How the social security bureau audit maternity allowance information

I. Maternity Insurance Benefits Audit

(A) Audit of Medical Expenses of Designated Medical Institutions

1. Declaration and Registration

(1) The declaration and registration post accepts the declaration of medical expenses submitted by designated medical institutions and confirms the truthfulness, accuracy, and validity of the declared information. Fill out the "medical expenses declaration handover form" in duplicate, after the declaration, the receiving party signed, one to keep, the other to the designated medical institution.

(2) based on the fixed-point medical institutions to submit declarations, check the information system uploaded data information, in the required time to complete the preliminary examination.

The fixed-point medical institutions are required to provide "Urumqi Municipal Maternity Insurance Medical Expense Declaration Summary Sheet", "Urumqi Municipal Maternity Insurance Prenatal and Postnatal Examination Expense Declaration Summary Sheet", "Urumqi Municipal Maternity Insurance Outpatient Medical Expense Declaration Summary Sheet", "Urumqi Maternity Insurance Inpatient Medical Expense Declaration Summary Sheet", and "Urumqi Maternity Insurance Hospitalized Expense Declaration Sheet for Complications".

The declaration materials include:

1 maternity hospitalization: a copy of the birth medical certificate, the original discharge certificate or diagnostic certificate, the unified bill for hospitalization expenses settlement, maternity discharge settlement (stamped with the special seal of the hospital).

2 maternity outpatient: original hospital outpatient uniform ticket, hospital outpatient uniform ticket corresponding to the details, maternity outpatient settlement (stamped with the hospital seal).

3 Complications of childbirth: original certificate of discharge or diagnostic certificate, original unified bill for hospitalization expenses, list of hospitalization expenses, and hospitalization medical records.

(3) The declaration of information is categorized and registered, the declaration of materials to the treatment audit post review.

2. Expense audit

(1) maternity audit post based on the information declared by the designated medical institutions, carefully check the social security system of medical institutions inpatient and outpatient uploaded information; strictly in accordance with the "autonomous region of the basic medical insurance drug directory, diagnostic and treatment directory, the scope of the directory of services and facilities" standard audit of the medical expenses of the insured person to seek medical treatment, the number of days of hospitalization, the cost of detailed information and other data. Audit no objections, the establishment of the corresponding medical expenses to pay the audit account; on the audit of doubtful, submitted to the department for discussion or written notice to the Audit and Audit Section to assist in field verification.

(2) the audit was allowed to pay the costs, print the "medical expenses audit sheet" in duplicate, signed by the auditor and stamped "maternity insurance treatment audit chapter", while the "medical expenses audit sheet" and the declaration of information submitted to the Work Injury and Maternity Insurance Treatment Review Section for review. Audit failed to communicate with the designated medical institutions in a timely manner to understand the situation, the cost of violations, fill out the "notice of refusal to pay medical expenses", according to the refusal to pay treatment.

(3) According to the reporting unit to establish the corresponding medical expenses audit ledger, while making good records. Audit requires that each of the medical expenses of the declaration of the total amount, the amount of refusal to pay the amount of settlement of the amount of data to be corresponded to one by one.

(B) individual cash medical expenses audit

of the participating units, hosting units or individuals declared hospitalization, outpatient and other medical expenses, through the review of information and query the system for relevant information, meet the conditions of the initial review to be declared admissible. For those who do not meet the conditions for cash declaration, they should refuse to accept and inform the policy provisions. For expenses that do not fully comply with the reimbursement policy, or for medical expenses that are abnormal, or other questionable expenses, the declaration is submitted to a meeting of maternity experts for a determination. Medical expenses that meet the requirements will be paid and settled in accordance with the reimbursement regulations and procedures.

1. Declaration and registration. Declaration of registration post on the management unit or the declarant to submit invoices and corresponding list of consultation, hospitalization invoices, cost lists, discharge diagnostic certificates, insurance contributions, medical records and other information for review, complete and in line with the provisions of the Work Injury and Maternity Insurance Treatment Audit Section in a timely manner.

2. Expense audit. Maternity audit post on the declaration materials for review, in line with the "maternity catalog" range of medical expenses, the establishment of the audit account, on the questionable medical costs, submitted to the department for discussion or written submission of maternity experts to determine the medical costs of the review meeting. Print the "Medical Expense Audit Sheet" in duplicate, signed by the auditor and stamped with the treatment audit seal, submit it to the declaration registration post for registration and submit the "Medical Expense Audit Sheet" and the declaration materials to the Work Injury and Maternity Insurance Treatment Review Section. If the audit fails to pass, fill in the Notice of Refusal of Payment of Medical Expenses, return the declaration materials to the management unit, community or individual, and explain the reasons for the refusal of payment.

Two, maternity insurance treatment review

(a) maternity treatment review acceptance

Industrial Accident and Maternity Insurance Treatment Review Section of the maternity expenses submitted by the audit department to review the materials, found that the audit of the costs of the error, the voucher information should be returned to the department of the treatment audit to re-examine the content of the review is as follows:

1. Whether the participant's declaration is complete; whether the declaration exceeds the deadline; whether the personal information of the declaration is consistent with the personal information of the social security information system.

2. Check whether the declared maternity medical expenses overlap with the paid records; whether the medical institutions attended by the maternity designated medical institutions; whether the reimbursement of maternity medical expenses of the person in line with the scope of the policy; whether there is a basis for approval of the reimbursement of maternity expenses in special circumstances.

3. Verification of "maternity medical treatment audit sheet", "maternity insurance hospitalization medical expenses summary table" whether the auditor signed and stamped.

(B) Maternity medical expenses review

1. Treatment review post based on the "maternity medical expenses declaration handover", "maternity insurance hospitalization medical expenses summary table", "maternity treatment medical audit sheet" and the declaration materials for review, check the basic information of the birth of a person, invoices and diagnostic certificates indicate the authenticity of the type of maternity and family planning surgery, to confirm that the credentials and materials are not incorrect.

2. Treatment review post reviewers in the "maternity treatment medical audit", "maternity insurance hospitalization medical cost summary form" on the signature, the establishment of a payment plan, print the "maternity treatment medical payment plan" in duplicate, by the reviewer, the section chief signed and stamped with a special seal for the review of maternity insurance treatment. Payment plan and a treatment audit sheet to the maternity designated medical institutions for settlement procedures.

3. Work-related injuries, maternity insurance treatment review section within 20 working days to complete the review, maternity designated medical institutions from the 20th to 30th of each month, with the "Maternity Medical Expenses Declaration Handover Order" to the work-related injuries, maternity insurance treatment review section to receive the "maternity treatment of medical payment plan" for financial settlement operations.

(C) Maternity allowance treatment review

1. In accordance with the requirements of the "Urumqi urban workers maternity insurance treatment and settlement of expenses related to the issue of notice" (Ulaodong [2009] No. 119), from the 1st to the 10th of each month to assist the maternity insurance office, audit section, audit section to the street office, social security sub-bureaus, the birth of the designated medical institutions of the completeness of the declaration materials, the accuracy of individual maternity insurance treatment electronic issuance information, and the accuracy of the information. The accuracy of the information on the electronic issuance of benefits, the authenticity of the type of childbirth and family planning surgery indicated on the invoice and diagnostic certificate is verified on a random basis.

2. According to the Work Injury and Maternity Insurance Treatment Audit Section submitted the "Maternity Treatment Allowance Batch Audit Sheet" to carry out the handover and batch review work, treatment reviewers based on the "Maternity Treatment Allowance Batch Audit Sheet" to check the birth of the personnel's basic information, the unit's contribution, the unit's base figure for the previous year and other information to confirm that there is no error, the reviewer in the "Maternity Treatment Allowance Batch Review Sheet" to sign the establishment of the payment scheme Print the Batch Payment Plan for Maternity Benefits in duplicate, signed by the reviewer and the section chief and stamped with a special seal for the review of maternity insurance benefits.

3. Will be "maternity treatment allowance batch payment plan" submitted to the Fund Management Section to do batch distribution, the payment plan and a treatment review sheet to the unit or individual retention.

(D) the handover of information and vouchers and internal audit file management

1. Review and registration post will be "maternity treatment payment plan", "maternity treatment allowance batch review order", "maternity treatment medical audit order" and the relevant declaration of materials for registration, and the section of the archivist to hand over.

2. The archive management post of the file materials for internal audit, internal audit of the undoubtedly organized and bound, and then transferred to the archives management section on time.

3. Monthly treatment review post and treatment audit post to check the number of people enjoying maternity benefits and the amount of money issued, and reconciliation with the Fund Management Section, the establishment of "maternity insurance treatment payment account", do a good job of the month, "Maternity Insurance Payment Balance Sheet".

(E) payment and settlement

Fund Management Section payment and settlement (issuance) post based on work-related injuries, maternity treatment review section submitted the "payment plan batch summary" or "maternity treatment payment plan", "maternity treatment medical payment plan", do the payment and settlement of maternity insurance treatment and issuance. Print the "handover sheet" or "handover summary form" in duplicate, signed by the operator, the section chief, reported to the supervisor for signature, before the maternity treatment can be submitted to do the payment and settlement and issuance of processing.