Article I In order to standardize the management of the designated medical institutions for urban workers' social medical insurance in our city, these measures are formulated in accordance with the Measures for Social Medical Insurance for Urban Workers in Shenzhen City (Municipal Government Decree No. 125, hereinafter referred to as the Measures) and the Measures for the Management of the Designated Medical Institutions for Urban Workers' Social Medical Insurance of the Ministry of Labor and Social Security of the State.
Article 2 The management of urban workers' social medical insurance designated medical institutions (hereinafter referred to as designated medical institutions) shall be governed by these Measures.
The fixed-point medical institutions referred to in these Measures are the medical institutions determined by the municipal social insurance administration (hereinafter referred to as the municipal social insurance institution), which provide medical services for the urban workers' social medical insurance participants in the city.
Article 3 The selection of designated medical institutions shall be based on the following principles:
(1) Convenient for the insured to seek medical treatment and easy to manage;
(2) Taking into account the specialties and comprehensive, traditional Chinese medicine and western medicine;
(3) Focusing on giving full play to the role of the community health service institutions;
(4) Promoting the optimal allocation of medical and health care resources, improving the efficiency of the utilization of medical and health care resources, and improving the quality of medical services. (d) To promote the optimal allocation of medical and health resources, improve the efficiency of their utilization, enhance the quality of medical services
, and control the unreasonable increase in medical costs.
Article 4 The municipal social insurance institutions, according to the city's regional health planning, the number of urban workers and social health insurance participants and
distribution, the development of designated medical institutions master plan, the total number of designated medical institutions to implement control.
Article 5 The city holds a valid license to practice medical institutions, non-profit medical institutions, with the following conditions, can apply to become a designated medical institution:
(a) with the level of the medical institution corresponding to the medical equipment and medical staff;
(b) compliance with the national, provincial and municipal laws, regulations, standards and regulations relating to the management of medical services;
(C) strict implementation of national, provincial and municipal regulations on non-profit medical fees and drug retail prices, fees and charges for the implementation of the public system;
(D) commitment to strict compliance with the implementation of the relevant policies and regulations of the social health insurance system for urban workers, the establishment of an internal management system compatible with the management of medical insurance, with a sound medical insurance management organization, a leader in charge of medical insurance work, with the necessary equipment and staff. (d) Commitment to strict compliance with the implementation of the relevant policies and regulations of the social medical insurance system for urban workers, the establishment of an internal management system suitable for the management of medical insurance, a sound medical insurance management organization, a leader in charge of medical insurance, with the necessary part-time or full-time management personnel, equipped with computers and other equipment to meet the needs of social medical insurance.
The internal medical institutions of enterprises and institutions that meet the conditions listed in the preceding paragraph and are located in units with more than 1,000 employees
can also apply to become designated medical institutions.
Article 6 In areas where non-profit medical institutions are insufficient to provide social health insurance services, for-profit medical institutions that have obtained a medical institution practice
license and meet the conditions listed in paragraph 1 of Article 5 of these Measures may apply to become a designated medical institution for municipal social insurance
.
Article 7 The application to become a designated medical institution shall be submitted to the municipal social insurance agency with the following written application materials and electronic
files:
(1) application for designated medical institution;
(2) a copy of the license of the medical institution to practice medicine (verification of the original);
(3) proof of the grade of the medical institution or relevant certificates of the health administration department;
(4) the certificate of the medical institution's grade or
(D) the drug supervision and management department of the annual inspection of the certificate;
(E) by pharmacological classification of the General Catalog of Drugs and social insurance drug list.
The application form for fixed-point medical institutions is uniformly printed by the municipal social insurance agencies.
Article 8 The municipal social insurance agency will not accept the application of a medical institution to become a designated medical institution if the medical institution has one of the following circumstances:
(a) the application information is incomplete or untrue;
(b) the qualification of the designated medical institution has been canceled for less than 2 years;
(c) there is a major violation of laws and regulations, which is under investigation and processing.
(C) major violations of the law, are under investigation.
Article 9 The municipal social insurance agency accepts the application materials of the medical institutions, shall organize relevant experts to apply for the
medical institutions to carry out on-site inspections, and conduct a comprehensive assessment.
The municipal social insurance agency shall decide whether to take the applicant
medical institution as the designated medical institution according to the overall planning of the designated medical institution in the city and the evaluation of the experts.
The decision in the preceding paragraph shall be made within 30 working days from the date of acceptance of the application, and the applicant medical institution shall be notified in writing.
Article 10 After the application medical institution is determined to be the designated medical institution, the municipal social insurance organization shall sign the agreement on the designated medical institution for social insurance with it, and the municipal social insurance organization shall issue the signboard of "Shenzhen City Urban Workers' Social Medical Insurance Designated
Medical Institutions", and announce it to the public.
The agreement signed between the municipal social insurance agency and the designated medical institution shall include the following main provisions:
(a) service items, departments and other services;
(b) quality of service requirements and supervision methods;
(c) settlement of medical expenses and reimbursement standards;
(d) liability for breach of contract;
(e) change of the agreement, termination of the agreement;
(f) the agreement shall be amended or terminated by the municipal social insurance agency. (v) Conditions and procedures for the change and termination of the agreement;
(vi) Other contents that both parties consider necessary to be agreed upon.
The agreement on social insurance designated medical institutions is valid for two years.
Article 11 The designated medical institutions shall do the following in accordance with the requirements of the agreement before the municipal social insurance agency issues the label of "Shenzhen Urban Workers' Social Medical Insurance Designated Medical Institutions"
(a) formulate the internal management system related to social medical insurance services.
(b) computer networking with the municipal social insurance agency;
(c) organization of medical staff and registration staff, bookkeepers, computer operators for health insurance training.
Article XII of the fixed-point medical institutions shall, in accordance with the "Measures" and the agreement, do the following:
(a) strict implementation of the relevant provisions of the management of social health insurance, in accordance with the basic medical insurance drug list
record, diagnostic and treatment items, the scope of medical services and facilities and the local supplemental medical insurance drug list, diagnostic and treatment items, to provide medical services
services;(b) medical facilities that meet more than 80% of the standard requirements for basic medical insurance services and more than 80% of the medicines in the basic medical insurance drug
catalog;
(c) separate accounts for medical expenses for social medical insurance and require accurate and timely provision of documents and information to the municipal social insurance agency
;
(d) New diagnostic and treatment items are implemented in accordance with the < Management Measures, and the costs of new diagnostic and treatment items that have not been applied for access shall not be counted as part of the account of the social medical insurance; (e) The outpatient medical record book that is uniformly required by the municipal social insurance institutions is used when providing medical services to the insured, prescription prescription, hospitalization expense bill, application form for examination and treatment of large-scale medical equipments, etc.; (f) verifying the "Shenzhen Workers' Social Insurance Card" when providing medical treatment and settling medical expenses for insured persons, and not charging medical expenses to the social medical insurance account for the holder of such card if it does not conform to the certificate of social insurance for the employee; (g) implementing a list system for outpatient expenses and a daily list system for hospitalization expenses. (vii) Implementing a list system for outpatient expenses and a daily list system for inpatient expenses, and providing an itemized list of all item expenses before the participant is discharged from the hospital and the participant or his/her family members sign it before settling the bill; (viii) Providing diagnostic and therapeutic items, drug lists, and service facilities outside the scope of the social medical insurance, and obtaining the consent and signature of the participant or his/her family members; (ix) Providing medical services for the participant and the family members of the participant; and ) The expenses for providing medical services to the insured shall be settled in accordance with the < Law. (j) Regularly inspect the implementation of the Measures, the Agreement and the relevant rules and regulations of the organization by the relevant departments, and copy the inspections to the municipal social insurance agency on a quarterly basis. Article 13 If a fixed-point medical institution requests to continue to serve as a fixed-point medical institution after the expiration of the agreement on social insurance fixed-point medical institutions , it shall submit an application to the municipal social insurance agency two months before the expiration of the agreement and re-examine the relevant procedures in accordance with the provisions of Articles 7, 8 and 9 of the Measures. Anyone who fails to apply by the expiration date shall be deemed to have automatically given up the qualification as a designated medical institution. In case of automatic abandonment of the qualification of designated medical institution , the municipal social insurance agency will terminate all social medical insurance business from the date of expiration of the agreement, and take back the signboard of "Shenzhen Urban Employees' Social Medical Insurance Designated Medical Institutions", and announce it to the public. Article 14 of the medical institutions outside the registered address or independent accounting branch, should apply for a separate fixed-point medical organization qualifications. The fixed-point medical institutions merged or separated, the nature of the institution, the address of practice, etc. approved by the health administrative department agreed to change , the fixed-point medical institutions should be from the date of approval of 15 working days with the relevant approval documents, to the municipal social insurance institutions to re- for the application procedures. The fixed-point medical institutions that have been approved by the health administration and management department to change the name of the unit, legal representative, etc., shall go to the municipal social insurance institution to apply for the change of registration formalities within 15 working days from the date of approval . If the fixed-point medical institution fails to do so, the municipal social insurance institution will be regarded as automatically giving up the qualification of the fixed-point medical institution. Article 15 The municipal social insurance agency shall strengthen the supervision and inspection of the fixed-point medical institutions, and may also jointly supervise and inspect with the relevant departments of health, drug supervision supervision, price and other relevant departments. The designated medical institutions shall provide timely and truthful information required for the supervision and inspection. Article 16 of the fixed-point medical institutions have "measures" one of the behaviors listed in Article 72, in addition to the recovery of losses, in accordance with the law, impose to 5,000 yuan more than 20,000 yuan below the fine, the circumstances are serious, the suspension of its qualification as a fixed-point medical institutions for three months to one year, or cancel the qualification of its fixed-point medical institutions. Article 17 The following behaviors are referred to in Article 72 of the Measures as "adopting other means to increase the expenditure of the medical insurance fund ", and shall be punished by the municipal social insurance agency in accordance with the provisions of Article 72 of the Measures: (1) Unauthorized inclusion of a medical institution that has not obtained the qualification of designated medical institution or its branches or collaborating institutions into the designated medical institution, or the inclusion of its branches or collaborating institutions into the designated medical institution. its branches or collaborating organizations into the fixed-point medical service model ; (b) exchange of medicine for medicine, exchange of medicine for goods, use of the employee social insurance card of the insured person, direct or disguised sales of nutritional insurance health care products, cosmetics, daily necessities, children's medicines, medical equipment, etc.; (c) contracting of the fixed-point medical institutions or their sections to continue social medical insurance bookkeeping business. For those directly responsible for the acts stipulated in the preceding paragraph and other acts stipulated in Article 72 of the Measures, the municipal social insurance agency structures, depending on the severity of the case, shall be warned, notified and criticized, or relieved of its medical insurance prescription rights for one year. Constitutes a crime , to the judicial organs to investigate criminal responsibility. Article 18 The fixed-point medical institutions, departments and individual medical personnel in the receipt of violation of the deduction notice and fine decision letter , the penalty decision is not convinced, according to law to the municipal government administrative reconsideration body to apply for reconsideration of the reconsideration decision is still not convinced , according to law, you can file a lawsuit to the people's court; the parties can also be directly to the People's Court according to law. Litigation. The parties to the administrative penalty decision or notice of the overdue application for reconsideration or prosecution, and does not fulfill, by the municipal social insurance agency to apply to the people's court for compulsory execution. Article 19 The application for reinstatement of qualification and prescription rights by a doctor who has been suspended from the qualification of a designated medical institution and relieved of the right to prescribe by medical insurance shall be handled in accordance with the following procedures: (1) Submission of an application for reinstatement of qualification report 10 working days prior to the expiration of the period of suspension of qualification or relieving of the right to prescribe, stating that it corrects the situation of the illegal behavior and the corresponding preventive measures; (ii) payment of compensation, fines; (iii) verification by the municipal social insurance agency; (iv) verification by the municipal social insurance agency that the correction of violations is true and the corresponding preventive measures are effective, notification of the reinstatement of the qualification of the designated medical institution or the right of prescription of health insurance within five working days from the date of verification . Suspension of the qualification of designated medical institutions or the lifting of the right to medical insurance prescription expired without applying for reinstatement, is considered to be an automatic abandonment of the qualification of designated point medical institutions or medical insurance prescription right. Anyone who gives up the qualification of a designated medical institution or the right to prescribe medical insurance shall not reapply for the qualification of a designated medical institution or the right to prescribe medical insurance within two years. Article 20 These measures shall be implemented from the date of issuance. I only found the Shenzhen side, there will not be too much difference, for your reference