Flow chart of medical insurance reimbursement for employee outpatient service

Medical insurance refers to the basic medical insurance premium paid in full and on time by employers and employees according to the principle of compulsory social insurance through national legislation. If it is not paid in full and on time, the basic medical insurance fund will not pay its medical expenses regardless of individual accounts.

Outpatient medical insurance reimbursement process and matters needing attention:

When reimbursing, you must bring the following information:

1, original ID card or social security card;

2, the original certificate of disease diagnosis issued by the designated medical institutions;

3, outpatient medical records, inspection, test results report and other original medical information;

4. Original receipt of outpatient charges of medical institutions with unified finance and taxation;

5. The detailed list of outpatient expenses printed by the hospital computer or the original payment of prescriptions issued by doctors;

6. Designated pharmacies: unified original invoices and computer-printed sales lists of taxable goods;

7. If it is an agent, you need to provide the original ID card of the agent.

Bring all the above information to the relevant departments of the local social security center. Upon examination, if the information is complete and meets the requirements, it can be handled immediately. When applying for reimbursement of outpatient medical expenses, the applicant should first deduct the amount allocated to the personal account of medical insurance in this social security year, and then verify the amount to be reimbursed.

The reimbursement process and matters needing attention of hospitalization medical insurance;

1. When entering or leaving the hospital, you must go through the registration formalities with the medical insurance IC card at the medical insurance management window of each designated medical institution. When in hospital, the individual pays the deposit of medical expenses in advance, and pays more and less after discharge. Medical expenses incurred before hospitalization registration are not included in the payment scope of basic medical insurance. If the emergency hospitalization fails to go through the hospitalization registration formalities in time, the emergency certificate should be used to go through the hospitalization formalities at the medical insurance management window the day after admission (postponed in case of holidays), and the overdue medical expenses should be borne by themselves.

2. The deductible line of the overall fund after the insured person is hospitalized: the deductible line varies from place to place, which is generally 10% of the average annual salary of employees in the whole city in the previous year. In a basic medical insurance settlement year, the medical expenses for multiple hospitalizations are calculated cumulatively.

3. If the insured person needs to be referred or transferred due to illness, the deputy chief physician or chief physician of the designated medical institution at or above the third level shall put forward the opinions of referral (hospital) after diagnosis, and the unit to which he belongs shall fill in the application form and go through the referral (hospital) formalities with the approval of the medical insurance management department of the designated medical institution.

The transfer is limited to provincial specialized hospitals, and the expenses are paid by me first. The reimbursement standard is 10% first, and then the reimbursable amount is calculated according to local regulations.

4. When the designated medical institutions are discharged from the hospital, the designated medical institutions will calculate the reimbursement amount of medical insurance and the amount that individuals should pay. The reimbursement amount will be settled by the designated medical institutions and urban social insurance agencies, and the amount that individuals should pay will be settled by the designated medical institutions and the insured.

Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.