Notice on issues related to the implementation of the documentNo. [202 1]46 issued by Lu Medical Insurance to adjust the policy of medical treatment in different places in our city
District (city) Medical Security Bureau and Finance Bureau:
In order to implement the Notice of Shandong Provincial Medical Security Bureau and Shandong Provincial Department of Finance on Issues Related to Adjusting the Policy of Medical Treatment for Insured Persons in Different Places in our province (Lu Medical Insurance Fa [2021] No.46), combined with the actual situation of our city, the relevant policies of social medical insurance in our city are now adjusted as follows:
First, integrate and simplify the classification of medical personnel in different places.
(1) Resettlement of retirees, permanent residents in different places, long-term residents in different places, migrant workers and entrepreneurs with foreign employment, unified integration and simplification into "long-term residents in different places". Long-term living in different places generally refers to people who have lived, lived and worked in different places for more than 6 months.
(2) Referrals, medical personnel who go out on their own, medical personnel who return to their domicile, temporary medical personnel who go out on business trips, visiting relatives, traveling, etc. All of them are unified and simplified as "temporary medical staff who go out for medical treatment".
Second, simplify the filing procedures for medical treatment in different places.
(a) medical records in different places do not need to provide supporting materials. "Long-term residence in different places" no longer provides proof materials such as household registration certificate and residence permit, and implements a commitment filing system (individuals promise to live, live and work in different places for more than 6 months); The registered "temporary medical personnel" no longer provide proof of referral or proof of going abroad for emergency treatment. The insured person can open a self-service record and enjoy medical treatment in different places immediately.
(two) to provide a variety of remote medical records channels. The insured can apply for filing through the window of the district and municipal medical insurance service hall and the primary medical insurance workstation; It can also be filed through various channels, such as official website of Qingdao Medical Insurance Bureau, official account of Qingdao Medical Insurance WeChat (applet), and national medical insurance service platform APP. Inter-provincial temporary medical treatment can be filed by telephone or fax published by the medical insurance departments of all districts and cities (provide my name, ID number, contact telephone number, filing type, filing city and other information).
(three) "long-term residents in different places" seek medical treatment in their long-term residence after filing, and the filing is valid for a long time. If they return to live in this city or change their city after 6 months, they will be terminated or changed in time.
(4) From June 5438+1 October1day, 2022, all inpatient, general outpatient, chronic disease and special disease outpatient services of "temporary medical personnel" who seek medical treatment across provinces will be cancelled, and medical expenses will be settled directly online.
Third, adjust the medical insurance policy in different places.
(a) "long-term residents in different places" cross-city, inter-provincial hospitalization and special disease outpatient medical expenses in the province, and enjoy the same proportion of medical insurance reimbursement as this Municipality; General outpatient medical expenses shall be implemented in accordance with the Notice on Promoting the Pilot Work of Inter-provincial Direct Settlement of Outpatient Expenses in Qingdao (Qing Medical Insurance 1 [20265438]).
"Long-term residents in different places" who have returned to the city for medical treatment for more than 6 months after filing enjoy the same proportion of medical insurance reimbursement as the city for medical treatment; If you go back to the city for medical treatment for less than 6 months after filing, the temporary medical reimbursement policy will be implemented; Medical expenses in different places before filing and medical expenses outside the long-term residence after filing shall be reimbursed for temporary medical treatment.
(II) "Temporary medical personnel" cross-city, inter-provincial hospitalization and special disease outpatient medical expenses in the province, and the payment ratio of basic medical insurance fund and serious illness medical insurance fund is 5 percentage points lower than that of medical institutions at the same level in this Municipality; General outpatient medical expenses shall be implemented in accordance with the Notice on Promoting the Pilot Work of Inter-provincial Direct Settlement of Outpatient Expenses in Qingdao (Qing Medical Insurance 1 [20265438]).
(III) The insured persons with chronic special diseases who seek medical treatment in cross-city and inter-provincial general outpatient clinics in the province are not limited by the scope and grade of contracted primary medical institutions, and can enjoy reimbursement treatment and realize online settlement.
(four) cancel the number of designated medical institutions in different places. Medical treatment in different places is directly filed at the place of medical treatment, and it is not necessary to file with a specific medical institution. The insured can choose medical treatment independently in all networked inpatient and general outpatient designated medical institutions where medical treatment is filed, and realize direct settlement. If the outpatient chronic special diseases are moved to the filing place, the number of designated medical institutions for outpatient chronic special diseases in different places across the city in the province will be cancelled.
Four, standardize the management of direct settlement of medical expenses in different places.
(a) if the insured person goes through the hospitalization formalities within the validity period of filing, the hospitalization expenses in different places can be settled directly through the Internet.
(two) the implementation of remote medical online direct settlement payment scope and related regulations (basic medical insurance drug list, diagnosis and treatment items and medical service facilities standards). The qifubiaozhun, payment proportion and maximum payment limit of social medical insurance fund shall implement the policies of our city.
Within a year, the medical expenses incurred by the insured in different places that meet the scope of medical insurance payment shall be calculated cumulatively with the medical expenses of this Municipality, and shall not exceed the maximum payment limit of that year. Among them, if the medical expenses for chronic diseases in different places cannot be settled online for various reasons, the insured can submit sporadic reimbursement by the medical insurance agency according to the catalogue of the insured place with valid hospitalization bills, detailed list of expenses summary, discharge records or outpatient medical records.
(3) The direct settlement process of the insured person's remote medical treatment network
1. Insured persons should apply for medical treatment in different places before seeking medical treatment in different places, among which "temporary medical personnel" do not need to seek medical treatment across cities in the province for the record.
2. The insured person holds the social security card, medical insurance electronic certificate or ID card to the designated medical institutions in different places where the network has been opened for medical treatment, and implements the medical treatment process and management service specifications of the medical institutions in the medical treatment area.
3. When the medical expenses in different places are directly settled online, the insured person only pays the expenses borne by the individual, and the part paid by the medical insurance fund is paid by the medical insurance agency and the designated medical institution according to the regulations.
(four) the capital flow process of online settlement of medical expenses in different places.
1. Tripartite reconciliation. Each designated medical institution inquires the settlement information of medical treatment in different places every day and initiates daily reconciliation. City agencies in a timely manner for medical, insurance and national (or provincial) telemedicine information system tripartite reconciliation, tripartite reconciliation through the data as the basis for cost settlement.
2. Review the deduction. Medical insurance agencies at all levels in our city are responsible for the review and deduction of medical expenses of designated medical institutions in different places within their jurisdiction, and the medical expenses involved in the violations of designated medical institutions will not be paid, and the paid illegal expenses will be deducted to offset the settlement expenses of medical treatment in different places. Designated medical institutions in violation of the provisions of the service agreement, collect liquidated damages, according to the provisions.
3. expense settlement. As a medical place, the municipal agency initiates a liquidation application, and uploads the liquidation information of medical expenses generated by the designated medical institutions after reconciliation confirmation and audit deduction every month. Liquidation information that is not uploaded on time will not be liquidated this month. District (city) level medical insurance agencies according to the cost settlement results, the completion of the designated medical institutions as medical places within the jurisdiction of the funds allocated.
4. Payment of expenses. As the insured place, the municipal agency is responsible for transferring the medical expenses of the insured in our city to the provincial medical insurance center for online settlement.
Verb (abbreviation of verb) is carefully implemented.
Reforming and adjusting the medical insurance policy for insured persons in different places is an important measure to deepen the reform in the field of medical insurance in our province. Each district (city) is responsible for the management of medical treatment in different places in designated medical institutions in the region, which should be highly valued, carefully organized and implemented. Intensify publicity, widely inform the masses through TV, newspapers, websites, Weibo and other media, do a good job in publicity and training of designated medical institutions, and ensure that all policies and measures are put in place. It is necessary to strictly strengthen the supervision and management of online settlement of medical treatment in different places, and it is strictly forbidden to falsify medical expenses, false reimbursement, and online and offline repeated reimbursement. All designated medical institutions should do a good job in the implementation of their own policies in different places to protect the legitimate rights and interests of medical personnel in different places.
This notice shall be implemented as of June 65438+ 10/day, 2022. If other documents are inconsistent with this notice, this notice shall prevail.
Qingdao Medical Security Bureau Qingdao Finance Bureau
202 1 65438+February 21