Shanghai retiree hospitalization reimbursement process

Shanghai inpatient medical insurance reimbursement process:

(1) When we make medical insurance reimbursement, the first thing we need to do is to show the medical insurance card to the designated hospital to prove the identity and registration of the insured. The part of medical insurance reimbursement is settled by medical insurance and hospitals, and individuals do not need to pay in advance before reimbursement. At the time of checkout, the part paid by the individual is paid by the balance of the medical insurance card and cash.

(2) After receiving the reimbursement materials, the window staff will issue the Receipt of Hospitalization Medical Expenses of Shanghai Insured Persons to the insured persons.

(3) 15 working days later, according to the needs, the insured in hospital can receive the Calculation Form of Social Medical Insurance Medical Reimbursement from the business hall window of the Municipal Social Security Bureau with the receipt of hospitalization medical expenses of the insured in * * urban areas.

Social medical insurance reimbursement is after discharge or transfer.

Settlement procedures for inpatient and outpatient treatment of special diseases:

Designated medical institutions should report the expense list, hospitalization list and related materials of patients discharged from hospital last month to the medical insurance agency before 10 every month, which will be used as the basis for monthly pre-allocation and year-end final accounts after examination;

The medical insurance agency pre-allocated the hospitalization and outpatient co-ordination expenses for special diseases last month;

Insured persons who have been identified as suffering from special diseases shall go to the designated medical institutions designated by the labor and social security departments for medical treatment and medicine purchase, and the medical expenses incurred shall be directly recorded and settled immediately.

Emergency settlement procedure: the medical expenses incurred by the insured in emergency rescue to non-designated medical institutions in the city and medical institutions in different places shall be paid in advance by individuals or units. After the emergency rescue, the medical insurance agency shall go through the reimbursement procedures according to the provisions with the hospital emergency medical records, inspections, laboratory tests, invoices and detailed list of medical expenses.

Resettlement procedures for people resettled in different places:

For the resettlement of staff from different places, the designated medical institution with the residence of 1-2 shall be designated by the unit to which it belongs, and it shall be reported to the medical insurance agency for the record;

The medical expenses incurred by the off-site staff in the outpatient department of the designated medical institution in their place of residence shall be paid in advance by themselves or their units. After the treatment, the unit holding the insured's diagnosis and medical records, effective bills, compound prescriptions and hospitalization expenses list shall settle the accounts with the social medical insurance agency on the specified date.

Referral to hospital for treatment:

If the insured person is transferred to other medical institutions for diagnosis and treatment due to the conditions of designated medical institutions or specialized diseases, it is necessary to fill in the referral approval form. The reasons for referral and transfer are put forward by the attending physician, the director of the department puts forward the opinions of referral and transfer, the medical institution medical insurance office reviews, the dean in charge signs, and the referral can only be made after the approval of the municipal medical insurance center;

In principle, referrals should be made outside the city, inside the province and outside the province. The city's referral regulations are carried out between designated medical institutions. The referral outside the city is proposed by the designated medical institutions above Grade III in this Municipality;

The medical expenses incurred after the insured person is referred to another hospital shall be paid by the individual or unit in cash. After the end of medical treatment, the insured person or his agent will submit the referral approval form, medical record certificate, prescription and valid documents to the medical insurance agency for reimbursement of hospitalization expenses that fall within the scope of the overall fund payment.

First, the reimbursement rate for hospitalization is 1. For a first-class hospital, 90% will be paid for the part above Qifubiaozhun to the highest payment limit; 2, secondary hospitals, Qifubiaozhun to 10000 yuan (inclusive) to pay 85%, more than 10000 yuan to pay 90%; 3. 80% of the minimum deductible of tertiary hospitals is above 5,000 yuan (inclusive), 85% of the minimum deductible of 5,000 yuan to 10000 yuan (inclusive), and 90% of the maximum deductible of 10000 yuan. 4. Retirees will increase by 5% on the basis of the above payment ratio.

Second, hospitalization reimbursement deductible line 1, 200 yuan, a first-class hospital; 2.500 yuan, a secondary hospital; 3.800 yuan, a tertiary hospital; 4, malignant tumor patients, in a medical year for many times due to radiotherapy and chemotherapy medical expenses, can only pay once.

Third, the proportion of reimbursement for chronic diseases Outpatient chronic diseases are divided into Class A chronic diseases and Class B chronic diseases.

legal ground

People's Republic of China (PRC) social insurance law

Article 29

The medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by social insurance agencies, medical institutions and pharmaceutical business units. The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.