Operating rules for online settlement of medical treatment in different places for urban basic medical insurance in Shandong Province

The reimbursement of emergency medical insurance in other towns of Shengli Oilfield shall be implemented in accordance with the "Operating Rules for Remote Networking Settlement of Urban Medical Insurance in Shandong Province".

I. Registration (filing) procedures

1) If the insured person is hospitalized in an emergency in a different place in the province, his relatives or unit managers can bring the original or photocopy of the emergency hospitalization certificate to the social medical insurance agency in the insured place to go through the formalities for medical treatment in a different place. The medical insurance agency shall timely file those who meet the requirements of emergency admission after examination, and upload the patient's brief illness description and hospitalization information to the provincial medical settlement information system platform.

2) Insured persons who meet the referral conditions for medical treatment in different places, after being audited by the medical insurance agency in the insured place, go through the filing procedures for hospitalization in different places through the local medical insurance system, and upload the filing information to the provincial settlement platform for medical treatment in different places. If it is necessary to transfer to other designated medical institutions for hospitalization during medical treatment in different places due to illness, it shall be approved by the medical insurance agency in the insured place.

2. What is the reimbursement standard for remote networking?

1) When the insured person is hospitalized, he/she must hold his/her social security card (certificate) and resident ID card, and collect the hospitalization deposit according to a certain proportion of the estimated total hospitalization expenses. The insured does not need to provide a medical record form in different places in Shandong Province. When the insured is discharged from the hospital, it shall be settled according to the policies stipulated by Shandong Province after being audited by the designated medical institutions. The part that needs personal burden is paid by the individual, and the part that should be paid by the overall fund is accounted for by the designated medical institution. After the completion of the discharge settlement procedures, the designated medical institutions provide the insured with the "Shandong Province Basic Medical Insurance Expense Settlement List", hospitalization expense invoices and other documents.

2) Settlement of hospitalization medical expenses for resettlement personnel in different places. Qifubiaozhun for hospitalization in tertiary medical institutions within a medical year: first hospitalization in 500 yuan, second hospitalization in 200 yuan; Qifubiaozhun for hospitalization in secondary and below medical institutions: 400 yuan for the first time, after the second time 150 yuan. The expenses between the Qifubiaozhun of tertiary medical institutions and the maximum payment limit of the overall fund shall be borne by the individual employees by 22% and paid by the overall fund by 78%; Personal burden of retirees 17%, and 83% paid by the overall fund; The individual burden of urban residents is 37%, and the overall fund pays 63%. For the expenses between the hospitalization Qifubiaozhun and the maximum payment limit of the overall fund in secondary and below medical institutions, the personal burden of the above categories of personnel was reduced by 3 percentage points respectively. Large Medicaid payment is higher than the maximum payment limit of the overall fund, and 8% is borne by the insured individual, and 92% is paid by large Medicaid.

3) Settlement of referral hospitalization expenses. Qifubiaozhun for hospitalization: the first hospitalization in 700 yuan and the second hospitalization in 300 yuan within a medical year. Between Qifubiaozhun and the maximum payment limit of the overall fund, it meets the base.

The provisions of this Ordinance, the medical expenses, the individual burden of 28%, the overall fund to pay 72%; The individual burden of retirees is 23%, and the overall fund pays 77%; The individual burden of urban residents is 43%, and the overall fund pays 57%. For the expenses paid by the large Medicaid that exceed the maximum payment limit of the overall fund, the personal burden of the insured person is 13%, and the large Medicaid payment is 87%.

4) In case of emergency hospitalization in different places in the province, the settlement of hospitalization medical expenses shall be implemented according to the referral policy. In addition, the maximum payment limit and large Medicaid payment limit of the urban workers' basic medical insurance pooling fund.

The amount and maximum payment limit of the basic medical insurance fund for urban residents shall be determined by the municipalities.

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