Nanjing Medical Insurance Outpatient Overall Reimbursement Policy

Standard of overall treatment for outpatient medical insurance for urban workers in Nanjing;

From 1, 65438+ 10 in 2023, Nanjing implemented the medical insurance outpatient mutual aid guarantee mechanism, canceled the outpatient qifubiaozhun, increased outpatient special diseases, and canceled the payment limit linked to the course of disease.

2, outpatient co-ordinate the implementation of the first diagnosis and referral system based on community health service institutions. Insured persons can be first diagnosed or referred to community-managed medical institutions in designated community health service institutions for urban workers' basic medical insurance; Specialized hospitals can be used as the first medical institutions for all insured persons. If the insured person needs a referral, the first-visit medical institution shall be responsible for the referral, and emergency rescue is not subject to this restriction.

3. After the outpatient chronic disease subsidy limit is used up, it will be settled directly according to the outpatient overall treatment standard from the next cost, and the original chronic disease in the door does not need to be referred. After the subsidy limit for specific outpatient projects is used up, referral procedures must be handled according to the provisions of outpatient co-ordination, and ordinary medical records can be used to enjoy outpatient co-ordination treatment. Buying medicine in a pharmacy does not enjoy the overall treatment of outpatient service.

Nanjing medical insurance outpatient co-ordination reimbursement policy: insured urban and rural residents must show their social security cards and swipe their cards when seeking medical treatment in designated medical institutions. There are no designated retail pharmacies for urban and rural residents' medical insurance, and pharmacies (except specialist pharmacies) cannot pay by credit card and do not enjoy medical insurance reimbursement.

Note: Medical expenses incurred by residents in non-medical insurance designated hospitals and medical expenses outside the scope of medical insurance shall be borne by individuals. When you go to the hospital, you must remember to brush the social security card for settlement!

Sporadic reimbursement process of medical insurance for employees in Nanjing

Personal reimbursement:

1. materials submitted by the applicant;

2 to Nanjing social insurance agencies to accept and review the application materials;

3. Print the Handover Sheet for Sporadic Reimbursement of Basic Medical Insurance for Urban Employees in Nanjing to the applicant to complete the reimbursement.

Unit reimbursement

1. The employer shall submit the application materials (the application materials for flexible employees shall be summarized by the district social security agency);

2. Fill in the Receipt for Sporadic Reimbursement of Basic Medical Insurance for Urban Employees in Nanjing;

3. After the examination and confirmation by the municipal social insurance agency, the third copy of the receipt will be fed back to the employer (district social insurance agency);

4. Complete the reimbursement.

Reimbursement for serious illness treatment in Nanjing employee medical insurance outpatient department

(1) application. If the insured suffers from serious outpatient diseases, he shall apply for disease identification to qualified doctors in the three-level designated medical institutions in this Municipality;

(2) recognition. After confirming that the doctor is the insured, fill out the Confirmation Form of Serious and Extraordinary Diseases in the Outpatient Department of Nanjing Basic Medical Insurance for Urban and Rural Residents (in duplicate), and at the same time, input the disease information of the insured, such as disease name, diagnosis basis and diagnosis time, into the HIS system of medical institutions;

(3) review. The insured person carries the outpatient serious illness identification form, diagnosis basis and other relevant information signed by the doctor to the medical insurance office of the designated medical institution for disease identification and audit;

(4) registration. The medical insurance office of designated medical institutions will transfer or input the disease information of the insured person's disease name, recognized doctor, diagnosis basis and diagnosis time from the HIS system of medical institutions into the basic medical insurance information system;

(5) fixed point. Insured persons also register disease information in designated medical institutions, and choose designated medical institutions for outpatient serious illness projects:

(1) The outpatient treatment of malignant tumor is limited to three designated medical institutions;

(2) The outpatient anti-rejection treatment after organ transplantation is limited to two designated medical institutions;

(3) Chronic renal failure, hemophilia, aplastic anemia, systemic lupus erythematosus and other diseases are limited to 1 designated medical institutions.

(6) printing. The insured carries:

(1) Confirmation form signed by the doctor and audited and sealed by the Medical Insurance Office;

(2) Relevant information on the basis of diagnosis (among them, the original and photocopy of the discharge summary of transplant operation must be provided for outpatient anti-rejection treatment after organ transplantation);

(3) One-inch recent bareheaded photos, and choose the nearest medical insurance agency in this city to print special medical records for serious illness clinics.

Legal basis:

Article 5 of the Constitution of People's Republic of China (PRC) stipulates: "Workers have the right to social security when they are old or sick": the State Council's Decision on Establishing the Basic Medical Insurance System for Urban Workers (hereinafter referred to as the Decision) clearly points out: "Accelerating the reform of the medical insurance system and ensuring the basic medical care for employees is an objective requirement and an important guarantee for establishing a socialist market economic system." All the above are the basic ideas that medical insurance legislation should follow.