What are the procedures and procedures for the second reimbursement?

Procedures for the second reimbursement:

1. Identity card or household registration book of hospitalized patients participating in social security; Mainly the patient's own valid documents.

2 to participate in the social security cooperative medical care certificate for inpatients;

3. Discharge certificate;

4. Receipt of medical expenses;

5. Detailed list of hospitalization expenses;

6 other materials required by the county and urban cooperative medical management institutions.

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.

The second reimbursement is for urban residents' medical insurance or residents of the new rural cooperative medical system. If you incurred high expenses in seeing a doctor last year, you can apply for critical illness insurance again in addition to normal reimbursement, and there is no capping line.

The expenses incurred in the designated medical institutions of the city's basic medical insurance that meet the reimbursement scope of the city's urban and rural residents' basic medical insurance shall be included in the payment scope of the city's urban and rural residents' serious illness insurance for "secondary reimbursement" after the reimbursement of the basic medical insurance, and the expenses paid by rural residents in the basic medical insurance policy that exceed the annual per capita disposable income of rural residents in the city in the previous year (hereinafter referred to as the "deductible").

The insured person shall provide the following materials for the second reimbursement of medical insurance for serious illness:

1, the original ID card or household registration book of the insured residents and the original participation guarantee (card);

2, the new rural cooperative medical compensation statement;

3, the cost list, the original discharge summary or a copy of the official seal of the receiving unit;

4. The original invoice of medical institution expenses or a copy of the official seal of the safekeeping unit;

5 patients with special chronic diseases provide chronic disease certificates, or special chronic disease diagnosis certificates and outpatient medical records issued by medical institutions above the second level;

6. The bank remittance account number of the patient himself or relevant personnel who can provide proof of the relationship with the patient.

First and second reimbursement process

1, application accepted

2. Receiving institutions

3. Application results

4. Expense accounting

5. Payment of expenses

Second, the settlement procedure of medical insurance

(1) Settlement procedures for inpatient and outpatient treatment of special diseases

Designated medical institutions shall submit the expense list, hospitalization list and related materials of discharged patients 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 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.

(2) Emergency settlement procedures

The medical expenses incurred by the insured due to 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 handle the reimbursement procedures according to the provisions with the emergency hospitalization medical records, inspection, laboratory test sheets, invoices and detailed list of medical expenses.

(three) resettlement procedures for resettlement personnel in different places

1. The personnel resettled in different places shall be designated as the designated medical institution of 1-2 by the unit to which they belong, and shall be reported to the medical insurance agency for the record.

2. 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 should hold the diagnosis, medical records and effective expenses of the insured.

Use bills, compound prescriptions, hospitalization expenses list, etc. Settle with the social medical insurance agency on the specified date.

(4) Referral and settlement.

1. 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, the approval form for referral and transfer shall be filled in. The reason for referral and transfer is put forward by the attending physician, the director of the department puts forward the opinion of referral and transfer, the medical institution medical insurance office reviews it, the dean in charge signs it, and it can be transferred only after being reported to the municipal medical insurance center for examination and approval.

2. 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.

3. 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 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.

Three. Reimbursement amount:

"piecemeal calculation, cumulative payment" 50% of the expenses incurred by the designated medical institutions of basic medical insurance above the "deductible amount" and within 50,000 yuan (inclusive) shall be reimbursed by the serious illness insurance fund; Expenses exceeding 50,000 yuan shall be reimbursed by the serious illness insurance fund by 60%. The minimum payment is 50% or more. I joined the new rural cooperative medical system that year. At that time, the balance of the new rural cooperative medical fund was large, and the local government introduced the second service policy. These documents are generally released at the beginning of the second year.

legal ground

Social insurance law

Twenty-third employees should participate in the basic medical insurance for employees, and the employer and employees should jointly pay the basic medical insurance premiums in accordance with state regulations.

Individual industrial and commercial households without employees, part-time employees who have not participated in the basic medical insurance for employees and other flexible employees can participate in the basic medical insurance for employees, and individuals pay the basic medical insurance premium in accordance with state regulations.

Article 25 The state establishes and improves the basic medical insurance system for urban residents.

The basic medical insurance for urban residents combines individual contributions with government subsidies.

People who enjoy the minimum living guarantee, disabled people who have lost their ability to work, elderly people and minors over 60 years old in low-income families, etc. , subsidized by the government.

Twenty-sixth basic medical insurance for employees, new rural cooperative medical care and basic medical insurance for urban residents shall be implemented in accordance with state regulations.