Article 1 In order to conscientiously implement the Measures for the Implementation of the Basic Medical Insurance for Urban and Rural Residents in Tangshan City and the Measures for the Administration of Special Diseases in the Outpatient Department of the Basic Medical Insurance for Urban and Rural Residents in Tangshan City, standardize the medical treatment management of the basic medical insurance for urban and rural residents in our city, and ensure the basic medical needs of the insured residents, these rules are formulated in combination with the actual work.
Article 2 These Rules shall apply to insured residents who seek medical treatment in the overall planning area and in different places.
Article 3 Designated medical institutions shall fully implement the Medical Service Agreement of Tangshan Designated Medical Institutions with Basic Medical Insurance, abide by the law in good faith, promote medical ethics, and increase penalties for violations of laws and regulations in accordance with the relevant provisions on risk prevention and control of clean government.
Article 4 Insured residents shall use social security cards when seeking medical treatment in designated medical institutions. If you have not received a social security card, you must provide a resident identity card. If you do not apply for a resident ID card, you must provide the first page of the household registration book, my page and a copy of the guardian ID card.
Fifth residents' medical insurance shall be designated for medical treatment and online settlement. Direct settlement of medical expenses incurred by insured residents in designated medical institutions. If the direct settlement of medical treatment in different places is not realized, it shall be paid by the individual first, and then the handling agency shall go through the procedures for reimbursement of medical expenses in accordance with the provisions at the medical insurance agency in the insured place.
For insured residents who have been identified by experts as suffering from chronic myeloid leukemia and gastrointestinal stromal tumors, targeted therapeutic drugs should be prescribed for fixed-point management, and designated medical institutions designated by the Charity Federation should be selected for prescription. After the individual advances, the agency shall go through the reimbursement procedures in the medical insurance agency of the insured place.
Article 6 The drugs taken out of the hospital should be oral western medicine, Chinese patent medicine or Chinese herbal pieces related to the treatment of hospitalized diseases. The dosage of oral western medicine and Chinese patent medicine shall not exceed 5 days, and the dosage of Chinese herbal pieces shall not exceed 7 days.
The outpatient examination and treatment items after discharge shall not be included in the hospitalization expenses.
Chapter II Overall Medical Management in the Region
Seventh insured residents in designated medical institutions for medical treatment or outpatient special diseases, need to go to other designated medical institutions for examination, should go through the formalities of off-site inspection and registration. In accordance with the provisions of the hospitalization expenses included in the hospitalization expenses, and indicated in the temporary doctor's advice; The expenses for external examination of outpatient special diseases shall be paid by designated medical institutions. Items beyond the scope of external inspection and filing are not included.
Section 1 Hospitalization Management
Eighth insured residents to the designated medical institutions in hospital, should go through the medical insurance hospitalization procedures.
Article 9 Designated medical institutions shall give priority to medicines and medical treatment items within the basic medical insurance catalogue. When using self-funded drugs, diagnosis and treatment items and medical materials exceeding the medical insurance payment limit standard outside the catalogue, the insured residents themselves or their families should be agreed and signed in advance.
Designated medical institutions shall provide a list of hospitalization expenses to insured residents every day, which shall be checked by the insured residents themselves or their families.
Article 10 Designated medical institutions shall go through the discharge settlement procedures for insured residents who reach the discharge standard after hospitalization, print the settlement documents and the summary table of medical expenses, and accurately and standardize the entry of information such as admission date, discharge date, disease diagnosis, department name, attending physician name, medical record number, etc. In the settlement system of basic medical insurance for urban and rural residents.
If the hospitalization expenses are supplemented, the type of supplementary records should be correctly selected.
Article 11 Insured residents who have completely lost their ability to take care of themselves can go through the formalities of therapeutic family beds after applying by themselves or their families and obtaining the doctor's certificate, fill out the Application Form for Family Bed of Tangshan Basic Medical Insurance, report it to the medical insurance department of designated medical institutions for the record, and report it to the medical insurance agency of the insured place for registration. The time limit for setting up family beds is one month. If it is necessary to continue the establishment due to illness, it shall re-apply.
Twelfth insured residents two-way referral, transfer out of designated medical institutions with two-way referral registration form, enter the relevant information after settlement. Insured residents who are transferred to designated medical institutions for hospitalization procedures within 2 days from the date of actual discharge shall not calculate Qifubiaozhun repeatedly.
Section 2 Overall Management of Outpatient Service
Thirteenth insured residents should be in the insured area has been networked outpatient co-ordination designated township hospitals, into the integrated management of administrative village clinics, community health service centers and other primary medical institutions.
Insured college students should go to the hospital or medical institution designated by the school.
Fourteenth outpatient designated medical institutions should strictly abide by the "prescription management measures" and other provisions, standardize medical management.
Section 3 Medical Management of Outpatient Special Diseases
Fifteenth designated medical institutions medical insurance settlement system outpatient special diseases are divided into Class A, Class B, Class C and Class D. The original basic medical insurance for urban residents and the reserved diseases of the new rural cooperative medical system are merged into Class C.
Sixteenth the original basic medical insurance for urban residents and the new rural cooperative medical system outpatient special diseases combined management, combined with the corresponding disease limits the same, and the implementation of the "cumulative limited disease annual limit standard".
Seventeenth insured residents through the identification, prescription and settlement of diseases involving multiple categories, respectively, select the corresponding categories of diseases and input them in turn.
Clinicians should treat diseases and use drugs rationally, and should not accidentally use quotas.
Eighteenth years of treatment after renal transplantation, from the date of discharge after transplantation. The natural year of coronary heart disease treatment is based on the date of stent discharge.
Nineteenth outpatient special diseases recognized by the administrative department of medical insurance shall be subject to special voucher management, which shall be handled by the agency to the medical insurance agency within its jurisdiction.
When handling for the first time, fill in the Checklist for Application for Special Disease Certificate of Tangshan Basic Medical Insurance Outpatient, and provide a copy of the applicant's social security card and a recent photo of 1.
When reporting the loss, please fill in the Application Form for Reporting the Loss and Cancellation of Special Disease Card in Tangshan Basic Medical Insurance Outpatient, and provide a copy of the applicant's social security card, 1 inch recent photo 1 piece, and a letter of introduction from the agency.
When canceling, fill in the Application Form for Reporting the Loss of Special Outpatient Disease Card of Tangshan Basic Medical Insurance and return it to the Special Outpatient Disease Card.
Twentieth insured residents to the social security card and the "special card for outpatient special diseases" to the designated medical institutions. Some designated medical institutions directly hold social security cards for medical settlement; Push it away in a timely and comprehensive manner.
Twenty-first insured residents identified by experts as malignant tumors do not need to apply for identification again when they are transferred to hospital, and they will be reimbursed by relevant medical records.
Twenty-second special disease outpatient treatment standards, according to the changes in medical expenses and the ability of the fund to bear.
The fourth quarter general medical expenses subsidy management
Twenty-third general medical expenses are subsidized by 8 yuan per person per course of treatment, and each person is subsidized for up to 3 courses per year, with each course lasting 3 days.
Twenty-fourth insured residents with social security cards in outpatient designated medical institutions, in line with the scope of the policy of general medical expenses, issued a free registration form, free of general medical expenses.
The free registration form shall be signed and confirmed by the insured residents themselves or their families. The first copy is retained by the primary medical institutions, and the second copy is retained by the insured residents.
Section 5 Management of Maternity Allowance
Twenty-fifth female insured residents who meet the national family planning policy shall go through the hospitalization formalities with the birth registration certificate or the certification materials issued by the population and family planning management department. Those who have not gone through the above procedures before hospitalization for personal reasons do not enjoy maternity allowance.
Section 6 Supplementary Records Management
Article 26 The medical expenses for special diseases of hospitalization or outpatient service that meet the requirements of medical insurance can be re-recorded due to the emergency rescue of insured residents, the transfer of personnel within 90 days, the newborn's insurance within 180 days, the overdue failure of insurance, the loss of social security card or the invalidation of social security card.
Insured residents in the designated medical institutions to give birth or accidental injury to treat diseases, medical expenses for the treatment of diseases can be added.
Twenty-seventh insured residents do not hold a social security card for medical treatment, designated medical institutions should go through the medical insurance hospitalization procedures and make up the expenses within 3 days after going through the hospitalization registration procedures. If it is not re-recorded within 3 days, the designated medical institution shall fill in the Application Form for Re-recording of Tangshan Medical Insurance, and the re-recording can only be carried out after the medical insurance agency's in-hospital physical examination department has reviewed and filed.
Article 28 If the transferred personnel are insured within 90 days, they will be re-recorded by the designated medical institutions after the residents' collection department of the medical insurance agency verifies the situation and issues opinions, and the residents' physical examination department puts on record.
Article 29 Newborns who are insured within 0/80 days of birth, residents who are insured during the supplementary period, and insured residents who are treated for illness or accidental injury during childbirth in designated medical institutions, who do not have a social security card for medical treatment and meet the requirements of medical insurance, can make up the medical expenses for hospitalization or outpatient service for special diseases only after going through the filing procedures in the medical insurance department of designated medical institutions.
Thirtieth social security card loss or failure, by the social security card business card printing department to verify and put forward opinions, by the designated medical institutions to make up the record, medical insurance agencies residents physical examination department for the record.
Section 7 Settlement of Medical Expenses
Thirty-first urban and rural residents medical insurance municipal co-ordination designated medical institutions to implement territorial settlement. Medical expenses incurred by insured residents in designated medical institutions in non-insured areas shall be settled by designated medical institutions and medical insurance agencies in medical places; Municipal institutions shall liquidate the funds prepaid by county-level institutions.
Designated medical institutions print statements from 26th to 28th every month.
Thirty-second family sickbed medical expenses shall be paid according to the settlement method of hospitalization medical expenses of insured residents. The medical insurance fund does not bear the medical expenses incurred by the family sickbed without filing. The medical insurance fund does not bear the cost of home visits.
Article 33 If the insured residents are hospitalized in different years, they shall go through the year-end carry-over procedures in accordance with the regulations, and only calculate the Qifubiaozhun once. The hospitalization expenses shall be calculated separately according to different insurance years.
Thirty-fourth insured residents to co-ordinate out-of-pocket expenses to reach the deductible line of serious illness insurance, designated medical institutions to achieve serious illness insurance networking, instant reimbursement; If it is not connected to the Internet, the individual shall apply for reimbursement to the insured commercial insurance company after paying in advance.
Chapter III Medical Treatment in Different Places
Section 1 Medical treatment in different places
Thirty-fifth insured residents with residence permit, real estate license and other proof of residence in different places to apply for the "certificate of medical treatment in different places".
/kloc-Newborns born within 0/80 days shall apply for medical treatment certificates in different places with their parents' residence certificates in different places.
Article 36 To apply for a certificate of medical treatment in a different place, you should fill in the Tangshan Basic Medical Insurance Information Filing Form, provide a copy of the applicant's ID card, 1 recent photo and 1 certificate letter from the agency, which will be handled by the agency in the medical insurance agency.
When completing the replacement, you should fill in the Application Form for Loss Reporting and Cancellation of Medical Certificates of Residents in Different Places of Tangshan Basic Medical Insurance, provide 1 recent photos of the applicant, and handle the loss reporting procedures.
The original long-term residence in a different place, when returning to this city, should handle the cancellation procedures of the "medical certificate in different places". Return the original certificate after reimbursement of medical expenses during the period of living in different places.
Thirty-seventh insured residents who apply for a "certificate of medical treatment in different places" shall seek medical treatment at the public medical institution designated by the medical insurance at their place of residence 1 ~ 3.
Change the designated medical institutions, should fill in the Tangshan city residents in different places basic medical insurance information filing form ",provide a copy of the applicant's ID card, 1 inch recent photos, remote medical certificate and agency letter, by the agency to the medical insurance agency for.
Unable to confirm the level of designated medical institutions, insured residents should provide proof of medical insurance agencies or medical institutions.
Thirty-eighth long-term residents to seek medical treatment in different places that outpatient special diseases involving multiple diseases, should be a separate prescription.
Those who are identified by experts as suffering from chronic myeloid leukemia and gastrointestinal stromal tumors should choose the local medical institutions designated by the Charity Federation and register with the medical insurance agency in the insured place before prescribing drugs.
Section 2 Transfer to hospital for medical treatment
Thirty-ninth insured residents who need to be transferred to the overall planning area for medical treatment due to illness shall go through the hospitalization procedures in advance. If it is not handled in time due to critical illness, it shall be re-submitted within 7 working days from the date of hospitalization at the transfer place, and explain the reasons for the emergency transfer.
Article 40 If a newborn needs to be transferred to another hospital for medical treatment due to illness during the uninsured period, it shall provide the referral certificate issued by the transferred medical institution when it is insured for reimbursement of hospitalization medical expenses within 180 days after birth. If the insured person is transferred outside the hospital, he shall go through the formalities of transfer for the record.
In the third quarter, emergency hospitalization in different places
Forty-first emergency hospitalization in different places shall be subject to medical records. The types of emergency admission and the scope of emergency rescue should be within the scope determined by the hospital work system of the Ministry of Health.
Section IV Reimbursement of Medical Expenses
Article 42 The reimbursement time is generally 1- 10 days per month.
Article 43 When applying for reimbursement of medical expenses for medical treatment in different places, an application form for reimbursement of medical expenses for basic medical insurance in Tangshan City shall be filled in, and a copy of the applicant's social security card, an application form for medical treatment in different places or an application form for hospitalization abroad, and valid materials issued by medical institutions shall be provided.
The effective materials for reimbursement of hospitalization expenses include: valid reimbursement documents for medical expenses, diagnosis certificates, summary tables of medical expenses, photocopies of the first page of medical records or admission records, photocopies of discharge summaries or discharge records, photocopies of surgical records and medical orders.
Effective materials for reimbursement of outpatient special disease expenses include: valid medical expense reimbursement documents, detailed list of medical expenses, prescriptions or copies of outpatient medical records.
Effective materials for reimbursement of maternity allowance expenses include: valid reimbursement documents for medical expenses, diagnosis certificate, summary of medical expenses, copy of first page of medical record or admission record, copy of discharge summary or discharge record, copy of operation record, copy of doctor's advice, B-ultrasound examination sheet provided for induced labor, original and copy of birth certificate, and original and copy of birth registration certificate.
When college students seek medical treatment at their family residence or practice place, the effective materials for reimbursement of hospitalization medical expenses include: valid reimbursement documents for medical expenses, diagnosis certificate, summary table of medical expenses, copy of the first page of medical records or admission records, copy of discharge summary or discharge records, copy of operation records, copy of doctor's advice, and letter of school certification.
Effective materials for reimbursement of medical expenses for outpatient special diseases include: effective reimbursement documents for medical expenses, detailed list of medical expenses, copy of prescriptions or outpatient medical records, and school certification letter.
Effective materials for outpatient targeted drug reimbursement for chronic myeloid leukemia and gastrointestinal stromal tumors include: effective reimbursement documents for medical expenses, detailed list of medical expenses, copies of prescriptions or outpatient medical records, and patient information manuals issued by the Charity Federation.
Forty-fourth the time to apply for reimbursement of funds is generally 6-20 days of the next month, and the agency shall fill in the Summary of Medical Expenses Reimbursement for Urban and Rural Residents for unified application.
Section 5 Relevant Provisions
Forty-fifth insured residents who are hospitalized in different places across the year are regarded as one hospitalization, and only one Qifubiaozhun is set. On February 25th every year, 65438-3 1 handles the intermediate settlement procedures of medical expenses, and prints the hospitalization expense bill and the medical expense summary table respectively. In the last year, the hospitalization medical expenses were not up to the Qifubiaozhun, and they were reimbursed together in the year of discharge; Meet the Qifubiaozhun, according to the annual reimbursement.
Forty-sixth insured residents should settle the medical expenses of urban and rural residents during the medical insurance treatment before going through the medical treatment procedures for long-term residence in different places or transferring to the medical insurance for urban workers.
Forty-seventh insured residents transferred for the record, in the same medical institution within 24 hours, as a hospitalization.
Article 48 In principle, the reimbursement of medical expenses in different places shall not exceed 12 months from the date of discharge; Special circumstances can be extended for 6 months. If the reimbursement is not made within 0/8 months from the date of discharge, the medical insurance fund will not bear it.
Chapter IV Supplementary Provisions
Article 49 These Detailed Rules shall come into force on1October 2007+1day. Inconsistent with these rules, these rules shall prevail.
Article 50 The Tangshan Human Resources and Social Security Bureau shall be responsible for the interpretation of these Rules.