Interim Measures for the Management of Outpatient Special Chronic Diseases of Nanchang Basic Medical Insurance

Article 2 The outpatient special chronic disease referred to in these measures refers to the relatively stable condition, the need for long-term outpatient treatment and included in the city's basic medical insurance fund to pay for chronic diseases.

Article 3 Participants in the city's basic health insurance for urban workers (including institutions) or urban and rural residents (hereinafter referred to as the insured) suffering from diseases within the scope of the prescribed outpatient special chronic diseases, can apply for outpatient special chronic diseases, enjoy the provisions of the outpatient special chronic disease treatment.

Article 4 The identification and treatment of outpatient special chronic diseases shall follow the principles of scientific standardization, objectivity and truthfulness, reasonableness and effectiveness.

Article 5 The Municipal Bureau of Human Resources and Social Security is responsible for outpatient special chronic disease management system, policy development and adjustment, guidance and coordination of health insurance agencies to implement the management of outpatient special chronic disease; health insurance agencies at all levels are responsible for the organization of outpatient special chronic disease appraisal, management and settlement work.

Chapter II scope of disease and treatment

Article 6 The scope of basic medical insurance outpatient special chronic disease, reimbursement ratio, single or multiple disease annual maximum payment limit, according to the participants in the basic medical insurance categories, respectively, according to the "Nanchang City, urban workers, the implementation of basic medical insurance municipal integrated views" (Hongfu Hall) Fa [2011] No. 147), "Nanchang Municipal Organs and Institutions Public Healthcare and Urban Employee Basic Medical Insurance System Convergence Implementation Measures (Trial)" (Hongfu Fa [2014] No. 16) and "Nanchang City Urban and Rural Residents' Basic Medical Insurance Interim Measures" (Hongfu Hall [2015] No. 37), respectively, according to the provisions of the "Nanchang City Basic Medical Insurance Municipal Coordination Implementation Opinions" (Hongfu Hall [2011] No. 147).

Chapter 3 Application Procedures

Article 7 Application Principles. Participants apply for the application according to the principle of local management, proximity and convenience.

Article VIII place and date of application. Participants in the legal working days to the city basic medical insurance designated medical institutions to apply.

The application is made to the basic medical insurance organization in the place where the insured person is resettled.

Article 9 Declaration materials. Participants or agents with their own identity cards, social security cards, fill out the "Nanchang basic health insurance outpatient special chronic disease identification form" (Annex 1), and in accordance with the provisions of the "Nanchang basic health insurance outpatient special chronic disease declaration materials, identification standards and enjoyment of the years" (Annex 2) to submit the materials for the application.

Declaration materials must be issued by the second level and above the original medical institutions, if you can not provide the original copy of the need to be stamped on the case room of the hospital treated and labeled with the case number.

Article 10 acceptance. The fixed-point medical institutions on the participant's declaration materials for the record, and the declaration materials for preliminary examination. Materials are complete, the fixed-point medical institutions summarized, before the 10th of each month, respectively, to the participants of the basic health insurance coverage of the city, county (district) health insurance agency; materials are incomplete, by the fixed-point medical institutions one-time written notice to the participants need to make up for the material; does not meet the reporting conditions, by the fixed-point medical institutions one-time written notice to the participants and return to the reporting materials.

Chapter IV Identification Management

Article 11 The city, county (district) health insurance agencies at two levels to establish outpatient special chronic disease identification of experts and responsible for the management.

Article 12 The experts selected for the appraisal expert pool should have the following conditions:

(a) familiar with the relevant laws and regulations of health insurance and related policies, with strong professional skills, professional practice time of more than ten years, have a certain degree of influence in the field of expertise, with a deputy director of the medical profession and above professional and technical titles;

(b) a high degree of responsibility, can adhere to the objective, impartial, factual and practical. Can adhere to the objectivity, impartiality, seeking truth from facts, scientific attitude, conscientious, honest and incorruptible fulfillment of their duties;

(C) in the past five years, no violation of law and discipline, no major accidents of responsibility.

Article XIII appraisal expert implementation of dynamic management, the implementation of the appointment system, the appointment term of three years.

Article 14 The identification of experts, if one of the following behaviors can be terminated at any time, and will be announced:

(a) the use of identification of experts in a special capacity and influence, for the hospitals and participants have an interest in facilitating the identification of the hospitals and participants through the identification of;

(b) solicitation or acceptance of the relevant health care institutions or other relevant people's belongings, banquets, or other benefits to affect the impartiality of the appraisal;

(ii) solicitation or acceptance of the relevant medical institutions or other relevant people's property, feast or other benefits, affecting appraisal impartiality;

(C) irresponsible, false, unable to objectively and impartially perform their duties;

(D) without justifiable reasons, refused to undertake the work task during the appointment period;

(E) appointment period of the occurrence of illegal and disciplinary acts were subject to criminal penalties, or subject to party disciplinary or administrative sanctions.

Article 15 The number of 'experts' participating in the identification work, according to the type and number of declared diseases.

The appraisal work is closed. Two days before the appraisal review meeting, by the city, county (district) health insurance agencies were randomly selected from the respective establishment of the appraisal expert database to participate in the assessment of experts, the composition of the evaluation group of the various types of disease, the evaluation of the declaration materials.

Article 16 The identification of outpatient special chronic diseases is carried out in accordance with the following procedures:

(a) The staff of the health insurance agency to introduce the members of the evaluation team and the team leader, and to announce the identification of discipline and identification of the work arrangements;

(b) The members of the evaluation team on the outpatient special chronic disease materials in accordance with the "Nanchang City, Nanchang, the basic health insurance outpatient special chronic disease declaration, identification standards and enjoyment of years" provisions of the assessment of the outpatient special chronic disease materials. standards and years of enjoyment". Each application materials need to be two members of the evaluation team to put forward their views;

(C) the evaluation team leader to convene the evaluation team members for collective deliberation, and sign the appraisal conclusions;

(D) the medical insurance agency of the appraisal of the participants declared the registration of the material for the record. Identification of the material, by the health insurance agency to retain, and the establishment of personal outpatient special chronic disease electronic files; identification of the material does not pass, by the health insurance agency issued a written notice, and according to the original declaration of the way back to the participant.

Article 17 In order to ensure the stability of the appraisal work, to participate in the appraisal of the assessment work of the experts issued evaluation labor costs. Evaluation of labor standards by the municipal human resources and social services departments of the municipal finance department in accordance with the level of economic development to determine in due course.

Chapter V Management

Article 18 of the outpatient special chronic disease medical implementation of "five" management.

(a) hospital management. Participants applying for outpatient special chronic disease to fill in the designated medical institutions in principle for their outpatient special chronic disease medical institutions. The insured person who is resettled in a different place, in my own registration of resettlement fixed-point medical institutions to choose a fixed-point medical institutions for medical treatment. Without special reasons, you can not change the designated medical institutions during the year.

Participants need to change the designated medical institutions in the following year, should be in the end of November each year, by the participant to fill out the "Nanchang basic health insurance outpatient special chronic disease designated medical institutions change form" (Annex 3), reported to the designated medical institutions to be attended the examination and signing of consent to accept the views of the designated medical institutions, and then by the designated medical institutions to the participants to participate in the local health insurance agency for change.

(ii) fixed time management. Participants from the expert review group identified by the next month to enjoy outpatient special chronic disease treatment. The treatment of each type of treatment to enjoy the years in accordance with the "Nanchang City, the basic health insurance outpatient special chronic disease declaration materials, identification standards and enjoyment of the years" provisions of the implementation.

The insured person must re-declare in accordance with the provisions of this method within 2 months before the expiration of the period of enjoying the outpatient special chronic disease. If the conditions for enjoyment are met, they can continue to enjoy the outpatient special chronic disease treatment. Failure to re-declare within the stipulated time or identification does not meet the conditions for enjoyment, do not enjoy the outpatient special chronic disease treatment.

(C) fixed medication management. Participants in the outpatient special chronic disease medication according to the "Nanchang basic medical insurance outpatient special chronic disease medication scope (for trial implementation)" provisions, beyond the scope of the integrated fund will not pay.

(d) the management of diagnosis and treatment. Participants outpatient special chronic disease examination and treatment in accordance with the "Jiangxi Province, the basic medical insurance diagnostic and treatment items, medical services and facilities range and payment standards catalog (2011 trial version)" provisions of the implementation of the non-application for the type of disease required for the cost of diagnostic and treatment items, the co-ordination fund will not pay.

(V) quota management. In order to not only guarantee the needs of the insured for chronic disease treatment, but also to guide the insured to rationally use the medical insurance fund, while avoiding the waste of medical resources, the insured's monthly outpatient prescription volume does not exceed 30 days of volume. In case of special circumstances such as visiting relatives in other places or traveling, if the insured person provides the original and copy of relevant documents (bus ticket, air ticket, etc.), the prescription quantity can be appropriately extended after the examination and approval of the hospital's medical insurance section, and the outpatient prescription quantity of the month shall not be more than 60 days' worth of prescriptions (the medical insurance section of the designated medical institution shall submit the original of the examination and approval form and the copy of the relevant documents with signature and stamp to the medical insurance agency in the beginning of the next month), and the prescription quantity of the outpatient prescription quantity shall not be duplicated in the extended period. The extension period cannot be repeated.

Chapter VI Settlement of Fees

Article 19 of the outpatient special chronic diseases to implement the card settlement. Outpatient special chronic disease co-ordination fund to pay part of the settlement by the medical insurance agency and the designated medical institutions, the individual out-of-pocket part of the individual account or cash payment by the participants.

The outpatient special chronic disease costs for relocated people are paid by the individual first, and then reimbursed by the medical insurance agency in the place where the participant is insured.

Chronic renal failure (uremia stage) hemodialysis participants, such as visiting relatives, travel and other reasons for temporary (within six months) out of the house, by the person to provide the relevant documents (tickets, air tickets, etc.) originals and photocopies of the original, to the insurance seat of the health insurance agency for the record, in the place where the hemodialysis treatment costs incurred in the place of the health insurance agency, by the insurance seat of the health insurance agency The company's website will be available on the Internet.

Chapter VII Supervision and Management

Article 20 If a designated medical institution or a designated retail pharmacy fraudulently obtains the expenditure of the medical insurance fund by fraud, falsification of supporting documents or other means, the administrative department of human resources and social security shall order the return of the fraudulently obtained medical insurance premiums, and impose a deduction of not less than two and not more than five times the amount of the fraudulent payment. For medical institutions and retail pharmacies that have signed service agreements with the medical insurance administration organization, the medical insurance administration organization shall pursue responsibility in accordance with the agreement, and if the circumstances are serious, it may terminate the service agreement signed with it. The directly responsible supervisors and other directly responsible personnel with practicing qualifications, by the human resources and social security administrative department recommended that the relevant competent authorities to grant their practicing qualifications revoke their practicing qualifications in accordance with the law.

Article 21 If an insured person obtains the qualification of outpatient special chronic disease by making a false claim, the medical insurance agency shall order the return of the fraudulent medical insurance premium, cancel the qualification of outpatient special chronic disease, and impose penalties in accordance with the relevant provisions.

Article 22 The medical insurance agency and its staff have violated the social insurance laws and regulations, by the human resources and social security administrative departments shall order correction. If the circumstances are serious, the directly responsible person in charge and other directly responsible persons shall be given sanctions.

Chapter 8 Supplementary Provisions

Article 23 The medical insurance agency shall establish outpatient special chronic disease health records. Through the establishment of "outpatient special chronic disease health records" to organize the past medical treatment data of the insured, the formation of a perfect standard database, to facilitate the medical insurance agency query, management of the patient's medical history, history of medication, consumption records, and other information, to assist the medical insurance agency to further enhance the fine management of the medical insurance fund and the ability to provide services.

Article 24 "Nanchang City, the basic health insurance outpatient special chronic disease identification declaration form", "Nanchang City, the basic health insurance outpatient special chronic disease designated medical institutions to change the form", by the city health insurance agencies to determine the unified, free of charge by the designated medical institutions.

Article 25 These measures shall be interpreted by the Municipal Bureau of Human Resources and Social Security.

Article 26 These measures shall be implemented from January 1, 2016 onwards.