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First, medical insurance.
Medical insurance refers to social medical insurance. It is a social insurance system that meets the basic medical needs of the state and society according to laws and regulations when workers are sick.
20 16 65438+ 10/2 the State Council issued "opinions on integrating the basic medical insurance system for urban and rural residents" to promote the integration of medical insurance for urban residents and the new rural cooperative medical system, and gradually establish a unified national medical insurance system for urban and rural residents.
On February 20th, 2065438+0616, Ministry of Human Resources and Social Security held a video conference on the nationwide networking of basic medical insurance and direct settlement of medical treatment in different places, and signed letters of responsibility with the first batch of 22 provinces including Beijing, which applied for nationwide networking of basic medical insurance and direct settlement of medical treatment in different places, marking the formal implementation stage of direct settlement of medical treatment in different places.
According to the statistical bulletin of June 20021year, the number of people participating in the national basic medical insurance in 2020 is 136 13 1 10,000, and the participation rate is stable at over 95%.
Second, the medical insurance settlement procedures
(1) Settlement procedures for inpatient and outpatient treatment of special diseases
Designated medical institutions shall submit the expense list, hospitalization list and related materials of patients discharged from hospital last month to the medical insurance agency before 10 every month, which will be used as the basis for monthly pre-allocation and year-end final accounts after examination. The medical insurance agency pre-allocated the hospitalization and outpatient expenses for special diseases last month.
Insured persons who have been identified as suffering from special diseases shall go to the designated medical institutions designated by the labor and social security departments for medical treatment and medicine purchase, and the medical expenses incurred shall be directly recorded and settled immediately.
(2) Emergency settlement procedures
The medical expenses incurred by the insured due to emergency rescue to non-designated medical institutions in the city and medical institutions in different places shall be paid in advance by individuals or units. After the emergency rescue, the medical insurance agency shall handle the reimbursement procedures according to the provisions with the emergency hospitalization medical records, inspection, laboratory test sheets, invoices and detailed list of medical expenses.
(three) resettlement procedures for resettlement personnel in different places
1. The personnel resettled in different places shall be designated as the designated medical institution of 1-2 by the unit to which they belong, and shall be reported to the medical insurance agency for the record.
2. The medical expenses incurred by the off-site staff in the outpatient department of the designated medical institution where the disease occurs at the place of residence shall be paid in advance by themselves or their units. After the treatment, the unit shall settle the diagnosis and medical records, effective expense bills, compound prescriptions and hospitalization expense lists of the insured. Go to the social medical insurance agency on the specified date.
(4) Referral and settlement.
1. If the insured person is transferred to other medical institutions for diagnosis and treatment due to the conditions of designated medical institutions or specialized diseases, the approval form for referral and transfer shall be filled in. The reason for referral and transfer is put forward by the attending physician, the director of the department puts forward the opinion of referral and transfer, the medical institution medical insurance office reviews it, the dean in charge signs it, and it can be transferred only after being reported to the municipal medical insurance center for examination and approval.
2. In principle, referrals should be made outside the city, inside the province and outside the province. The city's referral regulations are carried out between designated medical institutions. The referral outside the city is proposed by the designated medical institutions above Grade III in this Municipality.
3. The medical expenses incurred after the insured person is referred to another hospital shall be paid by the individual or unit in cash. After the medical treatment, the insured person or his agent will submit the referral approval form, medical record certificate, prescription and valid documents to the medical insurance agency for reimbursement of hospitalization expenses that fall within the scope of the overall fund payment.