Anhui Wuhu medical insurance chronic diseases including 25 kinds:
1 malignant tumor
2 chronic renal insufficiency
3 aplastic anemia
4 rheumatoid disease
5 chronic active hepatitis
6 chronic pancreatitis
7 tuberculosis
8 intestinal adhesion
9 Cerebrovascular accident response stage10 Liver cirrhosis decompensation stage
11 Chronic pulmonary heart disease
12 Chronic cardiac insufficiency
13 Arrhythmia
14 Coronary heart disease
15 Parkinson's disease
16 Hypertension
17 Diabetes mellitus
18Chronic prostatitis
19Prostatic hyperplasia
20Psychosis
21Leprosy
22Lupus erythematosus
23Chronic atrophic gastritis
24Organ transplantation and anti-rejection therapy
25Chronic pelvic stomatitis
Wuhu City, urban workers health insurance Implementing Rules for the Management of Outpatient Chronic Disease Medical Expenses
Article 1 In accordance with the Interim Measures for the Management of Outpatient Chronic Disease Medical Expenses of Wuhu City Urban Workers' Medical Insurance (Wujingban [2008] No. 6, hereinafter referred to as "the Measures"), the Implementing Rules are hereby formulated.
The second outpatient chronic disease categories included in the scope of the Measures.
Article 3 The insured persons who are eligible for outpatient chronic diseases can get the Application Form for Outpatient Chronic Diseases of Wuhu City Urban Workers' Medical Insurance (hereinafter referred to as the Application Form for Outpatient Chronic Diseases) at the medical insurance office of the designated medical institution above the second level of the municipal government or at the insured unit. The medical insurance office or the insured unit of each fixed-point medical institution is responsible for distributing and instructing outpatients with chronic diseases to fill in the Application Form for Outpatient Chronic Diseases.
Article 4 patients suffering from the diseases stipulated in Article 2 of the Measures, with the Outpatient Chronic Disease Application Form and the inpatient and outpatient medical records, examination reports and original and copies of ID cards in the past year, go to the municipal secondary or higher fixed-point healthcare institutions where they have been treated (for specialized diseases, they need to go to the corresponding specialized hospitals) for the recognition of outpatient chronic disease access.
Article 5: The designated medical institutions shall strictly follow the "Wuhu City Urban Workers' Medical Insurance Outpatient Chronic Disease Access Standards (Interim)" (Wulao Social Affairs Office Letter [2008] No. 45) for the recognition of disease access, and physicians above the deputy director of the relevant departments shall write down the specific diseases and sign in the column of the name of the chronic disease recognized in the Outpatient Chronic Disease Application Form, and the medical insurance office shall stamp the seal after reviewing and approving the application form.
Article VI of the designated medical institutions in the receipt of the insured person "door slow application form" within 15 working days, to put forward the audit opinion. At the same time, the "door slow application form" and related medical records, inspection report form by the insured person to the insured unit, by the insured unit to the municipal health insurance center for access identification procedures. Among them, the individual insured person by himself directly to the city health insurance center for admission procedures.
Prior to the introduction of the Measures, some diagnosed diseases, such as uremia, malignant tumors, kidney transplantation, etc., the insured person can bring the relevant information to the Municipal Health Insurance Center for access identification procedures directly.
Article 7 of the submission of complete information, the Municipal Health Insurance Center within 30 working days after receipt of the information for review and determination procedures. And is responsible for the outpatient chronic disease patients with the relevant data registration entry to the participant information base, while the list of personnel to notify their participating units and fixed-point medical institutions.
Article 8: Patients with outpatient chronic diseases who have been recognized after examination and approval shall bring the Application Form for Outpatient Chronic Diseases, their ID cards, medical certificates, health insurance IC cards and two one-inch recent photos without a crown to the Municipal Health Insurance Center to get the "Wuhu Urban Workers' Health Insurance Outpatient Chronic Diseases Visiting Card" (hereinafter referred to as the "Visiting Card"). If the admission is not confirmed after examination, the materials sent for examination will be returned.
Article 9: The treatment of patients with outpatient chronic diseases recognized as such shall start from the date of acceptance by the Municipal Health Insurance Center. The chronic disease expenses incurred during the period from the date of enjoyment of the treatment to the receipt of the "consultation card", the person will go directly to the Municipal Health Insurance Center to be reviewed and reimbursed in accordance with the provisions of the "Measures" after the receipt of the "consultation card". The reimbursement amount will be included in the annual limit.
Article 10: The outpatient chronic disease medical expenses of the personnel who are stationed abroad and resettled in other places shall be paid in cash by the individuals first, and then reviewed and reimbursed by the Municipal Health Insurance Center in accordance with the provisions of the Measures.
Article 11 of the outpatient chronic disease of the insured personnel access to the determination, the implementation of the annual review system. Annual review time for the following year's January 5 - February 20. Late, stop enjoying outpatient chronic disease treatment.
Article XII of the outpatient chronic disease patients due to changes in their condition or the occurrence of other diseases requiring hospitalization of medical costs, in accordance with the relevant provisions of the basic health insurance hospitalization, not included in the cumulative costs of outpatient chronic disease.
Article XIII of outpatient chronic disease patients in the designated medical institutions outpatient medical care, must use the "medical card" and health insurance IC card in the window of the health insurance registered outpatient chronic disease specialty number, with a special prescription for treatment; in the selected designated retail drugstores to purchase medicines, must be based on the "medical card" and the selected designated medical institutions and stamped with the seal of the outpatient chronic disease dispensing prescriptions. Without the stamped prescription, the coordinating fund will not pay for the expenses incurred at the designated retail pharmacy.
Article XIV in a natural year, outpatient chronic disease patients in the selected designated medical institutions and designated retail pharmacies in line with the health insurance policy of outpatient medical and pharmaceutical costs, where the individual part of the burden, by the participants with individual account funds or cash and the treatment of medical institutions or pharmacies; where the part of the overall fund to be paid for by the Municipal Health Insurance Center on a monthly basis and the designated medical institutions and retail pharmacies to settle. The part to be paid by the integrated fund will be settled by the municipal medical insurance center with the designated medical institutions and designated retail pharmacies on a monthly basis. Settlement ratio in accordance with the Wu Medical Reform Office [2006] No. 1 document implementation.
Article 15 of the fixed-point medical institutions and fixed-point retail pharmacies monthly settlement of outpatient chronic disease medical expenses, the city health insurance center first 90% of the approved cost of settlement, the remaining 10% according to the WuLaoBan letter [2008] No. 53 document the relevant provisions of the implementation.
The sixteenth outpatient chronic diseases according to different categories, the implementation of different annual limit management. The starting standard and the proportion of medical expenses paid by individuals are not counted in the annual limit.
Article 17 of the fixed-point medical institutions and fixed-point retail pharmacies for outpatient chronic disease patients for consultation and purchase of medicines, to strictly check the outpatient chronic disease patients' "medical certificate", "consultation card" and networking information, and print a detailed list of costs.
Article 18 of the fixed-point medical institutions treating physicians shall, according to the type of disease identified in the "consultation card", reasonable examination, reasonable use of medication, reasonable treatment. The medicines used must be those in the basic medical insurance drug catalog, and issue special compound prescriptions for outpatient chronic diseases, indicating the specific type of disease. If the use of non-medicare medicines is required by the condition or at the request of the insured person, the insured person shall be informed. Do not belong to the identification of chronic disease types of drugs, should be issued a separate prescription, and separate from the outpatient chronic disease medical fees.
Article 19 of the fixed-point medical institutions shall be treated by physicians in the medical insurance medical records in detail the name, quantity and use of medicines, as well as a variety of tests and treatments performed.
Article 20 of the medical expenses incurred for recognized chronic diseases, medical institutions and pharmacies shall account for the medical expenses incurred in the "outpatient chronic disease expense entry" interface, and shall not enter the medical expenses for non-recognized chronic diseases into it. The integrated fund will not pay for the medical expenses of non-cognized chronic disease categories included therein.
Article 21 of the fixed-point medical institutions in the process of treatment found not in line with the "Wuhu City urban workers' medical insurance outpatient chronic disease access standards (provisional)" of outpatient chronic disease patients, should be promptly reported to the municipal health insurance center, by the municipal health insurance center to verify, and then cancel its enjoyment of the outpatient chronic disease medical treatment.
Article 22 of the fixed-point retail pharmacies must be dispensed according to the fixed-point medical institutions outpatient chronic disease dispensing prescriptions according to the facts, and keep the outpatient chronic disease prescriptions of the insured for the municipal health insurance center for checking.
Article 23 of the designated medical institutions and designated retail pharmacies should be required to establish outpatient chronic disease files for patients. The Municipal Health Insurance Center will audit the outpatient chronic disease medical expenses and medication, examination and treatment items through online real-time monitoring and field investigation of the files.
Article 24: The Municipal Health Insurance Center will suspend or cancel the qualification of the designated physicians who falsely issue false diagnosis, examination and test reports, and will notify them.
Article 25 of the management of outpatient chronic disease medical expenses will be an important part of the year-end assessment of the designated medical institutions and designated retail pharmacies and the evaluation of hospitals in good faith. Violations of the medical costs, the city health insurance center will not be settled; has been settled, to be recovered. The seriousness of the violation, suspend or terminate the designated medical institutions or designated retail pharmacy service agreement.
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