About Medical Insurance and New Rural Cooperative Service Guidelines of Henan Xuchang City Central Hospital
Medical Insurance and New Rural Cooperative Service Guidelines of Henan Xuchang City Central Hospital: New Rural Cooperative Service
I. Implementation of New Rural Cooperative Service Policies and the Work of the Hospital:
The Hospital is the first hospital in Henan Province to be awarded the New Rural Cooperative Medical Insurance (NRCM).
2, in accordance with the requirements of the provincial department to carry out major diseases treatment work, since May 2013, our hospital has been identified by the Municipal Health Bureau as a municipal New Rural Cooperative Medical Care major diseases treatment designated medical institutions, identified by the Municipal Health Bureau of the major diseases treatment diseases **** there are 13 kinds of: respectively: congenital heart disease in children (≤ 14 years old), breast cancer, cervical cancer, lung cancer, esophageal cancer, gastric cancer, cleft lip, Cleft Palate, Colon Cancer, Rectal Cancer, Acute Myocardial Infarction (Coronary Thrombolysis, Coronary Intervention (1-2 and more stents)), Opportunistic Infections of AIDS, Hypospadias (≤14 years old).
3. According to the notice of the Provincial Department on doing a good job in the compensation and settlement of the New Rural Health Insurance for Major Diseases, our hospital started to carry out instant settlement of the New Rural Health Insurance for Major Diseases on October 1, 2014, and advanced the medical expenses for the hospitalized patients who are eligible for reimbursement of the insurance for major diseases.
4. According to the notice of the provincial department on the work of the New Rural Harmonization Harmonization Fixed Compensation for Common Diseases, our hospital carries out the work of the New Rural Harmonization Harmonization Fixed Compensation for 25 kinds of common diseases from November 1, 2014 onwards.
Second, the new rural cooperative hospitalization process
(a) directly to our hospital inpatient new rural cooperative patients:
The first step: admission to the receiving physician or nurse to perform the first informative procedures;
The second step: the patient in the "participation of inpatient informed consent" signed;
→ receiving The nurse or the physician in charge of the bed signed the form;
→ fill in the date of the day;
→ stamped with the official seal of the ward.
The third step: the patient within three days to the window of the New Agricultural Cooperative window for registration; need to bring the following documents
(1) hospitalization card
(2) patients with the cooperative medical book
(3) patient ID card (children need to provide the hukou book, inter-regional hospitalization of the patient need to provide the hukou book)
(4) "Participation in the hospitalization of patients with informed consent".
(Electronic referral procedures: (1) Xuchang County NAC: assisted by the hospital NAC office staff; (2) Yanling County, Changge City, Yuzhou City, Xiangcheng County, and inter-regional NAC patients, by the department of the receiving physician or nurse or the patient himself to contact with the local NAC office for processing).
(2) Normal referrals to our hospital:
You must provide a "Referral Certificate" issued by the county designated hospital and stamped by the county Agricultural Cooperation Office before admission or on the day of hospitalization. Go to the Agricultural Cooperative Window for registration.
Note: Henan Provincial Health Planning Commission notice: September 1, 2013 onwards for the same disease within the year multiple referrals to the same hospital inpatient treatment, the second hospitalization before the need to record the local Farmers' Cooperative Office. You can register at the hospital's Agricultural Cooperative Window.
(C) emergency admissions of new rural cooperative patients:
Department of the receiving physician must be based on the actual situation of the patient, for those who meet the conditions of emergency (critical condition, with rescue records), issued a certificate of emergency, shall not be issued false certificates. The patient is admitted to the hospital in an emergency, and must go to the window of the New Agricultural Cooperative for registration with the certificate of emergency.
(D) special circumstances:
1, Changge City, the new rural cooperative hospitalized patients: need to provide household registration and village doctor certificate, and limited to agricultural households; non-agricultural households are also required to provide proof of non-participation in other social insurance).
2, the newborn: provide the new rural cooperative referral certificate or "informed consent", the child's father and mother ID card, the newborn's birth medical certificate, the mother's cooperative medical book.
3, children under 14 years old (including 14 years old) patients: to provide the NAC referral certificate or "Informed Consent for Inpatient Hospitalization", the patient's hukou (hukou head of household and the patient's hukou person page), the patient's cooperative medical book.
4, trauma patients: in our hospital window for registration procedures for the NAC, discharged from the hospital at their own expense settlement back to the local reimbursement (for details, please consult the local co-management office).
5, adults without ID cards, need to provide the police station issued by the household registration certificate with a photo, trauma car accident perpetrators need to provide hit-and-run traffic police brigade escape certificate, motorcycle need to provide a driver's license.
Third, the new rural cooperative patients discharged for the process
After receiving the notification of the hospital district, the discharge settlement need to bring:
1, discharge card 2, diagnostic certificates, 3, discharge notification form, 4, the identity card of the recipient;
Special note:
1, emergency patients discharge settlement need to provide a copy of the hospitalization
2, patients with major diseases (oncology patients such as breast cancer, cervical cancer, etc.): a copy of the hospitalization record + pathology report card;
3, hospitalized people using human albumin: a copy of the hospitalization record + biochemistry report card.
Fourth, the new rural cooperative policy: the new rural cooperative fund compensation scope:
1, the new rural cooperative fund can only be used to participate in the medical cost compensation.
2, the following medical costs are not included in the scope of payment of the New Rural Cooperative Fund:
(1) should be borne by the public **** health;
(2) should be paid from the Workers' Compensation Insurance Fund;
(3) should be borne by a third party;
(4) caused by intentional crime, alcoholism, drug abuse, suicide, self-inflicted injuries, brawl and so on;
(5) outside the country for medical treatment;
(6) beyond the scope of the basic drug list, basic diagnostic and treatment items and medical service facilities catalog of the New Rural Cooperative reimbursement.
3, on the new rural cooperative hospitalization referral certificate: the provincial health department of the new rural cooperative management center requirements: hospitalization referral certificate issued time: must be in the patient before hospitalization, at the latest, the day of hospitalization, no delay. If the referral time is later than the hospitalization time without any special reason, the reimbursement will still be made in accordance with the 20% reduction ratio. Because the referral certificate is equivalent to a medical certificate, it is the basis for transferring to a higher-level hospital for treatment.
Medicare
First, the process of hospitalization of patients with medical insurance (1) urban workers, urban residents of the medical insurance patients for the hospitalization procedures, you need to take the medical insurance card, hospitalization card, ID card (within three days of hospitalization) to the medical insurance office for medical insurance hospitalization procedures, and the medical insurance card stored in the medical insurance office. The medical insurance card must be deposited at the Medical Insurance Office within three days of hospitalization. Patients hospitalized on holidays must register on the first day after work. (2) patients who do not bring their health insurance cards on the day of admission, first apply for admission procedures at their own expense, and must hold their health insurance cards, hospitalization certificates, and ID cards to the Office of Health Insurance within three days of hospitalization to make up for the health insurance procedures. (3) hospitalized for more than three days did not provide medical insurance card for hospitalization procedures ', as the patient to give up reimbursement treatment, hospitalization costs at their own expense. Second, the process of discharging patients with medical insurance settlement: patients need to be ready to discharge: (1) discharge notification form; (2) payment of the deposit bar; (3) hospitalization records (ward transfer hospitalization records to the Office of the medical insurance: it takes about 7-10 days time). The billing procedure can be performed only after the inpatient record has been transferred to the health insurance office for review. Third, the medical insurance hospitalized patients Note: (1) the implementation of IC card accounting for the medical insurance patients, after admission to the hospital should pay the full amount of the individual part of the deposit, is the part of the overall reimbursement by the hospital advance. Unit frozen patients registered, the cost of cash settlement. (2) patients who do special examination and special treatment during hospitalization must go to the hospital medical insurance office for approval, otherwise, the cost is at their own expense (except holidays). (3) Medical insurance patients are not allowed to transfer to other departments for treatment of different diseases during hospitalization, and the transfer of the same disease must be approved by the hospital medical insurance office, otherwise, the costs will be borne by themselves. (4) During hospitalization, patients must comply with the provisions of health insurance and the relevant rules and regulations of the hospital, and cannot leave the hospital without special circumstances. If you are hospitalized without a bed, you will not be reimbursed by the medical insurance. (5) During the hospitalization period, the doctor must obtain the consent of the patient or his/her family members and sign for the use of self-financed medicines and diagnostic and therapeutic items. (6) referral to the hospital: due to the technical conditions and equipment of the hospital can not diagnose and treat the disease, the physician to fill out the "referral to the hospital approval form", signed by the director of the department, the medical insurance office approved by the medical insurance center for the record, the patient can be transferred to the next level of designated hospitals for treatment. (7) Hospitalization for work-related injuries, fights and assaults, alcoholism, suicide, drug addiction, etc. are not covered by the medical insurance reimbursement. (8) The hospitalization of patients with foreign health insurance to implement the original participation in the local health insurance policy, hospitalization costs of their own advances, discharged back to the local health insurance department for reimbursement; such as the opening of the provincial settlement business, can be directly reimbursed in the hospital hospitalization. Fourth, the health insurance policy publicity 1, the health insurance patient reimbursement ratio: (1) in the workforce: the total cost of hospitalization - (the first to exclude the individual out-of-pocket part of the personal out-of-pocket part of the personal out-of-pocket part of the and the starting line) up to 20,000 yuan, reimbursement of 85%; 20,001 yuan The total cost of hospitalization - (excluding the out-of-pocket expenses, the out-of-pocket portion and the threshold) up to 20,000 yuan is 85% reimbursed; 20001 yuan - 41,000 yuan is 90% reimbursed. (2) Retired employees: 5% reimbursement on top of in-service basis. (3) Starting line for employee health insurance: 700 RMB for the first hospitalization, 600 RMB for the second hospitalization, 500 RMB for the third hospitalization, and 400 RMB for the subsequent hospitalization within the year. (4) Resident medical insurance hospitalization starting line: the starting line for hospitalization in tertiary hospitals 900 yuan / each time, the reimbursement rate of 65% (first remove the personal out-of-pocket expenses, personal out-of-pocket expenses and the starting line). 2. How to replace the lost IC card? Participants in the health insurance IC card should be properly stored, such as accidentally lost, should be immediately with their own ID card or account book original and copy, others also need to provide a proxy for the original ID card and a copy, to the municipal health insurance agency to handle the loss of formalities, and replacement of the new health insurance IC card. The loss of the IC card can no longer be used. 3, which diseases are not covered by the basic medical insurance reimbursement? According to the relevant provisions of the basic medical insurance, all the expenses incurred for the following diseases and behaviors do not belong to the basic medical insurance reimbursement scope: (1) occupational injuries, occupational diseases; (2) accidental injuries (with third-party liability) (3) congenital diseases (reimbursement according to the provisions of the medical insurance); (4) illegal crimes; (5) Fighting; (6) Suicide and self-injury; (7) Drug addiction; (8) Traffic accidents; (9) Medical malpractice; (10) Smoking cessation and alcoholism; (11) Sexually transmitted diseases (12) Other costs that do not fall within the scope of the basic medical insurance fund expenses. 4. How do insured persons seek medical treatment and medication in outpatient clinics? (1) Participants should go to the designated medical institutions for outpatient treatment with their medical insurance IC card. (2) participants outpatient medication, must adhere to the treatment of disease, the principle of rational use of medication, not to open the "ride party, large prescriptions, humane prescription"; a prescription amount of doctors should be in accordance with the amount of acute oral medication for three days, chronic diseases 7 days amount of herbal medicines not more than 5 doses, intravenous infusion not more than 3 days amount to control. (3) outpatient medical expenses incurred by the insured in the designated medical institutions, the balance of the individual account is enough to pay, in line with the provisions of the health insurance costs in the hospital health insurance charge window directly scratch the IC card settlement, out-of-pocket part of the cash; the balance of the individual account is not enough to pay, pay cash settlement. 5. How to get outpatient treatment for severe chronic diseases? When seeking outpatient medical treatment for severe chronic diseases, you should go to the designated designated medical institution for severe chronic diseases with the "Critical Chronic Disease Card", and the doctor should first verify the patient's identity in accordance with the regulations, and after the person and the card are in line with each other, you will be treated with medication for the diseases shown on the "Critical Chronic Disease Card", and the doctor should write down the type of disease, the disease, the card number, and the unit, etc., and should not exchange and take the medicines required for other diseases. 6, retired cadres, second class B or higher revolutionary disabled soldiers outpatient how to get medical treatment? Retired cadres and military personnel with revolutionary disabilities above the second class B outpatient medical care, should hold my "retired cadres medical card" and "special prescription for retired cadres" to the designated designated hospitals for retired cadres, the receiving doctor should first check whether the patient and the card held by the patient is consistent with, consistent with, the receiving doctor can only according to the provisions of the patient's condition to use the "special prescription for retired cadres" prescribed medication. 7, how to apply for hospitalization? When the insured person needs to be hospitalized due to illness (within the city), he should go to the hospital insurance office of the designated medical institution within 3 days with the hospitalization certificate issued by the designated medical institution, his own medical insurance IC card, the original and a copy of his ID card, and the unit's letter of introduction to the designated medical institution to go through the hospitalization procedures for the medical insurance patient after verifying his identity (the retired cadres hospitalization should be the "special prescriptions for retired cadres" and the "retired cadres' medical card" should be retained in the hospital medical insurance office), and the advance notice should be submitted to the medical insurance office of the hospital. (when the retired cadres are hospitalized, they should also keep the "Special Prescription for Retired Cadres" and "Medical Card for Retired Cadres" in the medical insurance office of the hospital), and pay in advance the hospitalization deposit which is enough to pay for the personal burden and out-of-pocket expenses. 8. How can the insured apply for referral to another hospital? (1) The principle of transferring to a hospital outside of the city: transferring up, not down. The transferred hospital must be a provincial or above provincial health insurance designated public hospital. (2) Conditions for out-of-town transfer. Participants due to disease, in the city of the second or third-class medical institutions within five days after expert consultation difficult to diagnose difficult diseases or has been clearly diagnosed, due to the limitations of the city's medical conditions, within 10 days of the treatment is ineffective or the condition can not be controlled. (3) Out-of-town transfer program. Meet the conditions of out-of-town transfer of insured persons, the first two or three designated medical institutions in the city by the attending physician to write the reason for the transfer, and fill out the "Xuchang City, urban workers and residents of the basic medical insurance referral transfer application form" (in triplicate), signed by the director of the department, signed by the medical department agreed to the Medical Insurance Office stamped medical insurance center for approval before the transfer of hospital treatment. 9, how to hospitalize and reimbursement of medical expenses for emergency? Participants due to emergency or rescue, can be the nearest non-designated medical institutions hospitalized, but should be hospitalized within 3 days by the unit operator to notify the health insurance agency, and registration procedures; patients need to continue treatment after the relief of the condition, must be transferred to the designated hospital within 3 days of health insurance. The medical expenses of the two hospitalizations are settled in cash, and after discharge, the emergency certificate, a copy of the medical record, a summary list of expenses (stamped by the hospital) and the regular hospitalization fee bills are submitted to the unit operator for reimbursement to the health insurance agency.