Guidelines for the use of Sickness Flows and SEDs and Portable Documents S1, S2, S3

Transcription

1 Guidelines for the use of Sickness Flows and SEDs and Portable Documents S1, S2, S3 Editors: Agata Szewczak, Ewa Miezien, Linda DeClercq, Noora Heinonen, Sophie Germont, Chris Segaert, Romain Schaul, Burchard Osterholz, Markus Weyres Date: 13 October 2014 Version:

2 Versioning fi- Date Version Comment Author Status ( editable, nal ) First version on Circa Markus Weyres final Update light review for version 2 Markus Weyres editable Update Flow F-S007, F-S008, F-S009, F-S011, F-S018 and F-S018a Updates regarding cost settlement: Flows F-S019, F- S021, F-S022, F-S Further update regarding cash benefits, aggregation of periods and long-term care Chris Segaert Noora Heinonen, Walter Zwieckhorst, Markus Weyres Ewa Miezien, Burchard Osterholz, Markus Weyres editable editable editable Several small adjustments for version 2 Markus Weyres final Updates regarding version 3 of flows and SEDs Markus Weyres, Ewa Miezien, Burchard Osterholz, Romain Schaul editable Further updates regarding version 3 of flows and SEDs Updates regarding flows f-s001, F-S002, F-S009, F- S Updates regarding flows F-S019, F-S021, F-S022 and F-S023 Markus Weyres Romain Schaul, Markus Weyres Markus Weyres editable editable editable Updates regarding flow diagrams and glossary of used symbols Markus Weyres Final Update regarding reimbursement lump sums Markus Weyres Final Updates regarding several issues Markus Weyres Final Updates regarding flow diagramms F-S019, F-S021 and F-S022 Markus Weyres Final Update chapter Cost settlement Markus Weyres Final Refinement chapter Cost settlement Markus Weyres Final Update/review of chapter 4 scheduled treatment (flows F-S007, F-S008, F-S009, and F-S011) Chris Segaert Final Update SED S009 Chris Segaert Guidelines SED Sickness Page 2/106

3 Update introduction, update horizontal SEDs list, update Annex I, change Annex II, delete annex III DG EMPL final Guidelines SED Sickness Page 3/106

4 Table of contents How to use the guidelines Introduction Entitlement Residence outside Competent Member State F-S001 - Person without entitlement document / request by state of residence F-S001a - Person without entitlement document / request by competent state F-S002 - Person with entitlement document F-S003 - Change or cancellation of entitlement document F-S004 - Change or cancellation of registration Entitlement Temporary Stay outside Competent Member State F-S005 - Necessary Treatment in MS of Stay - Request for Entitlement Document (European Health Insurance Card or Certificate of Provisional Replace) F-S006 - Necessary or Scheduled Treatment - Reimbursement Rates Scheduled Treatment F-S007 Scheduled Treatment - Information on Coverage of Specific Benefit in Kind F-S008 Scheduled treatment - Request Entitlement Document in Member State of Stay (Residence not in competent Member State) F-S009 - Scheduled treatment - Request extension of authorisation in Member State of Stay F-S011- Urgent vitally necessary treatment Request for authorisation in Member State of stay (residence not in competent Member State) Former Frontier Workers F-S018 - Request for entitlement document F-S018a Change or cancellation of entitlement document Cost Settlement Business flows Structured Electronic Documents (SED) Terms used in the SEDs F-S019 Actual Cost Claim Benefits in Kind F-S021 Inventory of months - fixed amounts F- S022 - Claim for Interest on late Payment F-S023 - Refund of Overpayment Long-term care...69 Guidelines SED Sickness Page 4/106

5 7.1 F-S015 Long-Term Care Cash Benefits - Application F-S016 - Long-term care Cash Benefits - Medical Examination F-S017 - Long-term Care Cash Benefits - Information on Payment F-S017a - Long-term Care Cash Benefits Change or cancellation Cash Benefits F-S012 Cash Benefits Application F-S013 Cash Benefits Administrative Check or Medical Examination F-S014 Cash Benefits Information on Payment F-S014a Cash Benefits Information Related to Cash Benefits in Respect of Incapacity for Work given by competent institution F-S014b Cash Benefits Information Related to Cash Benefits in Respect of Incapacity for Work given by institution of place of residence or stay Aggregation of Periods F-S024 - Aggregation of Periods Insurance Risk Type: Sickness, Paternity and Maternity Portable Documents S1 Registering for health care cover S2 Entitlement to scheduled treatment S3 Medical treatment for former cross-border worker in former country of work Horizontal SEDs ANNEX I Flows table...97 ANNEX II Changes in numbering and titles of SEDS version 3 compared to SEDs version ANNEX IV Glossary of Used Symbols Guidelines SED Sickness Page 5/106

6 How to use the guidelines These guidelines refer to the 3 rd version of the SEDs and Flows, as approved by the Administrative Commission for the Coordination of Social Security Systems on the 18-19th of December The purpose of these Guidelines is to: provide staff and institutions with general information and guidance about the use and completion of the SEDs, mostly for paper exchanges at present (on a similar basis to the E-forms exchanges) This guidance also includes the use of Portable Documents PD S1, PD S2 and PD S3 and the SEDs likely to be associated with their use; provide the basis on which social security institutions in Member States can prepare more detailed instructions for their staff should they so wish; provide guidance and further information on the more complex aspects of the SEDs; supplement the explanatory notes elaborated for each SED and should be read in conjunction with them. The Guidelines comprise: an explanation of the use of each SED and Flow; a short description of each SED, including any limits or conditions; examples of business situations to illustrate the use of SEDs in certain situations; a brief description of the horizontal SEDs which can be used for obtaining or providing certain types of information (detailed guidance on the specific use of Horizontal SEDs, can be found in the Horizontal SEDs and Flows Guidelines); a flows table (annex I); a table capturing the main differences regarding the changes in numbering the SEDs version 3 compared to SEDs version 1 (annex II). (For further explanation on the detailed changes implemented in the version 3 of SEDs please refer to: The Guidelines are not: exhaustive; an official interpretation of the provisions of the social security regulations (Regulations (EC) no 883/2004 and Regulation (EC) no 987/2009); describing in detail the use of the SEDs in an electronic environment (even if in certain cases some explanations refer to the future use of the SEDs in electronic exchange); providing guidance on the use or functionalities of an electronic exchange system; providing guidance on the use of the E-forms. Guidelines SED Sickness Page 6/106

7 Note: Currently the exchange of SEDs is based on the concept of "Flows". At the date of issuing these guidelines work is on-going for documenting and defining the SEDs exchanges based on "Business Use Cases" (i.e. a specific claim/case that a clerk will have to resolve, which aligns to a specific situation occurring in a Member State for which there is need to invoke a process under the provisions of the social security coordination regulations. Such examples include: a citizen wishing to claim an old age pension from a country in which they are not resident or a citizen having an accident while being outside of the competent Member State). Once this work is finalised, an updated version of the guidelines will be issued to reflect the outcomes. Availability of SEDs for download The version 3 of SEDs (all sectors and linguistic versions) is available on CircaBC. You do NOT need any special login credentials for accessing the relevant folder. In order to reach it you should: Follow the link below (please open your browser before clicking on the link): FormPrincipal:_idJsp35&FormPrincipal_SUBMIT=1&id=a075dbdb-23b1-4b40-9ca2- e74cb4d73f32&javax.faces.viewstate=ro0abxvyabnbtgphdmeubgfuzy5pymply3q7km5ynxbzk WwCAAB4cAAAAAN0AAExcHQAKy9qc3AvZXh0ZW5zaW9uL3dhaS9uYXZpZ2F0aW9uL2NvbnRhaW5l ci5qc3a alternatively: go to the CircaBC welcome page by searching "CicaBC" on Google or other search engine Then go to the CIRCABC Main Menu -> Browse Categories (left upper corner) -> Employment and Social Affairs (Under European Commission heading 3rd box down)-> Structured Electronic Documents -> Then click on Library (upper left of the page) then Select SEDs version 3 Guidelines SED Sickness Page 7/106

8 1 Introduction The following guidelines are meant to offer a general description of the use of each business flow and its SEDs. The guidelines describe business flows of the sickness section. This section can be subdivided into the following sub sections and the assigned business flows: - Entitlement - Residence outside competent member state (F-S001, F-S001a, F-S002, F- S003, F-S004) - Entitlement Temporary stay outside competent member state (F-S005, F-S006) - Scheduled treatment (F-S007, F-S008, F-S009, F-S011) - Former frontier workers (F-S018, F-S018a) - Cost settlement (F-S019, F-S021, F-S022, F-S023) - Long-term care (F-S015, F-S016, F-S017, F-S017a) - Cash benefit (F-S012, F-S013, F-S014, F-S014a) - Aggregation of periods (F-S024) Guidelines SED Sickness Page 8/106

9 2 Entitlement Residence outside Competent Member State 2.1 F-S001 - Person without entitlement document / request by state of residence Function of business flow This flow allows the institution of the place of residence to request an entitlement document for the person concerned. On the basis of this registration this person (and his/her family members) is entitled to all benefits in kind according to the legislation of the state of residence Legal foundation of business flow Art. 17 of Reg. 883/2004 Art. 24 of Reg. 987/ Trigger of business flow The person concerned contacts the institution of the place of residence without any entitlement document established by the competent institution (portable document S1 or former E-forms E106, E109, E120 or E121). As the registration is individualized, the institution of the place of residence initiates as many flows F-S001 as there are persons registered. Guidelines SED Sickness Page 9/106

10 2.1.4 Procedure of business flow Competent State Yes Date of registration or non-registration agreed to? END X No S071 S072 S073 S050 State of residence START Yes X No Entitlement confirmed by competent state? END SED S071 Request for entitlement document - residence A request from the institution of the place of residence is sent to the competent institution to check whether the person concerned is entitled to benefits in kind in the country of residence on behalf of the competent institution. On the basis of the person indications, the probable date of the requested registration should be provided and the probable status of the person concerned should be indicated SED S072 Entitlement document residence If applicable, the competent institution provides the entitlement document S072 that enables the insured person (or members of his/her family) to receive in the Member State of residence benefits in kind provided, on behalf of the competent institution. The validity period of the S072 is indicated and if not, the reason for refusal is provided. As the registration is individualized, the competent institution will be asked for an entitlement document S072 for the insured person and every family member. The institution of the place of residence determines the family members and will address as many S071 as there are family members to the competent institution in order to get the entitlement documents S072. Guidelines SED Sickness Page 10/106

11 SED S073 Information of registration - residence The member state of residence sends a confirmation of the registration or non-registration of the person and his/her family member(s) to the competent state. The S073 indicates the period of the registration or the reason for non-registration SED S050 Dispute registration date - residence This SED is optional and allows the competent institution to express a dispute in respect of the registration date indicated in the S073. If a S050 is sent, the institution of the member state of residence answers with a new S073 with the rectified date. In the same flow, several S050 with their subsequent S073 can be send until the competent state decides to accept the indicated registration dates and stops the reconciliation loop. 2.2 F-S001a - Person without entitlement document / request by competent state Function of business flow This flow allows the institution of the competent state to send the entitlement document for the person concerned. On the basis of this registration this person (and his/her family members) is entitled to all benefits in kind according to the legislation of the state of residence Legal foundation of business flow Regulation 883/2004 art. 17 Regulation 987/2009 art Trigger of business flow When the competent institution has received information regarding the institution of the place of residence or stay, it can initiate this flow F-S001a by its own. The competent institution does not have to wait for a request from the institution of the place of residence by flow F-S001 (see chapter 2.1). As the registration is individualized, the competent institution initiates as many flows F-S001a as there are persons registered. Guidelines SED Sickness Page 11/106

12 2.2.4 Procedure of business flow Competent State Yes Date of registration or non-registration agreed to? END START X No S072 S073 S050 State of residence SED S072 Entitlement document residence The competent institution provides the entitlement document S072 that enables the insured person (or members of his/her family) to receive in the Member State of residence benefits in kind provided, on behalf of the competent institution. The validity period of the S072 has to be indicated. As the entitlement document is individualized, the competent institution will issue an entitlement document S072 for the insured person and for every family member SED S073 Information of registration - residence The member state of residence sends a confirmation of the registration or non-registration of the person and his/her family member(s) to the competent state. The S073 indicates the period of the registration or the reason for non-registration SED S050 Dispute registration date - residence This SED is optional and allows the competent institution to express a dispute in respect of the registration date indicated in the S073. If the S050 is sent, the institution of the member state of residence answers with a new S073 with the rectified date. In the same flow, several S050 with their subsequent S073 can be send until the competent state decides to accept the indicated registration dates and stops the reconciliation loop. Guidelines SED Sickness Page 12/106

13 If the competent institution didn t send the SED S072 for every family member, the institution of the member state of residence asks for this entitlement document by using the flow F-S001 (see chapter 2.1). 2.3 F-S002 - Person with entitlement document Function of business flow This flow allows the institution of the place of residence to register person concerned and his/her family members. On the basis of this registration this person has (and his/her family members) entitlement to all benefits in kind according to legislation of the state of residence Legal foundation of business flow Regulation 883/2004 art. 17 Regulation 987/2009 art Trigger of business flow The flow F-S002 is initiated by presenting PD S1 (form E106, E109, E120, E121). As the registration is individualized, the institution of the place of residence initiates as many flows F-S002 as there are persons registered. Please note: If the competent institution didn t issue PD S1 for every entitled person (e. g. family member) the institution of member state of place of residence initiates flow F-S001. Guidelines SED Sickness Page 13/106

14 2.3.4 Procedure of business flow Competent State Date of registration agreed to? END Yes X No S073 S050 State of residence START SED S073 Information of registration residence On the basis of the entitlement document, the portable document S1, established by the competent institution, the institution of the place of residence informs the competent institution about registration of the person and his/her family members. The institution of the place of residence can inform the competent institution that the registration is not possible (in this case the reason should be provided) SED S050 Dispute registration date residence This SED is optional and allows the competent institution to express a dispute in respect of the registration date indicated in the S073. If the S050 is sent, the institution of the member state of residence answers with a new S073 with the rectified date. In the same flow, several S050 with their subsequent S073 can be send until the competent state decides to accept the indicated registration dates and stops the reconciliation loop. Guidelines SED Sickness Page 14/106

15 2.4 F-S003 - Change or cancellation of entitlement document Function of business flow This flow allows the competent institution to change or cancel the entitlement document. On the basis of this flow the previous registration can be either changed or fully or partially cancelled (for all persons within one family or just one or more family members) Legal foundation of business flow Regulation 883/2004 art. 17 Regulation 987/2009 art Trigger of business flow This flow begins when the reasons for previous registration change (e.g. when the insured person has moved to the competent or another state and therefore his/her registration in former state of residence is stopped ). The competent institution informs the institution of the place of residence about any change or cancellation of an existing registration Procedure of business flow Competent State Yes Ending date insurance equals ending date registration? END START X No S016 S017 S050 State of residence SED S016 Change or cancellation of entitlement document The Competent institution provides information about change or cancellation of the entitlement document to the institution of the place of residence. The reason should be mentioned. As the Guidelines SED Sickness Page 15/106

16 registration is individualized, if only a dependent family member is concerned, the S016 can concern only this family member and not necessarily the insured person SED S017 Reply to change or cancellation of entitlement document The institution of the place of residence informs the competent institution that the SED S016 has been registered and that the change or cancellation as indicated in the S016 is effective. In case of a contestation, the reason should be indicated SED S050 Dispute registration date - residence This SED is optional and allows the competent institution to express a dispute in respect of the change or cancellation date indicated in the S017. If the S050 is sent, the institution of the member state of residence answers with a new S017 with the rectified date. In the same flow, several S050 with their subsequent S017 can be send until the competent state decides to accept the indicated registration dates and stops the reconciliation loop. 2.5 F-S004 - Change or cancellation of registration Function of business flow This flow allows the institution of the place of residence to change or cancel the registration. On the basis of this flow the previous registration could be either changed or fully or partially cancelled (for all persons within one family or just one or more family members) Legal foundation of business flow Regulation 883/2004 art. 17 Regulation 987/2009 art Trigger of business flow This flows begins when the reasons for previous registration change (e. g. an insured person has died; a family member has started to work and therefore he/she should no longer be considered as a family member of the insured person ). The institution of the place of residence informs the competent institution about any change or cancellation of an existing registration. Guidelines SED Sickness Page 16/106

17 2.5.4 Procedure of business flow Competent State S018 S019 S050 State of residence START X No Yes Ending date registration agreed? END SED S018 Change or cancellation of registration The institution of the place of residence provides information about change or cancellation of registration to the competent institution. The reason should be mentioned. As the registration is individualized, if only a dependent family member is concerned, the S016 can concern only this family member and not necessarily the insured person SED S019 Reply to change or cancellation of registration The competent institution informs the institution of the place of residence that the SED S018 has been registered and that the change or cancellation as indicated in the S018 is effective. In case of a contestation, the reason should be indicated SED S050 Dispute registration date This SED allows the institution in the state of residence to express a dispute in respect of the change or cancellation date indicated in the S019. If the S050 is sent, the institution of the mem- Guidelines SED Sickness Page 17/106

18 ber state of residence answers with a new S019 with the rectified date. In the same flow, several S050 with their subsequent S019 can be send. Guidelines SED Sickness Page 18/106

19 3 Entitlement Temporary Stay outside Competent Member State 3.1 F-S005 - Necessary Treatment in MS of Stay - Request for Entitlement Document (European Health Insurance Card or Certificate of Provisional Replace) Function of business flow This flow allows requesting for a confirmation of the person s right to sickness benefits in kind during his/hers temporary stay in another Member State Legal foundation of business flow Regulation 883/2004 art. 19 Regulation 987/2009 art Trigger of business flow A person needs a necessary treatment during his/hers temporary stay in another Member State but does not have an entitlement document with him/her. Guidelines SED Sickness Page 19/106

20 3.1.4 Procedure of business flow Competent State S044 S045 State of residence or stay START END SED S044 - Request for Entitlement Document - Stay (European Health Insurance Card or PRC) Institution of the place of stay requests entitlement document for health benefits in kind in case of temporary stay. While indicating the time for which the SED should be valid, the Member State should give the beginning and ending date on which such certification is required SED S045 - Entitlement Document - Stay (European Health Insurance Card or PRC) Competent Institution informs whether or not the person concerned is entitled to sickness benefits from this Member State. If yes, the institution of place or stay may issue a national entitlement document. It is not foreseen to attach a provisional replacement certificate (PRC), as the PRC itself is not part of EESSI. Typically the PRC is issued if the insured person directly gets in touch with the competent institution. Guidelines SED Sickness Page 20/106

21 3.2 F-S006 - Necessary or Scheduled Treatment - Reimbursement Rates Function of business flow This flow allows establishing the reimbursement rates when the person has actually borne the costs of all or part of the benefits in kind him/herself, and the Competent Institution is requested by that person for reimbursement Legal foundation of business flow Regulation 883/2004 art. 19, 20, 27 Regulation 987/2009 art. 25, Trigger of business flow A person applies to the Competent Institution for reimbursement of treatment costs that he/she has borne in another Member State Procedure of business flow Competent State START END S067 S068 State of residence or stay SED S067 Request for reimbursement rates - stay A request from the Competent Institution to the Institution of the MS in which the treatment was provided to determine the reimbursement rates when the person has actually borne the costs of Guidelines SED Sickness Page 21/106

22 all or part of the health benefits in kind received; the receipts should be provided. The nature of treatment (necessary or scheduled treatment) should be indicated SED S068 Reply to reimbursement rates - stay Institution of the place of treatment informs Competent Institution about applicable reimbursement rates the SED allows to indicate the total amounts to be reimbursed; the Institution of Member State of stay indicates the amounts for which no reimbursement is foreseen in any case, e.g. private treatment the institution of Member State of stay could mention any other information in respect of reimbursement rates in point 3.5 Guidelines SED Sickness Page 22/106

23 4 Scheduled Treatment 4.1 F-S007 Scheduled Treatment - Information on Coverage of Specific Benefit in Kind Function of business flow This flow allows the competent institution to ask an institution in the Member State where the insured person is to undergo a scheduled treatment whether the particular treatment is covered in that Member State or not Legal foundation of business flow Art. 20 of Reg. (EC) 883/2004 Art. 26 of Reg. (EC) 987/ Trigger of business flow The person concerned has applied for an authorisation to the institution of the competent Member State (hereafter: competent institution). The competent institution, prior to issuing a portable document S2, needs to know whether the particular treatment is among the benefits in kind covered by the Member State of stay. (Business Flow done by letter during the application of the regulation (CE) 1408/71) SED S014 Request for information if treatment is provided by Member State of Stay - scheduled treatment SED S015 - Information if treatment is provided for by Member State of stay - scheduled treatment Guidelines SED Sickness Page 23/106

24 4.1.4 Procedure of business flow Competent State START END S014 S015 State of stay SED S014 - Request for information if treatment is provided for by Member State of stay - scheduled treatment This SED is used when an insured person asks an authorisation to receive an appropriate (scheduled) treatment outside the Member State of residence / competent Member State. In section 4 the competent institution indicates the nature of its request for information by ticking the appropriate box(es), i.e. to know : whether the particular treatment is provided for by the legislation of the Member State of stay, the estimated costs of the treatment. It is possible to tick both boxes. In section 5 the competent institution should mention additional information on: the particular treatment (data field 5.1), the place of treatment (data fields tot 5.2.5), the name of the provider (data field 5.3), any other specific information which may be useful (data field 5.4). Guidelines SED Sickness Page 24/106

25 In data field the competent institution fills in the ISO3166 country code of the Member State of stay / treatment SED S015 - Information if treatment is provided for by Member State of stay - scheduled treatment The reply of the institution of the Member State of stay provides the competent institution with the requested information on the scheduled treatment. In data field 4.1 the institution of the Member State of stay mentions the date on which the SED S014 was issued by the competent institution. In data field 4.2 the institution of the Member State of stay indicates the nature of its reply to the request for information on the treatment by ticking the appropriate box: is provided for by our legislation ; is provided for by our legislation but cannot be given within a time limit which is medically justifiable ; is not provided for by our legislation. In data field 4.3 the institution of the Member State of stay indicates, if requested, the estimated cost of the treatment (data field 4.3.1) and the currency (data field 4.3.2) 4.2 F-S008 Scheduled treatment - Request Entitlement Document in Member State of Stay (Residence not in competent Member State) Function of business flow This flow allows the institution of the Member State of residence, in case it is not the competent institution to issue an authorisation, to forward the request for an authorisation made an insured person/pensioner to the competent institution. The competent institution subsequently decides if an authorisation is granted or not, and issues a portable document S2 to the person concerned, and informs the institution of the Member State of residence of its decision Legal foundation of business flow Art. 20, 27 (3) of Reg. (EC) 883/2004 Art. 26 (2) of Reg. (EC) 987/2009 Guidelines SED Sickness Page 25/106

26 4.2.3 Trigger of business flow An insured person/pensioner, who does not reside in the competent Member State, requests the institution of his/her place of residence for an authorisation for a scheduled treatment outside the Member State of residence. The institution of the place of residence examines whether the conditions to issue an authorisation in the Member State of residence are met or not, and informs the competent institution of its conclusions Procedure of business flow Competent State Information sufficient? X No Yes S009 S076 S075 S010 State of residence START END SED S009 - Request for entitlement document - scheduled treatment outside Member State of residence The institution of the place of residence, which received the request from an insured person/pensioner for an authorisation for an appropriate (scheduled) treatment outside the Member State of residence - and outside the competent Member State if the latter Member State is mentioned in Annex IV of Regulation (EC) 883/2004, and in the case where it is not competent for issuing the authorisation, forwards the request to the competent institution. The following Member States are currently mentioned in Annex IV: Belgium, Bulgaria, Czech Republic, Germany, Greece, Spain, France, Cyprus, Luxemburg, Hungary, Netherlands, Austria, Poland, Slovenia and Sweden, as well as Iceland, Liechtenstein and Switzerland. Guidelines SED Sickness Page 26/106

27 The institution of the place of residence examines whether the conditions to issue an authorisation in the Member State of residence are met or not in accordance with article 20 (2) of Regulation (EC) 883/2004)), and informs the competent institution of its conclusions. Therefore, the institution of the place of residence indicates in section 4 whether the treatment is not provided for by the legislation of the Member State of residence, the person can be treated within a medically justifiable time. In section 4 the institution of the place of residence should also mention the requested period of entitlement (data field 4.3), including the start and end date (data fields and 4.3.2). In section 5 the institution of the place of residence should mention additional information on: the particular treatment (data field 5.1), the date on which the insured person/pensioner applied for the authorisation (data field 5.2) the place of treatment (data fields tot 5.3.5), In data field the institution of the place of residence fills in the ISO3166 country code of the Member State of stay. the name of the provider (data field 5.4). The institution of the place of residence is requested to attach all relevant medical data (medical report, treatment options, medical evaluation/examination by a medical officer,...) which the competent institution may need to examine the request of its insured person/pensioner for an authorisation for a scheduled treatment. It should mention the number of attachments in the data field Number of attachments SED S075 Request additional info scheduled treatment outside Member State of residence Although the competent institution has to accept the findings and the treatment options of the doctors approved by the institution of the Member State of residence, it retains the right to have the insured person examined by a doctor in the Member State of stay or residence during the whole procedure. The SED S075 is used by the competent institution and sent to the Member State of residence to request additional information on the scheduled treatment of its insured person. In section 4 the competent institution has to indicate in data field 4.1 the nature of its request for additional information by ticking the appropriate box(es) : medical examination by; medical report; specific information; other. Guidelines SED Sickness Page 27/106

28 If the competent institution has ticked the box medical examination by in data field 4.1, it should mention in data field 4.2 the name of the doctor of its own choice (and other useful information as the address of this doctor) in the Member State of residence. If the competent institution has ticked the box specific information in data field 4.1, it should mention in data field 4.3 the nature of the specific information it requests. If the competent institution has ticked the box other in data field 4.1, it should mention in data field 4.3 the nature of the other information it requests SED S076 Reply to request additional info scheduled treatment outside Member State of residence The reply of the institution of the Member State of residence provides the competent institution with the requested information on the scheduled treatment of the insured person who applied for an authorization. In section 4 the institution of the Member State of residence has to indicate in data field 4.1 the nature of its reply to the request for additional information by ticking the appropriate box(es): medical examination; medical report; specific information; other. The institution of the Member State of residence sends its reply as an attachment. It should therefore mention the number of attachments in the data field Number of attachments SED S010 - Reply to request for Entitlement Document - scheduled treatment outside Member State of residence In case the competent institution grants the authorisation to its insured person/pensioner for a scheduled treatment outside the Member State of residence / competent Member State, it issues a portable document S2 to the person concerned. The competent institution informs the institution of the Member State of residence of its decision by sending a SED S010. In data field 4.1 the competent institution mentions the number of the SED (i.e. SED S009) sent by the institution of the place of residence and to which it replies. In data field 4.2 the competent institution mentions the date on which the SED S009 was issued by the institution of the place of residence. In section 5 the competent institution has to indicate, by ticking the appropriate box, whether the authorisation for the scheduled treatment: is granted ; is not granted. Guidelines SED Sickness Page 28/106

29 If the competent institution has ticked the box is granted in section 5, it should mention the start (data field 6.1) and end date (data field 6.2) as they appear on the authorisation to receive a scheduled treatment issued to the insured person/pensioner (i.e. data fields and of the portable document S2). If the competent institution has ticked the box is not granted in section 5, it should tick the appropriate box(es) in section 7 explaining why the authorisation has not been granted: the authorisation is not granted because the treatment is among the benefits provided for by the legislation of the Member State of residence and can be given in within a time-limit which is medically justifiable; the authorisation is not granted because treatment is among the benefits provided for by the legislation of the competent Member State and can be given within a time-limit which is medically justifiable; other reason. If the competent institution has ticked the box Other reason in section 7, it may provide more information as to the reason why it refused to grant the authorisation in a separate document. In that case it should mention the number of attachments in the data field Number of attachments. In section 8 the competent institution should mention additional information on: the particular treatment (data field 8.1), the address of the place where the treatment is to be provided (data fields to 8.2.5) ; in data field the competent institution fills in the ISO3166 country code of the Member State of stay and whether a copy of the authorisation (i.e. portable document S2) is attached ( Yes) or not ( No) to the SED S010 by ticking the appropriate box. 4.3 F-S009 - Scheduled treatment - Request extension of authorisation in Member State of Stay Function of business flow An insured person has been granted an authorisation for a scheduled treatment outside the Member State of residence / competent Member State. An institution of the Member State of stay asks for an extension of this authorisation Legal foundation of business flow Art. 20 and 27 (3) of Reg. (EC) 883/2004 Art. 26 (5) of Reg. (EC) 987/2009 Guidelines SED Sickness Page 29/106

30 4.3.3 Trigger of business flow The institution of the place of stay in practice it will likely be at the demand of the care provider (hospital, doctor...) treating the patient requests the competent institution for an extension of the authorisation (portable document S2) issued by the latter institution Procedure of business flow Competent State S035 S037 State of stay START END S035 - Request for extension of entitlement document - scheduled treatment The institution of the place of stay sends a request for an extension of the entitlement document for a scheduled treatment to the competent institution of the person concerned in case it appears medically appropriate to supplement the treatment covered by the existing authorisation. In data field 4.1 the institution of the place of stay mentions the date on which the authorisation (portable document S2) was issued by the competent institution and for which it requests an extension. The institution of the place of stay fills in the start date (field 4.2.1) and end date (data field 4.2.2) of the requested extension of the authorisation to a scheduled treatment. In data field 4.3 the institution of the place of stay has to tick the appropriate box indicating whether a medical report is attached ( Yes) or not ( No) to the SED S035. It is recommended Guidelines SED Sickness Page 30/106

31 to attach a medical report containing the necessary medical information in order to allow the competent institution to examine the request for an extension of the authorisation it has issued. In section 5 the competent institution should mention additional information on: the treatment (data field 5.1), such as pathology, medicines taken, and the place of treatment (data fields tot 5.2.5) ; in data field the institution of the place of stay fills in the ISO3166 country code of the Member State of stay S037 - Reply to request for extension of entitlement document - scheduled treatment The competent institution informs the institution of the place of stay (= place of treatment) of its the decision in respect of the extension of the entitlement document for a scheduled treatment by sending a SED S037. In data field 4.1 the competent institution mentions the number of the SED (i.e. SED S035) sent by the institution of the place and to which it replies. In data field 4.2 the competent institution mentions the date on which the SED S035 was issued by the institution of the place of stay. In section 5 the competent institution has to indicate, by ticking the appropriate box), whether the extension of the authorisation for the scheduled treatment: is granted ; is not granted. No new portable document S2 has to be issued for the extended period, but in case the competent institution has ticked the box is granted in section 5, it should mention the start (data field 6.1) and end date (data field 6.2) of the period of extension of the authorisation for a scheduled treatment. If the competent institution has ticked the box is not granted in section 5, it has to tick the appropriate box(es) in section 7 explaining why the extension of the authorisation has not been granted: the authorisation is not granted because treatment is among the benefits provided for by the legislation of the competent Member State and can be given within a time-limit which is medically justifiable ; the authorisation is not granted because the treatment is not among the benefits provided for by the legislation of the competent Member State ; other reason. If the competent institution has ticked the box Other reason in section 7, it may provide more information as to the reason why it refused to grant the authorisation in a separate document. In that case it should mention the number of attachments in the data field Number of attachments. In section 8 the competent institution should mention additional information on: the treatment (data field 8.1), such as pathology, medicines taken, and Guidelines SED Sickness Page 31/106

32 the place of treatment (data fields tot 8.2.5) as it appears in section 5 of the SED S035 sent by the institution of the place of stay. After receiving the decision by the competent institution with regard to the extension of the entitlement document for a scheduled treatment (SED S037), the institution of the place of stay (= place of treatment) informs the care provider of this decision. 4.4 F-S011- Urgent vitally necessary treatment Request for authorisation in Member State of stay (residence not in competent Member State) Function of business flow This flow allows the institution of the Member State of residence to inform the competent institution that it has issued, on its behalf, an authorisation for a treatment outside the Member State of residence on the basis that the insured person was in need of an urgent vitally necessary treatment. The competent institution then acknowledges to the institution of the Member State of residence the receipt of the information of the granting of the authorisation, and informs the institution of the Member State of stay, where the urgent vitally necessary treatment is provided, that the claim for reimbursement can be sent directly to the competent institution. The flow also allows the competent institution to request additional information from either the institution of the Member State of residence or the Member State of stay at any time during the procedure of granting the authorisation Legal foundation of business flow Art. 20, 27 (3) of Reg. (EC) 883/2004 Art. 26 (3), (4) of Reg. (EC) 987/ Trigger of business flow An insured person who does not reside in the competent Member State applies for an authorisation (portable document S2) to receive an appropriate (scheduled) treatment outside the Member State of residence Procedure of business flow Guidelines SED Sickness Page 32/106

33 State of residence END START S011 S012 S075 S076 S013 Competent State No + + X Yes Information sufficient? + S075 S076 S013 State of stay END SED S011 Information on urgent vitally necessary treatment outside Member State of residence In case an insured person who does not reside in the competent Member State is in need of an urgent vitally necessary treatment, and the authorisation cannot be refused in accordance with the second sentence of article 20 (2) of Regulation (EC) 883/2004, the authorisation (portable document S2) shall be granted by the institution of the Member State of residence on behalf of the competent institution. The institution of the Member State of residence informs the competent institution for whom it has issued an authorisation to receive an urgent vitally necessary treatment. If the institution of the Member State of residence has information on the institution of the Member State of stay, it should mention this information in section 4. In data field 4.1 it fills in the ISO country code of the Member State of stay. In data field 4.2 it fills in the institution code of the institution of the Member State of stay as it appears in the Master Directory. In data field 4.3 it fills in the institution name of the institution of the Member State of stay as it appears in the Master Directory. In section 6 the institution of the Member State or residence fills in the start (data field 6.1) and end date (data field 6.2) as it appears on the prior authorisation to receive a scheduled treatment outside Member State of residence issued to the insured person (i.e. data fields and of the portable document S2). In section 7 the institution of the Member State of residence mentions the attachments joined to the SED S011, and ticks the appropriate box : Guidelines SED Sickness Page 33/106

34 medical report is attached ; authorisation is attached ; other. In section 8 the institution of the Member State of residence should mention additional information on : the treatment (data field 8.1) as it appears in the data field 2.1 Treatment of the portable document S2, and the place of treatment (data fields tot 8.2.5) as it appears in data field 2.2 Location of the treatment of the portable document S2 ; in data field the institution of the Member State of residence fills in the ISO country code of the Member State of stay SED S012 Acknowledgement of receipt Information on authorisation for urgent vitally necessary treatment The SED S012 is used by the competent institution to acknowledge the receipt of the information that the institution of the Member State of residence has granted, on its behalf, an authorisation for an urgent vitally necessary treatment. In field 4.1 the competent institution fills in the date on which the SED S011 and/or the portable document S2 was issued. In field 4.2 the competent institution mentions the date of reception of the SED S SED S075 Request additional info scheduled treatment outside Member State of residence Although the competent institution has to accept the findings and the treatment options of the doctors approved by the institution of the Member State of residence that issued the prior authorization (portable document S2), in respect of the need for urgent vitally necessary treatment, it retains the right to have the insured person examined by a doctor of its own choice in the Member State of stay or residence during the whole procedure. The SED S075 is used by the competent institution and sent to the Member State of stay and/or Member State of residence to request additional information on the scheduled treatment of its insured person. In section 4 the competent institution has to indicate in data field 4.1 the nature of its request for additional information: medical examination by; medical report; specific information; Other. Guidelines SED Sickness Page 34/106

35 If the competent institution has ticked the box medical examination by in data field 4.1, it should mention in data field 4.2 the name of the doctor of its own choice (and other useful information as the address of this doctor) in the Member State of stay or residence depending on whether the request was sent to institution of the Member State of stay or residence. If the competent institution has ticked the box specific information in data field 4.1, it should mention in data field 4.3 the nature of the specific information it requests. If the competent institution has ticked the box Other in data field 4.1, it should mention in data field 4.3 the nature of the other information it requests SED S076 Reply to request additional info scheduled treatment outside Member State of residence The reply of the institution of the Member State of stay or residence provides the competent institution with the requested information on the scheduled treatment of the insured person who has been granted an authorization. In section 4 the institution of the Member State of stay or residence has to indicate in date field 4.1 the nature of its reply to the request for additional information: medical examination by; medical report; specific information; other. The institution of the Member State of stay or residence sends its reply as an attachment. It should mention the number of attachments in the data field Number of attachments SED S013 Notification of payment Urgent vitally necessary treatment Further to the receipt of the SED 011 (see point supra) and in addition to the SED S012 (see point supra), the competent institution informs the institution of the Member State of stay, where the urgent vitally necessary treatment is provided on the basis of the portable document S2, that the claim for reimbursement can be sent directly to the competent institution. In section 4 the competent institution fills in some information as it appears on the portable document S2, such as: the start (data field 4.1) and end date (data field 4.2) of the entitlement ; the date on which the portable document S2 was issued (data field 4.3) ; information on the institution of the Member State of residence which issued the portable document S2 or SED S010, such as the ISO country code of the Member State of residence (data field 4.4.1), the institution code (data field 4.4.2) and the institution name (data field 4.4.3) of the institution of the Member State of residence as it appears in the Master Directory. Guidelines SED Sickness Page 35/106