Article 1 In order to further protect the legitimate rights and interests of workers with work-related injuries (including occupational diseases, the same below), standardize the management of medical settlement of work-related injury insurance, and ensure the rational use of work-related injury insurance funds, these Provisions are formulated in accordance with the Regulations on Work-related Injury Insurance and the relevant provisions, combined with the actual situation of our city.
Article 2 These Provisions shall apply to employers, employees with work-related injuries or their relatives, medical institutions with work-related injury insurance, work-related injury insurance agencies, etc. Within the administrative area of our city.
Article 3 Work-related injury insurance shall provide agreed medical services. Industrial injury insurance agencies shall sign medical service agreements with qualified medical institutions on the basis of open, fair and equal consultation. A medical institution with an industrial injury insurance agreement (hereinafter referred to as the agreed medical institution) shall conscientiously fulfill the obligations stipulated in the agreement, and provide timely, convenient and high-quality medical services for employees with industrial injuries in line with the principle of "treatment due to injuries, reasonable examination, reasonable treatment, rational drug use, reasonable charges and separation of injuries".
Article 4 After the employees of the employing units participating in work-related injury insurance (hereinafter referred to as insurance) suffer from work-related injuries, they shall promptly send the injured employees to the agreed medical institutions for treatment. If it is really necessary to send it to the nearest non-agreement medical institution for rescue, the employer shall report to the industrial injury insurance agency within 3 days, and transfer it to the agreement medical institution for treatment in time after the injury is stable. Employees injured at work in other places can be given priority to the agreed medical institutions where the accident occurred.
Article 5 When an employee goes to an agreed medical institution to treat a work-related injury, the employing unit shall issue a certificate of participation in work-related injury insurance to the agreed medical institution. The agreed medical institution should take the initiative to ask the employer about the insured situation. If the employer is unable to issue an insurance certificate for some reason, it shall explain the situation to the first-time physician and the medical insurance department, and fill in the insurance certificate within 3 days. The medical expenses of employees with work-related injuries shall be paid by the employer in advance. After the medical treatment is terminated or the disability level is assessed, the employer may go to the industrial injury insurance agency for settlement with medical receipts and other related procedures in accordance with relevant regulations.
Article 6 The agreed medical institutions shall implement the system of one-day list and monthly report for the treatment of workers with work-related injuries, and the total amount of expenses can be printed uniformly when the workers with work-related injuries leave the hospital.
Seventh workers work-related injury treatment drugs, with reference to the "Liaoning province industrial injury insurance drug list" implementation; Work-related injury insurance diagnosis and treatment projects and medical service facilities projects shall be implemented in accordance with the Catalogue of Basic Medical Insurance Diagnosis and Treatment Projects and Medical Service Facilities in Liaoning Province, and adjusted accordingly according to relevant national and provincial documents.
Article 8 Employees who need to do large-scale instrument examination or special treatment such as dynamic electrocardiogram, ECT, nuclear magnetic resonance, color Doppler blood vessel examination, interventional radiotherapy, electronic endoscope, hyperbaric oxygen chamber treatment due to work-related injuries shall apply by the attending physician of the agreed medical institution, and be approved by the medical insurance department of the agreed medical institution and the work-related injury insurance agency. If special examination and treatment are needed due to special circumstances such as rescue, the examination and treatment can be carried out first, and the examination and approval procedures can be completed within 3 days.
Medical institutions should strengthen the management of large-scale medical equipment and special treatment projects, strictly grasp the indications for diagnosis and treatment, and the positive rate of large-scale equipment inspection should meet the standards set by the health administrative department.
Ninth inductrial injury worker hospital bed costs, according to the price department approved the general ward standard settlement; If the patient needs to live in the intensive care unit due to injury, the bed fee shall be settled according to the standard of intensive care unit approved by the price department. After the injured workers in intensive care unit are relieved, the agreed medical institution shall adjust the ward in time.
Tenth injured workers in the city hospital treatment of work-related injuries, the daily food allowance standard is calculated according to the daily 26 yuan. Workers with work-related injuries need to be approved for medical treatment outside the overall planning area, and the daily food subsidy standard is calculated according to the daily 37 yuan.
Article 11 If the injured workers need to place pacemakers, replace artificial organs, place disposable medical materials in their bodies or use them in treatment due to their injuries, an application shall be made by an agreed medical institution, and they can only be used after being approved by the industrial injury insurance agency. In principle, domestic products should be used when using the above equipment. If the price of imported products is higher than that of domestic similar products or there are no domestic similar products, 70% of the expenses incurred will be written off.
Twelfth injured workers need to be transferred to different places for treatment because of their injuries, and they must be referred by the employing units and individuals and reported to the industrial injury insurance agency for approval. Medical expenses during medical treatment in different places shall be reimbursed according to relevant regulations.
Workers with work-related injuries who need to be transferred to different places for treatment due to work-related injuries can be reimbursed for their round-trip transportation expenses for each medical treatment by train tickets, boat tickets and bus tickets after filing, except for train soft sleeper tickets and air tickets.
Workers with work-related injuries who need to be transferred to other places for treatment due to work-related injuries shall be reimbursed by the work-related injury insurance fund within 3 days before hospitalization after filing, and the standard is 150 yuan per person per day.
Thirteenth workers in the field of business accidents, after the rescue of foreign hospitals, the injury is basically stable, it should be promptly transferred back to the city's agreed medical institutions for treatment. If an employee is sent to work abroad, the medical expenses incurred by his treatment abroad shall be reimbursed with reference to the average cost of the same injury in China.
Fourteenth employees in the working hours of sudden post illness treatment, according to the relevant provisions of the basic medical insurance. After being rescued, he died within 48 hours, and was identified as work-related death by the administrative department of human resources and social security in accordance with the regulations. If the medical expenses are audited by the industrial injury insurance agency and meet the requirements, they shall be paid by the industrial injury insurance fund.
Article 15 If the employer fails to pay work-related injury insurance premiums for employees according to law, if the employer fails to pay work-related injury insurance benefits for employees after work-related injuries, or if the work-related injuries are caused by a third person, and the third person fails to pay the medical expenses for work-related injuries or cannot identify the third person, the work-related injury insurance fund shall pay in advance in accordance with regulations and make compensation according to law.
Article 16 If an employee is injured by an accident and the employer applies for work-related injury identification within the prescribed time limit, the medical expenses incurred before the administrative department of human resources and social security accepts the application for work-related injury identification shall be borne by the employer.
Article 17 If new inflammation or pathological changes occur in the injured parts or organs that need to be treated, or new inflammation or pathological changes occur in the injured parts or organs that need to receive specialized treatment on a regular basis, the confirmation procedures must be handled by the procedures for identifying the injured workers and the conclusion of the appraisal of the degree of disability. If it is confirmed by expert consultation that it belongs to the recurrence of old injuries or special treatment of specialties, the industrial injury insurance agency shall designate an agreed medical institution for treatment, and the medical expenses shall be paid by the industrial injury insurance fund.
Workers with work-related injuries have relapsed and need hospitalization. During hospitalization, food subsidies are paid by the industrial injury insurance fund, and medical institutions give subsidies according to standards.
Eighteenth agreed medical institutions should strictly implement the relevant provisions of the "Prescription Management Measures" (Order No.53 of the Ministry of Health), writing medical records, special prescriptions for work-related injuries, discharge doses, outpatient (emergency) prescription doses, etc. , and provide a detailed list of expenses; The expenses incurred due to over-dose medication and over-standard drug expenses shall be borne by the agreed medical institutions. The medical expenses for non-work-related injuries shall not be paid by the work-related injury insurance fund.
Article 19 If it is agreed that a medical institution uses drugs other than the Catalogue of Work-related Injury Insurance Drugs in Liaoning Province and the Catalogue of Medical Treatment Items and Medical Service Facilities in Liaoning Province, or provides services other than medical treatment items and facilities, it shall obtain the consent of the employing unit or the injured employee or his relatives, and go through the formalities at its own expense, and the expenses shall be paid by the employing unit or the injured employee or his relatives. The expenses incurred by the agreed medical institutions in unauthorized use of drugs other than the Catalogue of Work-related Injury Insurance Drugs in Liaoning Province and the Catalogue of Medical Treatment Items and Facilities in Liaoning Province or in providing services other than medical treatment items and facilities shall be borne by the agreed medical institutions.
Twentieth agreed medical institutions should actively cooperate with the rehabilitation of work-related injuries. When the injured workers' hospitalization injury is basically stable, the agreed medical institution shall put forward rehabilitation suggestions to the injured workers with rehabilitation value, so that the rehabilitation agreement institution can intervene in medical rehabilitation and vocational rehabilitation at an early stage. Rehabilitation confirmation, rehabilitation management and rehabilitation cost settlement of injured workers shall be implemented in accordance with the relevant provisions of the Trial Measures for Rehabilitation Management of Injured Workers in Dalian.
Workers with work-related injuries need to be rehabilitated and hospitalized after being confirmed by the work-related injury insurance agency. Food subsidies during hospitalization are paid by the work-related injury insurance fund, and medical institutions give subsidies according to the standards.
Twenty-first agreed medical institutions in violation of the provisions of medical expenses, industrial injury insurance fund will not pay. If the agreed medical institution fails to provide services according to the service agreement, the industrial injury insurance agency may handle it according to these provisions and the relevant provisions of the Industrial Injury Insurance Medical Service Agreement until the service agreement is terminated.
Twenty-second industrial injury insurance agencies should conscientiously do a good job in the audit and settlement of medical expenses of insured employees, and allocate the expenses incurred by the approved medical institutions last month to the account before the 25th of each month. After the expenses paid by the employer are approved, the industrial injury insurance agency shall immediately reimburse and settle the accounts.
Twenty-third municipal human resources and social security administrative departments shall supervise and inspect the payment of work-related injury insurance premiums according to law. If the industrial injury insurance agency fails to settle the expenses in full and on time, the administrative department of human resources and social security shall order it to make corrections.
Article 24 Where an employer, an injured worker, a designated medical institution or an industrial injury insurance agency disputes the payment of medical expenses for work-related injuries, it may apply for administrative reconsideration according to law, or bring an administrative lawsuit to a people's court according to law, or with the consent of the parties concerned, it shall be handled by the administrative department of human resources and social security in coordination.
Twenty-fifth employers or individuals who cheat work-related injury insurance benefits or cheat work-related injury insurance funds shall be punished according to relevant regulations. If the circumstances are serious enough to constitute a crime, criminal responsibility shall be investigated according to law.
Article 26 These Provisions shall come into force as of 201101. "Dalian City Industrial Injury Insurance Medical Settlement Management Measures" (Dalaofa [2004] No.6) shall be invalidated.
Attachment:
Work-related injury insurance agreement list of medical institutions and medical subjects
serial number
Specify the name of the hospital
Diagnostic and therapeutic subjects
1
Dalian Central Hospital
Comprehensive diagnosis and treatment subjects
2
The First Affiliated Hospital of Dalian Medical University
Comprehensive diagnosis and treatment subjects
three
The Second Affiliated Hospital of Dalian Medical University
Comprehensive diagnosis and treatment subjects
four
Zhongshan Hospital Affiliated to Dalian University
Comprehensive diagnosis and treatment subjects
five
Dalian Second People's Hospital
Bone surgery, brain surgery, ophthalmology
six
Dalian Third People's Hospital
Bone surgery, brain surgery, ophthalmology, thoracic surgery, urology, general surgery
seven
Dalian Friendship Hospital
Bone surgery, brain surgery, general surgery
eight
Xinhua Hospital Affiliated to Dalian University
General surgery, brain surgery, hand surgery
nine
China People's Liberation Army No.210 Hospital
Orthopedics, general surgery, thoracic surgery
10
Dalian Fourth People's Hospital
Bone surgery, burn department, occupational disease, brain surgery
1 1
Dalian Fifth People's Hospital
Orthopedic surgery, thoracic surgery
12
Dalian Ganjingzi District People's Hospital
Orthopedic surgery, hand surgery
13
Dalian Shipbuilding Hospital
Bone surgery
14
Dahua group limited liability company hospital
Burn department, occupational disease, general surgery
15
Dalian Liao Yu Hospital
Bone surgery, brain surgery
16
Dalian locomotive hospital
Comprehensive diagnosis and treatment subjects
17
Dalian port hospital
Orthopedic surgery, general surgery
18
China People's Liberation Army No.210 Hospital No.403 Clinical Department
Orthopedic surgery, hand surgery
19
Dalian Hospital of Liaoning Provincial Armed Police Corps
Comprehensive diagnosis and treatment subjects
20
Jinzhou District No.1 People's Hospital
Comprehensive diagnosis and treatment subjects
2 1
Lvshunkou District People's Hospital
Comprehensive diagnosis and treatment subjects
22
Changhai county people's hospital
Comprehensive diagnosis and treatment subjects
23
Wafangdian city Third Hospital
Comprehensive diagnosis and treatment subjects
24
Pulandian city Central Hospital
Comprehensive diagnosis and treatment subjects
25
Zhuanghe city Central Hospital
Comprehensive diagnosis and treatment subjects
26
Wafangdian bearings hospital
Orthopedics, Neurology, Occupational Diseases
27
Dalian Economic and Technological Development Zone Hospital
Comprehensive diagnosis and treatment subjects
28
Dalian Economic and Technological Development Zone Jinyuan Hospital Co., Ltd.
Comprehensive diagnosis and treatment subjects
29
Shenyang military area command Dalian Sanatorium 2 15 Hospital
Department of psychiatry
30
Dalian tuberculosis hospital
Occupational disease (tuberculosis)
3 1
Dalian moushi hospital
Bone surgery
32
Dalian bonded area hospital
Comprehensive diagnosis and treatment subjects