Category
SED 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 However, the document or the information herein may not be published or posted on the Internet, nor released outside of the EESSI community.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
v4.3.4
30/04/2024
Implementation of change request EESSI-11699 by updating paragraphs
08 and 09 are updated for the scenario when the period of benefits is
not (fully) covered by one single entitlement document but instead is fully covered by a subsequent entitlement document.
Also corrected minor typos and added the Document history table.
SED S082: Contestation of individual claim (COC)
Purpose of the SED:
The SED S082 is used to send a contestation for a claim. SED S082 is used as contestation of individual claim, based on Articles 62, 66(1), 67 of Regulation (EC) No 987/2009
S082 cannot be sent for claims which were already withdrawn by the Creditor Liaison Body (Case Owner) with the 'Credit Note – benefits in kind (CRN)'- SED S085;
S082 cannot be sent after 18 months of the end of the end of the month during which the claims were introduced to the liaison body of the debtor Member State;
S082 can be sent several times, each time for a new batch of the individual claims which are contested;
S082 can be issued even after the process has been finalized and information on payment has been received.
A Claim may be rejected and returned to the creditor if for example:
It is incomplete and/or incorrectly filled out;
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.
A 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.
Acronyms used in S082:
CLA – claim for reimbursement
COC – contestation of a claim
Reimbursement SEDs include 2 parts: global and individual.
Global part of S082 includes following mandatory fields:
Reference numbers:
“Global CLA reference Creditor Liaison Body” – a reference number of the claim specified in the S080, which should be copied without any change;
“Global COC reference Debtor Liaison Body” – a reference number of the contestation for a claim which allows to identify the contestation in the next steps of the exchange and in any future communication (links the SEDs). It is a unique number for given contestation and is repeated subsequently in the following SEDs at the global and at the individual level of the SEDs.
Total number of contestations – which summarizes the number of individual contestation and should be equal to the number of repeated () individual parts;
Total amount of contestations – which summarizes the amounts of the contested claims which are specified in each individual claim;
Date of submission – with a date on which S082 is submitted by the
Debtor Liaison Body (Counterparty).
Individual part of S082, which can be repeated (), allows to provide information about contestation for each individual claim and includes following mandatory fields:
ID Creditor / Debtor Institution – copied from S080 – with identification data (Institution ID, institution name) either of the institution of the place of residence / stay which provided benefits and requested reimbursement (Creditor) or the competent institution which issued entitlement document and is responsible for covering the cost of the benefits (Debtor);
References – a set of references which allows to identify the COC on global and individual level and connect it with the previous SEDs, including:
“Global CLA Reference Creditor Liaison Body” – a reference number of the claim specified in the S080, which allows to link individual COC with the original global claim (S080) and should be copied without a change;
“Global COC Reference Debtor Liaison Body” – a reference number of the COC specified in the global part of S082 which allows to link individual contestations with the global part of S082 and should be copied without a change;
“Individual CLA Number Creditor Liaison Body” – a reference number of the individual claim specified in the individual part of S080 which allows to link the individual COC (S082) with individual claim (S080) and should be copied without a change;
“Individual COC Number Debtor Liaison Body” - a reference number of the individual COC which allows to identify the contestation in the next steps of the exchange and in any future communication (links the SEDs). It is a unique number for given individual contestation and is repeated subsequently in the following SEDs at the individual level of SED.
Person receiving benefits – copied from S080 – information about the person who received the benefits in kind;
Contestation refusal code – with a list of predefined reasons:
01 – This document does not concern us – should be chosen if the claim
is issued for the incorrect institution;
02 – Institution code is incorrect. Please provide correct institution ID –
should be chosen if the institution ID provided in the individual part of a claim does not allow to identify the competent institution;
03 – Unable to identify the person from the information provided.
Please check the data – should be chosen if, based on the personal data for the person who received the benefits in kind, the person cannot be identified;
04 – Entitlement documents is unknown or not found. Please provide
copy – should be chosen if the entitlement document mentioned in S080 cannot be found by the competent institution;
05 - Scheduled treatment may be suspected. Please check.
06 – There is an overlapping in hospitalisation periods. Please adjust the
claim– should be chosen if the periods of hospitalisation mentioned in individual part of S080 are overlapping;
07 – Person was not insured during benefits period. Please provide copy
of entitlement document – should be chosen if the person was not insured in the time when benefits were provided and the benefits can be reimbursed only of if the person has presented a valid entitlement document in order to get benefits;
08 – The period of benefits in kind is not covered by the entitlement
period – should be chosen if the entitlement document mentioned in S080 does not cover the period of the provided benefits; even if the contestations reason is fulfilled, the debtor institution should check the entitlement of the person concerned and, in case an entitlement document has been issued for the person concerned, not contest the individual claim; in addition to this, entitlement information might to be updated;
09 – The period of benefits in kind is partially covered by the
entitlement period - should be chosen if the entitlement document mentioned in S080 does not cover the
whole period of the benefits; even if the contestations reason is fulfilled, the debtor institution should check the entitlement of the person concerned and, in case an entitlement document has been issued for the person concerned, not contest the individual claim; in addition to this, entitlement information might to be updated;
10 - The costs are to be settled by lump-sum as from [date should be
filled in].
11 - The costs are to be settled by lump-sum until [date should be filled
in].
12 - The person is not registered on the entitlement document
13 - The entitlement document has not been registered.
14 – Double invoice – should be chosen if individual claim has been
already requested to be reimbursed;
15 - The entitlement in the state of residence started on [date should be
filled in].
16 - The benefits seem to concern an accident at work that happened on
[date should be filled in].
17 – The person died on [date should be filled in] – should be chosen if
the period of benefits for which reimbursement is requested exceeds date when person died. Date has to be provided;
18 – Lack of information about the other benefits provided. Please
specify – should be chosen if description of the other benefits is missing or is insufficient. Reference number of the global CLA and individual CLA number of the duplicated claim have to be provided;
19 – Total amount of claim different to the sum of individual claims –
should be chosen if the total amount specified in global part of the S080 does not correspond to the amounts specified in the individual parts;
20 – Total amount of individual claim different to the sum of the
benefits – should be chosen if the total amount of individual claim specified in individual part of the S080 does not correspond to the sum of all mentioned benefits;
21 – Cost of benefits have been refunded in full or partially to the
insured person – should be chosen if the cost of benefits was paid by the person and already refunded. Details of the contestation have to be provided if this reason was chosen;
22 – Claim introduced after deadline [date should be filled in] – should
be chosen if the claims are introduced later than within 12 months of the end of the calendar half-year during which those claims were recorded in the accounts of the creditor institution. Date on which claim was introduced has to be provided;
23 - Contestation reply received after deadline [date should be filled
in].
24 – Entitlement ended [date should be filled in]
25 – The person receives a dominating pension from another state
26 – Details provided are inconsistent with the nature of benefits
99 - Other [field Other should be filled in] – should be chosen if none of
the reasons available is applicable and it is a free text field. If this reply is chosen details about the other reason must be provided in the free text field;
Individual amount contestation - the amount of contested claim. This amount can be either equal to the amount of the individual claim specified in S080 or only partial if the contestation is issued only for part of the claim. This amount is being summarized in the Total amount of contestations in the global part.
It is possible to add attachments to S082. Especially the proof to support the reasons for contestations. All attachments supporting the reply must be attached to the individual part of the SED. An attachment that is not
correctly referenced to a specific individual part might not be handled properly.
In order to see the content and explanatory notes of the SED S082 please click here.