Measures for the Management of Outpatient Major Diseases of Shenzhen Social Medical Insurance
Shenzhen Labor and Social Regulation [2008] No. 11
Article 1: In order to guarantee the medical treatment of outpatient major diseases for the city's social medical insurance enrollees (hereinafter referred to as the enrollees), and to standardize the management of outpatient major diseases, these measures have been formulated based on the relevant provisions of the Measures for Social Medical Insurance of Shenzhen Municipality and the "Guidelines on the Management of Specific Diseases in Guangdong Province for the Management of Basic Medical Insurance" (YLSS Letter [2006] No. 1446). According to the relevant provisions of "Shenzhen Social Medical Insurance Measures" and "Guidance on the Management of Guangdong Province Basic Medical Insurance Outpatient Specific Diseases" (Guangdong Labor and Social Affairs Letter 〔2006〕 No.1446), these measures are formulated.
The outpatient major diseases referred to in Article 2 of these Measures are as follows:
The first category includes: hypertension (Stage II and Stage III), coronary heart disease, chronic cardiac insufficiency, cirrhosis of the liver (inoperative stage), chronic viral hepatitis (Type B, Type C, active stage), moderate and more than moderate chronic obstructive pulmonary disease, rheumatoid arthritis, systemic lupus erythematosus, diabetes mellitus, dysjunctions of the bead protein production (thalassemia or anaemia of the ocean), and the outpatient specific diseases of the outpatient medical insurance of Guangdong Province. (thalassemia or marine anemia), aplastic anemia, hemophilia, Parkinson's disease, schizophrenia.
The second category includes: outpatient dialysis for chronic renal insufficiency (uremic stage), post-transplantation (anti-rejection therapy), and outpatient chemotherapy, radiotherapy, and nuclear therapy for malignant tumors.
Anti-rejection treatment after kidney, heart valve, cornea, bone, skin, blood vessel and bone marrow transplants is applicable to Basic Medical Insurance participants; anti-rejection treatment after heart and liver transplants is applicable to Local Supplementary Medical Insurance participants.
The municipal labor security administrative department will increase the number of outpatient major illnesses in phases according to the fund's income and expenditure.
Article 3 of the first category of outpatient major diseases of this method of the relevant provisions of the comprehensive medical insurance participants; the second category of outpatient major diseases of this method of the relevant provisions of the comprehensive medical insurance, inpatient medical insurance and rural migrant workers' medical insurance participants.
Article 4: When a participant suffers from an outpatient major disease, he/she shall go through the following procedures for diagnosis and examination at the diagnostic hospitals designated by the municipal labor security administrative department (for a detailed list, please refer to Appendix I):
(1) The attending physician of the specialty shall fill in the "Diagnostic Certificate of Outpatient Major Diseases of Shenzhen Social Medical Insurance" (hereinafter referred to as the Certificate), and it shall be examined and signed by the two physicians in the corresponding specialty diagnostic team (one of them shall be the head of the diagnostic team). One of them is the head of the diagnostic team), the medical insurance office to confirm the seal, by the designated medical institutions will be entered into the medical insurance information system, passed to the municipal social insurance agency to confirm the original certificate and copies of the relevant disease documents by the diagnostic hospitals on a monthly basis to report to the municipal social insurance agency to build a file for safekeeping.
Participants who have been diagnosed with a major outpatient disease in the past and continue to be treated with medication in the past month should provide the attending physician of the diagnostic hospital with a record of the recent outpatient visit and relevant information on the original diagnosis of the disease (check the originals and keep the copies), and then follow the above procedures.
The diagnosing hospital shall provide the Certificate to the insured person in accordance with the admission criteria for outpatient major diseases.
(2) Participants who are eligible for off-site medical treatment shall have the Certificate issued by the diagnostic hospital in the city or by a local medical institution of the second level or above where they have filed a record with the municipal social insurance agency, and submit it to the municipal social insurance agency for examination and confirmation.
The diagnostic hospital shall report to the municipal social insurance institution the list of specialist diagnostic team and doctors related to outpatient major diseases, and the head and members of the diagnostic team shall be the incumbents with the title of deputy chief physician or above in this specialty; when there is a change of personnel in the diagnostic team, the diagnostic hospital shall report the change to the municipal social insurance institution in time.
Article 5 of the insured person suffers from outpatient serious illnesses, the municipal social insurance agencies to confirm the audit, should hold their own social security card, "Shenzhen social health insurance outpatient medical records of major illnesses and certificates" in the city of outpatient medical institutions, not in the city of medical institutions, the fund will not be paid to the corresponding social health insurance treatment, except for the following circumstances:
(a) in the event of emergency rescue;
(b) in the city social insurance institutions to receive monthly pensions of retirees, in other areas of the country (excluding Hong Kong, Macao, Taiwan, hereinafter the same) long-term residence, in the place of residence to select three local health insurance designated medical institutions as their outpatient medical institutions for major illnesses (the first category), and has been to the municipal social insurance institutions for the record
(3) Participants with household registration of the city who are permanently stationed in other cities in China (excluding Hong Kong, Macao and Taiwan, the same hereinafter), and have selected three local designated medical institutions for medical insurance as their medical institutions for outpatient major illnesses (the first category) in their place of residence, and have already filed a record of such institutions with the municipal social insurance institution.
If a participant needs outpatient hemodialysis due to chronic renal insufficiency (uremic stage), he/she shall undergo hemodialysis in the designated designated designated medical institutions in the city (see Annex II for the specific list).
Participants should use the "Shenzhen Social Health Insurance Outpatient Medical Record for Major Diseases" when seeking medical treatment, and keep the medical record and auxiliary examination results for inspection. If a participant suffers from more than one major outpatient disease at the same time, he/she will not receive the "Shenzhen Social Health Insurance Outpatient Medical Record for Major Diseases" when the second major outpatient disease is recognized.
Shenzhen Social Health Insurance Outpatient Medical Record for Major Diseases can be obtained at the municipal social insurance organization or the diagnostic hospital in the city with the social security card, ID card and Certificate, and the old Shenzhen Social Health Insurance Outpatient Medical Record for Major Diseases should be provided for inspection when replacing the old one. If a participant loses the Certificate or the Specialized Outpatient Medical Record for Outpatient Major Diseases of Shenzhen Social Medical Insurance, he should apply for a replacement (claim) at the medical insurance office of the original diagnostic hospital or the municipal social insurance institution with his social security card and ID card.
The designated medical institution shall submit the replacement medical record of the insured person to the social insurance institution for archiving.
Article 6 of the comprehensive medical insurance participants suffering from outpatient major diseases (category I), the city social insurance agency audit confirmation, enjoy the following outpatient medical insurance treatment:
Comprehensive medical insurance participants suffering from outpatient major diseases (category I) in the outpatient outpatient incurred in the cost of drugs within the drug list of the basic medical insurance and the local supplemental medical insurance, diagnostic and therapeutic items catalog of the diagnostic and therapeutic item costs, paid by the individual account; the individual account; individual account shall be paid; the fixed-point medical institutions shall submit the replacement medical records to the archives of the social security agency. If the individual account is insufficient to cover the costs, outpatient basic medical insurance costs and local supplementary medical insurance costs that exceed 5% of the average annual salary of on-the-job workers in the previous year in a medical insurance year, and are within the scope of the outpatient specialty corresponding to the outpatient major illness, shall be included in the accounting scope of the basic medical insurance co-ordination fund and the local supplementary medical insurance co-ordination fund at a rate of 70%, respectively. Outpatient large-scale equipment examination and treatment programs are not included in the scope of accounting under this article.
Article 7: The basic medical expenses incurred by participants of comprehensive medical insurance, inpatient medical insurance and rural migrant workers' medical insurance due to outpatient major diseases (category II), approved by the municipal social insurance institutions, shall be included in the scope of payment of the basic medical insurance fund for major diseases at 90%, and local supplementary medical expenses shall be paid by the local supplementary medical insurance fund at 80%.
Article 8: The outpatient medical expenses incurred by the insured for major diseases (category I) are reviewed and reimbursed according to the medical insurance year, and bookkeeping is gradually implemented.
Article 9 of the comprehensive medical insurance participants due to outpatient major diseases (category I) in the designated medical institutions for outpatient specialist medical fees, belonging to the basic medical insurance fund and the local supplementary medical insurance fund part of the payment by the designated medical institutions, belonging to the part of the individual payment by personal account or cash payments, due to the lack of funds in the personal account of the individual cash payments should also be recorded.
The dialysis expenses of outpatient hemodialysis for chronic renal insufficiency (uremia stage) of the insured, which belong to the basic medical insurance expenses and local supplemental medical insurance expenses, shall be recorded by the designated designated medical institutions in accordance with the regulations.
Article 10 of the participants in one of the following circumstances, can be prescribed to the city social insurance institutions for review and reimbursement:
(a) in the city designated medical institutions for chronic renal insufficiency (uremic stage) outpatient peritoneal dialysis, organ transplantation (anti-rejection reaction treatment), malignant tumors, outpatient chemotherapy, radiotherapy, nuclide therapy;
(b) the Measures The three circumstances stipulated in Article 5, paragraph 1.
Article 11 of the fixed-point medical institutions will be outpatient major illnesses of the cost of the monthly summary to the municipal social insurance agency to apply for settlement.
Article 12 of the insured person is recognized as suffering from outpatient serious illness (category I), enjoy the outpatient treatment of serious illness (category I) provided for in these measures is valid for two years, such as the disease has not yet been cured, and need to continue outpatient treatment, should be re-applied for recognition within three months before the expiry of the validity of the formalities.
Article 13 In the process of recognizing outpatient serious illnesses, if the diagnosing hospital or the insured person makes a false claim, the claim shall be invalidated and the insured person shall be re-identified as an outpatient serious illness.
Article XIV of these measures shall be implemented from April 1, 2008 onwards.
Article 1 in order to protect the rights and interests of the city's social health insurance participants, standardize the medical behavior of the participants, the rational use of health insurance funds, according to the "Shenzhen Municipal Measures for Social Health Insurance" (hereinafter referred to as "the Measures"), the formulation of these measures.
The second has participated in social medical insurance, including comprehensive medical insurance, hospitalization medical insurance, migrant workers' medical insurance, maternity medical insurance, medical management of participants apply to this approach.
Article 3: The insured person shall present his social security card to the designated medical institution, which shall be used as the voucher for the account and reimbursement of the insured person's medical treatment, and at the same time, he shall hold the "Outpatient Medical Record Book" in the unified format of the municipal health administrative department, and shall be treated according to the illness and use the medication reasonably; the condition, examination and treatment, and use of medication shall be recorded in the Outpatient Medical Record Book in detail during the medical treatment.
Article 4: Participants of inpatient medical insurance and rural migrant workers' medical insurance shall select a community health center in the city according to the following provisions and seek outpatient medical treatment at the selected community health center:
(1) For inpatient medical insurance on-the-job participants and rural migrant workers' medical insurance participants, the employing unit shall apply for the selection of the nearest community health service center or community medical service station;
(2) Rural urbanized persons who are insured by villages or joint-stock companies shall be selected by the villages or joint-stock companies by applying at the nearest community health service center or community medical service station;
(iii) Other persons shall be selected by themselves by applying at the nearest community health service center or community medical service station, according to their place of residence.
Article 5: The medical expenses incurred by the insured when using the drugs, diagnostic and therapeutic items and medical service facilities listed in the basic medical insurance and the local supplementary medical insurance during their visits to the designated medical institutions shall be paid by the basic medical insurance fund and the local supplementary medical insurance fund in accordance with the provisions of the Measures.
The basic medical insurance fund shall not reimburse the medical expenses incurred by the insured person in the designated medical institutions which are listed in Annex I of these Measures.
Medical expenses incurred by maternity health insurance participants while seeking medical treatment that are listed in Annex II of these Regulations shall be paid by the Maternity Health Insurance Fund.
Article 6: When a participant goes to a designated medical institution for outpatient medical treatment, he/she shall follow the following provisions:
(1) He/she shall hold an outpatient medical record book and his/her own social security card;
(2) A participant suffering from a major outpatient disease shall hold a special outpatient medical record book for the outpatient major diseases of the social health insurance of the city when he/she goes to a medical institution for medical treatment;
(3) A participant shall not transfer his/her own social security card to another person for use in the outpatient medical treatment. social security card to others, shall not ask for over-prescription of medicines, non-therapeutic medicines, modification of medical records, or exchange of medicines for medicines, medicines for goods, or cash.
Article 7: When an insured person is hospitalized in a designated medical institution, the following provisions shall be followed:
(1) When going through the admission procedures, he shall provide his social security card, ID card, signature and fingerprints of himself or his family members on the certificate of admission;
(2) If he is unable to provide his social security card when going through the admission procedures, he shall provide the card within three days from the date of the admission procedures, and if he fails to provide the card after that time, the social security card shall be provided to the insured person. If the social security card is not provided within three days of the date of admission, the hospitalization medical expenses shall not be recorded;
(3) During the period of hospitalization, the participant shall cooperate with the doctor for active treatment;
(4) The participant shall not be hospitalized in the name of the hospital or under a false name, and shall not be admitted to the hospital for minor illnesses;
(5) The participant shall not be delayed in discharge if he or she is eligible to be discharged;
(6) The participant shall not be discharged from hospital with an overdose of medicines or diagnostic and therapeutic items. (vii) Migrant workers' health insurance participants shall be hospitalized at the settlement hospital of the selected social health center;
(viii) If a migrant workers' health insurance participant needs to be referred to the hospital due to his/her medical condition, he/she shall be referred to the hospital by the original settlement hospital at the next level, or to a medical institution with specialties at the same or the next higher level in the city.
(The original settlement hospital shall issue a certificate of referral to a medical institution of the same or higher level in the city with specialized expertise.
(i) The insured person shall not violate the principle of medical treatment and put forward other unreasonable requests for medical treatment and medication;
Article 8: The insured person shall apply for out-of-town referral for medical treatment in accordance with the following provisions:
(1) No out-of-town referral shall be required for the disease that can be diagnosed and treated in the city;
(2) Out-of-town referral shall be made in accordance with the items of the referral for medical treatment, and a certificate of referral shall be issued in case of a referral to the same hospital. (c) The referral certificate or the letter of introduction to foreign designated medical institutions shall not be used more than once;
(d) The referral certificate or the letter of introduction to foreign designated medical institutions shall be valid for one course of treatment; those who need to go back to the original medical institution for hospitalization and re-examination do not need to go through the transfer procedure, but shall go to the social insurance institution for the re-examination filing procedure before the re-examination; those who need to go to a medical institution outside the city for medical treatment shall be referred to the social insurance institution for the re-examination filing procedure; and those who need to go to the medical institution outside the city for medical treatment shall be referred to the social insurance institution for the re-examination filing procedure again. For those who need to be referred outside the city for medical treatment, they need to go through the referral approval procedures again;
(e) The hospital to be referred out should be a local non-profit, level 3 or above designated medical institution.
Article 9: When a participant with household registration of the city who is permanently assigned to work in other cities in China or a participant who resides in other cities in China after retirement seeks medical treatment in the local area, he/she shall do so in accordance with the following provisions:
(i) The participant shall select three local designated medical institutions as the medical institutions for local medical treatment and file the record with the municipal social insurance institution;
(ii) The participant shall seek medical treatment in the (b) the locally selected medical institutions for medical treatment, in accordance with the provisions of the Measures to enjoy medical insurance treatment; participants in the local medical institutions before the record of medical expenses incurred, according to their own out-of-town medical treatment treatment;
(c) participants to return to the city to work or settle in the municipal social insurance institutions should be timely cancellation of the record to the municipal social insurance institutions.
Article 10 of the long-term stationed in other cities in the country to work in the city's household registration or retired participants living in other cities in the country in the local choice of fixed-point medical institutions should be carried out in accordance with the following provisions:
(a) fill out the "Shenzhen City, the social health insurance participant in a different place for medical treatment fixed-point medical institutions registration form" (in triplicate);
(b) choose three Local township (township) level or higher public medical institutions as their medical institutions, by the medical institutions stamped, reported to the local social security institutions for examination and stamping;
(c) by the insured unit or the person with the stamped registration form unit to the affiliated social insurance institutions for the record;
(d) meet the conditions of the record of the local medical care, by the social insurance institutions to issue the record voucher.
Article 11 by the municipal social insurance institutions to determine the audit of the outpatient major illnesses of the participants for medical treatment, according to the "Shenzhen social health insurance outpatient major illnesses of the management measures" provisions of the implementation.
Article 12 of the maternity health insurance participants, in line with the family planning policy, their perinatal prenatal checkups, delivery hospitalization, postpartum visits, family planning surgery (excluding baby expenses), shall be carried out in accordance with the following provisions:
(a) when seeking medical treatment at the designated medical institutions in the city to produce their social security cards, their identity cards, medical records, marriage certificates and family planning service certificates (family planning certificate);
(ii) Procedures for medical treatment of persons in the Mainland (ii)(((((9 for perinatal prenatal checkups, hospitalization for delivery, postnatal visits and family planning surgeries (excluding baby expenses) in other cities in China are carried out in accordance with the "Administrative Measures for Cash Reimbursement of Social Medical Insurance in Shenzhen".
Article 13 If a participant has one of the following circumstances, the municipal social insurance agency may conduct an investigation, and the participant shall cooperate, truthfully reflect the situation and provide relevant materials:
(1) The number of general outpatient visits accumulates to more than 15 times in a month; (per four-hour visit)
(2) The number of general outpatient visits accumulates to more than 30 times in a consecutive three months; (per four-hour visit)
(2) The number of general outpatient visits accumulates to more than 30 times in a consecutive three-month period; ( (per four-hour visit)
(iii) outpatient medical expenses totaling more than 6,000 yuan in a month;
(iv) general outpatient medical expenses totaling more than 20,000 yuan in the same medical insurance year.
(v) The total outpatient medical expenses of an inpatient insurance participant exceeds 800 yuan in a health insurance year.
(vi) Tumor radiotherapy, chemotherapy and other monthly outpatient expenses greater than 10,000 yuan;
(vii) Uremia dialysis monthly outpatient expenses greater than 15,000 yuan;
(viii) Kidney transplantation post-anti-rejection treatment monthly outpatient expenses greater than 15,000 yuan;
(ix) Falsely enrolling in the insurance;
(x) Transferring one's social security card (x) Lending one's social security card to another person or fraudulently using another person's social security card;
(xi) Keeping one's social security card in a designated medical institution or designated retail pharmacy;
(xii) Reported violation of the provisions of the Measures;
(xiii) Other cases of violation.
Article 14 If a participant is in violation of Article 13 of the Measures, the social insurance organization may notify the participant that he/she should bring his/her social security card, ID card, medical records, receipts of medical expenses and other information to the social insurance organization to explain his/her situation within 10 working days. If the participant fails to explain the situation after the deadline or the explanation is insufficient, the social insurance organization may open a case for investigation and suspend his/her social medical insurance account from the date of opening the case for investigation and notify the participant in writing.
Participants whose social medical insurance accounts are suspended are still entitled to social medical insurance benefits, but they are changed to cash settlement, and their medical expenses paid in cash are examined and reimbursed in accordance with the provisions of the "Measures for the Management of Cash Reimbursement of Social Medical Insurance in Shenzhen".
The municipal social insurance agency shall complete the verification within 90 days from the date of suspension of social medical insurance bookkeeping and deliver it within 10 working days.
Article 15 After the investigation and verification, the municipal social insurance institution shall deal with the matter as follows:
(1) If there is no violation of the provisions of the social medical insurance, the participant shall resume his/her social medical insurance bookkeeping within 5 working days from the date of the verification;
(2) If there is any violation of the provisions of the social medical insurance, the municipal social insurance institution shall investigate and deal with it in accordance with the relevant provisions of the Measures;
(c) If the participant is suspected of committing a crime, the municipal social insurance agency shall refer the case to the judicial authorities.
Article 16 of the retirees and disabled military personnel with disabilities of the first to the sixth level of medical management with reference to the implementation of this Measures
Article 17 of these Measures shall come into force from April 1, 2008 onwards. The former Measures for the Administration of Medical Treatment for Shenzhen Urban Workers' Social Medical Insurance Participants (SZSSF [2003] No. 82) shall be repealed as of the date of implementation of these Measures.
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