Legal analysis: The scope of reimbursement for urban residents' medical insurance in Taiyuan City includes: (a) medical expenses for hospitalization; (b) medical expenses within 7 days prior to the date of emergency detention and transfer to inpatient treatment; (c) medical expenses in accordance with the provisions of special outpatient diseases for urban residents; and (d) other expenses in accordance with the regulations. The reimbursement rate standard is according to the category of the insured person.
Legal basis: Taiyuan City Medical Insurance Management Service Center, "Notice on the Issuance of 'Operational Measures on Improving the Management of Medical Treatment and Treatment Standards of Urban Basic Medical Insurance in Taiyuan City'
I. Management of Transferring to Outside Medical Treatment
When medical institutions in the province are unable to satisfy the needs of the participants in medical treatment due to medical technology, equipment and other reasons, in addition to the original provisions can be transferred to Beijing, Shanghai and Tianjin urban basic medical insurance designated medical institutions for medical treatment, in addition to the original provisions, can also be transferred to other provinces and cities urban basic medical insurance designated medical institutions for medical treatment.
(I) Referral Management
When the insured person seeks medical treatment in the designated medical institutions in the province, if the medical technology and equipment cannot meet the needs of the insured person, he/she can be referred to the designated hospitals of urban basic medical insurance in other provinces and cities for medical treatment, and the patient who meets the conditions of referral can fill out the "Approval Form of Referral for Referral for Urban Basic Medical Insurance in Taiyuan" in the designated hospitals, and go through the procedure of referral. The patients who meet the conditions for referral will fill in the "Approval Form for Referral to Taiyuan City Urban Basic Medical Insurance" at the designated hospital and go through the procedure of referral.
(2) Referral designated hospitals
Malignant tumor patients need to be referred by the Shanxi Provincial Cancer Hospital for referral procedures; orthopedic diseases need to be referred by the Second Hospital of Shanxi University of Medical Sciences for referral procedures; due to eye diseases need to be referred by the Shanxi Provincial Ophthalmology Hospital for referral procedures (excluding the residents); due to renal diseases need to be referred by the Second People's Hospital of Shanxi for referral procedures; infectious diseases by Taiyuan City, the Second People's Hospital for referral procedures; the Second People's Hospital of Shanxi for referral procedures. Procedures; infectious diseases will be handled by the Third People's Hospital of Taiyuan; tuberculosis will be handled by the Fourth People's Hospital of Taiyuan; and mental illness will be handled by the Psychiatric Hospital of Taiyuan. The referral of non-specialized diseases will be handled by the Shanxi Provincial People's Hospital, the First Hospital of Shanxi Medical University, the Second Hospital of Shanxi Medical University, Taiyuan Central Hospital, and the Shanxi Provincial Cardiovascular Disease Hospital. Shanxi Maternal and Child Health Hospital is the designated hospital for referral of insured residents.
(3) Reimbursement Management
1. After the referral treatment, the insured patients should go to the fixed-point hospitals for settlement and audit, and bring along the "Referral Approval Form of Taiyuan Urban Basic Medical Insurance", regular invoices, discharge certificates, total details of expenses, medical manuals, copies of inpatient medical records, the "Identification Confirmation Form of Taiyuan Urban Basic Medical Insurance" and the grade certificates of the hospitals they visit. grade certificate.
2. When reviewing medical expenses, hospitals should strictly implement the "Three Catalogs", and drug charges should be reviewed and entered according to the actual quantity, amount and category; diagnostic and therapeutic items should be reviewed and entered according to Taiyuan's charging standards, and charges higher than Taiyuan's charging standards should be implemented according to Taiyuan's standards, and charges lower than the standard price of Taiyuan's charging standards should be implemented according to the actual price; materials placed inside the body should be entered according to the price limit; and charges below the standard price should be entered according to the price limit. According to the maximum price entry; below the maximum price according to the actual amount of entry; belongs to the catalog outside the disposable supplies, materials can be totaled by a fee as a category C item entry.
3. After reviewing the medical expenses, the hospitals will enter them into the computer system and upload them to the Taiyuan Medical Insurance Management Service Center. In addition, the hospital should bring relevant materials to the settlement section of Taiyuan Medical Insurance Management Service Center for settlement procedures.
(4) Hospital Management
The designated medical institutions should strictly follow the regulations for the insured to handle the procedures of referral in time. After the patients are referred out, the referral hospitals should submit the "Referral Approval Form of Taiyuan Urban Basic Medical Insurance" to the Taiyuan Medical Insurance Management Service Center for record, and the referral hospitals should upload the fees and handle the settlement procedures for the insured patients in time after the treatment is completed. The Taiyuan Health Insurance Management Service Center will supervise and inspect the referral for medical treatment.