Article 1 Jiangxi Province Urban Resident Basic Medical Insurance designated medical institutions (hereinafter referred to as designated medical institutions) refer to medical institutions that have been determined and signed by the medical insurance agency after qualification review by the coordinating regional labor and social security administrative department. Service contracts are medical institutions that provide basic medical services to people who have participated in the basic medical insurance for urban residents.
Article 2 The review and determination of designated medical institutions should follow the following principles:
(1) Convenience for insured persons to seek medical treatment and management;
(2) Taking into account both specialist and comprehensive medicine, traditional Chinese medicine and western medicine, the layout is reasonable, and community health service institutions play the first diagnosis role;
(3) It is conducive to the optimal allocation of medical and health resources and promotes reasonable competition among medical institutions;
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(4) It is conducive to controlling the cost of medical services and improving service quality.
Article 3 The following categories of medical institutions that have been approved by the health administrative department and have obtained the "Medical Institution Practice License" may apply for designated qualifications from the coordinating regional labor and social security administrative department:
(1) General hospitals, hospitals of traditional Chinese medicine, hospitals of integrated traditional Chinese and Western medicine, and specialist hospitals;
(2) Maternal and Child Health Hospitals (institutes);
(3) Specialist disease prevention and treatment hospitals (institutes) , station);
(4) Community health service agencies.
Article 4 Designated medical institutions must meet the following conditions:
(1) Be approved by the health administrative department and obtain the "Medical Institution Practice License";
(2) Strictly implement the medical service and drug price standards stipulated by the state and the price department; abide by the laws, regulations and standards for medical and health service management, and have a sound and complete medical service management system and business management specifications;
(3) The service quality and service attitude are good, the social evaluation is high, and the company voluntarily applies to become a designated medical institution;
(4) A medical insurance management department that can provide basic medical insurance services for urban residents or Equip management personnel and formulate management systems;
(5) Be able to configure necessary computer application equipment (including computers and POS machines) in accordance with the business requirements of urban residents’ basic medical insurance, and have computer networking capabilities and skilled operations Personnel;
(6) Strictly implement the relevant policies and regulations of the Jiangxi Province Urban Resident Basic Medical Insurance System and perform the service contracts signed with the medical insurance agency.
Article 5. Approval procedures for designated medical institutions:
(1) Application qualifications
Meet the basic conditions of designated medical institutions and be willing to undertake basic medical care for urban residents Medical institutions providing insurance services can submit a written application to the coordinating regional labor and social security administrative department, fill in the "Urban Resident Basic Medical Insurance Designated Medical Institution Application Form" (printed by each district or city), and provide the following information:
1. Copy of "Medical Institution Practice License";
2. List of major medical technical equipment and charging standards;
3. Outpatient and inpatient diagnosis and treatment services in the previous year (Including the number of outpatient visits, average medical expenses per person, number of hospitalizations, average hospitalization days for discharged patients, average hospitalization medical expenses for each discharged patient, average daily hospitalization medical expenses for discharged patients, etc.);
4 , materials proving that the drug regulatory department and the price department have passed the supervision and inspection;
5. The following statements for the previous year at the time of application:
① Comprehensive statistical table of grassroots health units - Table 1 (Health System 1 Table 1-11);
② Comprehensive statistical table of grassroots health units - Table 2 (Health System 2 Table 1-5);
③ Health department hospitals Annual report on disease classification of inpatients (Health Statistics Table 32);
④ Health Department Hospital Discharged Patient Questionnaire (Health Statistics Table 33).
(2) Qualification review and determination
The coordinating regional labor and social security administrative department will conduct a designated qualification review based on the application of the medical institution and the information provided, and sign the "Application Form" as qualified For qualified medical institutions, after filing with the labor and social security administrative department of the districted city, the labor and social security administrative department of the districted city will print and issue a "Qualification Certificate for Designated Medical Institutions".
(3) Signing an agreement
The medical insurance agency shall sign an agreement with the designated medical institution. The content of the agreement includes the service population, service scope, service content, service quality, charging standards, medical expense settlement methods, medical expense payment standards and medical expense review and control measures, and clarifies the responsibilities, rights and obligations of both parties. The validity period of the agreement is tentatively set at 1-3 years. If either party violates the agreement, the other party has the right to terminate the agreement, but must notify the other party one month in advance.
(4) Announcement and listing
Designated medical institutions that have signed agreements will be announced to the public by the medical insurance agency and awarded licenses. The signage refers to the style of signage for urban employees’ basic medical insurance designated medical institutions and is uniformly produced by the labor and social security bureaus of each district and city. The signage is hung in a prominent position on the street of the designated medical institution.
Article 6 The medical insurance management department or staff of designated medical institutions should work together with the medical insurance agency *** to provide designated medical services. Separate accounts must be created for the medical expenses of participants in the basic medical insurance for urban residents, and the "Monthly Statistical Table of Medical Expenses for Participants in the Basic Medical Insurance for Urban Residents" (designed by each coordinating region), etc. should be submitted to the medical insurance agency on time. Relevant information.
Article 7 Designated medical institutions shall be equipped with full-time (part-time) personnel to be responsible for work related to basic medical insurance for urban residents.
Article 8 Designated medical institutions shall provide training on basic medical insurance for urban residents to medical staff so that they can become familiar with the relevant policies of basic medical insurance for urban residents and the content of designated agreements. Provide medical services in accordance with policies and protocols at work. At the same time, they are required to actively promote the information to medical personnel.
Article 9 Designated medical institutions must strengthen the construction of medical ethics and medical ethics, continuously improve medical technology, improve service attitudes, provide high-quality services to insured medical personnel, and standardize diagnosis and treatment behavior and use of drugs in accordance with The principle of treating patients according to the disease is to achieve reasonable examination, reasonable treatment and rational use of drugs.
Article 10 Designated medical institutions must strictly implement the charging items and charging standards stipulated by the state and the price department, and integrate the charging items, charging standards and convenience preferential measures, and place the main charging items and charging standards in significant The location is announced to facilitate the verification and supervision of insured persons, so as to ensure reasonable charging.
Article 11 Designated medical institutions must strictly implement the relevant management measures and regulations of urban residents’ basic medical insurance. In the process of providing medical services to insured persons, when using drugs outside the catalog, self-paid diagnosis and treatment items, or super-standard medical service facilities, you must fulfill the obligation to inform and obtain the consent and signature of the person or family member (except for emergency rescue) before implementation. It is strictly prohibited to commit bed-related hospitalization, empty-bed hospitalization, and illegal activities such as exchanging prescription drugs for non-approved drugs, health products or other items to obtain funds.
Article 12 The medical insurance management department of designated medical institutions shall be responsible for reviewing whether the medical behaviors such as certificates, medication prescriptions, functional examinations, and hospitalization diagnosis and treatment of insured inpatients comply with regulations.
Article 13 Designated medical institutions should uniformly use compound prescriptions that comply with the writing standards for medical documents, as well as various documents such as outpatient clinics, special disease outpatient clinics, and hospitalization monthly settlement forms approved by the labor and social security departments and the health department. and account statements and card books, and use invoices that comply with regulations.
Article 14 Medical insurance agencies must settle medical expenses with designated medical institutions in full and in a timely manner in accordance with the time, payment items and settlement methods stipulated in the agreement. If the medical insurance agency cannot pay the settlement fees of designated medical institutions in full and on time, the medical institutions can apply for a timely settlement by the labor and social security department and the health administrative department.
Article 15 Medical insurance agencies must strengthen the inspection and review of the medical expenses of insured persons at designated medical institutions. Designated medical institutions are obliged to provide medical insurance agencies with all the information needed to review medical expenses (except for information involving personal privacy and medical disputes).
Article 16 The labor and social security administrative department shall work with the health, finance, price and other departments to strengthen supervision and inspection of the services and management of designated medical institutions, and establish an evaluation of the service quality of designated medical institutions. For designated medical institutions that violate regulations, the labor and social security administrative departments will order them to make corrections within a time limit, notify them of criticism, or cancel their designated qualifications, depending on the circumstances.
Article 17 The labor and social security administrative departments shall implement an annual inspection system for the qualifications of designated medical institutions. The following materials are provided by designated medical institutions during the annual inspection:
(1) Annual inspection application form;
(2) "Designated Medical Institution Qualification Certificate";
( 3) Annual work summary of the basic medical insurance business for urban residents;
(4) Financial information on urban residents’ medical insurance;
(5) Labor and social security administrative departments and health administration Other information specified by the department.
Article 18 For designated medical institutions that fail to complete annual inspection procedures as required, the labor and social security administrative department will cancel their designated qualifications within the next year and announce it to the public.
Article 19: These Measures shall be implemented from the date of promulgation