Ningxia Hui Autonomous Region, The Basic Medical Insurance Service Monitoring

Original Language Title: 宁夏回族自治区基本医疗保险服务监督办法

Read the untranslated law here: http://www.chinalaw.gov.cn/article/fgkd/xfg/dfzfgz/201310/20131000392291.shtml

Ningxia Hui autonomous region, the basic medical insurance service monitoring

    (July 2, 2013 people's Government of Ningxia Hui autonomous region, the 8th Executive Meeting July 6, 2013, people's Government of Ningxia Hui autonomous region, the 55th release come into force on September 1, 2013) first in order to standardize the basic medical insurance service, maintenance of the basic medical insurance fund security, protect the interests of insured persons to basic medical, according to the People's Republic of China social security law and other laws and regulations, these measures are formulated.

    Article on medical insurance, retail pharmacies, medical services, medical treatment and basic medical insurance agency medical service supervision, these measures shall apply.

    Hospitals, retail pharmacies in these measures refers to basic medical services and basic medical insurance agency signed agreement of medical institutions and retail pharmacies.

    Insured persons mentioned in these measures refers to pay basic medical insurance fees in accordance with the provisions, access to basic medical insurance treatment of staff.

    Article Social Security Administration Department is responsible for the supervision of basic medical insurance service, medical insurance of its monitoring agencies on their behalf, is responsible for the supervision of basic medical insurance service specific tasks.

    Development and reform, finance, audit, health and food and drug supervision, price and other administrative authorities, shall, within their respective mandates to do basic health care supervision.

    Article fourth medical institutions should strictly implement the State and the autonomous communities to basic medical insurance drug list, medical services, clinics the project directory services as well as medical supplies paid standard catalog requirements, performing basic medical services agreement, for the insured person to provide reasonable and necessary medical services.

    Article fifth retail pharmacy shall comply with the provisions of drug prices and medical insurance policies, implementation of basic medical insurance service agreement, for the insured person to provide prescription drug distribution and non-prescription drug purchases the services.

    VI basic health insurance agencies should carry out basic medical insurance service agreement, open handling procedures, establish and improve the business, financial, security, and risk management systems.

    Basic medical insurance agency should be public at least once a year is within the scope of the basic medical insurance fund's cijun hospitalization costs and growth rate, average length of reimbursement rate, the proportion of basic medical insurance for non-hospital costs and other major indicators information.

    Seventh contractor insurance business insurance agencies and financial institutions bear the costs of basic medical insurance payment, should be strictly in accordance with the agreement for hospitals, retail pharmacies and insurance personnel, provide convenient, fast, attentive service.

    Article eighth insured persons shall be honest and trustworthy, comply with the basic health insurance laws, regulations and policies.

    Nineth medical organizations, retail pharmacy and the basic medical insurance institution shall not under any of the following cheat basic medical insurance funds Act:

    (A) provide proof of false diagnoses, medical records, prescriptions, and medical bills and other information to defraud funds of basic medical insurance expenditure;

    (B) allow non-insured persons on behalf of the insured person for medical treatment;

    (C) allowed funds of basic medical insurance of medical costs paid by the insured person at his own expense;

    (D) allows the use of basic health insurance vouchers to purchase basic medical insurance for non-payment of medicines or medical supplies;

    (E) deficiency in mind expenses, uninsured SWOP for Medicare payment program payments;

    (F) excessive fees or decomposition, repeating charges;

    (VII) through fictitious purchase facts, personal medical insurance accounts liquidated insured;

    (VIII) not in accordance with the condition need to abuse of large equipment checks, precious drugs to the insured or to provide other necessary medical services;

    (IX) lent health care Terminal to non-protocol services unit uses non-Protocol service units or the use of medical insurance individual account funds for settlement;

    (10) he knows to be false reimbursement expenses of basic medical insurance funds;

    (11) other acts of obtaining basic medical insurance fund.

    Article tenth insured persons shall not in any of the following acts of obtaining basic health insurance benefits:

    (A) the basic medical insurance certificates provided to others or used in medical institutions;

    (B) the use of others ' basic medical insurance certificate for medical treatment;

    (C) forging or altering medical records, prescriptions, diagnosis and medical treatment of diseases Bill;

    (D) other acts of obtaining basic health insurance benefits.

    11th the employer shall abide by the basic medical insurance laws and regulations and related requirements, or for insured persons issuing false medical certificates, basic medical insurance for helping the insurance swindler.

    12th monitoring information system of social insurance administration by basic medical insurance, medical insurance institutions, retail pharmacy services, medical treatment and basic medical insurance agency monitored health care settlement and other related information in real time.

    13th medical institutions should strengthen information construction, retail pharmacy, electronic medical records, medical, medical and other aspects of the project management to protect its information systems and basic medical insurance agency the cost of clearing systems, basic medical insurance of supervisory information system interoperability.

    Hospitals, retail pharmacies and the basic medical insurance agency shall be promptly and accurately to the basic medical insurance system to upload diagnosis and treatment and the cost of clearing and other related information. 14th no units and individuals in violation of the basic provisions of the health insurance act is entitled to report complaints.

    Social Security Administration Department should be promptly investigated, and informants, and the written replies to the complainants the processing result.

    15th report to the social security administration by monitoring in real time, receiving complaints, medical institutions, retail pharmacies, primary health insurance agencies and insurance personnel investigation into alleged violations of the provisions of basic medical insurance for verification.

    Social Security Administration Department to investigate alleged violations of the provisions of basic medical insurance verification, should produce valid certificates, you can take the following measures:

    (A) read, record, copy, and basic medical insurance fund, management-related information, may be transferred, concealed or destroyed information be sealed;

    (B) subjects relating to the inquiry and investigation units and individuals, requiring them to investigating issues related to the clarification, provided the relevant supporting documents;

    (C) to obtain basic medical insurance fund or treatment be stopped and ordered corrective action.

    16th social security Administrative Department to carry out investigations, may invite relevant experts, to medical institutions, retail pharmacies, primary health insurance agencies and insurance personnel suspected of violating provisions of the professional opinion of basic medical insurance.

    17th medical institutions, retail pharmacies, primary health insurance agencies and insurance personnel, found violations of the Social Security Administration disagrees with the conclusion of basic medical insurance, social insurance may apply orally or in writing that the Administration reconsider.

    Social Security Administration Department shall receive within ten working days from the date the party's application, relevant parties, managers and experts, the relevant facts, evidence, data analysis, evidence, finds that conclusion.

    Units and individuals to social security administration finds that refuses to accept the conclusions of its violation of basic medical insurance, may apply for administrative reconsideration or bring an administrative suit.

    18th social security administrative departments of medical institutions, retail pharmacies, primary health insurance agencies and practitioners, insurance personnel violate the provisions of the basic medical insurance treatment results, should be open to the public.

    Article 19th social security administration of medical institutions, staff in retail drugstores and medical insurance services agreement, comply with the provisions included in the credit information system and management of basic medical insurance.

    20th finance sector, auditing organs should strengthen the basic medical insurance fund management and supervision on the use of checks.

    21st medical organizations, retail pharmacy, basic medical insurance agency violates the measures article Nineth fraudulent expenditure of basic medical insurance fund, returned from social security Administrative Department in charge shall command the basic medical insurance fraud, fined not more than the amount defrauded more than twice times five times.

    Medical institutions, retail pharmacies in violation of the provisions of the preceding paragraph, suspend the performance of more than three months to six months following service agreement in serious cases, terminate the service agreement directly in charge of personnel and other persons directly responsible licensing, revoked its licensing.

    22nd personnel violating these rules article tenth of insured in one of the basic medical insurance benefits fraudulently, by the social security administration ordered to return the basic medical insurance fraud, fined not more than the amount defrauded more than twice times five times.

    23rd the employer in violation of these regulations section 11th, for the insurance officer issued false certificates, basic medical insurance for helping the insurance swindler, granted by the social security administration warning; the circumstances are serious, be criticized.

    24th social insurance administration and monitoring institutions and their staff in basic medical insurance health care oversight, abuse of power, deception, negligence, the directly responsible person in charge and other direct liable persons shall be given administrative sanctions.

    25th diagnosis and treatment of work-related injury insurance and maternity insurance clinics, retired health care services such as monitoring, in accordance with the measures implemented. 26th article of the rules take effect on September 1, 2013.