(2) Facilitating cross-provincial referral of eligible insured persons for medical treatment. Participants should be in accordance with the relevant provisions of the hierarchical diagnosis and treatment of medical care in an orderly manner, and if the condition requires cross-provincial medical treatment, they can be referred to out-of-province medical institutions through the designated medical institutions in the place where they are insured. The designated medical institutions shall formulate a reasonable diagnosis and treatment plan based on the patient's condition, and when referral is needed, referral can be arranged through different forms, and hospitalization in the local area shall not be regarded as a prerequisite for the issuance of referral. If the insured person really needs to continue treatment in the place of medical treatment or transfer to another place for medical treatment due to the same kind of disease, the office of the place of insurance should simplify the procedure of filing for medical treatment in a different place, so as to make it convenient for the insured person to enjoy the service of inter-provincial direct settlement for medical treatment in a different place.
(3) Regulating the medical treatment of insured persons with medical insurance electronic vouchers and social security cards. When the insured persons seek medical treatment across provinces, they should take the initiative to indicate their insured status in the cross-provincial networked designated medical institutions in the place of medical treatment, and present the valid certificates such as the electronic vouchers of medical insurance or social security cards. The cross-provincial network of designated medical institutions should do a good job in verifying the identity of the 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 cross-provincial cross-district medical settlement services for the out-patients (in case of emergencies) and hospitalized patients in compliance with the regulations of the place of medical treatment.
(4) Standardizing the process of cross-provincial direct settlement. In the direct settlement of cross-provincial cross-district medical treatment, the place of medical treatment shall convert the detailed information of inpatient expenses into the nationally standardized information of major types of expenses, divide the outpatient expenses (including general outpatient expenses and outpatient slow and special illnesses) into expenses according to the scope of payment of the place of medical treatment and the relevant regulations for each item of detailed expenses, and then transmit them in real time to the place of participation in the insurance policy through the national and provincial cross-district medical treatment settlement systems, and the place of participation in the insurance policy calculates, in accordance with the provisions of the local policy, the expenses that should be borne by the participants, as well as the payments to be made by various medical insurance funds. The place of participation calculates the amount to be borne by the participant and paid by the medical insurance funds according to local policies, and transmits the results 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 cross-provincial networked designated medical institution shall collect the relevant information of the insured person based on the electronic vouchers of medical insurance or valid vouchers such as social security cards, and upload the details of medical expenses, diagnosis and other information of medical treatment to the national medical security information platform in a timely manner, and support the national pilot project of online manual reimbursement of medical treatment for cross-provincial cross-location medical treatment.
(5) Implementing unified management in the place of medical treatment. The agency in the place of medical treatment should integrate the medical personnel from other places into the unified management of the local area, provide the same services and management as the local insured personnel in terms of medical information record, performance evaluation, medical behavior monitoring, cost audit, total budget, etc., and make it clear in the medical insurance service agreement of the designated medical institution. Localities are encouraged to explore the application of DRG/DIP and other health insurance payment method reforms in the settlement of cross-location medical settlements, and to guide designated medical institutions in rational diagnosis and treatment.
(6) Strengthening the coordinated management of business for medical treatment in other places. Medical insurance departments at all levels should gradually improve the working mechanism, form a management system for cross-provincial cross-district medical care business coordination with a clear division of labor, clear responsibilities, and a unified process, and comprehensively improve the business coordination and management capabilities of medical insurance agencies at all levels in terms of coordination of problems, online reimbursement, cost coordination, and information***sharing. The national-level handling agencies are responsible for unifying, guiding, supervising and comprehensively coordinating the management and service work of inter-provincial direct settlement of inter-provincial cross-district medical consultations; the provincial-level handling agencies are responsible for unifying, coordinating and implementing the management and service work of inter-provincial direct settlement of inter-provincial cross-district medical consultations within the provincial scope; and the handling agencies of the co-ordinated areas do a good job of inter-provincial cross-district medical consultations management and service work in accordance with the requirements of the state and the provincial level.
Strengthening the management of funds for cross-provincial and cross-district medical treatment
(1) The portion of medical insurance fund payment for cross-provincial and cross-district medical treatment expenses is implemented in the inter-region area by pre-payment and then clearing. Before the end of January each year, national-level agencies in principle, based on the fourth quarter of the previous year, twice the monthly average value of the medical insurance settlement funds to approve the amount of annual advance payment, and confirm the amount of adjustment of the current year's advance payment. Each province may realize the advance payment of funds by, for example, collecting in advance the funds for different medical treatment in each integrated region within the province. In principle, the advance payment comes from the medical insurance fund of each coordinated region.
(2) The liquidation of expenses for cross-provincial medical treatment in other places is carried out in accordance with the method of national unified liquidation, and the liquidation at provincial and municipal levels is carried out in full on a monthly basis. The funds for the liquidation of cross-provincial medical expenses are transferred between the provincial financial accounts of the insured places and the provincial financial accounts of the places where the medical expenses are incurred. Provincial-level handling agencies and financial departments should work together to do a good job of transferring and collecting the clearing funds in accordance with the requirements of the "Procedures for Handling Direct Settlement of Cross-provincial and Cross-district Medical Treatment for Basic Medical Insurance" (see the Annex). The national-level handling agencies are responsible for coordinating and urging the provinces to disburse the funds in a timely manner in accordance with the regulations.
(3) Matters related to the management of funds for cross-provincial medical treatment in different places. Bank handling fees and bank bill costs incurred in the process of transferring funds for cross-provincial medical treatment shall not be charged to the fund. The interest generated by the prepaid funds in the special account of the financial institution of the place of medical treatment shall belong to the place of medical treatment. The prepayments and provisional receipts formed in the process of settlement and clearing of medical expenses for cross-provincial and cross-location medical treatment are accounted for in accordance with the provisions of the relevant accounting system.
Enhancing the standardized support of health insurance informationization
(1) Continuously deepening the application of the national unified health insurance information platform for the entire business and process. It has solidly pushed forward the dynamic maintenance and deepening application of codes, improved the operation and maintenance management system of health insurance informationization, and continuously upgraded the level of health insurance data governance, so as to provide strong system support for the direct settlement of cross-provincial and cross-location medical treatment. It has shared data with relevant departments*** in accordance with regulations, deepened the popularization and application of health insurance e-vouchers, health insurance mobile payment, health insurance e-prescription flow, health insurance service platforms, APPs and mini-programs, and pushed forward more cross-provincial cross-district medical settlement services across provinces.
(2) Promoting system optimization and improvement. Provincial health insurance departments should, in accordance with the unified interface standard specification, continuously improve the provincial cross-provincial cross-district medical management subsystem, and continue to push forward the interface transformation and adaptation work of fixed-point medical institutions, accelerate the promotion of electronic vouchers for health insurance and residents' identity cards as the medium for medical treatment, optimize the performance of the system, reduce the response time, and practically improve the experience of direct settlement of cross-provincial cross-district medical treatment for the insured persons. When the local health insurance system is down for switching, it should do a good job of reporting beforehand, verifying during the process, and monitoring afterward to ensure that the data migration is timely, complete, and accurate, and to resolve the impact of changes in information such as personal number on the business in transit, so as to ensure the smooth convergence of the business and the stable operation of the system.
(3) Strengthen system operation and maintenance management and security. Each provincial health insurance department should build a professional and reliable operation and maintenance management team, construct operation and maintenance management processes in the areas of infrastructure, network security, cloud platforms, and business subsystems, and form a scientific and effective operation and maintenance management system. Implement security management responsibilities, improve system security operation and maintenance capabilities, strengthen information system boundary protection, strictly prohibit the information system of designated medical institutions connecting to the health insurance system from accessing the Internet, standardize cross-provincial medical identity verification, and safeguard data security. Unify and standardize the quality control standards for abnormal transaction error reporting information, do a good job of classifying problems, and describe the causes of errors in a concise and easy-to-understand manner, so as to facilitate the problem localization of abnormal transactions and timely response to deal with them.
Strengthening the supervision of cross-provincial direct settlement fund for medical treatment in different places
Soundly improving the supervision mechanism of cross-provincial direct settlement fund for medical treatment in different places, perfecting the working system of regional collaboration and joint inspection, strengthening the guidance to key areas and regions for direct settlement of cross-provincial direct settlement of medical treatment in different places, and strengthening the supervision and assessment. Implementing the supervisory responsibility of the place of medical treatment and the place of insurance participation, the medical insurance department of the place of medical treatment shall take the direct settlement of cross-provincial cross-district medical treatment as the key content of daily supervision, special inspection, flight inspection, etc., and combat all kinds of fraudulent and deceptive acts by combining the local actuality and the characteristics of the work of cross-provincial cross-district direct settlement of medical treatment, and at the same time cooperate with the place of insurance participation in the relevant verification. The medical insurance departments of the insured places should regularly analyze the use of the medical insurance fund for cross-provincial and cross-district medical treatment, pinpoint the clues of suspicious problems, and actively carry out verification of the problems, so as to ensure the safe and reasonable use of the medical insurance fund. Cross-provincial medical supervision and recovery of medical insurance funds, deductions, etc., according to the original channel to return to the account of the insured place, administrative penalties, agreement liquidated damages, etc., by the medical insurance department of the place of medical treatment in accordance with the provisions of the treatment.
(a) Strengthen the organization and leadership. Medical insurance departments at all levels should take the direct settlement of cross-provincial medical treatment as an important task to deepen the reform of the medical insurance system, strengthen leadership, overall planning, coordination and promotion, and incorporate into the management of the assessment of objectives and tasks. The financial departments should allocate funds for cross-provincial medical treatment in a timely manner according to the regulations, reasonably arrange for the work expenses of the agencies, and strengthen the management of reconciliation with the agencies to ensure that the accounts are in line with the accounts and the accounts are in line with the money.
(2) Do a good job of convergence and transition. Local health insurance departments should adjust the policy measures that are inconsistent with this notice in a timely manner, to ensure that by the end of December 2022 with the national policy convergence; combined with the local actuality, to further clarify and refine the policy and management regulations, streamline the handling materials, simplify the handling process, optimize the management services; synchronized adjustment of the information system with the notice, to protect the direct settlement of cross-provincial cross-border medical settlement work a smooth transition.
(3) Strengthening team building. Provincial medical security departments should strengthen the provincial cross-provincial cross-district medical care management and management team construction, there should be a full-time full-time responsible for cross-district medical care direct settlement work. The coordinating regions should, according to the needs of management services, actively coordinate with relevant departments, strengthen the protection of institutions, personnel and office conditions, reasonably allocate professional staff, ensure the quality of services and improve work efficiency.
(4) Do a good job of publicizing and guiding. All localities should increase the policy propaganda efforts, using the form of the public to do a good job of policy interpretation, make full use of the existing 12345 or 12393 consulting service telephone, medical insurance portal and APP, expand a variety of information service channels, timely response to public concerns, and reasonable guidance of social expectations.
Legal basis:
Social Insurance Law of the People's Republic of China
Article 29
The portion of the medical expenses of the insured that should be paid by the basic medical insurance fund shall be settled directly by the social insurance administration agencies with the medical institutions and the drug business units. The administrative departments of social insurance and the administrative departments of health shall establish a settlement system for medical expenses incurred for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance by insured persons.