How much can you get reimbursed for an outpatient visit to a third-party health insurance

Three-tier Medicare outpatient visits can be reimbursed about eighty percent.

Third-class social security card has a year's worth of outpatient expenses, about a thousand yuan balance, in the medical treatment can be reimbursed about 80 percent.

If it's part of a general outpatient visit, then Class A and Class I drugs are reimbursed at 80 percent and 60 percent. One-way diagnosis and treatment and medical materials belonging to the medical insurance catalog can be reimbursed 90 percent, but the maximum payment can only be 120 yuan. And the community outpatient coordinating fund pays for the medical expenses of Shenzhen's three classes of social security participants not exceeding 1,000 yuan a year. Outpatient large equipment examination and treatment costs for a single maximum payment of no more than 120 yuan. If it is an outpatient major illness, then it can pay 60-90 percent according to the length of time.

Application for reimbursement process:

1, application

Applicants go to the window to submit application materials after pre-application in the provincial government service network;

2, acceptance of materials

The front desk clerk examines and approves the applicant's conditions of application and application materials;

3, contractor

After the acceptance department receives the application materials, the The back-office operator reviews within 1 working day whether the statutory conditions for reimbursement are met and whether the statute of limitations is correct, and, at the same time, determines whether it is necessary to submit supplementary materials, and, if supplementary materials are required, shall issue the "Notice of Supplementary Materials for Approval of Social Health Insurance Expenses" within 2 working days to inform the applicant of all the contents to be supplemented at once, and the participant is required to make up all the materials within 5 working days after the receipt of the notice of supplemental materials, and, if the materials are not supplemented, the operator shall notify the applicant at once. If no correction is made, the operator will make a decision of approval or disapproval according to the existing materials; in the case of disapproval, if the applicant meets the conditions of application, he/she can make a new application according to the provisions of the law within the statutory period of validity after preparing all the materials;

4. Audit

The operator will carry out a detailed audit on the list of reimbursement within 5 working days, and the business will be sent to the approver after confirming that there is no error;

5. 5、Approval

The approver will approve the claim within 2 working days, and after checking the corresponding information and confirming that there is no error, make a decision on whether the claim should be approved or rejected;

6、Completion

After the approval is completed, the business will be completed instantly, and the system will automatically send the relevant information of the completed business to the finance department and the window acceptance platform;

7、Delivery

After receiving the information on business completion, the staff will issue the Decision on Approval of Social Health Insurance Expenses and Reimbursement of Social Health Insurance Expenses if it is approved, or issue the Decision on Disapproval of Social Health Insurance Expenses if it is not approved, and the documents will be delivered by mail or window according to the wishes of the participants.

In summary, the three-stage medical insurance reimbursement rate is not fixed, the reimbursement rate for different conditions is different, general outpatient reimbursement of 80% of Category A drugs, Category B drugs reimbursement of 60%.

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 catalog, diagnostic and therapeutic items, standards of medical service facilities, as well as those for emergency and rescue, shall be paid from 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.