Notice of Beijing Municipal Health Insurance Bureau on Further Improving the Direct Settlement of Medical Treatment in Different Provinces of Basic Medical Insurance
Beijing Medical Insurance No.41 [2022].
The medical insurance bureaus of all districts, the Social Affairs Bureau of Beijing Economic and Technological Development Zone, and the designated medical institutions:
In order to continuously improve people’s sense of gain, happiness and security in medical treatment settlement in different places, according to the spirit of the Notice of the National Medical Insurance Bureau and the Ministry of Finance on Further Improving the Direct Settlement of Medical Treatment in Different Provinces of Basic Medical Insurance (No.22 [2022] of Medical Insurance), this Municipality further improves the direct settlement of medical treatment in different provinces of basic medical insurance (hereinafter referred to as direct settlement) and regulates the management of direct settlement services. The relevant matters are hereby notified as follows:
First, improve the direct settlement policy
(a) unified hospitalization, general outpatient and outpatient chronic diseases direct settlement fund payment policy. The medical expenses for inpatient, general outpatient and outpatient chronic and special diseases directly settled by the insured shall, in principle, implement the payment scope and relevant regulations (payment scope of basic medical insurance drugs, medical service items and medical consumables) stipulated by the insured place, and implement the relevant policies such as the basic medical insurance fund Qifubiaozhun, payment ratio, maximum payment limit and outpatient chronic and special diseases.
(two) to clarify the scope of medical records in different provinces. Insured persons in this city can apply for inter-provincial medical record when they need medical treatment in different places. After the record, the insured persons can enjoy direct settlement service in the inter-provincial networked designated medical institutions where medical treatment is filed.
(3) Standardizing the validity period of inter-provincial medical records in different places. Insured persons in this Municipality may, when filing medical treatment in different places across provinces, choose their own effective period of filing according to actual needs, and the effective date and deadline of filing shall be subject to the date of system registration. When the insured person’s place of filing for medical treatment or unit, insurance type and other insured relationships change, it is necessary to go through the filing procedures again, and the original filing validity period will automatically expire after re-filing.
(4) It is allowed to re-submit medical records in different provinces and places, and the injured insured without third-party liability can enjoy direct settlement services. Before the settlement of the insured’s inter-provincial medical treatment in different places, the inter-provincial networked designated medical institutions shall provide direct settlement services for the insured. If the insured person who goes to different provinces for medical treatment goes through the filing formalities according to the regulations after being discharged from hospital at his own expense, he can apply for manual reimbursement of medical insurance according to the regulations of the insured place. At the same time, the medical expenses of trauma without third-party liability that meet the management regulations of medical treatment places can be included in the direct settlement scope.
Two, standardize the direct settlement management services
(a) simplify the inter provincial medical record. Insured persons in this city need to go through the inter-provincial medical record before seeking medical treatment in different places. The filing procedures can be handled through online and offline channels, such as the national medical insurance service platform APP, the national remote medical filing applet, the the State Council client applet or the window of each district agency, by registering my information and signing a personal commitment letter.
(two) clear the scope of direct settlement. When the insured persons in this city apply for medical treatment in different provinces for the record, in principle, the medical treatment place only needs to be put on record in the co-ordination area where the medical treatment place is located. All the inter-provincial networked designated medical institutions in the co-ordination area for the record medical treatment are designated medical institutions for the insured persons in different places, and they can enjoy hospitalization, general outpatient service or direct settlement service for drug purchase. The insured persons in this city who seek medical treatment for special diseases in different provinces need to be filed with the designated medical institutions at the place where they seek medical treatment. In principle, two designated medical institutions can be selected for a special disease, and they can seek medical treatment in the inter-provincial networked designated medical institutions that have opened the direct settlement service for corresponding outpatient chronic and special diseases, and the treatment expenses related to special diseases can enjoy direct settlement service.
(three) standardize the insured to medical insurance electronic certificate, social security card. Insured persons who seek medical treatment in different places across provinces should take the initiative to show their insured status in the designated medical institutions networked across provinces where they seek medical treatment, and produce valid certificates such as medical insurance electronic certificate or social security cards. Inter-provincial networking designated medical institutions should do a good job in the authentication of insured persons in different places, guide those who have not filed for the record to go through the filing procedures in time, and provide reasonable and standardized diagnosis and treatment services and convenient and fast settlement services for insured persons who meet the requirements of medical places.
(4) Standardize the direct settlement process. When medical treatment is directly settled in different provinces, the medical treatment place should upload the cost information to the national medical security information platform according to the unified requirements of the state for direct settlement between designated medical institutions and insured persons connected across provinces. If it cannot be settled directly for some reason, the inter-provincial networked designated medical institutions should also upload medical expenses details, diagnosis and other medical information, and support the pilot online processing of manual reimbursement.
(five) the unified management of medical treatment. Medical insurance agencies at all levels should bring medical personnel from different places into the unified management of this Municipality, and provide the same services and management as the insured in this Municipality in terms of medical information recording, performance appraisal, medical behavior monitoring, cost audit, total budget, etc., and make it clear in the medical security service agreement of designated medical institutions; Explore the application of medical insurance payment reform in medical settlement in different places, and guide designated medical institutions to make reasonable diagnosis and treatment.
(six) to strengthen the collaborative management of medical services across provinces. Medical insurance departments at all levels should gradually improve the working mechanism, form a coordinated management system of inter-provincial medical services in different places with clear division of labor, clear responsibilities and unified processes, and comprehensively improve the coordinated management ability of inter-provincial medical services in terms of problem coordination, online reimbursement, cost investigation and information sharing.
Three, strengthen the management of medical funds across provinces and different places.
The medical insurance fund payment part of the inter-provincial medical expenses in different places shall be paid in advance and then liquidated. Inter-provincial medical expenses in different places shall be settled in full on a monthly basis in accordance with the unified national clearing method. The municipal medical insurance agency and the municipal finance department shall, in accordance with the detailed rules for the implementation of direct settlement of medical treatment in different provinces of Beijing (Annex), coordinate in the allocation and collection of clearing funds. Bank charges and bank bill fees incurred in the process of allocating funds for medical treatment in different provinces shall not be charged in the fund. The interest generated by the advance payment in the financial special account of the medical treatment place belongs to the medical treatment place.
Fourth, improve the support for standardization of medical insurance informationization
(a) continue to deepen the national unified medical insurance information platform for the whole business process application. Medical insurance departments at all levels should solidly promote the dynamic maintenance and deepening application of coding in accordance with the unified national norms and requirements, improve the management system of medical insurance operation and maintenance of information technology, continuously improve the level of medical insurance data governance, and provide strong system support for direct settlement.
(2) Continue to optimize and improve the system. Medical insurance departments at all levels should constantly optimize system performance, reduce response time and effectively improve the direct settlement experience of insured persons in accordance with the unified national interface standards and specifications. When the medical insurance system stops and switches, it should be reported in advance, verified in the process and monitored afterwards to ensure that the data migration is timely, complete and accurate, to solve the influence of information changes such as personal number on the business in transit, and to ensure the smooth connection of business and the stable operation of the system.
(3) Strengthen system operation and maintenance management and security. Medical insurance departments at all levels should continue to build professional and reliable operation and maintenance management teams, build operation and maintenance management processes in infrastructure, network security, cloud platforms, business subsystems and other fields, and form a scientific and effective operation and maintenance management system. Implement safety management responsibilities, improve system safety operation and maintenance capabilities, strengthen information system boundary protection, prohibit cross-provincial networked designated medical institutions from connecting the information system of medical insurance system to the Internet, standardize cross-provincial medical identity verification, and ensure data security. Standardize the quality control standard of abnormal transaction error information, classify the problems, describe the reasons of errors concisely and easily, facilitate the problem location of abnormal transactions, and respond to them in time.
Five, strengthen the supervision of direct settlement funds
Medical insurance departments at all levels should earnestly implement the regulatory responsibilities of medical treatment places and insured places. As a place for medical treatment, direct settlement should be regarded as the key content of daily supervision, special inspection and flight inspection, and all kinds of fraudulent insurance fraud should be severely cracked down. At the same time, it is necessary to cooperate with medical insurance departments in different places to do relevant verification; As an insured place, it is necessary to regularly analyze the use of medical insurance funds across provinces and different places, accurately lock the clues of suspicious problems, and actively carry out problem verification to ensure the safe and rational use of medical insurance funds.
Medical insurance departments at all levels shall, in accordance with the spirit of this circular, take direct settlement as an important task to deepen the reform of the medical security system, strengthen organizational leadership, coordinate and promote, and do a good job in publicity and training to ensure a smooth transition of direct settlement in this Municipality.
This notice shall be implemented as of January 1, 2023. If the previous documents are inconsistent with this notice, this notice shall prevail.
Beijing Municipal Medical Security Bureau
December 30, 2022