Reply to Claim for Reimbursement - Administrative Check /Medical information

H021 - Reply to Claim for Reimbursement - Administrative Check /Medical information
Article 87 of Regulation (EC) No 987/2009

SED API version: 0.15.2 build 3
Model version: 4.1.0

1. Global Claim * [ SED ]

1.1. Creditor institution * [ CC ]

1.1.1. Institution ID *

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

1.1.2. Institution Name *

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

1.2. Global Reference set by Creditor Institution *

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

1.3. Global Reference set by Debtor Institution *

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

1.4. Total number of invoices *

[ PRIM ] {{metaSection.totalNumberInvoices.$$error}} {{metaSection.totalNumberInvoices.$$warning}}

1.5. Payment [ SED ]

1.5.1. Total Claim Amount in currency of creditor institution * [ CC ]

1.5.1.1. Amount *

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

1.5.1.2. Currency *

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

1.5.2. Total Claim Amount Rejected In Creditor Currency [ CC ]

1.5.2.1. Amount *

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

1.5.2.2. Currency *

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

1.5.3. Total Payment In Creditor Currency * [ CC ]

1.5.3.1. Amount *

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

1.5.3.2. Currency *

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

1.5.4. Payment reference for transfer to creditor institution

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

2. Claim [ SED ]

2.1. Person * [ CC ]

2.1.1. Person Information * [ CC ]

2.1.1.1. Family name(s) *

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

2.1.1.2. Forename(s) *

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

2.1.1.3. Date of birth *

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

2.1.1.4. Sex *

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

2.1.2. Family name(s) at birth

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

2.1.3. Forename(s) at birth

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

2.1.4. Person Identification Number * [ CC ]

2.1.4.1. PIN of the person in Competent Member State *

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

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

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

2.2. Reimbursement * [ SED ]

2.2.1. In reference to our *

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

2.2.2. Issued on *

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

2.2.3. Invoice number of creditor institution *

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

2.2.4. Invoice amount in currency of creditor institution * [ CC ]

2.2.4.1. Amount *

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

2.2.4.2. Currency *

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

2.2.5. Rejection:

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

2.2.6. Detail of Partial or Full Rejection [ SED ]

2.2.6.1. Invoice Amount Rejected in currency of creditor institution [ CC ]

2.2.6.1.1. Amount *

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

2.2.6.1.2. Currency *

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

2.2.7. Rejection reason

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

2.2.8. Please fill in the following if "Rejection reason" = "Other" [ SED ]

2.2.8.1. Other

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

2.2.Reimbursement

{{ row.severityMessage }} : {{ row.message }}

H021 - Reply to Claim for Reimbursement - Administrative Check /Medical information Article 87 of Regulation (EC) No 987/2009

H021 - Reply to Claim for Reimbursement - Administrative Check /Medical information
Article 87 of Regulation (EC) No 987/2009