Frequently asked questions of social basic medical insurance in Dongguan

Frequently asked questions of social basic medical insurance in Dongguan

Four, the relevant provisions of outpatient treatment and treatment declaration

23. How can the insured enjoy the basic medical treatment of outpatient service?

Outpatient medical treatment shall implement the designated medical system, and the insured person shall seek medical treatment at the designated outpatient medical point or meet the prescribed outpatient referral, rescue or emergency medical expenses, which may be paid by the overall fund according to the regulations.

24. The insured person goes to the designated outpatient clinic for medical treatment. How to handle the relevant medical treatment and reimbursement procedures?

(1) Registration: The insured person shall go through the registration formalities at the designated outpatient registration office with his social security card and ID card (ID card for those who have not issued social security cards, and his social security card for those below 18).

(2) Outpatient treatment: The attending doctor provides outpatient treatment services for the insured. When the insured needs to use drugs, materials, inspection and treatment items at his own expense or partially at his own expense due to illness, it must be confirmed by the insured or his family.

(3) reimbursement of outpatient medical expenses: the insured person can go through the reimbursement procedures on the spot with his social security card, ID card and outpatient prescription. And the insured only needs to pay part of the expenses at his own expense.

25. How to understand the basic outpatient medical expenses?

Outpatient basic medical expenses refer to outpatient medical expenses that meet the relevant provisions of outpatient medical management, medical insurance outpatient drug list, diagnosis and treatment items, service facilities and payment standards.

26. How is the designated outpatient medical point determined?

According to the principle of territoriality, a designated community health service institution is designated as the outpatient service point of the insured person within the jurisdiction of the village (neighborhood) Committee (i.e.? Designated clinic? ); If there are no designated community health service institutions in China, the adjacent designated community health service institutions shall be designated as temporary designated outpatient service points.

27. If the residence of the insured registered in this city is not in the same village (neighborhood committee) as the designated outpatient medical point, how to determine the designated outpatient medical point?

Where the residence and the designated outpatient medical point belong to the same town (street) but not in the same village (neighborhood) committee, the insured with the household registration in this city need to change the designated outpatient medical point to the residence, and apply to the designated community health service institution in this town (street) with my social security card and ID card. After approval, his outpatient clinic can be changed to a designated outpatient clinic in the same town (street).

28. Can I change it halfway after I have determined the designated outpatient point?

In the following cases, the system will automatically change the designated outpatient points when handling the change of the insured relationship, and the change will take effect the following month:

Migration of employers;

● The insured person changes the work unit;

● The household registration migration of the insured registered in this city;

● The change of residence of the insured registered in this city;

● Other circumstances stipulated by the social security department.

29. Can I go to a medical institution other than the designated clinic?

The insured person can only enjoy the corresponding outpatient medical treatment according to the regulations if he visits the designated outpatient medical point. If it is really necessary to go to a higher medical institution for treatment due to illness, it shall be referred to the designated outpatient medical point according to the principle of step-by-step referral, and then transferred to the town (street) community health service center. If he needs to be referred again, the community health service center will refer him to the outpatient department of the headquarters of the town (street) designated hospital, the outpatient department of the municipal designated specialist hospital or the outpatient department of the municipal designated tertiary hospital. Because of the urgent need of illness, it can be directly referred by the designated clinic.

Outside the designated outpatient hours, you can go directly to the town (street) community health service center for emergency treatment. Outpatient rescue can go directly to the medical institutions in the city.

30. If I really need a referral, how should I go through the referral procedures?

If the attending doctor of the designated outpatient clinic makes a referral according to the condition of the insured, fill in? Recommendation notice? , reported to the designated community health service center for approval, the insured can be referred.

3 1. What's the difference between the payment standards of pooling funds for various medical conditions?

(1) The basic medical expenses incurred by the insured person during the designated outpatient time due to emergency directly to the town (street) community health service center shall be paid by the overall fund according to the regulations.

(2) the insured person directly to the town (street) community health service center outpatient rescue of basic medical expenses, the overall fund to pay in accordance with the provisions; The proportion of basic medical expenses incurred by direct visits to designated outpatient clinics and outpatient rescue in medical institutions outside the town (street) community health service center will be reduced by 10%.

(3) The designated outpatient service is referred to the community health service center, and the overall fund is paid as required; Transferred to the outpatient department of the town (street) designated hospital headquarters or the outpatient department of the municipal designated specialized hospital headquarters, the proportion of overall fund payment decreased by10%; Transfer to the outpatient department of the designated tertiary hospital in the city, and the payment ratio will be reduced by 20%; Transferred to other medical institutions, the overall fund will not be paid.

(4) In addition to the above situation, the insured person goes to a medical institution other than the designated outpatient clinic for medical treatment, and the overall fund will not pay.

32 in the town (street) community health service center referral, outpatient rescue or emergency expenses, can directly handle the reimbursement procedures in the center?

The outpatient rescue or emergency expenses incurred by the insured in the town (street) community health service center can be directly reimbursed in the center.

33. If you refer to the outpatient department of a designated hospital in the city, can you go through the on-site reimbursement procedures directly in the hospital?

The insured person refers to the outpatient medical expenses of the headquarters outpatient department of the designated hospital in the city, and can go directly to the outpatient charge office of the designated hospital for reimbursement after seeing a doctor.

34. Can I go through the on-site reimbursement procedures for emergency treatment in the outpatient service of medical institutions in the city?

I can't. In this case, the basic medical expenses shall be paid in advance by the insured, and the insured shall return to the designated community health service center in this town (street) for reimbursement within 30 days after receiving medical treatment: the original receipt of medical charges, a copy of outpatient medical records, a copy of detailed list of medical charges (or outpatient prescriptions), a copy of inspection and laboratory results reports, social insurance cards and ID cards and other related materials.

35. What are the rules for reimbursement of outpatient medical expenses?

The medical expenses incurred by the insured in the outpatient clinic according to the regulations shall be handled in accordance with the following provisions:

Use our city? What is the scope of social basic medical insurance and community health service outpatient drugs? (hereinafter referred to as the scope of community outpatient drugs), and strictly control the dosage. Outpatient acute diseases generally do not exceed three days, chronic diseases generally do not exceed seven days, and specific outpatient services generally do not exceed one month, of which intravenous medication does not exceed one day;

2 use? What are the basic medical insurance treatment items, medical service facilities and payment standards for employees in Dongguan? Hereinafter referred to as the diagnosis and treatment projects and medical service facilities) within the scope of the diagnosis and treatment projects or medical materials, the single cost is lower than 120 yuan (including 120 yuan, the same below) according to the provisions of the overall fund to pay;

For example, if the single cost of a medical material used by the insured is 100 yuan, the project can be reported as 100 * 60% = 60 yuan; B If the single expense of the insured for using a medical material is 150 yuan, the item can be reported as 120*60%=72 yuan.

(3) the use of traditional Chinese medicine prescription, each prescription within 3 doses of basic medical expenses paid by the overall fund in accordance with the provisions;

(4) The expenses incurred by drugs and medical treatment projects beyond the above-mentioned provisions or using community clinics, medical treatment projects and medical service facilities shall be paid by the insured.

36. Can the insured handle the on-site reimbursement procedures when the equipment in the designated outpatient clinic fails or other reasons cannot handle the computer settlement?

You can handle it. If the computer settlement cannot be handled in the designated outpatient clinic due to equipment failure, the person in charge of the designated outpatient clinic will manually calculate the insured person's personal payment amount and social security bookkeeping amount according to the medical insurance policy, and then fill it in manually? Outpatient fee receipt? (Invoice) in triplicate, collect the amount paid by the insured on site and complete the reimbursement procedures.

37. The insured person's information is unclear, and it is impossible to apply for on-site reimbursement at the designated outpatient clinic or the town (street) designated community health service center. What should I do?

Because? Arrears? Or the names in the social security system are inconsistent, and the insured information is not clear, so it is impossible to go through the reimbursement procedures in the designated community health service institutions. The medical expenses are paid by the insured first, and the manager of the toll office is there? Outpatient fee receipt? The reason is written and stamped on the back of the first copy (invoice)? Special seal for medical insurance? What happened after that, Will? Outpatient fee receipt? (Invoice) First copy to the insured.

If the social security department confirms that you can enjoy medical insurance benefits, what can the insured base on? Outpatient fee receipt? The first copy (invoice), the detailed list of outpatient medical records and the receipt of medical expenses (copy of outpatient prescription), Recommendation notice? (Referral patients only), copies of test results reports, social insurance cards, ID cards and other related materials shall go through the reimbursement procedures at the community health service center designated by the town (street).

38. Can the referral notice be used multiple times?

It can be used several times according to the condition during the validity period of referral. When the attending doctor makes a referral according to the insured's condition, he must be in? Recommendation notice? Indicate the validity period of referral, and the insured can transfer information according to the condition? Recommendation notice? Use it many times after copying.

39. Under what circumstances can outpatient service not be reimbursed?

In any of the following circumstances, the overall fund will not pay:

(1) unable to produce valid identification materials for medical treatment;

(2) beyond the scope of payment of basic medical insurance;

(3) Lending my social insurance card to others for use, fraudulently using other people's certificates or deliberately forging or altering prescriptions, diagnosis certificates and other related materials;

(4) Medical expenses incurred due to the insured's request for medical treatment that is not suitable for the illness or unreasonable and compliant;

(5) Go to a medical institution other than the designated outpatient service for medical treatment (except for outpatient rescue and emergency treatment that meet the requirements).

40. Under what circumstances can I not enjoy the basic medical insurance benefits?

(1), paid from the industrial injury insurance fund;

(2) It shall be borne by a third party;

(3), should be borne by public health;

(4) Go abroad for medical treatment.

4 1. How can the insured who has applied for resettlement enjoy outpatient medical treatment?

The insured person who has applied for settlement in different places, the outpatient medical insurance premium is allocated to the insured person's outpatient medical treatment once a year, and no longer enjoys the overall treatment of outpatient service in our city.