The new rules of medical insurance reimbursement 2022 latest tianjin

Recently, the Tianjin Municipal Bureau of Medical Protection issued a "Municipal Medical Insurance Bureau Municipal Bureau of Finance on the basic medical insurance medical expenses related to accidental injury related expenses reimbursement work notice.

The main content is as follows ↓

District Medical Insurance Bureau, Finance Bureau, the relevant units:

In order to effectively do a good job of the city's basic medical insurance participants accidental injury medical expenses reimbursement work, safeguard the legitimate rights and interests of the participants, according to the "National Health Insurance Bureau Ministry of Finance on the establishment of the views of the list system of medical care insurance treatment" (medical insurance hair [2021] No. 5) and "Municipal Health Insurance Bureau Municipal Finance Bureau Municipal Human Resources". Social Affairs Bureau, Municipal Civil Affairs Bureau, Municipal Disabled Persons' Federation, Municipal Taxation Bureau on the establishment of the medical insurance treatment list system notice" (Jin Medical Insurance Bureau issued [2021] No. 98) and other relevant provisions, combined with the actuality of the city, is hereby notified on the relevant matters as follows:

First, accurately grasp the scope of protection

Participants in the city's basic medical insurance, in the period of enjoying the normal benefits of the basic medical insurance benefits due to a sudden, foreign, The medical expenses of accidental injuries caused by sudden, foreign, non-disease objective events are included in the scope of coverage and will be reimbursed in accordance with the regulations. One of the following circumstances of accidental injury medical expenses are not included in the medical insurance fund:

(a) should be borne by a third party;

(b) should be paid from the Workers' Compensation Insurance Fund;

(c) should be borne by the public **** health;

(d) occurring outside the country.

Second, a good and steady convergence of treatment

Participants in the designated medical institutions in line with the policy scope of outpatient or hospitalized accidental injury medical expenses, no longer set up a separate reimbursement treatment, unified in accordance with the city's basic health insurance, major medical insurance and other complementary medical insurance, medical assistance and other policies for reimbursement of the ladder.

Participants in the implementation of this notice in the accidental injury before the implementation of the medical costs, the costs incurred in the year of the underwriting commercial insurance organization in accordance with the insurance responsibility to pay; participants in the implementation of this notice in the accidental injury before the application of disability or death insurance benefits, by the accidental injury occurs at the time of the underwriting commercial insurance organization to be paid.

Third, effectively improve the effectiveness of the service

Participants in the accidental injury with the medical insurance electronic vouchers, social security cards (including electronic social security cards) and other medical settlement; can not be provided, in accordance with the implementation of the full amount of the advance. Participants due to accidental injury in the city for the first time outpatient (emergency) or hospitalization, accidental injury medical expenses, in accordance with the following procedures:

(a) registration. The person or agent based on the time, place and cause of the accident, fill out the "Tianjin Basic Medical Insurance Accidental Injury First Report Card". The designated medical institution will enter the relevant information into the medical insurance system, and according to the clinical symptoms combined with the patient's main complaint, the accidental injury does not involve a third party, to be handled by the network of direct settlement; for the accidental injury involving third-party liability, the implementation of the full amount of advances, advances the details of medical costs uploaded to the medical insurance system.

(ii) Audit. Involving third-party liability costs, the city health insurance fund management center, urban and rural residents health insurance service centers in accordance with their duties to take access to medical records, access to the public security organs and other relevant departments of the accident certificate and other forms of accidental injuries review, eligible for reimbursement in accordance with the provisions of the regulations. On the implementation of the network has been directly settled costs, the city health insurance settlement center in accordance with a certain percentage of random checks, found suspected of third-party liability, should take the form of access to medical records, access to the public security organs and other relevant departments of the accident certificate, and based on the results of the audit to be dealt with accordingly.

The insured person due to accidental injury in the field treatment of medical expenses incurred, the accidental injury does not involve a third party, by the insured person in accordance with the provisions of the personal commitment, according to the provisions of the city or a different medical network settlement range; involving third-party liability for accidental injury, the full amount of the advance, by the Municipal Health Insurance Fund Management Center, the urban and rural residents of the Health Insurance Service Center in accordance with the responsibility to take the medical records, check the public security organs and other relevant departments of the accident certificate and other forms, and according to the audit results of the corresponding treatment. The public security organs and other relevant departments of the accident certificate and other forms of accidental injuries, after review, eligible for reimbursement in accordance with the provisions.

The public security organs and other relevant departments determined that the participant bears part of the responsibility for the accidental injury medical expenses, the medical insurance fund according to the participant to assume responsibility for the review and payment. For the first time, the participants have been reimbursed for accidental injury costs, follow-up treatment, recurrence of old injuries, medical expenses incurred in accordance with the first time the responsibility for medical treatment, the implementation of network settlement.

Fourth, strictly do a good job of assessment and supervision

Medical insurance agencies to establish relevant business procedures, equipped with the necessary staff, combined with relevant business needs, do a good job of system development and transformation and convergence. The designated medical institutions should be combined with the accidental injury management work needs, the establishment of accidental injury consultation and management process and related systems, further standardization and optimization of services, equipped with the necessary personnel and equipment, with the medical insurance agency to do a good job of system development and transformation, real-time uploading of information on accidental injuries and medical expenses network settlement.

The medical insurance agencies, designated medical institutions and their staff have violated the law, belonging to the medical insurance agreement, in accordance with the agreement to deal with; belonging to the laws, rules and regulations of the scope of administrative penalties, according to the administrative penalties; constitutes a crime, according to law, the investigation of criminal responsibility.

Fifth, carefully promote the organization and implementation

Do a good job of the insured personnel accidental injury medical expense reimbursement is related to the majority of insured personnel of vital interests, the community is highly concerned. The relevant departments to further refine the implementation of the responsibility for the establishment of a mechanism for coordination of work, proper policy landing, management, system development and other key work. At the same time, to further strengthen the positive interpretation of the policy and social publicity, to explain the reform arrangements and policy effects, and actively respond to social concerns, to build a good atmosphere for reform.

This notice shall come into force on January 1, 2023, and shall be valid until December 31, 2027.

Municipal Health Insurance Bureau Municipal Finance Bureau

November 1, 2022