The scope of payment of medical insurance fund shall be determined by the administrative department of medical insurance ()

In order to strengthen the supervision and management of the use of medical insurance funds, ensure the safety of funds, promote the effective use of funds, and safeguard the legitimate rights and interests of citizens' medical insurance, according to the Social Insurance Law of People's Republic of China (PRC) and other relevant laws and regulations, it was adopted at the executive meeting of the State Council 1 17 on February 9, 2020, and the People's Republic of China (PRC) Order (No.7777777777777 [2

Principles of use The use of medical security funds should be centered on people's health, the level of security should be commensurate with the level of economic and social development, and the principles of legality, safety, openness and convenience should be followed. ? [2]?

The use of funds. The use of medical insurance funds shall conform to the scope of payment stipulated by the state.

The scope of medical insurance fund payment shall be formulated by the administrative department of medical insurance in the State Council according to law. The people's governments of provinces, autonomous regions and municipalities directly under the Central Government shall, in accordance with the authority and procedures prescribed by the state, supplement the specific items and standards paid by the medical security fund within their respective administrative areas, and report them to the administrative department of medical security of the State Council for the record.

Second, the state has established and improved a unified national medical security management system, provided standardized and standardized medical security handling services, and achieved full coverage of provinces, cities, counties, towns (streets) and villages (communities).

Three, medical insurance agencies should establish and improve the business, finance, safety and risk management system, do a good job in service agreement management, cost monitoring, fund allocation, treatment review and payment, and regularly disclose the income, expenditure and balance of medical insurance funds to the public, and accept social supervision.

Four, medical insurance agencies should establish a collective consultation and consultation mechanism with designated medical institutions, reasonably determine the budget amount and disbursement time limit of medical insurance funds of designated medical institutions, and according to the needs of safeguarding public health needs and managing services, negotiate with designated medical institutions to sign service agreements, standardize medical service behaviors, and clearly define violations of service agreements and their responsibilities.

The medical insurance agency shall promptly announce to the public the list of designated medical institutions that have signed service agreements.

The administrative department of medical security shall strengthen supervision over the conclusion and performance of service agreements.

Five, medical insurance agencies should be in accordance with the service agreement, timely settlement and disbursement of medical insurance funds.

Designated medical institutions shall provide medical services in accordance with regulations, improve service quality, rationally use medical security funds, and safeguard citizens' health rights and interests.

Six, designated medical institutions in violation of the service agreement, medical insurance agencies can urge them to fulfill the service agreement, in accordance with the service agreement agreed to suspend or not to allocate fees, recover the illegal costs, suspend the relevant responsible personnel or departments to participate in the use of medical insurance funds for medical services, until the termination of the service agreement; Designated medical institutions and their relevant responsible personnel have the right to make statements and defend themselves.

If the medical security agency violates the service agreement, the designated medical institution has the right to request correction or submit it to the administrative department of medical security for coordination and rectification, and may also apply for administrative reconsideration or bring an administrative lawsuit according to law.

Seven, designated medical institutions shall establish an internal management system for the use of medical insurance funds, and specialized agencies or personnel shall be responsible for the use and management of medical insurance funds, and establish and improve the assessment system.

Designated medical institutions shall organize training on relevant systems and policies of medical security funds, regularly check the use of medical security funds of their own units, and promptly correct the irregular use of medical security funds.

Eight, designated medical institutions and their staff shall implement the provisions of real-name registration system Municipality on the administration of medical treatment and drug purchase, verify the medical security certificate of the insured, provide reasonable and necessary medical services in accordance with the diagnosis and treatment norms, truthfully issue expense documents and related materials to the insured, and shall not decompose hospitalization, hanging bed hospitalization, over-diagnosis, over-examination, prescription decomposition, over-prescription, repeated prescription, repeated charges, over-standard charges and itemized charges, and shall not exchange drugs in violation of the diagnosis and treatment norms.

Designated medical institutions shall ensure that the expenses paid by the medical security fund meet the prescribed scope of payment; Except in special circumstances such as emergency and rescue, the provision of medical services beyond the scope of medical security fund payment shall be subject to the consent of the insured or their close relatives and guardians.

Nine, the designated medical institutions shall, in accordance with the provisions, keep financial accounts, accounting vouchers, prescriptions, medical records, treatment and examination records, expense details, medicines and medical consumables in and out of the warehouse records and other materials, timely, comprehensively and accurately transmit relevant data on the use of medical security funds through the medical security information system, report the information required for the supervision and management of the use of medical security funds to the administrative department of medical security, disclose information on medical expenses and cost structure to the public, and accept social supervision.

Ten, the insured medical treatment, drug purchase should hold my medical insurance certificate, and take the initiative to produce for inspection. Insured persons have the right to require designated medical institutions to truthfully issue expense documents and related materials.

Insured personnel should properly keep medical insurance certificates to prevent others from using them. If it is necessary to entrust others to purchase drugs for special reasons, the identity certificates of the principal and the trustee shall be provided.

Insured persons shall enjoy medical security benefits according to regulations and shall not enjoy them repeatedly.

Insured persons have the right to request medical insurance agencies to provide medical insurance consulting services and put forward suggestions for improvement in the use of medical insurance funds.

Eleven, in the process of using the medical insurance fund, medical insurance and other administrative departments, medical insurance agencies, designated medical institutions and their staff shall not accept bribes or obtain other illegal income.

Twelve, the insured shall not take advantage of the opportunity to enjoy medical security benefits to resell drugs, accept cash, return in kind or obtain other illegal benefits.

Designated medical institutions shall not provide convenience for the insured to resell drugs, and shall not accept cash or physical return or obtain other illegal benefits by enjoying medical security benefits.

Thirteen, medical insurance agencies, designated medical institutions and other units and their staff and insured persons shall not cheat the medical insurance fund by forging, altering, concealing, tampering, destroying medical documents, medical certificates, accounting vouchers, electronic information and other relevant materials, or fictional medical services.

Fourteen, the medical security fund is earmarked, and no organization or individual may occupy or misappropriate it. ? [2]?

Supervision and management. The supervision and management of the use of medical insurance funds should combine government supervision, social supervision, industry self-discipline and personal trustworthiness.

Second, medical security, health, Chinese medicine, market supervision and management, finance, auditing, public security and other departments should work together and cooperate with each other, establish mechanisms such as communication and coordination, case transfer, and do a good job in the supervision and management of the use of medical security funds.

The administrative department of medical security shall strengthen the supervision of medical services and medical expenses included in the payment scope of medical security funds, standardize the medical security handling business, and investigate and deal with illegal use of medical security funds according to law.

Three, the State Council medical security administrative department is responsible for the formulation of service agreement management measures, standardize, simplify and optimize the designated application, professional evaluation and negotiation procedures of medical institutions, and formulate and regularly revise the model service agreement.

The administrative department of medical security in the State Council shall listen to the opinions of relevant departments, medical institutions, trade associations, the public and experts when formulating the measures for the administration of service agreements.