(A) system networking "one-stop" settlement
65438+Medical expenses that meet the claim conditions from 0: 00 on July 0 to 24: 00 on June 30, 2022 shall be settled simultaneously with basic medical insurance and serious illness insurance.
(II) Sporadic reimbursement and settlement The medical expenses incurred by the insured who do not meet the "one-stop" settlement situation and meet the claim conditions shall be reimbursed and settled sporadically. Under the premise of complying with the relevant policies and regulations of Qingdao basic medical insurance, if the insured fails to settle the medical insurance online in time in this city or other places due to special reasons, it is necessary to submit materials to the service window of the medical insurance agency to apply for medical insurance settlement, and simultaneously settle the reimbursement of Qindao E insurance.
(3) Claims agreement and process for special drugs/materials
1. Application and payment agreement for premium of special drugs/special materials:
(1) Prescription of special drugs/materials: Prescriptions for using drugs or consumables must be made by the responsible doctor designated by the designated hospital of Qingdao Basic Medical Insurance during the insurance period, which belongs to the drugs or consumables necessary for the current treatment of the insured. The dosage of prescription drugs or consumables shall not exceed one month at a time, and the prescription shall not exceed the indication range of the drug or consumables manual. The prescription is valid according to the relevant prescription management regulations of the state or local government departments. According to Article 18 of the Prescription Management Measures issued by the former Ministry of Health, the prescription is valid on the date of issuance. If it is necessary to extend the validity period under special circumstances, the prescriber shall indicate the validity period, but the longest validity period shall not exceed 3 days.
(2) Application for special drugs/materials: If the hospital that issued the prescription does not have corresponding drugs or consumables, it is necessary to purchase drugs or consumables at the designated pharmacy of the product with the prescription and the purchase certificate obtained after approval. This product also supports on-site service by appointment. If the insured (or beneficiary) applies for direct payment of special drugs/special materials purchased at the designated pharmacy, he only needs to pay personal expenses.
(3) Prescription review: this product will review the insured's prescription of special drugs/special materials according to the agreed insurance liability, and the special drugs/special materials shall conform to the trade name, drug name, consumable name, manufacturer, indication and restriction agreement agreed in the Catalogue of Special Drugs/Special Materials. According to the relevant application materials of the insured's prescription of special drugs/special materials, if the following special problems occur in the audit of this product, it will have the right to request to supplement other medical materials related to the audit of special drugs/special materials. The special circumstances of prescription review of special drugs/special materials include, but are not limited to: the medical materials related to special drugs/special materials submitted by the outpatient department (pharmacy) of the insured are insufficient to support the formulation or review of prescriptions of special drugs/special materials; The reported results of relevant scientific inspection methods in medical materials do not support the prescription of special drugs/materials. If the prescription of special drugs/materials fails to pass the examination, this product will not bear the relevant insurance liability.
legal ground
People's Republic of China (PRC) social insurance law
Twenty-eighth medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency treatment and rescue shall be paid by the basic medical insurance fund in accordance with state regulations.
Twenty-ninth medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by the social insurance agency, medical institutions and pharmaceutical business units. The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.