Standard of insurance reimbursement process, reimbursement conditions and reimbursement time

How to reimburse social medical insurance?

Social medical insurance reimbursement flow chart

Description of drug purchase and medical insurance reimbursement:

Insured persons can purchase medicines at designated medical institutions and retail pharmacies with medical insurance cards, and their medical expenses can be settled directly by credit card. When purchasing drugs, they are not included in the overall social planning, and all of them are paid by personal accounts. If the personal account runs out of funds, you can pay in cash.

Outpatient medical insurance reimbursement process and matters needing attention:

The following information must be brought when submitting the reimbursement form: 1. Original ID card or social security card; 2. The original disease diagnosis certificate issued by the designated medical institution; 3. Outpatient medical records, inspection, test results report and other medical materials; 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 at the medical insurance management window of each designated medical institution with a medical insurance IC card. 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. After the insured is hospitalized, the deductible line of the overall fund is different from place to place, which is generally 10% of the average annual salary of employees in the 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.

How to reimburse commercial medical insurance?

Situation 1: People who reimburse insurance for additional expenses.

According to the principle that social insurance takes precedence over commercial insurance, after social medical insurance is generally paid, the insurance company will pay for the remaining medical expenses.

Youbao's expert. Com said that the insurance company will first determine the items that can be paid according to the insurance terms (generally consistent with the scope of social security claims), and then deduct the amount already paid by social security to get the actual amount of compensation.

Example: Assume that the commercial insurance coverage is 5,000 yuan, and the total medical expenses incurred are10,000 yuan, all within the insurable range. Commercial insurance payout ratio 90%, deductible 100 yuan. Then, the number of commercial insurance claims is (10000-100) × 90% = 8910 yuan. After 80% social security reimbursement, there is still 2,000 yuan left, which is within the range of 89 10, and does not exceed the insured amount, so all 2,000 yuan is borne by the insurance company.

In the above situation, if the insurance coverage of commercial insurance is less than 2,000 yuan, the insurance company's claims will be limited to the insurance coverage.

Youbao's expert. Com suggests that social security agencies and insurance companies should submit their invoices for reimbursement, especially when social security requires the original. Therefore, when applying for social security reimbursement, staff should be reminded to issue separate invoices for later commercial insurance reimbursement applications.

If the employer pays the medical expenses, the individual shall be regarded as social insurance when taking out insurance.

Situation 2: People who supplement the critical illness insurance and subsidy insurance.

These two kinds of commercial insurance and social medical insurance do not conflict when settling claims. Youbao.com experts said that commercial critical illness insurance is generally paid after diagnosis. Even if the treatment has not started at the time of application, the insured can get the insured amount at one time with the confirmation certificate issued by the hospital, so as to ensure that there is sufficient treatment funds at the first time and the follow-up treatment can be carried out smoothly.

Similarly, subsidized insurance cannot be reimbursed by invoices. As long as you provide proof of surgery or hospitalization (specific product regulations), you can get insurance money from the insurance company as compensation for lost time or nutrition expenses.

After receiving the critical illness insurance money or allowance, the insured can still apply to the social security agency for reimbursement of medical expenses with the medical expense invoice.

As can be seen from the reimbursement situation, commercial health insurance can appropriately supplement social medical insurance, so as to increase the amount of protection, enhance the timeliness of insurance and increase the number of protection items.

How to enjoy basic medical insurance benefits according to regulations?

If the insured who has continuously participated in the basic medical insurance for more than 1 year is interrupted for no more than 3 months in the 1 medical insurance year due to job changes, the continuous enrollment years before and after the interruption can be combined and calculated, and after re-payment, they can enjoy the basic medical insurance benefits; In the medical insurance year, the cumulative interruption of insurance for more than 3 months is recalculated.

After retirement, men who have paid the basic medical insurance premiums for 25 years and women who have paid the basic medical insurance premiums for 20 years shall go through retirement procedures in accordance with state regulations. Those who receive the basic pension or retirement fee on a monthly basis will enjoy the basic medical insurance benefits for retirees and will no longer pay the basic medical insurance premium.

Personal accounts pay the following medical expenses: outpatient and emergency medical expenses; The cost of purchasing drugs at designated retail pharmacies; Medical expenses below the Qifubiaozhun of the basic medical insurance pooling fund; Medical expenses that exceed the qifubiaozhun of the basic medical insurance pooling fund and should be borne by individuals in proportion. The insufficient payment of personal account shall be paid by myself.

The basic medical insurance fund pays the following medical expenses: hospitalization expenses; Emergency rescue observation and income hospitalization, medical expenses within 7 days before hospitalization observation; Outpatient medical expenses of taking anti-rejection drugs after radiotherapy and chemotherapy, renal dialysis and renal transplantation for malignant tumors.

The basic medical insurance fund will not pay the following medical expenses: seeing a doctor in a medical institution other than the medical institution designated by me, except for emergency; Buying drugs at non-designated retail pharmacies; Injuries caused by traffic accidents, medical accidents or other accidents; Drug abuse, fighting or other illegal acts cause injuries; Treatment for suicide, self-mutilation, alcoholism and other reasons; Treatment abroad or in Hongkong, Macao Special Administrative Region and Taiwan Province Province; In accordance with the provisions of the state and this Municipality, it shall be paid by individuals.

Specific reimbursement conditions and procedures of Beijing medical insurance

First, outpatient expenses.

(1) Reimbursement scope: general outpatient and emergency expenses incurred by the insured in designated medical insurance hospitals or specialized hospitals, traditional Chinese medicine hospitals and 3A hospitals (Friendship, Xuanwu, Guang 'anmen Traditional Chinese Medicine, Tongren, Sheikh, Third Hospital of Beijing Medical University, Peking University People, Peking University One, Jishuitan, Chaoyang, Gong Jian and Liangxiang).

(2) Reimbursement ratio: the total emergency expenses of general outpatient clinics in a natural year exceed 2,000 yuan, 50% of which are paid by some large medical mutual funds with a price of more than 2,000 yuan, and 50% are paid by individuals themselves. The retirees have accumulated more than 1.300 yuan, and the part exceeding 1.300 yuan is covered by the large-scale medical mutual aid fund over 70 years old, with 70% paid by individuals, 30% paid by individuals, 80% paid by the large-scale medical mutual aid fund over 70 years old and 20% paid by individuals. The maximum payment limit in a natural year is 20000 yuan.

(3) Medical management: individual cash payment for general outpatient and emergency expenses, and the medical expenses incurred shall conform to the scope of the three major medical insurance catalogues. When purchasing drugs, special prescriptions should be issued in designated hospitals and stamped with the special seal for medical insurance outsourcing, and then drugs should be purchased in designated pharmacies.

(4) Reimbursement process: If the cumulative Qifubiaozhun exceeds the minimum Qifubiaozhun in a natural year, the insured shall submit the documents to the unit or social security office, which will enter the documents into the enterprise version and declare the electronic information and documents to the medical insurance center. The medical insurance center will complete the examination, settlement and payment within 15 working days.

(5) Application materials: general outpatient and emergency receipts, medical insurance prescriptions (dual-price prescriptions), and details of examination and treatment expenses.

(VI) Date of declaration: every month1-20th, the expenses of the current month will be declared next month, and the expenses of the current year will be declared again before1October 20th, 65438+.

Second, the hospitalization expenses

(1) Reimbursement scope: hospitalization expenses incurred by the insured in designated hospitals or specialized hospitals, Chinese medicine hospitals and 3A hospitals selected by the individual.

(2) Reimbursement ratio: The minimum threshold for the first hospitalization in a natural year is 1.300 yuan, and 650 yuan every time thereafter. The payment ratio is divided into three grades. Take a tertiary hospital as an example. The floating standards are: 30,000 yuan, 85% on the job, 9 1% for retirement, 90% for 30,000-40,000, 94% for retirement, more than 40,000, 95% for employment and 97% for retirement. 90 days of general hospitalization is a settlement cycle. Psychiatric hospitalization for 360 days is a settlement cycle, and the floating standard is halved. In a natural year, the overall fund pays a maximum of 70,000 yuan. The maximum hospitalization amount is 654.38+10,000 yuan, and the hospitalization ratio is 70%.

(3) Medical management: Please use the Beijing Medical Insurance Manual for medical treatment. If the unit pays in full, the individual only needs to pay part of the hospitalization prepayment to go through the hospitalization procedures. The medical expenses incurred should conform to the scope of the three major catalogues of medical insurance.

(IV) Reimbursement process: When leaving the hospital, the hospital and the individual will settle the self-funded and self-funded amount, and the reimbursement amount of the overall fund will be settled by the hospital and the district medical insurance center.

Third, outpatient special diseases

(1) Reimbursement scope: outpatient medical expenses incurred by the insured after going through the examination and approval procedures for special diseases due to radiotherapy and chemotherapy for malignant tumors, renal dialysis and taking anti-rejection drugs after renal transplantation.

(2) Reimbursement ratio: Reimbursement ratio is the same as hospitalization. The settlement period of outpatient special diseases is 360 days.

(3) Medical management: the insured can only choose one hospital as the designated hospital for special diseases. Please use the Beijing Medical Insurance Manual for medical treatment. If the unit pays the full amount, the individual only needs to pay the personal out-of-pocket expenses and the self-funded part, and the reimbursement amount of the overall fund is settled by the hospital and the district medical insurance center.

(4) Reimbursement process: the insured submits the documents to the unit or social security office, and the unit declares the documents to the medical insurance center. The medical insurance center completed the audit, settlement and payment on the same day.

Medical insurance reimbursement needs to be submitted to the local medical insurance management center or the medical insurance checkout window of designated medical institutions. Procedures include: my ID card, medical insurance card, original invoice, medication list, medical records and other materials. It is very convenient to reimburse at the medical insurance checkout window when leaving the hospital.

The reimbursement regulations for medical insurance clinics vary from place to place. Above the deductible line, only outpatient expenses for special diseases are generally reimbursed. For example, Chengdu stipulates that outpatient reimbursement can only be enjoyed for dozens of diseases such as chronic leukemia, outpatient radiotherapy and chemotherapy for malignant tumors, peritoneal dialysis and hemodialysis for chronic renal failure, organ transplantation, diabetes, essential hypertension, multidrug-resistant tuberculosis and schizophrenia, as well as some routine examinations and infusions, but you can't enjoy outpatient reimbursement when you see a cold in the hospital. Urban workers can not enjoy outpatient reimbursement for gastric lavage, blood routine, skin test, intramuscular injection and other expenses like urban and rural residents. The reimbursement rate for outpatient service is about 80%.

Not all hospitalization expenses will be reimbursed, but the reimbursement ratio is (total cost-threshold fee-self-funded part-self-funded part) *, the reimbursement ratio is =[(75+ age *0.2)/ 100], and the threshold fee is linked to the hospital level, namely, the first-level hospital 200 yuan, the second-level hospital 400 yuan and the third-level hospital 800 yuan. Generally speaking,