On social security in Xiamen and other places.

Operating Rules for Medical Expense Reimbursement of Xiamen Basic Medical Insurance

In order to strengthen the management of reimbursement of medical expenses and ensure the reasonable payment and safe operation of the basic medical insurance (hereinafter referred to as medical insurance) fund, according to the Provisions of Xiamen Municipality on Basic Medical Insurance for Urban Workers (DecreeNo. 108 of the municipal government, Revised Decree No.2005 of the municipal government). 122), Interim Measures for Basic Medical Insurance for Migrant Workers in Xiamen (No.26 of Xiamen Government [2000]/kloc), Interim Measures for Medical Insurance for Urban Residents in Xiamen (No.28 of Xiamen Government Office [2006]1) and Interim Measures for Medical Insurance for Minors in Xiamen.

I. Scope of reimbursement

1. Reimbursement target: people who participated in medical insurance in Xiamen and various personnel entrusted by social security institutions (retired cadres, 5. 12 retired cadres) are all referred to as insured.

2. Scope of payment:

(1) The medical expenses mentioned in these Provisions refer to the medical expenses incurred by the insured in designated medical institutions (except emergency) in China (except Hong Kong, Macao and Taiwan) due to illness, which are paid by the insured in cash, in line with the provisions of the Measures for the Administration of Drug Catalogue of Basic Medical Insurance in Xiamen and the Measures for the Administration of Diagnosis and Treatment Projects of Basic Medical Insurance in Xiamen and other relevant documents, and belong to the scope of medical insurance fund payment.

(2) The social security agency shall review the medical treatment project materials provided by the insured according to the highest payment standard for medical treatment projects stipulated in the relevant medical insurance documents, and the local and foreign medical treatment project expenses shall be settled and paid according to the standard of medical service charges in Xiamen.

(3) Medical expenses that have been paid by other types of insurance, third-party responsible persons or charitable donations are no longer paid by the medical insurance fund.

3. Reimbursement category:

(1) Medical expenses in different places:

(1) Medical expenses for medical treatment, work in different places, resettlement or residence in different places; The provincial medical insurance network cannot swipe the card normally;

(2) the cost of purchasing drugs at the selected pharmacy for "off-site registration";

(3) Emergency expenses during business trip, visiting relatives and traveling in other places;

(4) The medical examination expenses for the resettlement of employees in different places and medical insurance in the current year;

⑤ Medical expenses for delivery in different places;

⑥ The medical expenses in different places belong to the Notice of Disposal of Medical Expenses in Different Places when the insured of basic medical insurance fails to go abroad for medical treatment (declaration in different places).

(2) the cost of medical treatment in this city:

(1) social security computer system downtime or failure period, social security card (original IC card) loss reporting period (including the expenses of emergency department on the day before loss reporting, and the invoice must be stamped and confirmed by the social security agency), social security business card printing delay period, and outpatient service exceeding the limit of 20 times per month;

(2) The expenses incurred from the billing month 1 day after the suspension of insurance renewal and the delay of local tax collection in the next month after the change of the insured's work unit or identity;

③ 120 Pre-hospital first aid (medical expenses) and emergency outpatient expenses of that day;

(four) retired cadres due to clinical needs, approved to the designated medical institutions for medical treatment, provided by the medical institutions outside the medical insurance directory of drugs, medical items and special materials;

(5) The expenses paid by the insured for specific diseases such as kidney transplantation and bone marrow transplantation;

⑥ Newborns are insured in time according to regulations, and medical expenses are paid in advance within three months of birth;

⑦ The medical expenses paid by the insured in the designated medical institutions of medical insurance managed according to the agreement without credit card.

(3) Other medical expenses:

(1) Medical expenses incurred by the insured due to traffic accidents (except those caused by drunk driving, driving without a license and other self-intentional behaviors);

(2) The insured is not responsible for the traffic accident, but the perpetrator cannot be held accountable for escaping for more than one year; If the insured is injured by others, the injured person cannot be investigated (those who participate in fights or violate public security regulations cannot be reimbursed). If the time is more than one year and there are other special circumstances, it must be discussed and approved by the medical expense reimbursement audit team and handled according to the audit conclusion.

Second, the specific requirements

1. If the insured person is transferred to a foreign hospital for medical treatment, he shall go through the examination and approval procedures for "transferring to a foreign hospital for medical treatment" in advance in accordance with the Interim Measures for the Administration of Transferring Basic Medical Insurance to Foreign Hospitals in Xiamen (in case of emergency, he shall go through the examination and approval procedures within 7 days of transferring to a foreign hospital), and after the medical treatment is terminated, he shall go to the social security agency for examination and settlement with the materials listed in the attached table; If it is really necessary to postpone hospitalization due to illness at the same time, it shall, within 7 days from the date of expiration, carry the certificate of recent illness treatment issued by the hospital and go through the extension formalities at the municipal social insurance management center.

2. If the insured person resettles, lives or works in different places, the examination and approval procedures for "filing in different places" shall be handled in advance in accordance with the Notice on Implementing the Work and Life Declaration of Medical Insurance Insured Persons in Different Places; If the insured registered in different places need to be transferred for medical treatment, the registered tertiary hospital shall issue a referral proposal and affix its official seal.

3. The medical expenses incurred by the insured during business trip, visiting relatives and traveling abroad due to acute diseases shall be provided with the certificate issued by the unit or community and stamped with the official seal.

4. Need to check and treat in other hospitals other than the hospital, must be approved in writing by the department in the hospital and the hospital. This approval is one of the reimbursement vouchers.

5, off-site delivery must comply with the family planning policy and provide proof of maternity leave.

6. Individual insured persons such as flexible employment have lived in other places for a long time due to employment: if they have lived in other places for more than 6 months, they will be managed by employees in different places after applying for filing; Those who go out to work for less than 6 months are limited to reimbursement of emergency expenses and maintenance of medical care in chronic disease clinics. In addition to providing proof of work in the field, the latter also needs to provide medical outpatient medical records related to peacetime in Xiamen.

7, did not do the transfer (off-site filing) procedures for off-site medical expenses:

(1) is a malignant tumor case in the course of chemotherapy and radiotherapy and is regularly reviewed. When applying for reimbursement, in addition to the materials listed in the concise table, it is also necessary to provide the follow-up radiotherapy and chemotherapy treatment plan and course certificate issued by the original hospital;

(2) If there is no one to take care of during hospitalization in Xiamen, and it is really necessary to take refuge in immediate family members, and be hospitalized in local medical insurance designated medical institutions, in addition to the materials listed in the concise table, the proof of immediate family members issued by the local neighborhood Committee should also be provided when applying for reimbursement;

(3) In addition to the materials listed in the concise table, the former should also provide the notice of study abroad, and the latter should also provide the medical outpatient records related to Xiamen at ordinary times when the employees go out to study and the retirees go out to reimburse the maintenance expenses of chronic diseases clinics;

(4) The insured does not understand the policy, and the illness really needs to be transferred to hospital for medical treatment, and it is the first time that he has not gone through the formalities of transferring to hospital for medical treatment;

(5) Although the procedures for going abroad for medical treatment have been completed, if the medical treatment period is exceeded and there is no delayed medical treatment certificate, in addition to the materials listed in the concise table, the delayed medical treatment certificate issued by the original hospital for going abroad for medical treatment should also be provided when applying for reimbursement;

(6) For the first time, the insured person was transferred to other local designated medical institutions at the same level or higher level after being transferred to hospital for medical treatment because he did not understand the policy;

In the above circumstances, the insured shall submit a written application report and related materials when applying for reimbursement.

8. The insured person belongs to the outpatient medical expenses incurred during the emergency rescue, social security card confirmation damage or loss reporting, and shall be reimbursed by medical records and expense list. The outpatient medical expenses incurred during the annual shutdown settlement of medical insurance and the failure of medical insurance computer system shall be certified and signed by the hospital.

9. The medical expenses paid by the insured person in advance due to traffic accidents shall be submitted to the social security agency for review and reimbursement with the proof of responsibility issued by the traffic police department and the materials listed in the Concise Form of Local Outpatient and Local Hospitalization after the medical treatment is over. The proportion of medical insurance fund payment shall be subject to the proportion of the insured's responsibility.

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1 1. The insured person goes to the outpatient department of the designated medical institution in this city for medical treatment. If the number of visits in a month exceeds 20, a complete outpatient medical record must be provided, and unified reimbursement will be made from the next month.

12. When the insured needs to go to other designated medical institutions in this city for examination, treatment and dispensing in medical insurance coverage during his hospitalization in this city, he must obtain the written consent of the medical institution where he lives, and the medical expenses incurred shall be paid in advance by the insured, and will be reimbursed by the inpatient medical institution at the time of discharge settlement, which will be included in the total medical expenses of this hospitalization.

13. The bills provided by the insured must comply with the regulations on the administration of financial bills, and the materials provided must have relevant signatures.

14. The medical insurance reimbursement in this city is paid by bank transfer, and the applicant is required to provide local UnionPay cards (except all credit cards and cards issued by China Merchants Bank and China CITIC Bank).

15. If you entrust others to reimburse medical expenses, you should establish an entrustment relationship with the client, show the social security card of the client, and submit complete materials required for reimbursement. Customers should also show the original and photocopy of their ID cards, and the original and photocopy of UnionPay cards. (Note: Customer's social security card, customer's ID card and UnionPay card can be copied together on a piece of A4 paper)

Third, the agency

Xiamen City, District Social Insurance Management Center is responsible for the audit and reimbursement of medical expenses.

Fourth, the time limit for reimbursement

The medical insurance year is 1 year from July to June 30th of the following year. The hospitalization expenses incurred in other places across the medical insurance year must be settled in advance on June 30th of the medical insurance year, and the list of expenses shall be printed separately on June 30th. The deadline for reporting expenses is September 30th of the next medical insurance year, and it will not be accepted after the deadline.

Verb (abbreviation for verb) acceptance time

The time for the handling agency to accept the reimbursement of medical expenses is during normal working hours from Monday to Friday. If there are special circumstances, the agency will make an appointment separately.

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