Reimbursement Contestation

U023 - Reimbursement Contestation
Articles 65(6), 65(7) of Regulation (EC) No 883/2004, Article 70 of Regulation (EC) No 987/2009

SED API version: 0.16.2 build 2
Model version: 4.2.0

Local case numbers

Local Case Number

Country *

Case number *

Institution

Institution ID *

Institution Name *

Local Case Number

General information *

Reimbursement request ID *

Reimbursement contestation ID *

Individual claims contested *

Individual claim contested *

Reimbursement request ID *

Reimbursement contestation ID *

Sequential number of Individual claim *

Contested individual claim ID *

Person *

Family name(s) *

Forename(s) *

Date of birth *

Sex *

Contestation type *

Non-acceptance of the individual claim*
Partial acceptance of the individual claim*

Reason for non-acceptance *

Please fill in the following if "Reason for non-acceptance" = "99 - Other reason or additional information" :

Information about other reason or additional information

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Reason for partial non-acceptance *

Please fill in the following if "Reason for partial non-acceptance" = "01 - Partial acceptance due to ceiling under national law" :

Amount intended to be reimbursed *

Amount *

Currency *

Please fill in the following if "Reason for partial non-acceptance" = "03 - Reimbursement claim incomplete" :

Information on missing data

Please fill in the following if "Reason for partial non-acceptance" = "99 - Other reason or additional information" :

Additional information

Individual claim contested

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U023 - Reimbursement Contestation Articles 65(6), 65(7) of Regulation (EC) No 883/2004, Article 70 of Regulation (EC) No 987/2009

U023 - Reimbursement Contestation
Articles 65(6), 65(7) of Regulation (EC) No 883/2004, Article 70 of Regulation (EC) No 987/2009