Dongguan social security reimbursement scope

Social security reimbursement is divided into medical insurance reimbursement, maternity insurance reimbursement and workers' compensation insurance reimbursement, and the use of social security card reimbursement should refer to the medical insurance reimbursement, the employee in the hospital for treatment can be used to medical insurance direct billing, if there is no direct billing is the reimbursement process is as follows:

Medical reimbursement

One, outpatient clinics

(a) the use of the medical insurance card to outpatient clinics see a doctor, real-time settlement, without reimbursement.

(2) If you visit the outpatient clinic without a medical insurance card, please use the Beijing Medical Insurance Handbook (medical blue book).

1. Scope of reimbursement: general outpatient and emergency expenses incurred by the insured person at the medical insurance designated hospitals or specialized hospitals of his/her choice, Chinese medicine hospitals and Class A hospitals.

2. Outpatient starting line: general outpatient and emergency expenses incurred in a natural year exceeding 1,800 yuan in total.

3. Reimbursement rate: 70% for hospitals and 90% for communities for the portion above 1800 yuan, and the ceiling line: 20,000 yuan.

4. Required materials:

Original ID card;

Original medical diagnostic certificate;

Original medical documents such as outpatient medical records, report cards of examination and test results;

Original receipts of fees for general outpatient services and emergency services,

Original list of outpatient expenses or original prescriptions (the prescriptions are pasted on the back of the receipts according to the date). ).

5. Submission time: 1-10th of each month, the current month's fees to be submitted the following month, the current year's fees need to be submitted by January of the following year.

6. Process: If the total amount exceeds the starting standard in a natural year, the unit operator will enter all the documents into the enterprise version of the software, and report the generated electronic information and statements to the medical insurance center, which will complete the audit, settle the accounts, and pay the reimbursement fees within 30 working days.

II. Hospitalization

1. Reimbursement scope: hospitalization expenses incurred by insured persons at the designated hospitals or specialized hospitals of medical insurance of their choice, Chinese medicine hospitals and Class A hospitals.

2. Starting line for hospitalization: the starting line for the first hospitalization in a natural year is 1,300 yuan, and 650 yuan for each subsequent hospitalization.

3. Reimbursement rate: 90% for Class I hospitals, 87% for Class II hospitals, 85% for Class III hospitals, and a cumulative reimbursement of 300,000 yuan for hospitalization.

4, the process: please use the "Beijing Municipal Health Insurance Manual" when seeking medical treatment, if the unit pays in full, the individual only needs to pay part of the hospitalization advance payment, you can go through the hospitalization procedures, the medical expenses incurred should be in line with the scope of medical insurance, the hospital and the individual to clear the amount of out-of-pocket expenses when the hospital is discharged, and the amount of reimbursement of the integrated fund will be settled by the hospital and the district health insurance center.

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