Tianjin will carry out a pilot project of online reimbursement of medical expenses for medical treatment in other places, launch a pilot project of direct settlement of general outpatient medical treatment in Beijing, Tianjin and Hebei without filing, and expand the scope of designated medical institutions for direct settlement of general outpatient medical treatment and outpatient chronic and special diseases for medical treatment in other places.
Target plan
01. By the end of 2022, Tianjin will improve the settlement method for medical treatment in other places, optimize the service of filing for medical treatment in other places, and deepen the synergistic development of medical treatment in other places in Beijing, Tianjin and Hebei.
02. By the end of 2023, Tianjin will expand the online service channels for direct settlement of medical bills for medical treatment in other places, and carry out a pilot project of online reimbursement of medical expenses for medical treatment in other places.
03. By the end of 2025, the system of direct settlement of medical expenses for medical treatment in other places and the system of handling and management services will be further improved, the supportive role of the national unified medical insurance information platform will be strengthened, the capacity of settlement services for medical treatment in other places will be enhanced, the rate of direct settlement of inpatient medical expenses for medical treatment in other places will reach more than 70%, and the fixed-point medical institutions that have opened direct settlement services for general outpatient medical treatment for medical treatment in different places will basically achieve "full coverage", the number of designated medical institutions for direct settlement of outpatient medical treatment for five kinds of outpatient slow special diseases such as hypertension and diabetes has increased significantly, the record-keeping service for outpatient medical treatment has become more standardized and convenient, and the online and offline cross-provincial handling of medical insurance reimbursement has been realized.
Improving the system of direct settlement for medical treatment in other places
I. Defining the payment policy for direct settlement for medical treatment in other places
In principle, the hospitalization, general outpatient and outpatient slow and special disease medical expenses incurred by insured persons in this city through direct settlement for medical treatment in other places shall be subject to the scope of payment and the relevant regulations stipulated in the place of medical treatment, and the starting standard, payment ratio, maximum payment limit, and outpatient and slow and special disease medical expenses stipulated by the basic medical insurance fund of the place of participation shall be carried out. The starting payment standard, payment ratio, maximum payment limit, and the scope of outpatient chronic special diseases and other relevant policies of the basic medical insurance fund stipulated by the place of participation are implemented.
II. Clarifying the policy of direct settlement for medical treatment in other places for insured persons without third-party liability for traumatic injuries
Traumatic injuries without third-party liability incurred by insured persons in this city in other places in compliance with the management regulations of the place of medical treatment can be included in the scope of direct settlement for medical treatment in other places; for traumatic injuries without third-party liability incurred by insured persons from other countries in our city in compliance with the management regulations of the place of medical treatment, the fixed-point medical institutions should include them in the scope of direct settlement for medical treatment in other places. The designated medical institutions shall include them in the scope of direct settlement for medical treatment in other places; and the administrative organizations in the place of medical treatment shall include the relevant costs in the scope of verification according to the regulations.
Three, clear cross-provincial medical insurance reimbursement policy
The city's insured persons in accordance with the provisions of the filing procedures for medical treatment, can be filed in the place and the place of participation in the two-way enjoyment of health insurance treatment, for the insured there are many times to and from the settlement of medical treatment in the two places or at the same time period of the occurrence of bidirectional settlement of medical treatment and other suspected irregularities, the health insurance supervisory departments should focus on verification. The general outpatient and inpatient medical expenses incurred by the medical personnel referred from other places for medical treatment in the transferred medical institutions are included in the scope of medical insurance reimbursement, and the reimbursement ratio is implemented in accordance with the relevant provisions of the city.
Fourth, clear direct settlement of cross-district medical care designated medical institutions coverage
In conjunction with the development trend of the city's designated medical institutions, and actively promote the expansion of cross-district medical care general outpatient and inpatient direct settlement of the scope of the designated medical institutions, and the timely inclusion of the new designated medical institutions in the districts and qualified designated retail pharmacies in the scope of coverage. Fully mobilize and promote the participation of designated medical institutions in all districts to participate in the pilot work of direct settlement for outpatient chronic and special diseases for medical treatment in other places, and open more than 260 designated medical institutions by the end of 2022, so as to achieve a significant increase in the number of designated medical institutions for direct settlement for outpatient chronic and special diseases for medical treatment in other places by the end of the Fourteenth Five-Year Plan period.
Optimizing the filing service for medical treatment in other places
A unified scope of persons filing for medical treatment in other places
Participants in the city who belong to the scope of persons residing permanently in other places across provinces or going out temporarily to seek medical treatment in other provinces can apply for the corresponding procedures of filing for medical treatment in other places and then enjoy the service of direct settlement for medical treatment in other places.
1. Long-term residents across provinces: including retirees resettled in other places, long-term residents living in other places, permanent staff in other places, etc. who participate in the basic medical insurance for employees or residents in Tianjin, and who work, reside and live in provinces other than Tianjin for a long period of time;
2. Temporary out-of-towners across provinces: including out-of-towners who are referred to other places for medical treatment, emergency medical and rescue personnel who live in other places for reasons of work or travel, as well as other out-of-towners who are temporarily out-of-towners for medical treatment. Emergency rescue personnel and other temporary out-of-province medical personnel.
II. Unification of the effective period of filing for medical treatment in other places
After the registration of the personnel residing in other places for a long time across the provinces, the filing will be effective for a long time, and the insured personnel can set the effective period of the filing according to the actual situation, and make changes or cancel it. After the registration of cross-provincial temporary medical personnel, the record is valid for a maximum of 12 months, and during the validity period, according to the needs of the condition, they can visit the place of medical treatment several times and enjoy the cross-provincial direct settlement services for medical treatment in other places.
Third, the unification of cross-location medical filing regulations
Participants in the city can open cross-location direct medical settlement services through online channels such as the national health insurance service platform APP, the Tianjin Health Insurance APP, the Tianjin Office APP, the national cross-location medical filing program, the State Council client program, etc., or go to the district health insurance sub-centers to handle cross-location filing and enjoy cross-location direct medical settlement services. enjoy the direct settlement service for medical treatment in other places.
When the insured persons in this city apply for the record of medical treatment in a different place, they can directly record to the province, city or municipality directly under the central government where they seek medical treatment and enjoy the direct settlement service for hospitalization and general outpatient expenses in the inter-provincial networked fixed-point medical institutions in the place where the record is opened.
During the pilot period of direct settlement of outpatient chronic special diseases for medical treatment in other places, the insured persons can, on the basis of outpatient chronic special disease designated medical institutions originally selected by them, additionally select two designated medical institutions in the place of filing which have already opened the outpatient chronic special disease direct settlement service as their own designated medical institutions for direct settlement of outpatient chronic special diseases for medical treatment in other places.
Fourth, the unification of the foreign medical record and exemption from the record
Participants in the cross-provincial settlement of the hospital before the foreign medical record, the medical network of designated medical institutions should be for the participants in the cross-provincial direct settlement of medical costs. The city's medical insurance department to strengthen the settlement policy publicity and interpretation, guidance to the city's designated medical institutions for eligible participants to make up for the record of foreign medical procedures and network settlement. The insured persons in this city can submit relevant documents and make up the filing formalities after they are discharged from hospitals for settlement of out-of-pocket expenses for cross-provincial medical treatment, and the medical expenses incurred can be reimbursed manually by the medical insurance in accordance with the regulations.
Deepening the Beijing-Tianjin-Hebei medical insurance collaborative development, January 1, 2023 to start the Beijing-Tianjin-Hebei cross-border medical treatment of general outpatient direct settlement "free of filing" pilot, give priority to the city to undertake the non-capital function of the project to carry out the pilot in the key administrative areas, the pilot range of the city's insured people to Beijing, Hebei Province has been The city's insured persons within the scope of the pilot go to Beijing and Hebei Province and have opened the direct settlement of outpatient medical expenses incurred by the designated medical institutions for medical treatment in other places can be directly settled, summarize the experience of the pilot, and gradually expand the pilot area and the scope of medical expenses.
Doing a good job of management services for settlement of medical bills in other places
I. Doing a good job of management of vouchers for insured persons
When insured persons in this city seek medical treatment in other places across the provinces, they should take the initiative to show their identity as insured persons in the inter-provincial networked designated medical institutions in the place of medical treatment and present the electronic vouchers for medical insurance or valid vouchers such as the social security card. The designated medical institutions of the city should do a good job of verifying the identity of foreign insured persons, and guide those who have not filed for the record to go through the filing procedures in a timely manner, so as to provide reasonable and standardized diagnostic and treatment services as well as convenient and fast direct settlement services for cross-provincial and cross-district medical treatment in accordance with the provisions of the outpatient clinics and inpatient hospitalization in the place of medical treatment.
Second, do a good job of settlement of expenses for cross-provincial cross-district medical treatment
When cross-provincial cross-district medical treatment is directly settled, the place of medical treatment should convert the detailed information of inpatient expenses into the nationally standardized major types of expense information, and the outpatient expenses will be divided into expenses according to the scope of payment of the place of medical treatment and the relevant regulations for each expense detail, and then be transmitted in real time through the national and provincial cross-district medical treatment settlement systems to the place of participation in the policy, which should calculate the amount to be paid by the insured person according to the local policies and regulations. The place of participation calculates the amount to be borne by the participant and paid by the medical insurance fund in accordance with the local policies and regulations, and transmits the result back to the fixed-point medical institutions in the place of medical treatment for direct settlement between the fixed-point medical institutions and the insured persons.
If the insured person is unable to make direct settlement for any reason, the designated medical institution of the city shall collect the relevant information of the insured person according to the electronic vouchers of the medical insurance or the valid vouchers of the social security card and upload the details of the medical expenses, diagnosis and other information of the visit to the national medical insurance information platform in time, and support the pilot project of the nationwide pilot project of the manual reimbursement of the medical expenses of the inter-provincial medical treatment in a different place on the line.
Third, do a good job of medical insurance management in the place of medical treatment
Municipal health insurance agencies should be included in the local unified management of foreign medical personnel, in the medical information records, performance evaluation, medical behavior monitoring, cost audit, total budget and other aspects of the same services and management with local participants, and in the fixed-point medical institutions to be clear in the agreement on medical insurance services. Combined with the city's health insurance payment method reform work, in due course to explore the DRG/DIP and other health insurance payment method reform in the application of settlement of medical treatment in other places, to guide the designated medical institutions reasonable diagnosis and treatment.
Four, do a good job of business cooperation management
Municipal and municipal health insurance departments should establish and improve the working mechanism, the formation of a clear division of labor, clear responsibilities, the process of unified cross-provincial business cooperation management system for medical treatment across the province, in the problem of coordination, online reimbursement, cost coordination, information **** enjoy the comprehensive enhancement of the health insurance management business cooperation management capabilities. The Municipal Medical Insurance Center is responsible for the unified organization, coordination and implementation of cross-provincial cross-district medical treatment direct settlement management services within the city, and does a good job of cross-provincial cross-district medical treatment direct settlement management services according to the requirements of the state and the city.
Promoting the construction of cross-provincial cross-district medical care subsystems
Actively promoting the data **** enjoyment, deepening the promotion and application of the health insurance e-voucher, the health insurance mobile payment, the health insurance e-prescription flow, the health insurance service platform web hall, APP and applet, etc., continuously improving the cross-provincial cross-district medical care management subsystems, advancing the interface transformation adaptation with the fixed-point medical institutions, and accelerating the promotion of the health insurance e-voucher, Resident identity card as a medical medium, optimize system performance, reduce response time, and enhance the experience of direct settlement of medical treatment in other places for insured persons.