Notice on Strengthening the Management of the Issues Related to the Transfer of Medical Care
Liaocheng City Medical Insurance Business Office2016/8/13
Liaocheng Medical Insurance Word [2016] No. 48
Counties (cities and districts) medical insurance agencies, municipal development zones social security office:
In order to standardize the management of the transfer of employees and residents to participate in the medical insurance personnel of the transfer of the medical care of the other side. In order to standardize the management of referral of employees and residents participating in medical insurance, and to ensure the reasonable and effective use of medical insurance fund, according to the Interim Provisions of Liaocheng City Basic Medical Insurance for Urban Employees (Liaocheng Zhengfa [2000] No. 88), Interim Measures of Liaocheng City Residents' Basic Medical Insurance (Liaocheng Zhengbao Fa [2014] No. 46) and other relevant documents, the management of referral and transfer to hospitals of different places for medical insurance is hereby notified as follows:
One. The conditions that need to be met at the same time for referral from other places
(a) the highest level of local hospitals or the city's tertiary general hospitals or municipal specialized hospitals, medical experts above the deputy chief physician consultation, can not be diagnosed by the difficult and complicated; or limited to the medical technology and equipment conditions can not be disposed of cases; or clinically acute and critical cases, it is difficult to carry out effective treatment of the case.
(2) The hospitals referred to other places should be local medical insurance designated medical institutions; the level of diagnosis and treatment should be higher than that of the local area, and the hospitals referred to other provinces are in principle the tertiary public designated hospitals for medical insurance in major cities such as Beijing, Tianjin and Shanghai.
Second, the procedure for referral to other places
(a) For malignant tumor treatment, heart surgery, organ transplantation and other special diseases, when transferring to provincial hospitals, the patient or his family members can bring the medical insurance card (card), recent information on the condition, and go directly to the medical insurance agency to apply for the medical network procedures in the province, and the incurred medical fees can be directly networked settlement.
When transferring to an out-of-province hospital for medical treatment, the patient or his/her family members can bring a recent one-inch crownless color photo, medical insurance card, recent diagnosis or examination results to the medical insurance agency to fill in the Liaocheng City Medical Insurance Overseas Hospitalization Information Feedback Form, and then transfer to an out-of-province hospital for medical treatment with a seal for the record. The medical expenses incurred will be paid by the individual first, and then reimbursement will be made to the place of insurance with relevant materials after discharge.
(2) For diseases other than malignant tumor treatment, heart surgery, organ transplantation and other special diseases, the referral for medical treatment needs to provide a certificate of recommendation for referral issued by a local designated hospital of the highest level or a local tertiary general hospital or municipal designated hospital for specialties with a deputy chief physician or above. If you transfer to a provincial hospital for medical treatment, you can go to the medical insurance agency for the registration procedures of the provincial network; if you transfer to an out-of-province medical treatment, you need to provide one recent one-inch, crown-free color photo, and fill out the Liaocheng City Medical Insurance Feedback Form for Information on Hospitalization in Other Places at the medical insurance agency, and then transfer to an out-of-province hospital after filing the form with a seal.
(3) If the insured person has to be transferred to a foreign hospital immediately for medical treatment due to an acute or serious illness and cannot fulfill the normal procedures for transferring to a foreign hospital, he/she can be transferred to a foreign hospital for medical treatment first and make up for the procedures for transferring to a foreign hospital for medical treatment within five working days of transferring to a foreign hospital for medical treatment.
(4) The validity period of an off-site referral is 6 months. If the approved diseases are treated several times in the same hospital and the treatment is finished within the validity period, there is no need to apply for referral again. More than six months to continue treatment, need to re-apply for referral procedures. Not in the same hospital treatment or non-approved diseases, need to re-apply for referral procedures.
Three, the reimbursement rate
(a) Referred to the provincial designated hospitals, according to the provisions of the referral procedures and registration procedures for networking, the reimbursement rate in accordance with the implementation of the province's unified rate; referred to the designated hospitals outside the province, according to the provisions of the referral and the record of the formalities, the individual in accordance with the prescribed proportion of the self-proportionate reimbursement of the local tertiary hospitals to deal with the proportion; not in accordance with the provisions of the record or the networking procedures, will not be reimbursed. If you don't go through the formalities of record-keeping or networking, you will not be reimbursed.
For malignant tumor treatment, cardiac surgery, organ transplantation and other special illnesses, without providing a certificate of recommended referral, the individual's first self-responsibility ratio will be increased by 10% compared with that of the prescribed referral and filing procedures, and then processed according to the reimbursement ratio of the local tertiary hospitals.
(ii) The cost of outpatient examination within 7 days prior to hospitalization, or during hospitalization, or on the day of discharge at the same hospital can be incorporated into the total medical expenses of this hospitalization.
Documents to be provided for reimbursement
1, a copy of hospitalization medical record;
2, a summarized list of expenses;
3, valid bills (original invoices);
4, a copy of the patient's or immediate family's medical insurance cooperative bank passbook or bank card;
5, the Liaocheng City Medical Insurance Off-site Hospitalization Information Feedback Form" (signed by the physician and head nurse of the hospital in which the patient resides, and stamped by the hospital's medical insurance office);
6. Proof of the unit or school (whether or not the patient's hospitalization time, condition, and the hospital in which the patient resides are true);
7. Suggested referral to another hospital (stating whether or not the patient agrees to be transferred to a higher-level hospital for treatment).
V. Time Limit for Reimbursement
Medical expenses incurred in transferring to a provincial networked hospital can be settled instantly at the time of discharge from the network. For hospitalization outside the province, the medical insurance agency needs to conduct investigation and verification, and the time limit for reimbursement after acceptance shall not exceed 60 days.
Six, irregularities
Transferring out of the medical personnel, such as fraud, falsification of documents or other means of fraudulent medical insurance treatment, the human resources and social services departments will be in accordance with the "Chinese People's *** and the State Social Insurance Law", and ordered to return fraudulent medical insurance fund, and impose a fraud amount of more than twice the amount of five times the following fine, stop the medical insurance treatment; constitutes a crime, the transfer of the judicial authorities Handling.
August 12, 2016
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