Amended reimbursement request reacting to contestation

U029 - Amended reimbursement request reacting to contestation
Articles 65(6), 65(7) of Regulation (EC) No 883/2004, Article 70 of Regulation (EC) No 987/2009

SED API version: 0.15.2 build 3
Model version: 4.1.0

1. Local case numbers [ CC ]

1.1. Local Case Number [ CC ]

1.1.1. Country *

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1.1.2. Case number *

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1.1.3. Institution [ CC ]

1.1.3.1. Institution ID *

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

1.1.3.2. Institution Name *

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

1.1.Local Case Number

2. General information * [ SED ]

2.1. Reimbursement request ID *

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

2.2. Reimbursement contestation ID *

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

2.3. Amended reimbursement request ID *

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

2.4. Updated total amount requested * [ CC ]

2.4.1. Amount *

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2.4.2. Currency *

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

3. Individual claims * [ SED ]

3.1. Individual claim * [ SED ]

3.1.1. Reimbursement request ID *

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

3.1.2. Reimbursement contestation ID *

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

3.1.3. Amended reimbursement request ID *

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

3.1.4. Sequential number of Individual claim *

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

3.1.5. Contested individual claim ID

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

3.1.6. Amended contested individual claim ID *

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

3.1.7. Individual claim status * [ SED ]

3.1.7.1. Status *

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3.1.7.2. Please fill in the following if "Status" = "06 - Under Dispute" : [ SED ]

3.1.7.2.1. Reasoning

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

3.1.8. Person * [ SC ]

3.1.8.1. Person identification * [ CC ]

3.1.8.1.1. Family name(s) *

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

3.1.8.1.2. Forename(s) *

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

3.1.8.1.3. Date of birth *

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

3.1.8.1.4. Sex *

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3.1.8.1.5. Family name(s) at birth

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

3.1.8.1.6. Forename(s) at birth

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

3.1.8.1.7. PIN of the person in each institution [ CC ]

3.1.8.1.7.1. Personal Identification Number(s) * [ CC ]

3.1.8.1.7.1.1. Country *

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

3.1.8.1.7.1.2. Personal Identification Number (PIN) *

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

3.1.8.1.7.1.3. Sector

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

3.1.8.1.7.1.4. Institution [ CC ]

3.1.8.1.7.1.4.1. Institution ID *

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

3.1.8.1.7.1.4.2. Institution Name *

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

3.1.8.1.7.1.Personal Identification Number(s)

3.1.8.1.8. If PIN not provided for every institution, please provide [ CC ]

3.1.8.1.8.1. Place of birth [ CC ]

3.1.8.1.8.1.1. Town *

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

3.1.8.1.8.1.2. Region

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

3.1.8.1.8.1.3. Country *

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

3.1.8.1.8.2. Father's family name at birth

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

3.1.8.1.8.3. Forename of father

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

3.1.8.1.8.4. Mother's family name at birth

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

3.1.8.1.8.5. Forename of mother

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

3.1.8.2. Additional information on the person [ SC ]

3.1.8.2.1. Nationality

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

3.1.9. Institution which certified insurance record * [ CC ]

3.1.9.1. Institution ID *

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

3.1.9.2. Institution Name *

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

3.1.10. Working periods considered * [ SED ]

3.1.10.1. Working period considered * [ CC ]

3.1.10.1.1. Start Date *

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

3.1.10.1.2. End Date *

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

3.1.10.1.Working period considered

3.1.11. Reimbursement period * [ CC ]

3.1.11.1. Start Date *

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

3.1.11.2. End Date *

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

3.1.12. Last payment date *

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

3.1.13. Requested amount for reimbursement * [ CC ]

3.1.13.1. Amount *

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

3.1.13.2. Currency *

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

3.1.Individual claim

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U029 - Amended reimbursement request reacting to contestation Articles 65(6), 65(7) of Regulation (EC) No 883/2004, Article 70 of Regulation (EC) No 987/2009

U029 - Amended reimbursement request reacting to contestation
Articles 65(6), 65(7) of Regulation (EC) No 883/2004, Article 70 of Regulation (EC) No 987/2009