Beijing outpatient medical insurance how to reimbursement

Beijing outpatient medical insurance reimbursement process is as follows:

1, the insured personnel outpatient, hospitalization must present their social security card and swipe the card to the clinic, outpatient must inform the hospital of the type of consultation (such as outpatient chronic diseases, outpatient special), on the failure to present the card or the type of consultation is not clear to inform the insured workers to the medical treatment of the medical expenses incurred by the medical fund will not be paid;

2, the insured personnel in the designated retail pharmacies to buy drugs must present their own card, according to the relevant policies, swipe the card to purchase medicines. If a participant purchases medicine at a designated retail pharmacy, he/she must present his/her citizen card, inform the type of consultation (e.g., outpatient chronic disease, outpatient special), and purchase the medicine with the card according to the relevant policies; if he/she purchases medicine on behalf of another person due to special circumstances, he/she must present the ID cards of the participant and the person who purchases medicine on behalf of the participant and the pharmacy must register the medicine for the record;

3. The outpatient coordination is implemented by the first diagnosis and referral system, which is mainly based on the community health service organizations. Participants can make their first visit to the designated community health service organizations or medical institutions that refer to the community management of the basic medical insurance for urban employees; specialized hospitals can serve as the first medical institution for all the participants. If a participant needs to be referred to a medical institution, the first medical institution shall be responsible for the referral, and emergency treatment and rescue are not subject to this limitation. After the limit of outpatient chronic disease subsidy is used up, participants will enjoy outpatient coordinated treatment directly from the next payment, and they do not need to be referred to the original outpatient fixed-point medical treatment for chronic diseases. After the limit of outpatient specific item subsidy is used up, one must go through the referral procedure and use the general medical record according to the regulations of outpatient coordinated treatment in order to enjoy the outpatient coordinated treatment. Drugs purchased at pharmacies are not eligible for the outpatient coordinated treatment.

Hospitalization medical insurance reimbursement process:

1. When you are admitted to or discharged from the hospital, you must go to the medical insurance management window of each designated medical institution with your medical insurance IC card to go through the registration procedures for entering and leaving the hospital. When you are hospitalized, you will have to pay a deposit for the medical fee in advance, and you will have to pay more or less after you are discharged from the hospital. Medical fees incurred before hospitalization registration are not covered by basic medical insurance. If you are hospitalized due to an emergency and cannot register for hospitalization in time, you should go to the medical insurance management window on the next day after you are admitted to the hospital with a certificate of emergency to make up for the hospitalization procedures (postponed in case of holidays), and you will be responsible for the medical fees that exceed the time limit;

2. Starting line of the integrated fund for the hospitalization of the insured: the starting line varies from place to place and the standard is generally 10% of the average annual salary of the city's employees of the previous year, and it is not covered in the payment of the medical fees in a basic medical insurance settlement year for multiple hospitalizations. In a basic medical insurance settlement year, the medical fees for multiple hospitalizations are calculated cumulatively;

3. If an insured person needs to be referred to a doctor or hospital because of his condition, he must be diagnosed by the deputy chief physician or the head of the department of the designated medical institution at or above the third level and then put forward the opinion of referral, and then his unit will fill in the application form, and then submit it to the municipal social security institution for approval after the approval of the medical insurance management department of the designated institution for the procedure of referral. The procedure.

The transfer is limited to the provincial special hospital, the cost of which will be paid by the person first, and the reimbursement standard should be 10% of the first, and then calculate the amount of reimbursement according to the local regulations;

4. When discharged from the fixed-point medical institution, the fixed-point medical institution will calculate the amount of reimbursement of medical insurance and the amount that the person should pay out of pocket according to the relevant policies, and the reimbursement will be settled by the fixed-point medical institution and the municipal social insurance agency. The reimbursement amount will be settled by the fixed-point medical institution and the urban social insurance agency, and the amount to be paid by the individual will be settled by the fixed-point medical institution and the insured person himself.

In summary, bring all the required information to the relevant departments of the local social security center to apply for processing, after examination, the information is complete and meet the conditions, it can be instantly processed. When the applicant applies for reimbursement of outpatient medical expenses, the amount transferred to the individual account of medical insurance in the current social security year will be deducted first, and then the amount to be reimbursed will be approved.

Legal basis:

Article 28 of the Social Insurance Law of the People's Republic of China

Medical expenses that are in line with the basic medical insurance drug list, diagnostic and treatment items, standards of medical service facilities, as well as those for emergencies and salvages, shall be paid out of the basic medical insurance fund in accordance with state regulations.

Article 29

The portion of the medical expenses of insured persons that should be paid by the basic medical insurance fund shall be settled directly between the social insurance administration organization and the medical institutions and drug business units.

The administrative departments of social insurance and the administrative departments of health shall establish a settlement system for medical expenses incurred for medical treatment in other places, so as to facilitate the enjoyment of basic medical insurance by insured persons.