Frequently Asked Questions about Dongguan Basic Social Medical Insurance
Fourth, outpatient consultation and treatment declaration regulations
23. How do insured persons enjoy basic outpatient medical treatment?
Outpatient medical treatment is a designated medical system, and the basic medical fees incurred by the participants in the designated outpatient medical treatment points or outpatient referrals, rescue or emergency treatment in accordance with the regulations can be paid by the integrated fund in accordance with the regulations.
24. How to apply for medical treatment and reimbursement for medical treatment at designated outpatient clinics?
(1) Registration: The insured person can go to the registration desk of the designated outpatient medical center with his/her social security card and ID card (if he/she has not been issued with a social security card, he/she can hold his/her own social security card) to go through the registration procedure.
(2) Outpatient medical care: the attending doctor provides outpatient medical services to the insured person, and when the condition requires the use of self-paying or partially self-paying medicines, materials, examinations, and treatments, the use of such medicines, materials, examinations, and treatments must be confirmed by the insured person or his/her family members.
(3) Reimbursement of outpatient medical fees: participants with their social security cards, ID cards, outpatient prescriptions, etc. can be reimbursed on-site at the designated outpatient clinic fee collection office, and participants are only required to pay for their own personal out-of-pocket expenses.
25. How to understand the basic outpatient medical fees?
Basic outpatient medical fee refers to the outpatient medical expenses in line with the management of outpatient medical care, outpatient medicine catalog, diagnostic and therapeutic items, the scope of services and facilities, and payment standards and other related regulations.
26. How is the designated outpatient medical center determined?
According to the principle of territoriality, a designated community health service organization is designated as the outpatient medical center for the insured within the jurisdiction of the village (neighborhood) committee (i.e., the "designated outpatient medical center"). Designated outpatient medical center?) If there is no designated community health service organization in the area, the neighboring designated community health service organization will be designated as the temporary designated outpatient medical point.
27. How to determine the designated outpatient point of care if the place of residence and the designated outpatient point of care are not in the same village (neighborhood) committee of the insured person with household registration in the city?
The place of residence and designated outpatient clinic location belongs to the same town (street) but not in the same village (neighborhood) Committee of the city's household registration participants, the need to change the designated outpatient clinic clinic to the place of residence, with their social security card, ID card to the town (street) designated community health service organizations to apply for consent, the outpatient clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic clinic in the same town (street) the place of residence.
28. After determining the designated outpatient medical center, can I change it halfway?
In the following cases, the system automatically changes the designated outpatient medical center at the same time as the change in the insurance relationship, and the change takes effect from the following month:
●The employer moves;
●The participant switches the workplace;
●The participant's household registration moves;
●The participant's household registration changes;
●Change of residence;
●Other cases as stipulated by the social security department. Other cases as stipulated by the social security department.
29. Can I go to a medical institution other than the designated outpatient clinic?
Participants can only enjoy the corresponding outpatient medical treatment in accordance with the provisions of the designated outpatient clinics, and if the condition requires a higher level of medical care, it should be referred by the designated outpatient clinics, and in accordance with the principle of referral level by level, the first referral to the town (street) community health centers, and then referrals are required by the community health centers to the outpatient departments of the town (street) hospitals, the municipal specialty hospitals and the outpatient departments of the municipal specialty hospitals. The outpatient department of the designated specialist hospital or the outpatient department of the designated tertiary hospital in the city; due to the urgent need of the condition, can be directly referred by the designated outpatient point of care.
Outside the service hours of the designated outpatient clinics, the emergency can be directly to the town (street) community health centers. Outpatient resuscitation can be directly to the city's medical institutions.
30. If there is a need for referral, how should the referral procedures be carried out?
Designated outpatient medical point of the attending physician according to the condition of the insured person proposed referral, fill out? The referral notification form?
31. What is the difference in the payment standard of the integrated fund for each kind of consultation?
①Participants in the designated outpatient clinic outside the service time, due to emergency directly to the town (street) community health centers, the basic medical expenses incurred, the integrated fund according to the provisions of the payment.
② participants directly to the town (street) community health centers outpatient rescue of basic medical expenses, the integrated fund is required to pay; directly to the designated outpatient clinic and the town (street) community health centers outside the city medical institutions outpatient rescue of basic medical expenses, the integrated fund to pay the proportion of 10% lower.
3 by the designated outpatient point of referral to the community health centers, the integrated fund in accordance with the provisions of the payment; referred to the town (street) designated hospital headquarters outpatient department or the city's designated specialist hospital headquarters outpatient department, the integrated fund to pay the proportion of a reduction of 10%; referred to the city's designated tertiary hospital headquarters outpatient department, the proportion of the payment of a reduction of 20%; referred to other health care institutions, the integrated fund will not pay.
4. In addition to the above cases, if the insured person goes to a medical institution other than the designated outpatient clinic, the integrated fund will not pay.
32. Can the referral, outpatient resuscitation or emergency expenses incurred at the town (street) community health center be reimbursed directly at the center?
Participants in the town (street) community health centers in the outpatient rescue or emergency expenses, can be directly in the center for reimbursement procedures.
33. For those who are referred to the main outpatient department of the designated hospital in the city, can they go through the on-site reimbursement procedures directly at the hospital?
Participants referred to the outpatient medical fees incurred at the main outpatient department of the designated hospital in the city can go through the reimbursement procedures directly at the outpatient charging office of the designated hospital after the consultation.
34. Can I apply for on-site reimbursement for outpatient resuscitation at medical institutions in the city?
No. The basic medical expenses incurred in this case, the first by the participant advance payment, medical treatment within 30 days after the participant with the following information to return to the town (street) designated community health centers for reimbursement procedures: the original medical fee receipts, copies of outpatient medical records, copies of the list of medical charges (or outpatient prescription), copies of the results of inspection and laboratory reports, social insurance cards and ID cards and other relevant information.
35. What are the rules for reimbursement of outpatient medical expenses?
The medical expenses incurred by the insured person in outpatient medical treatment are handled in accordance with the following provisions:
①Using the city? The basic social health insurance community health services outpatient drug scope? (hereinafter referred to as the scope of community outpatient medication) within the drug, and strictly control the amount of medicine. Acute outpatient generally no more than three days, chronic diseases generally no more than seven days, specific outpatient generally no more than one month, of which intravenous drugs no more than one day;
② use? Dongguan City employees basic medical insurance diagnosis and treatment items, medical services and facilities range and payment standards? (hereinafter referred to as the scope of diagnostic and treatment items and medical service facilities) within the diagnostic and treatment items or medical materials, a single cost of 120 yuan (including 120 yuan, the same below) of the part of the integrated fund in accordance with the provisions of the payment;
For example: A participant to use a medical material for a single cost of 100 yuan, then the item can be reported as 100 * 60% = 60 yuan; B participant to use a single cost of a medical material for 150 yuan, then the item can be reported as 120 yuan;
The use of a medical material for a single cost of 150 yuan, then the item can be reported as 120 yuan. 150 yuan, then the item can be reported 120 * 60% = 72 yuan
3 ③ the use of Chinese herbal medicine prescription, each prescription within three doses of the basic medical fees by the integrated fund in accordance with the provisions of the payment;
④ beyond the provisions of the part or the use of community outpatient medication, diagnostic and therapeutic items and medical services outside the scope of the medicines and treatment items, etc., the participant will pay the costs.
36. If the designated outpatient clinics have equipment failure or other reasons for not being able to process the computerized settlement, can the participants go through the on-site reimbursement procedures?
Yes. Due to equipment failure or other reasons can not be in the designated outpatient clinic for computer billing, the designated outpatient clinic fee office operator in accordance with the provisions of the health insurance policy manually calculate the amount of the participant's personal payment and social security accounted for the amount of money, manually fill out the? Outpatient fee receipt (invoice) in triplicate, collect the amount of personal payment from the insured person on the spot, and complete the reimbursement procedures.
37. Participation information is not clear, can not be in the designated outpatient medical point or the town (street) designated community health center for on-site reimbursement, how to deal with?
Due to? The company's website is a great source of information about the company's services. or with the social security system in the name does not match the insurance information is not clear, can not be in the designated community health service center for on-site reimbursement procedures, the medical fee first by the participant advances, the charge of the Office of the operator in the? Outpatient fee receipt (invoice) on the back of the first coupon, and stamped with the ? The medical insurance seal will be stamped on the back of the first copy of the outpatient receipt (invoice). After that, the fee office will send the The first copy of the outpatient fee receipt (invoice) will be stamped with the special medical insurance seal.
If the social security department confirms that you can enjoy the medical insurance treatment, the participant will be able to get the medical insurance treatment by presenting the outpatient fee receipt. The first copy of the outpatient fee receipt (invoice) is handed over to the participant. (invoice), outpatient medical records, a detailed list of medical fee receipts (copies of outpatient prescriptions), a copy of? Referral notification form (only for patients who have been referred) (referral patients only), a copy of the report card of examination and laboratory results, social insurance card and ID card and other relevant information to the town (street) designated community health center for reimbursement procedures.
38. Can the referral notice be used more than once?
Within the validity period of the referral, it can be used multiple times according to the condition. When the attending physician proposes a referral based on the condition of the insured person, he/she must submit the referral form in the "referral notification form". The referral form must indicate the validity period of the referral. Within the validity period of the referral, the participant can make copies of the referral slip according to his/her condition. The patient can make a copy of it and use it several times.
39. What are the circumstances under which outpatient visits cannot be reimbursed?
In the following cases, the Fund will not pay:
(1) not be able to produce a valid identity document for medical treatment;
(2) beyond the scope of payment of basic medical insurance;
(3) lending the social insurance card to others, fraudulent use of other people's documents, or intentional forgery, alteration of prescription, diagnosis, and other relevant information;
(4) the social insurance card will not be able to pay the medical expenses, but will not pay the medical expenses, so the Fund will not pay the medical expenses.
(4) medical expenses incurred because the insured person himself/herself puts forward medical treatment requirements that are not suitable for his/her condition or are not reasonably compliant;
(5) outpatient treatment at medical institutions other than those designated as outpatient medical centers on his/her own (excluding outpatient resuscitation and emergency medical treatment in compliance with the regulations).
40. What are the circumstances that do not qualify for basic medical insurance treatment?
(1), should be paid from the Workers' Compensation Insurance Fund;
(2), should be borne by a third party;
(3), should be borne by the public ****health;
(4), outside of the country for medical treatment.
41. How to enjoy outpatient medical treatment for participants who have applied for settlement in a foreign country?
Participants who have applied for settlement abroad, the outpatient medical insurance premiums are allocated to the participant's outpatient medical treatment in a lump sum every year, and they no longer enjoy the city's outpatient treatment.