Interpretation of direct settlement policy of Handan medical insurance hospitalization in different places

I. Drafting background and policy basis

In order to fully implement the relevant requirements of the National Medical Insurance Bureau and the Ministry of Finance on standardizing the direct settlement of inter-provincial hospitalization expenses, according to the Notice of Ministry of Human Resources and Social Security and the Ministry of Finance on Doing a Good Job in the Direct Settlement of Inter-provincial Hospitalization Expenses for Basic Medical Insurance, the notice of the Ministry of Finance on printing and distributing the Accounting System for Social Insurance Funds, and the notice of the National Medical Insurance Bureau and the Ministry of Finance on doing a good job in the direct settlement of inter-provincial hospitalization expenses in 2020, we will speed up the improvement of the settlement service for medical treatment in different places. Improve the management mechanism of direct settlement of medical insurance hospitalization in different places, further improve the direct settlement of medical insurance hospitalization in different places in our province, effectively protect the rights and interests of insured persons in different places, and ensure the safe, standardized and effective operation of the fund. Combined with the reality of our province, the direct settlement process of medical insurance hospitalization in different places in Hebei Province was studied and formulated.

Second, the main content of "handling procedures"

Procedures for handling cases Chapter XI, Article 58. It is divided into general principles, scope objects, registration and filing, medical settlement management, medical expense reconciliation, advance payment management, medical expense settlement, fund financial management, business collaborative management, audit supervision,

The first chapter is the general provisions, with 6 articles in total. Clarify the policy basis, work content and management principles for formulating handling procedures. The second chapter is the scope object, the article *** 1. Clarify the scope of medical personnel in different places. The third chapter is registration and filing, with 5 articles in total. Clear the way and process of medical registration in different places. Chapter IV Management of Medical Settlement, with 8 articles in total. Clarify the settlement process, fee transfer requirements and settlement policies for medical treatment in different places. The fifth chapter is the reconciliation of medical expenses, with 4 articles in total. Clarify the definition, workflow and time limit of medical expense reconciliation. The sixth chapter is the management of advance payment, with 8 articles in total. Clarify the definition, approved amount, payment process and time limit of advance payment, clearly establish the advance warning and increase mechanism, and standardize the increase and payment process of advance payment. The seventh chapter is the liquidation of medical expenses, with 7 articles in total. Clarify the definition, process, time limit and liquidation method of medical expenses liquidation, and establish a liquidation fund notification system. The eighth chapter is the financial management of funds, which consists of two articles. Clearly establish provincial and municipal financial accounts for medical treatment in different places, and standardize accounting treatment for medical treatment in different places. The ninth chapter is business collaborative management, with 6 articles in total. Clearly rely on the national telemedicine settlement system business collaboration module and the national telemedicine filing applet to establish a telemedicine business collaboration management mechanism. Chapter 10 is auditing and supervision, with 6 articles in total. It is clear that the medical service behavior of medical treatment in different places is supervised by the medical treatment place, and the direct settlement of medical treatment in different places is included in the agreement management. Chapter 11 is the supplementary provisions, with 5 articles in total. Clarify the file management, work requirements and implementation time of medical treatment in different places.

Three, the characteristics of "handling procedures"

Standardize the content of medical treatment in different places. The insured mentioned in the Handling Regulations refers to urban workers and urban and rural residents who participate in the basic medical insurance in Hebei Province. Direct settlement of hospitalization in different places refers to the behavior that the insured person is hospitalized in a designated medical institution that has opened direct settlement of medical treatment in different places outside the insured place, and realizes direct settlement of hospitalization through the settlement system of medical treatment in different places, including direct settlement of medical treatment in different provinces and direct settlement of medical treatment in different places in the province.

Standardize the scope of medical treatment in different places. It is clear that the direct settlement personnel for medical treatment in different places are divided into two categories: long-term residents in different places and temporary medical personnel.

Simplify the filing process of medical treatment in different places. Simplify the filing procedures for medical treatment in different places. Medical personnel in different places can apply for medical treatment in different places by themselves through the official WeChat account or portal of the medical security department, so as to realize the service of "running errands without meeting" in different places and provide more convenient and efficient medical services for the masses. At the same time, the insured person can also go to the medical insurance agency in the insured place to handle it.

Clarify the content of prepayment management. It is clear that the advance payment for inter-provincial medical treatment in different places is approved in principle according to the amount that can pay the medical expenses for inter-provincial medical treatment in different places for six months in the previous year, and it is liquidated once a year. Establish an advance warning and increase mechanism. When the utilization rate of advance payment reaches 90% or above, it is a red warning, and medical provinces can apply for an emergency increase of inter-provincial advance payment for medical treatment, which refines the process and time limit for advance payment increase.

Standardize the liquidation process of medical expenses. It is clear that the clearing of direct settlement expenses for cross-provincial medical treatment in different places will be allocated by provincial agencies and other provinces according to the facts, and the clearing of direct settlement expenses for medical treatment in different places in the province will be organized by provincial medical insurance agencies to further standardize the clearing process and time limit of medical expenses.

Standardize the financial management of funds. It is clear that provincial financial departments should set up special accounts for medical treatment in different places, provincial medical insurance agencies should set up "provincial special accounts for medical treatment in different places" and municipal medical insurance agencies should set up "municipal special accounts for medical treatment in different places". Combined with the actual work, the accounting treatment of medical treatment in different places has been improved, the financial management of medical treatment funds in different places has been standardized, and the safe operation of funds has been ensured.

Establish a working mechanism for collaborative management of medical services in different places. Clearly relying on the business system module of the national remote medical treatment settlement system and the national medical insurance remote filing applet, we will establish three collaborative management mechanisms: remote medical treatment settlement fees, collaborative problem handling and information sharing, clarify the work content, and strengthen the management of remote medical treatment settlement business.