Interim Measures for the Management of Medical Insurance Designation of Medical Institutions

Chapter I General Provisions Article 1 In order to strengthen and standardize the medical insurance designated management of medical institutions, improve the efficiency of the use of medical insurance fund, and better protect the rights and interests of the majority of participants, according to the "Chinese People's *** and the State Social Insurance Law", "Chinese People's *** and the State of basic medical care and health promotion law" and "Regulations on the Management of Medical Institutions" and other laws and regulations, to formulate the present measures. Article 2 The management of medical insurance designation of medical institutions shall adhere to the people's health as the center, follow the principles of basic protection, fairness and impartiality, clarity of rights and responsibilities, and dynamic balance, strengthen the fine management of medical insurance, promote the supply-side reform of medical institutions, and provide appropriate medical care for insured persons. Article 3 The administrative department of medical insurance is responsible for formulating policies on the management of designated medical institutions, and supervising the medical insurance management organization (hereinafter referred to as the "management organization") and designated medical institutions in the process of application for designated medical institutions, professional assessment, consultation and negotiation, conclusion of the agreement, fulfillment of the agreement, and termination of the agreement. The agency is responsible for determining the designated medical institutions, signing medical insurance service agreements (hereinafter referred to as "medical insurance agreements") with the designated medical institutions, providing administrative services, and carrying out the management and assessment of the medical insurance agreements. Targeted medical institutions shall comply with medical insurance laws, regulations, rules and relevant policies, in accordance with the provisions of the medical services provided to the insured. Chapter II fixed-point medical institutions to determine Article 4 the integrated area of medical insurance administrative department according to the public health needs, management service needs, health insurance fund income and expenditure, regional health planning, medical institutions set up planning to determine the integrated area of the fixed-point medical service allocation of resources. Article 5 The following medical institutions that have obtained the license to practice medical institutions or Chinese medicine clinic record certificate, as well as military medical institutions approved by the competent departments of the military with the qualification of civilian services can apply for medical insurance designated:

(a) general hospitals, hospitals of traditional Chinese medicine, Chinese and Western medicine hospitals, hospitals of ethnic medicine, specialized hospitals, rehabilitation hospitals;

(b) Specialized disease prevention and treatment hospitals (institutes, stations), Maternal and Child Health Center;

(c) community health centers (stations), central health centers, township health centers, street health centers, outpatient clinics, clinics, health centers (stations), village health offices (offices);

(d) independent first aid centers;

(e) hospice centers, hemodialysis centers, nursing homes;

(f) elderly institutions Medical institutions within.

Internet hospitals may rely on their entity medical institutions to apply for the signing of a supplemental agreement, and the relevant costs incurred by the medical services provided by them that are in line with the scope of payment of medical insurance shall be settled by the co-ordinating region's management agency and its entity medical institutions in accordance with the regulations. Article 6 A medical institution applying for medical insurance designation shall have the following basic conditions:

(1) It has been in formal operation for at least three months.

(2) There shall be at least one physician who has obtained a medical practitioner's license, a rural doctor's license, or a medical practitioner's qualification certificate of traditional Chinese medicine (specialization) and whose first place of registration is in the medical institution.

(3) the main person in charge of health insurance work, with full-time (part-time) health insurance management personnel; 100 beds or more medical institutions should set up an internal health insurance management department, arrange full-time staff.

(4) It has a medical insurance management system, financial system, statistical information management system, and core system of medical quality and safety in line with the requirements of medical insurance agreement management.

(5) The hospital information system technology and interface standards in line with the management requirements of the medical insurance agreement, to achieve effective docking with the medical insurance information system, as required, to the medical insurance information system to transmit all the relevant information on the medical staff, to provide direct network settlement for the insured. The hospitals set up basic databases of medicines, diagnostic and treatment items, medical service facilities, medical consumables and disease types, and use the unified national medical insurance codes as required.

(F) comply with laws and regulations and other conditions specified by the provincial and higher medical insurance administrative departments. Article 7 The medical institutions shall submit the application for designated medical insurance to the coordinating regional agency, and provide at least the following materials:

(1) the application form of designated medical institutions;

(2) a copy of the license of medical institutions or the record certificate of traditional Chinese medicine clinic or the license of the military medical institutions to provide services for the people;

(3) the internal management system and the financial system that corresponds to the medical insurance policy Text;

(4) Materials related to the information system of medical institutions in relation to medical insurance;

(5) Predictive analysis report on the use of medical insurance fund after being included in the fixed-point system;

(6) Other materials required by the provincial medical insurance administrative departments in accordance with relevant regulations. Article 8 The application for fixed-point by a medical institution shall be accepted immediately by the coordinating regional agency. If the application materials are incomplete, the agency shall inform the medical institution to supplement the application within five working days from the date of receipt of the materials. Article 9 The coordinating regional agency shall organize an assessment team or entrust a third-party agency to carry out the assessment in written and on-site forms. Members of the assessment team shall be composed of professionals in medical insurance, medicine and health, financial management and information technology. The assessment will take no more than three months from the date of acceptance of the application materials, and the time taken by the medical organization to supplement the materials will not be counted as part of the assessment period. The assessment includes:

(a) verification of the license of medical institutions or Chinese medicine clinic filing certificate or military medical institutions for civilian service license;

(b) verification of physicians, nurses, pharmacy and medical technology and other professional and technical personnel practice information and the physician's first place of registration information;

(c) verification of diagnosis, treatment, surgery, hospitalization, compatible with the function of the service, drug storage and distribution, inspection, testing and radiology infrastructure and instrumentation;

(d) verification of the internal management system and financial system corresponding to the health insurance policy, the results of the health department's assessment of medical institutions;

(e) verification of whether the information system of the medical institutions related to health insurance is in a position to carry out the conditions for direct network settlement.

The assessment results are categorized as qualified and unqualified. The coordinating regional administrative organization shall report the assessment results to the medical insurance administrative department at the same level for the record. For the qualified assessment, it should be included in the list of medical institutions to be signed agreement, and publicized to the community. For those that fail the assessment, it shall inform them of the reasons and put forward suggestions for rectification. From the date of delivery of the results of the notification, rectification of three months after the assessment can be re-organized, the assessment is still unqualified, 1 year shall not re-apply.

Provincial medical insurance administrative departments can, on the basis of this approach, according to the actual situation, to develop specific assessment rules.