Zhengzhou City employee health insurance outpatient reimbursement

Zhengzhou City workers' health insurance outpatient reimbursement process:

1, the insured person outpatient, hospitalization must present their social security card and swipe the card to the clinic, outpatient clinic must inform the hospital of the type of consultation (such as outpatient chronic diseases, outpatient special), the failure to present the card or the type of consultation to inform the unclear, the insured employee medical expenses incurred in medical treatment, the health insurance fund will not be paid;

2, the insured person When purchasing medicines at designated retail pharmacies, the insured person must present his/her citizen card, inform the type of consultation (e.g. outpatient chronic diseases, outpatient specialties), and purchase medicines with the card according to the relevant policies; when purchasing medicines on behalf of another person due to special circumstances, the ID cards of the insured person and the person on behalf of whom the medicine is purchased must be presented and the pharmacy must register the medicines for the record;

3. Outpatient care is coordinated through the first-visit and referral system, which is mainly implemented by 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 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, outpatient coordinated treatment can only be enjoyed if referrals are made in accordance with the outpatient coordinated treatment regulations and general medical records are used. Purchase of medicines at pharmacies is not eligible for outpatient coordinated treatment.

Medicare reimbursement includes:

1. medical expenses during resuscitation;

2. medical expenses during hospitalization;

3. surgical materials and auxiliary appliances;

4. bed charges: according to the standard of the local medical insurance. If due to acute - traumatic brain injury, complex visceral injury coma need to stay in ICU (intensive care unit) except, but out of danger should be immediately transferred to the general ward;

5, rehabilitation and physical therapy fees: according to the local health insurance standards. In principle, not more than 3 kinds of rehabilitation physiotherapy outside the scope of medical insurance will not be compensated;

6, drug replacement and rehabilitation function guidance training: according to the local medical insurance standards combined with the needs of the condition approved;

7, ambulance fees: according to the local health department and the price department of the approved standards;

8, other costs: in accordance with the provisions of the uncompensated costs will not be compensated;

9. Renewal of medical expenses: the insured can pay in advance for the future determinable and necessary renewal of medical expenses for the injured in order to close the case in advance. Must be in the discharge certificate or diagnostic certificate of the competent doctor has a clear record of the need to continue treatment or half a year, a year after the removal of internal fixation or regular review or record the follow-up treatment costs, while the compensation provided by the insurance payment vouchers on the record of the follow-up costs have been paid to review the medical fee. The review of renewal fees will be based on the needs of the medical condition and will not be reimbursed for expenses that are clearly beyond the needs of the medical condition.

In summary, bring all the required information to the relevant departments of the local social security center to apply for processing, after review, complete information, eligible for immediate processing. 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 12 of the Social Insurance Law of the People's Republic of China

The employer shall pay the basic pension insurance premiums in accordance with the ratio of the total wages of the employees of the employer as stipulated by the State, and credit it to the Basic Pension Insurance Co-ordination Fund. Employees shall pay basic pension insurance premiums in proportion to their own wages as prescribed by the State and credit them to their individual accounts. Individual business households without employees, part-time workers who do not participate in the basic pension insurance in the employer and other flexible employment to participate in the basic pension insurance, should pay the basic pension insurance premiums in accordance with the state regulations, respectively, credited to the basic pension insurance fund and individual accounts.