Medical insurance management working system

1. Carefully check the patient’s identity. When the insured person goes to see a doctor, he or she should check the certificate, card and person. Strictly control the situation and prevent violations such as using or borrowing one’s medical insurance identity to prescribe medicines, diagnosis and treatment; implement a first-diagnosis responsibility system, in which the attending doctor records the medical history and treatment process in accordance with the prescribed medical records, and falsification is strictly prohibited. 2. Fulfill notification obligations. Inpatients are informed that they must provide their medical insurance card when they are hospitalized, and the medical insurance card will be handed over to the charging room for safekeeping during hospitalization.

3. Strictly implement the "Ningbo Basic Medical Insurance Drug Catalog and Medical Service Item Catalog". Do not use drugs, diagnosis and treatment beyond the limited payment range of medical insurance. Self-paid drugs, diagnosis and treatment items and medical service facilities must be provided. Obtain the consent of the insured person in advance and sign in the medical record for confirmation. Otherwise, any complaints from patients caused by this will be handled by the relevant responsible person.

4. Strictly follow the relevant provisions of the "Prescription Management Measures". Each prescription shall not exceed 5 types of medicines (Western medicines and Chinese patent medicines can be prescribed separately). The amount of medicines dispensed for each outpatient clinic shall generally not exceed 3 days' supply for acute diseases, 7 days' supply for general diseases, and no more than half a month's supply for chronic diseases. Inpatients must consume the oral medicine before they can be prescribed the second bottle of medicine, otherwise the medical insurance will handle the overdose. Strictly control the indications for medication, and inpatients need to consolidate their treatment and take medication when they are discharged, and follow the above implementation. 5. Examine and approve in strict accordance with regulations. Medicines restricted by medical insurance must be approved by the hospital before they can be used under medical insurance if they comply with the medical insurance restrictions. Otherwise, they will be used at their own expense and patients will be informed.

6. Medical records must be written in a standardized, objective, truthful, accurate, timely and complete manner to record the outpatient and inpatient medical records of insured patients. Patients with various accidental injuries must be included in outpatient and emergency medical records and inpatient course records. The time, place and cause of accidental injuries must be truthfully recorded.

7. Rational use of drugs and reasonable examinations to protect the interests of insured patients. Inpatients who require repeated examinations must have cause analysis records. Control the use of antibacterial drugs and self-paid drugs

8. Strictly control the admission and discharge standards of medical insurance patients. It is strictly prohibited to disaggregate outpatient prescriptions and prescribe medicines or artificially disaggregate the number of hospitalizations; it is prohibited to hospitalize patients with outpatient treatment or examinations, and the contents of inpatient medical records must be standardized and complete.

9. Charges and calculations shall be strictly in accordance with regulations. fees, and put an end to arbitrary charges and overcharges. The inpatient department implements a daily list system. The daily list should be handed over to the patient for signature and confirmation. Timely billing must be achieved to avoid repeated charges. All kinds of expense accounting must be consistent with medical records and medical orders. The relevant responsible doctors and nurses will be responsible for the full amount of medical insurance refusal to pay due to arbitrary charges, overcharges, and repeated charges.

10. All doctors fully understand the relevant policies of medical insurance through various channels. The hospital regularly inspects and publicizes the medical insurance work, and organizes timely in-hospital organizational study of the latest medical insurance policies, documents, etc.

11. The terminal software provided by the medical insurance management center must be properly maintained; new medical insurance policies are introduced, download and modify programs in a timely manner as required, and upload and download in a timely manner to ensure the safety and integrity of medical insurance data for insured patients. Provide 24/7 card-based medical treatment services.

Those who violate the above system regulations will be dealt with according to the employee reward and punishment regulations, and will be fully responsible for medical insurance refusal payments.

Legal basis:

Article 30 of the "Social Insurance Law of the People's Republic of China" The following medical expenses are not included in the payment scope of the basic medical insurance fund:

(1) Should be paid from the work-related injury insurance fund;

(2) Should be borne by a third party;

(3) Should be borne by the public health department ;

(4) Seeking medical treatment abroad.

Medical expenses should be borne by a third party in accordance with the law. If the third party fails to pay or the third party cannot be identified, the basic medical insurance fund shall pay first. After the basic medical insurance fund has paid in advance, it has the right to recover compensation from the third party.