In order to do a good job in the management of medical insurance payment in internet plus, Tianjin, the Municipal Medical Insurance Bureau has formulated the Measures for the Management of Medical Insurance Payment in internet plus, Tianjin, which defines the medical insurance payment policy of Internet medical care, and the measures will be implemented from June 165438+ 10/day, 2022.
The full text is as follows
Measures for the Administration of Internet Plus Urban Medical Insurance Payment for Medical Services
Chapter I General Provisions
Article 1 In order to strengthen and standardize the management of medical insurance payment for Internet+medical services, these Measures are formulated according to the requirements of documents such as Opinions of the General Office of the State Council on Promoting the Healthy Development of Internet+Medical Services, Guiding Opinions of the National Health Insurance Bureau on Actively Promoting the Medical Insurance Payment for Internet+Medical Services, and Implementation Opinions of the General Office of Tianjin Municipal People's Government on Promoting the Healthy Development of Internet+Medical Services.
Article 2 The term "internet plus" medical service and medical insurance payment management as mentioned in these Measures refers to the activities of medical insurance designated medical institutions approved by this Municipality to set up Internet hospitals or carry out Internet diagnosis and treatment activities according to law to provide "internet plus" medical services for the insured, which involves the medical insurance institutions' application for signing contracts, medical insurance payment policies, medical insurance settlement, agreement management, management and supervision.
Article 3 The Municipal Medical Insurance Bureau shall be responsible for the medical insurance management of Internet+medical services in the whole city, and determine the conditions that designated medical institutions should have to carry out Internet+medical services, the application signing procedures, the price of Internet+medical services and the medical insurance payment policy.
The District Medical Security Bureau is responsible for the supervision and management of Internet+medical services and medical insurance payment within its jurisdiction.
City medical insurance fund management center and its branches in various districts shall organize the implementation of the "internet plus" medical service medical insurance agreement management according to their responsibilities.
City medical insurance fund settlement center is responsible for the "internet plus" medical service medical insurance payment audit and settlement work.
The Municipal Medicine Procurement Center is responsible for improving the procurement platform and supporting designated medical institutions to carry out online procurement of medicines needed for medical services and medical insurance payment in internet plus.
The supervision and inspection of the municipal medical insurance fund is entrusted by the Municipal Medical Insurance Bureau, and is responsible for the supervision and inspection of the implementation of the laws, regulations and rules of medical insurance in the payment of medical services in internet plus.
Chapter II Application for Institutional Signing
Article 4 Designated medical institutions for medical security that have been approved by this Municipality to set up Internet hospitals or carry out Internet diagnosis and treatment activities according to law may, on a voluntary basis, apply to the medical insurance sub-center for signing a supplementary agreement on Internet+medical services. If the entity medical institution is a non-designated medical institution, it may also apply for signing a supplementary agreement of "internet plus" medical service when applying for signing a designated medical insurance agreement.
Article 5 A medical institution applying for the Internet+medical service supplementary agreement shall meet the following basic conditions:
It has the conditions for docking with the national unified medical insurance information business code, as well as basic information databases such as drugs, medical consumables, diagnosis and treatment projects, medical service facilities and diseases;
Have the conditions for data exchange with the medical insurance information system, realize mobile payment of medical insurance in combination with the construction of a unified national medical insurance information platform, and provide patients with electronic bills, electronic invoices or paper bills in time;
Relying on the medical insurance electronic certificate for real-name authentication to ensure that the insured use their real identities;
The electronic medical records, electronic prescriptions, drug purchase records, confirmed medical records and other information provided by patients during the diagnosis and treatment of insured persons can be completely preserved, and the whole process of diagnosis, treatment, prescription and dispensing can be traced back;
Be able to verify whether the patient is a follow-up patient and master the necessary medical information;
The information system of medical institutions should be able to distinguish off-line medical services, off-site medical services and internet plus medical services;
In accordance with the relevant requirements of the state and the city's medical insurance information platform management, complete the transformation of the "internet plus" medical insurance network settlement system;
Other requirements.
Article 6 A medical institution applying for the Internet+medical service supplementary agreement shall provide the following materials:
An application for signing a supplementary agreement on Internet+medical services;
A copy of the license approved by the competent department to set up an Internet hospital or carry out Internet diagnosis and treatment activities;
"internet plus" medical service medical insurance payment related information system related materials;
List of doctors related to medical insurance payment of "internet plus" medical service;
Other materials that need to be provided according to relevant regulations.
Seventh medical institutions to the medical insurance sub-center to sign the "internet plus" medical service supplementary agreement application, the medical insurance sub-center should immediately accept. If the application materials are incomplete, the medical insurance sub-center shall notify the medical institution to supplement them once within 5 working days from the date of receiving the materials.
Article 8 The medical insurance sub-center shall organize an evaluation team to conduct written and on-site evaluation on the medical institutions applying for signing the supplementary agreement of Internet+medical services. From the date when the entity medical institution accepts the application materials or signs the medical insurance agreement, the evaluation time shall not exceed 2 months, and the time when the medical institution supplements the materials shall not be included in the evaluation period. The evaluation contents include:
Check the permission of the competent department to approve the establishment of an Internet hospital or carry out Internet diagnosis and treatment activities;
Check the medical institutions "internet plus" medical insurance network settlement and national medical insurance electronic certificate, mobile payment system docking and other information systems;
Check the medical institutions "internet plus" medical services and medical insurance payment related doctors;
Check whether the medical service of the medical institution "internet plus" can check whether the patient is a follow-up patient and master the necessary medical information of the patient;
Check whether the medical service of the medical institution "internet plus" can completely retain the electronic medical records, electronic prescriptions, drug purchase records and other information during the diagnosis and treatment of the insured;
Check other materials that medical institutions should provide according to relevant regulations.
Ninth _ evaluation of qualified medical institutions, municipal medical insurance center or medical insurance sub-center should sign a supplementary agreement with medical institutions within 5 working days, and the period of supplementary agreement should be consistent with the designated medical institutions of their supporting units. If the assessment is unqualified, the medical insurance sub-center shall inform the reasons in writing and put forward rectification suggestions.
Chapter III Payment Policy of Medical Insurance
Tenth medical institutions to set up "internet plus" medical service projects, in accordance with the national and municipal "internet plus" medical service prices and medical insurance payment related policies. Designated medical institutions to provide medical follow-up services in line with the provisions of the "internet plus", according to the public hospital general outpatient service project price charges and payments. The drug expenses incurred are paid according to the payment standards and policies stipulated by offline medical insurance.
Eleventh designated medical institutions to provide "internet plus" medical follow-up services for the insured, should be within the scope of offline medical institutions, and shall not exceed the scope of Internet medical subjects. Internet diagnosis and treatment services provided by designated medical institutions for the insured are limited to the follow-up visits of common diseases and chronic diseases that can be independently completed online.
Twelfth designated medical institutions to provide "internet plus" medical referral prescription for the insured, should comply with the relevant provisions of the health department of Internet diagnosis and treatment, prescription management. Online prescriptions purchased in our hospital or designated retail pharmacies must be electronically signed by doctors and uploaded to the medical insurance settlement system according to regulations after being audited by pharmacists.
Article 13 If the medical expenses and drug expenses incurred by the insured during the follow-up and prescription in the designated medical institutions of internet plus medical service in this Municipality meet the scope of medical insurance payment, they shall be paid in accordance with the relevant provisions of this Municipality's medical insurance. The expenses borne by the individual can be paid by the employee's medical insurance personal account according to the regulations. The cost of providing drug distribution services is not included in the scope of medical insurance payment.
Chapter IV Settlement of Medical Insurance
Fourteenth city medical insurance center should promptly publish the "internet plus" medical service medical insurance settlement management interface specification. Designated medical institutions that carry out "internet plus" medical services should transform their internal systems according to the interface specifications, and maintain effective docking with the medical security information platform of this Municipality as required to realize online settlement of medical insurance. Designated medical institutions independently choose the operation and maintenance suppliers of relevant information systems connected with medical insurance. Medical insurance agencies shall not charge any fees and designate suppliers in any name.
Fifteenth Internet medical insurance of the insured shall rely on the real-name authentication of medical insurance in the electronic certificate, and complete the settlement of medical insurance expenses of "internet plus" medical service through mobile payment.
The insured shall activate the electronic medical insurance certificate through the third-party channel authorized by the National Medical Insurance Bureau.
Article 16 Designated medical institutions shall provide consulting fees for Internet plus medical services that meet the requirements, as well as drug expenses incurred in institutions providing Internet plus medical services or third-party institutions designated by them. According to the provisions, the part that should be paid by the medical insurance fund shall be settled directly with the designated medical institutions by the medical insurance agency. "internet plus" medical follow-up prescription in the city designated retail pharmacies circulation of drug costs, according to the provisions should be paid by the medical insurance fund, by the medical insurance agencies and designated retail pharmacies settlement.
Seventeenth designated medical institutions should be required to declare the medical expenses paid by the "internet plus" medical service and medical insurance, and realize the distinction between offline medical expenses. City medical insurance settlement center according to the requirements of the relevant provisions of the administrative department of medical security, the administrative department of health and the market supervision department, adopt the method of combining intelligent audit and manual key audit, and audit the legality and rationality of medical expenses paid by medical insurance according to the duties of "internet plus" medical service. Pay the fees that meet the requirements, and do not pay the fees that have been audited for the violation declaration.
Article 18 The designated medical institutions that carry out "internet plus" medical services and their offline designated medical institutions are regarded as the same management service subject, and their medical insurance payment management is implemented in accordance with the existing relevant regulations such as the total budget management of the city's regional integral method, the fixed payment according to diseases, the total payment according to heads, and the payment according to projects.
Chapter V Agreement Management
Nineteenth designated medical institutions to carry out "internet plus" medical services, should abide by the medical insurance agreement of designated medical institutions in this Municipality and the supplementary agreement of "internet plus" medical services. Medical insurance agencies should, in accordance with the requirements of the agreement, do a good job in the management and service of designated medical institutions, promptly announce to the public the list of designated medical institutions that have signed "internet plus" medical services, and urge the designated medical institutions to announce to the public the main service contents and charging prices of "internet plus" medical services. ___
Article 20 Medical insurance service doctors who carry out Internet diagnosis and treatment activities shall obtain the corresponding qualifications of practicing doctors according to law, have more than three years of independent clinical work experience, and abide by the relevant contents of this Municipality's medical insurance agreement, supplementary agreement for medical insurance service doctors and supplementary agreement for Internet+medical services.
Twenty-first medical insurance agencies or their entrusted third-party institutions shall regularly conduct performance appraisal on the medical institutions providing "internet plus" medical services and the entity medical institutions they rely on. Establish an evaluation index system centered on the use of medical insurance funds, the quality of medical services and patients' satisfaction with medication. The assessment results are linked to the signing of medical insurance agreement and medical insurance payment.
Article 22 The municipal medical insurance center shall improve the contents of the supplementary agreement on medical services in internet plus, establish an exit mechanism, and suspend or terminate the supplementary agreement according to regulations. The entity designated medical institutions are suspended or terminated, and the supplementary agreement for providing "internet plus" medical services is suspended or terminated at the same time; Medical institutions providing "internet plus" medical services are suspended or terminated, and the medical insurance agency shall decide whether to suspend or terminate the corresponding fixed-point agreement according to the fixed-point agreement of the entity medical institution.
Chapter VI Management and Supervision
Article 23 Designated medical institutions shall establish an online prescription review system and a medical service behavior supervision mechanism, upload information such as electronic medical records, online electronic prescriptions, drug purchase records and real-name authentication records to the medical security information platform in real time, gradually implement the scanning and sales of drug traceability codes, properly preserve medical and other related electronic information, make the whole process of medical treatment, prescription, transaction and distribution traceable, realize the whole process monitoring of information flow, capital flow and logistics, ensure the rationality of medical treatment and prevent fictitious medical services.
Article 24 Medical insurance agencies should strengthen the responsibility of cost audit, comprehensively use big data, the Internet and other technical means, and use the intelligent medical insurance audit monitoring system to conduct real-time supervision on details such as Internet medical service fee settlement, drugs, consumables, medical service items, outpatient medical records, etc. Audio and video are used to test the authenticity of doctors participating in internet plus medical service. Comprehensive grasp of the insured medical information and medical institutions to check the follow-up behavior of the relevant records. Refusing to pay inspection fees and medicine fees that do not meet the requirements shall be handled as agreed.
Article 25 The urban two-level medical security departments shall, in accordance with their duties, bring Internet plus medical services provided by designated medical institutions and their medical insurance service physicians into the scope of supervision, strengthen big data analysis through medical insurance intelligent audit and real-time monitoring system according to medical insurance laws and regulations and service agreements, and severely crack down on illegal behaviors of Internet plus medical services and medical insurance payment.
Article 26 The urban two-level medical security departments shall, in accordance with the relevant provisions, disclose the illegal situation of designated medical institutions, medical insurance service physicians and insured persons to the public in internet plus, notify the health and market supervision departments, and incorporate them into the national credit information sharing platform, law enforcement supervision platform and other credit management platforms, and implement joint punishment for dishonesty according to law.
Twenty-seventh designated medical institutions and their medical insurance service physicians and the insured who accept the "internet plus" medical service violate these management measures and belong to the contents agreed in the medical insurance agreement, which shall be handled by the municipal medical insurance center or medical insurance sub-center according to the agreement; Belonging to the scope of administrative punishment prescribed by laws, regulations and rules, the medical security department shall give administrative punishment according to law; If a crime is constituted, criminal responsibility shall be investigated according to law.
Medical security departments at all levels abuse their powers, neglect their duties or engage in malpractices for selfish ends in the management of Internet+medical services and medical insurance payment, and the directly responsible person in charge and other directly responsible personnel shall be punished according to law; If a crime is constituted, criminal responsibility shall be investigated according to law.
Chapter VII Supplementary Provisions
Twenty-eighth medical security departments at all levels should do a good job in the network security of medical insurance payment related data of "internet plus" medical service to prevent data leakage and ensure the information security of medical insurance system. Designated medical institutions and their medical insurance service physicians shall strictly implement the provisions of the state and this Municipality on information security to ensure the safety of insured persons and medical insurance data and information.
Twenty-ninth designated medical institutions as mentioned in these Measures refer to designated medical institutions and designated retail pharmacies.
The medical insurance agency refers to the municipal medical insurance center, medical insurance sub-center and municipal medical insurance settlement center.
Medical insurance agreement refers to the agreement signed by medical insurance agencies and medical institutions through consultation, which is used to standardize medical service behavior and clarify the rights, obligations and responsibilities of both parties.
Thirtieth these Measures shall come into force on June 1 day, 2022, and shall be abolished on June 1 day, 2027.