These Measures are formulated in accordance with the actual situation of the city in order to protect the basic medical needs of the insured, to standardize and strengthen the supervision and management of the basic medical insurance, and to safeguard the safety of the medical insurance fund. Article 2 (Scope of Application)
These Measures are applicable to the supervision and management activities of the designated medical institutions for basic medical insurance (hereinafter referred to as designated medical institutions), the designated retail pharmacies for basic medical insurance (hereinafter referred to as designated retail pharmacies), and the individuals' compliance with the provisions of the city's basic medical insurance.
The basic medical insurance referred to in these measures includes basic medical insurance for urban workers, basic medical insurance for urban residents and other basic medical insurance. Article 3 (Supervision and Administration of Medical Insurance)
The Municipal Bureau of Human Resources and Social Security is the administrative department in charge of basic medical insurance and is responsible for the supervision and administration of basic medical insurance in the city. The Human Resources and Social Security Bureaus of the districts (counties) are responsible for the supervision and inspection of the basic medical insurance within their respective jurisdictions.
The Municipal Health Insurance Supervision and Inspection Institute is entrusted by the Municipal Bureau of Human Resources and Social Security with the specific implementation of basic health insurance supervision and inspection and other administrative law enforcement work, and the supervision and inspection force is enriched and strengthened according to the needs of supervision and inspection work.
Development and reform, health, food and drug supervision, industry and commerce administration, finance, audit, public security, pricing and other departments shall, within their respective areas of responsibility, cooperate in the supervision and management of basic medical insurance. Article 4 (Medical Insurance Information System)
The Municipal Bureau of Human Resources and Social Security shall establish and improve the information system of physicians practicing in the designated medical institutions and the basic medical insurance expense settlement system, and carry out real-time supervision of the basic medical insurance expenses incurred by the designated medical institutions and their physicians in the process of providing medical services, so as to regulate the behavior of physicians practicing in the designated medical institutions in their medical services.
The designated medical institutions and designated retail pharmacies shall, in accordance with the requirements of the city's basic medical insurance network settlement, be equipped with the necessary networking equipment, comply with the basic medical insurance information technology norms and information security regulations, and upload the basic medical insurance fee settlement and other relevant information in a timely and accurate manner. Article 5 (Internal Management)
Designated medical institutions and designated retail pharmacies shall establish and improve the basic medical insurance management system, equipped with the necessary management personnel, and carry out inspections and supervision of compliance with the provisions of the city's basic medical insurance. Article 6 (Medical Insurance Expense Management)
Specified medical institutions shall implement the city's basic medical insurance payment expense budget management, total prepaid expense management of the relevant provisions of the basic medical insurance, to protect the basic medical needs of the insured, and standardize the use of medical insurance funds. Article 7 (Re-determination of the qualification of the fixed-point)
The fixed-point medical institutions merge or the nature of the institution, practice address, the number of approved beds change, the fixed-point retail pharmacy business address or business scope change, should be in accordance with the relevant provisions of the city, to the Municipal Bureau of Human Resources and Social Security to re-approve the qualification of the fixed-point of the basic medical insurance for examination and approval procedures. Article 8 (Requirements on services provided by designated medical institutions)
Designated medical institutions shall reasonably select diagnostic and treatment items and reasonably determine the use of medicines according to the conditions of the insured persons and in accordance with the provisions of the basic medical insurance on diagnostic and treatment items, medical service facilities, prescription management and the scope of medicines.
The designated medical institutions shall comply with the provisions of the basic medical insurance on diagnostic and treatment items, medical service facilities, the scope of medication, payment standards, and the fees and charges determined by the price department, and provide the participants with the settlement of medical bills. Article 9 (Requirements on services provided by designated retail pharmacies)
When providing prescription drug dispensing and non-prescription drug self-acquisition services for insured persons, designated retail pharmacies shall not settle basic medical insurance expenses for dispensed prescriptions that do not comply with the provisions on the use of medicines for basic medical insurance; and the non-prescription medicines provided for the insured persons shall not violate the provisions of basic medical insurance on the scope, varieties, and quantities of medicines to be used. The non-formulary drugs provided to the insured shall not violate the scope, variety and quantity of drugs used in basic medical insurance.
Designated retail pharmacies shall comply with the relevant provisions on price management in providing dispensing services to the insured persons, and provide the insured persons with the relevant cost settlement documents. Article 10 (Presentation and Verification of Basic Medical Insurance Vouchers)
Participants shall present their basic medical insurance vouchers when registering, consulting, examining, dispensing medicines, hospitalizing, settling medical expenses at designated medical institutions or dispensing medicines at designated retail pharmacies.
Participants are not allowed to lend their basic medical insurance vouchers to others.
Designated medical institutions and designated retail pharmacies shall verify the basic medical insurance vouchers of the insured when they provide relevant medical services or dispense medicines for the insured. Article 11 (Timely Supervision and Inspection)
District (county) Human Resources and Social Security Bureaus and Municipal Health Insurance Supervision and Inspection Institutes shall strengthen the supervision and inspection of designated medical institutions and designated retail pharmacies.
If the basic medical insurance settlement costs of a designated medical institution deviate from the budget target or the prepaid target is large, the district (county) Human Resources and Social Security Bureau and the Municipal Institute for Supervision and Inspection of Medical Insurance shall carry out supervision and inspection in a timely manner. Article 12 (real-time monitoring)
The Municipal Health Insurance Supervision and Inspection Institute shall conduct real-time monitoring of the number of monthly outpatient emergency room visits by insured persons and the basic medical insurance costs incurred by them. If the number of outpatient emergency visits and the basic medical insurance fees incurred by a participant exceed the prescribed range, the method of accounting and settlement of outpatient emergency basic medical insurance fees may be temporarily changed.
The Municipal Health Insurance Supervision and Inspection Office shall notify the insured person of the temporary change in the accounting and settlement of outpatient and emergency basic medical insurance fees and shall conduct a timely audit of his medical treatment. After the audit did not find a violation of the basic medical insurance provisions of the behavior, should be audited on the day of completion of the inspection, to restore their outpatient emergency basic medical insurance costs billing and settlement method.