Reply to Contestation of Credit Note (RPY_COC

DA012R - Reply to Contestation of Credit Note (RPY_COC_CRN)
Articles 35, 41 of Regulation (EC) No 883/2004, 62, 66 (1), 67 of Regulation (EC) No 987/2009

SED API version: 0.15.2 build 3
Model version: 4.1.0

1. Global Note RPY_COC_CRN * [ SED ]

1.1. Global CLA reference Creditor Liaison Body *

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1.2. Global CRN reference Creditor Liaison Body *

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1.3. Global COC_CRN reference Debtor Liaison Body *

[ BDT ] {{metaSection.globalCOCCRNReferenceDebtorLiaisonBody.$$error}} {{metaSection.globalCOCCRNReferenceDebtorLiaisonBody.$$warning}}

1.4. Global RPY_COC_CRN reference Creditor Liaison Body *

[ BDT ] {{metaSection.globalRPYCOCCRNReferenceCreditorLiaisonBody.$$error}} {{metaSection.globalRPYCOCCRNReferenceCreditorLiaisonBody.$$warning}}

1.5. Total Number Of Individual RPY_COC_CRN

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1.6. Total amount of accepted credit notes contestations * [ CC ]

1.6.1. Amount *

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1.6.2. Currency *

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1.7. Date Of Submission *

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2. Individual RPY COC CRNs * [ SED ]

2.1. Individual RPY_COC_CRN * [ SED ]

2.1.1. ID Creditor Institution * [ CC ]

2.1.1.1. Institution ID *

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2.1.1.2. Institution Name *

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2.1.2. ID Debtor Institution * [ CC ]

2.1.2.1. Institution ID *

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2.1.2.2. Institution Name *

[ CDT ] {{metaSection.institutionName.$$error}} {{metaSection.institutionName.$$warning}}

2.1.3. References * [ SED ]

2.1.3.1. Global CLA Reference Creditor Liaison Body *

[ BDT ] {{metaSection.globalCLAReferenceCreditorLiaisonBody.$$error}} {{metaSection.globalCLAReferenceCreditorLiaisonBody.$$warning}}

2.1.3.2. Global CRN Reference Creditor Liaison Body *

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2.1.3.3. Global COC_CRN Reference Debtor Liaison Body *

[ BDT ] {{metaSection.globalCOCCRNReferenceDebtorLiaisonBody.$$error}} {{metaSection.globalCOCCRNReferenceDebtorLiaisonBody.$$warning}}

2.1.3.4. Global RPY_COC_CRN Reference Creditor Liaison Body *

[ BDT ] {{metaSection.globalRPYCOCCRNReferenceCreditorLiaisonBody.$$error}} {{metaSection.globalRPYCOCCRNReferenceCreditorLiaisonBody.$$warning}}

2.1.3.5. Individual CLA Number Creditor Liaison Body *

[ BDT ] {{metaSection.individualCLANumberCreditorLiaisonBody.$$error}} {{metaSection.individualCLANumberCreditorLiaisonBody.$$warning}}

2.1.3.6. Individual CRN Number Creditor Liaison Body *

[ BDT ] {{metaSection.individualCRNNumberCreditorLiaisonBody.$$error}} {{metaSection.individualCRNNumberCreditorLiaisonBody.$$warning}}

2.1.3.7. Individual COC_CRN Number Debtor Liaison Body *

[ BDT ] {{metaSection.individualCOCCRNNumberDebtorLiaisonBody.$$error}} {{metaSection.individualCOCCRNNumberDebtorLiaisonBody.$$warning}}

2.1.3.8. Individual RPY_COC_CRN Number Creditor Liaison Body *

[ BDT ] {{metaSection.individualRPYCOCCRNNumberCreditorLiaisonBody.$$error}} {{metaSection.individualRPYCOCCRNNumberCreditorLiaisonBody.$$warning}}

2.1.4. Person receiving benefits * [ CC ]

2.1.4.1. Person Information * [ CC ]

2.1.4.1.1. Family name(s) *

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2.1.4.1.2. Forename(s) *

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2.1.4.1.3. Date of birth *

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2.1.4.1.4. Sex *

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2.1.4.2. Family name(s) at birth

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2.1.4.3. Forename(s) at birth

[ BDT ] {{metaSection.forenameAtBirth.$$error}} {{metaSection.forenameAtBirth.$$warning}}

2.1.4.4. Person Identification Number * [ CC ]

2.1.4.4.1. PIN of the person in Competent Member State *

[ BDT ] {{metaSection.pINPersonInCompetentMemberState.$$error}} {{metaSection.pINPersonInCompetentMemberState.$$warning}}

2.1.4.4.2. PIN of the person in Member State of Stay or Residence

[ BDT ] {{metaSection.pINPersonInMemberStateStayOrResidence.$$error}} {{metaSection.pINPersonInMemberStateStayOrResidence.$$warning}}

2.1.5. Reply to credit note contestation *

[ ENUM ] {{metaSection.replyCreditNoteContestation.$$error}} {{metaSection.replyCreditNoteContestation.$$warning}}

Please fill in the following if "Reply to credit note contestation" = "01 - Rectified corresponding claim number" : [ SED ]

Please fill in the following if "Reply to credit note contestation" = "03 - We accept contestation" : [ SED ]

Please fill in the following if "Reply to credit note contestation" = "02 - Credit note correction" : [ SED ]

Please fill in the following if "Reply to credit note contestation" = "99 - Other [field Other should be filled in]" [ SED ]

2.1.6.1. Rectified claim number *

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2.1.7.1. Amount of accepted contestation of credit note [ CC ]

2.1.7.1.1. Amount *

[ BDT ] {{metaSection.amount.$$error}} {{metaSection.amount.$$warning}}

2.1.7.1.2. Currency *

[ ENUM ] {{metaSection.currency.$$error}} {{metaSection.currency.$$warning}}

2.1.8.1. Credit Note Correction [ SED ]

2.1.8.1.1. Benefits period [ CC ]

2.1.8.1.1.1. Start Date *

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2.1.8.1.1.2. End Date *

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2.1.8.2. All benefits amount * [ SC ]

2.1.8.2.1. Medical Care Amount

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2.1.8.2.2. Medicine Amount

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2.1.8.2.3. Dental Care Amount

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2.1.8.2.4. Long-term Care Amount

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2.1.8.2.5. Hospitalisation Benefits [ SC ]

2.1.8.2.5.1. Hospitalisation benefit [ SC ]

2.1.8.2.5.1.1. Hospitalisation period [ CC ]

2.1.8.2.5.1.1.1. Start Date *

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2.1.8.2.5.1.1.2. End Date *

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2.1.8.2.5.1.2. Hospitalisation Amount *

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2.1.8.2.5.1.Hospitalisation benefit

2.1.8.2.6. Other benefit(s) [ SC ]

2.1.8.2.6.1. Other benefit [ SC ]

2.1.8.2.6.1.1. Other Benefit Description *

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2.1.8.2.6.1.2. Other Benefits Amount *

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2.1.8.2.6.1.Other benefit

2.1.8.3. Adjusted Amount of Credit Note * [ CC ]

2.1.8.3.1. Amount *

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2.1.8.3.2. Currency *

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2.1.9.1. Other *

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2.1.Individual RPY_COC_CRN

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DA012R - Reply to Contestation of Credit Note (RPY_COC_CRN) Articles 35, 41 of Regulation (EC) No 883/2004, 62, 66 (1), 67 of Regulation (EC) No 987/2009

DA012R - Reply to Contestation of Credit Note (RPY_COC_CRN)
Articles 35, 41 of Regulation (EC) No 883/2004, 62, 66 (1), 67 of Regulation (EC) No 987/2009