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In order to do a good job in the management of medical insurance payment for Tianjin’s “Internet +” medical services, the Municipal Medical Insurance Bureau has formulated the “Tianjin’s “Internet +” Medical Services "Medical Insurance Payment Management Measures", which clarifies the medical insurance payment policy and other contents of Internet medical care, and will be implemented from November 1, 2022.
The full text is as follows
Tianjin’s “Internet +” Medical Services Medical Insurance Payment Management Measures
Chapter 1 General Provisions
Article 1 is Strengthen and standardize the management of medical insurance payment for "Internet +" medical services in this city. According to the "Opinions of the General Office of the State Council on Promoting the Development of "Internet + Medical Health"" and the "National Medical Security Administration's Notice on Actively Promoting Medical Insurance Payment for "Internet +" Medical Services" These measures are formulated according to the requirements of documents such as the Guiding Opinions of the Tianjin Municipal People's Government and the Implementation Opinions of the General Office of the Tianjin Municipal People's Government on Promoting the Development of "Internet + Medical Health".
Article 2 The “Internet +” medical service medical insurance payment management referred to in these Measures refers to the medical insurance designated medical institutions approved by this city to set up Internet hospitals or approved to carry out Internet diagnosis and treatment activities in accordance with the law to provide insured persons with "Internet +" medical services involve activities such as application and contract signing of medical security institutions, medical insurance payment policies, medical insurance settlement, agreement management, management and supervision.
Article 3 The Municipal Medical Security Bureau is responsible for the city’s “Internet +” medical services and medical insurance management, and determines the conditions that designated medical institutions should meet to carry out “Internet +” medical services, the application contract procedures, and the “Internet +” "Policies such as medical service prices and medical insurance payment.
The District Medical Security Bureau is responsible for the supervision and management of medical insurance payment for "Internet +" medical services within its jurisdiction and other related work.
The Municipal Medical Security Fund Management Center and its branches in each district organize and implement the management of "Internet +" medical services and medical insurance agreements in accordance with their responsibilities.
The Municipal Medical Security Fund Settlement Center is responsible for the review and settlement of medical insurance payment fees for "Internet +" medical services.
The Municipal Pharmaceutical Procurement Center is responsible for improving the procurement platform and supporting designated pharmaceutical institutions to carry out online procurement of drugs required for "Internet +" medical services and medical insurance payment.
The Municipal Medical Security Fund Supervision and Inspection Office is entrusted by the Municipal Medical Security Bureau to implement medical insurance laws, regulations, and regulations on designated medical institutions, medical insurance service physicians, and insured persons in the "Internet +" medical service medical insurance payment. Carry out supervision and inspection work according to regulations and other conditions.
Chapter 2 Institutional Application for Contracting
Article 4 The city’s approved establishment of Internet hospitals or designated medical institutions for medical security that carry out Internet diagnosis and treatment activities in accordance with the law may be carried out in accordance with the principle of voluntariness. Physical medical institutions apply to the Medical Insurance Branch for signing a supplementary agreement on "Internet +" medical services. If the physical medical institution is a non-designated medical institution, it can apply for an "Internet +" medical service supplementary agreement at the same time as it applies to sign a medical insurance designated agreement.
Article 5 Medical institutions applying for the “Internet +” medical service supplementary agreement shall meet the following basic conditions:
Have the conditions to connect with the national unified medical insurance information business code, as well as drugs, Basic information database of medical consumables, diagnosis and treatment items, medical service facilities, disease types, etc.;
Has the conditions for data exchange with the medical insurance information system. Combined with the construction of a national unified medical insurance information platform, medical insurance mobile payment can be realized. Patients provide electronic bills, electronic invoices or timely mailed paper bills;
Relying on medical insurance electronic vouchers for real-name authentication to ensure that insured persons use their true identities;
Insurance can be completely retained Information such as electronic medical records, electronic prescriptions, drug purchase records, and medical records with clear diagnoses provided by patients during personnel diagnosis and treatment can be traced throughout the entire process of diagnosis, treatment, prescriptions, and dispensing;
Be able to verify that the patient is a follow-up patient patients, master the necessary medical information;
The information system of medical institutions should be able to distinguish offline medical service business, off-site medical service business and "Internet +" medical service business;
According to the national Complete the transformation of the "Internet +" medical insurance online settlement system in accordance with the relevant requirements for the management of this city's medical insurance information platform;
Other conditions that should be met according to regulations.
Article 6 Medical institutions applying for a supplementary agreement on “Internet+” medical services shall provide the following materials:
Application form for signing a supplementary agreement on “Internet+” medical services;
Copy of the license approved by the competent department to set up an Internet hospital or carry out Internet diagnosis and treatment activities;
Related information system materials related to medical insurance payment for "Internet +" medical services;
List of doctors related to medical insurance payment for "Internet +" medical services;
Other materials that need to be provided in accordance with relevant regulations.
Article 7 If a medical institution applies to the Medical Insurance Sub-Center for signing a supplementary agreement on "Internet +" medical services, the Medical Insurance Sub-Center shall accept it immediately. If the application materials are incomplete, the medical insurance branch center will notify the medical institution to make supplements within 5 working days from the date of receipt of the materials.
Article 8 The medical insurance sub-center should organize an evaluation team to evaluate the medical institutions that apply to sign the "Internet +" medical service supplementary agreement in writing, on-site, etc. The evaluation time shall not exceed 2 months from the date of acceptance of application materials or the signing of a medical insurance agreement by an entity medical institution, and the time for medical institutions to supplement materials is not included in the evaluation period. The assessment content includes:
Verification of the license issued by the competent department for the establishment of an Internet hospital or the development of Internet diagnosis and treatment activities;
Verification of medical institutions’ “Internet+” medical insurance network settlement and national medical insurance electronic vouchers, Relevant information systems such as mobile payment system docking;
Verify the situation of doctors related to medical insurance payment for "Internet +" medical services of medical institutions;
Verify whether "Internet +" medical services of medical institutions are Able to verify that the patient is a follow-up patient and grasp the patient's necessary medical information;
Verify whether the "Internet +" medical service of the medical institution can completely retain the insured person's electronic medical records, electronic prescriptions, and drug purchase records during the diagnosis and treatment process and other information;
Check other materials that medical institutions should provide in accordance with relevant regulations.
Article 9_ After evaluating a qualified medical institution, the Municipal Medical Insurance Center or Medical Insurance Sub-center shall sign a supplementary agreement with the medical institution within 5 working days. The term of the supplementary agreement shall be consistent with the entity designated medical institution on which it relies. If the evaluation is unsatisfactory, the medical insurance branch center shall notify the reasons in writing and make suggestions for rectification.
Chapter 3 Medical Insurance Payment Policy
Article 10 When medical institutions establish “Internet +” medical service projects, they shall follow the national and local “Internet +” medical service prices and medical insurance payment. Policy implementation. Designated medical institutions provide "Internet +" medical follow-up services that comply with regulations, and charge and pay according to the prices of general outpatient examinations in public hospitals. The drug expenses incurred shall be paid in accordance with the payment standards and policies stipulated by offline medical insurance.
Article 11 The "Internet +" medical follow-up services provided by designated medical institutions for insured persons shall be within the scope of diagnosis and treatment subjects of their offline physical medical institutions and shall not exceed the scope of their Internet diagnosis and treatment subjects. The Internet diagnosis and treatment services provided by designated medical institutions to insured persons are limited to follow-up consultations for common and chronic diseases that can be completed independently online.
Article 12 The "Internet +" medical follow-up prescriptions provided by designated medical institutions for insured persons should comply with relevant regulations on Internet diagnosis and treatment, prescription management and other regulations of the health department. Prescriptions issued online must be electronically signed by a physician and uploaded to the medical insurance settlement system in accordance with regulations after being reviewed by a pharmacist and purchased at our hospital or at a designated retail pharmacy.
Article 13. The medical examination fees and drug fees incurred by insured persons for follow-up consultation and prescription issuance at designated medical institutions for “Internet +” medical services in this city, if they are within the scope of medical insurance payment, shall be paid in accordance with the relevant regulations of this city’s medical insurance. Pay. Among them, the expenses borne by individuals can be paid from the employee's personal medical insurance account according to regulations. The cost of providing drug delivery services is not included in the scope of medical insurance payment.
Chapter 4 Medical Insurance Settlement
Article 14 The Municipal Medical Insurance Center shall promptly publish the "Internet +" medical service medical insurance settlement management interface specifications. Designated medical institutions that carry out "Internet +" medical services should transform their internal systems in accordance with interface specifications, maintain effective connection with the city's medical security information platform as required, and achieve online settlement of medical insurance. Designated medical institutions shall independently select suppliers for the operation and maintenance of relevant information systems that interface with medical insurance. Medical insurance agencies are not allowed to charge any fees or designate suppliers in any name.
Article 15 For Internet medical treatment, insured persons shall rely on the name authentication of the electronic medical insurance voucher and complete the settlement of medical insurance fees for "Internet +" medical services through mobile payment.
Insured persons should activate the electronic medical insurance voucher after physical authentication through a third-party channel authorized by the National Medical Security Administration.
Article 16: Examination fees for "Internet +" medical services provided by designated medical institutions that comply with regulations and drug fees incurred at institutions providing "Internet +" medical services or their designated third-party institutions shall be calculated as follows: It is stipulated that the portion that should be paid by the medical insurance fund shall be settled directly by the medical insurance agency with the designated medical institution. The drug expenses incurred when "Internet +" medical follow-up prescriptions are transferred to designated retail pharmacies in this city. According to regulations, the part that should be paid by the medical insurance fund shall be settled by the medical insurance agency and the designated retail pharmacies.
Article 17 Designated medical institutions should declare the medical expenses paid by medical insurance for "Internet +" medical services as required, and distinguish them from offline medical expenses. In accordance with the relevant regulations and requirements of the medical security administrative department, health administrative department, market supervision and other departments, the Municipal Medical Insurance Settlement Center adopts a method of combining intelligent review and manual key review to legally conduct medical expenses paid by medical insurance for "Internet +" medical services in accordance with its responsibilities. Sexuality and rationality review. Fees that comply with the regulations will be paid, and fees that have been reviewed and verified for violations declared will not be paid.
Article 18: Designated medical institutions that carry out "Internet +" medical services and their offline physical designated medical institutions are regarded as the same management service entity, and their medical insurance payment management is managed in accordance with the city's regional point method and total budget management And the current relevant regulations such as fixed payment according to disease type, payment according to total capita, and payment according to project shall be implemented.
Chapter 5 Agreement Management
Article 19 Designated medical institutions that provide “Internet +” medical services shall abide by the medical insurance agreement of designated medical institutions in this city and the “Internet +” Medical Services Supplement. In accordance with the requirements of the agreement, the medical insurance agency shall do a good job in the management and service of designated medical institutions, promptly announce to the public the list of designated medical institutions that have signed "Internet +" medical services, and urge designated medical institutions to announce "Internet +" medical services to the public Information such as the main service content and charging prices of the service. ___
Article 20 Medical insurance service physicians who carry out Internet diagnosis and treatment activities shall obtain corresponding medical practitioner qualifications in accordance with the law, have more than 3 years of independent clinical work experience, and shall abide by the city’s medical insurance agreement, the additional agreement for medical insurance service physicians and “ Relevant contents of the Supplementary Agreement on “Internet +” Medical Services.
Article 21 Medical insurance agencies or third-party agencies entrusted by them should regularly conduct performance appraisals of medical institutions that provide "Internet +" medical services and the physical medical institutions they rely on. Establish an assessment index system centered on the use of medical insurance funds, quality of medical services, and patient satisfaction with medical treatment and drug collection. The assessment results are linked to the signing of medical insurance agreements and medical insurance payments.
Article 22 The Municipal Medical Insurance Center should improve the content of the “Internet +” medical service supplementary agreement, establish an exit mechanism, and suspend or terminate the supplementary agreement in accordance with regulations. If the agreement of an entity designated medical institution is suspended or terminated, the supplementary agreement for providing "Internet +" medical services shall be suspended or terminated at the same time; if the agreement of a medical institution providing "Internet +" medical services is suspended or terminated, the medical insurance agency shall be based on the entity's The stipulations in the designated medical institution agreement determine whether to suspend or terminate the corresponding designated agreement.
Chapter 6 Management and Supervision
Article 23: Designated medical institutions should establish an online prescription review system and a medical service behavior supervision mechanism, and integrate electronic medical records, online electronic prescriptions, and purchase Drug records, real-name authentication records and other information are uploaded to the medical security information platform in real time, and drug traceability codes are gradually implemented for scan-and-sell, and relevant electronic information such as medical diagnosis and treatment is properly preserved, so that the entire process of diagnosis and treatment, prescriptions, transactions, and distribution can be traced, and information can be realized The flow, capital flow, and logistics can be monitored throughout the entire process to ensure the rationality of diagnosis and treatment, prevent fictitious medical services, and maintain the safety of medical insurance funds.
Article 24 Medical insurance agencies must strengthen their expense review responsibilities, comprehensively use big data, the Internet and other technical means, and use the medical insurance intelligent review and monitoring system to conduct "Internet +" medical service expense settlement details, drugs , consumables, medical service items, outpatient medical records and other information for real-time monitoring. Use audio, video and other forms to test the authenticity of doctors receiving "Internet +" medical services. Comprehensively grasp the medical treatment information of insured persons and relevant records of review and follow-up visits by medical institutions. Medical examination fees and drug fees that do not meet the regulations will be refused and handled in accordance with the agreement.
Article 25 Municipal and municipal medical security departments shall, in accordance with their duties, include the "Internet +" medical services and other content provided by designated medical institutions and their medical insurance service physicians into the scope of supervision, in accordance with medical insurance laws, regulations and rules , service agreement, through the intelligent review and real-time monitoring system of medical insurance, strengthen big data analysis, and severely crack down on illegal activities in medical insurance payment for "Internet +" medical services.
Article 26 The municipal and municipal medical security departments shall, in accordance with relevant regulations, disclose to the public cases of violations of laws and regulations by designated pharmaceutical institutions, medical insurance service physicians, and insured persons in "Internet +" medical services, and report to the public health The health, market supervision and other departments have notified it, and it has been incorporated into credit management platforms such as the National Credit Information Sharing Platform and the Law Enforcement Supervision Platform, and joint punishments for dishonesty are implemented in accordance with the law.
Article 27 If designated medical institutions and their medical insurance service physicians and insured persons receiving "Internet +" medical services violate these management measures and fall within the provisions of the medical insurance agreement, the Municipal Medical Insurance Center or Medical Insurance The branch center will deal with the matter in accordance with the agreement; if it falls within the scope of administrative penalties stipulated in laws, regulations and rules, the medical security department will impose administrative penalties in accordance with the law; if it constitutes a crime, criminal responsibility will be pursued in accordance with the law.
If medical security departments at all levels abuse their power, neglect their duties, or practice favoritism in the management of medical insurance payment for "Internet +" medical services, the directly responsible supervisor and other directly responsible personnel shall be punished in accordance with the law; this constitutes Anyone who commits a crime shall be held criminally responsible in accordance with the law.
Appendix to Chapter 7
Article 28 Medical security departments at all levels should do a good job in network security of data related to medical insurance payment for "Internet +" medical services to prevent data leakage Leakage to ensure the security of medical insurance system information. Designated medical institutions and their medical insurance service physicians should strictly implement relevant national and municipal information security regulations to ensure the security of insured personnel and medical insurance data.
Article 29 The term “designated medical institutions” as mentioned in these Measures refers to the collective name of designated medical institutions and designated retail pharmacies.
Medical insurance handling agencies refer to the Municipal Medical Insurance Center, Medical Insurance Sub-centers and Municipal Medical Insurance Settlement Center.
Medical insurance agreement refers to an agreement signed by a medical insurance agency and a medical institution after consultation and negotiation, which is used to regulate medical service behavior and clarify the rights, obligations and responsibilities of both parties.
Article 30 These Measures will be implemented from November 1, 2022, and will be abolished on October 31, 2027.