Shanghai Basic Medical Insurance Regulatory Approach

Original Language Title: 上海市基本医疗保险监督管理办法

Read the untranslated law here: http://www.chinalaw.gov.cn/article/fgkd/xfg/dfzfgz/201108/20110800346713.shtml

Shanghai basic medical insurance regulatory approach

    (January 24, 2011, Shanghai Municipal People's Government Executive session of the 96th through January 30, 2011, Shanghai Municipal People's Government, the 60th announced as of May 1, 2011) the first (goal)

    In order to guarantee basic medical needs of the insured, standardizing and strengthening supervision and administration of basic medical insurance, maintaining health insurance fund, according to the municipality, these measures are formulated.

    Article II (scope of application)

    , Basic medical insurance, this approach applies to the designated medical institutions (hereinafter referred to as designated medical institutions) appointed retail drugstores, basic health insurance (hereinafter referred to as designated retail pharmacies), personal, basic medical insurance, comply with the provisions of exercising supervision and management activities.

    The basic medical insurance in these measures, including the urban workers ' basic medical insurance, basic medical insurance and other basic medical insurance for urban residents.

    Article III (health insurance supervision and management departments) Municipal human resources and Social Security Bureau is the Department of basic medical insurance administration, responsible for the supervision and administration of urban basic medical insurance.

    The district (County) of human resources and Social Security Bureau is responsible for basic medical insurance supervision and inspection work within their respective jurisdictions.

    City health insurance supervision inspection commissioned by the municipal Bureau of human resources and social security, implementation of administrative law enforcement supervision work of basic medical insurance and regulatory work needs, enriching to strengthen supervision and inspection.

    Development and reform, health, food and drug supervision and administration of industry and commerce, finance, auditing, security, price and other administrative departments shall, within their respective mandates, with the supervision and administration of basic medical insurance.

    Fourth (health insurance related information system)

    Municipal human resources and Social Security Bureau should establish and improve the designated medical practitioner information systems as well as the costs of basic medical insurance system, to designated medical institutions and practitioners in the provision of basic medical insurance costs incurred in the course of medical services in real-time monitoring, standardized sentinel practitioners in medical institutions of medical service behavior.

    Designated medical institutions and appointed retail drugstores should be based on the requirements of the urban basic medical insurance network settlement, equipped with the necessary networking equipment, adherence to basic medical insurance information technical specifications and information security regulations, timely, accurate to upload information on basic medical insurance costs.

    Fifth (management)

    Designated medical institutions and appointed retail drugstores should establish and improve the management of basic medical insurance system, equipped with the necessary management staff, to comply with the basic provisions of the health insurance authority.

    Sixth (medical insurance cost management)

    Designated medical institutions should implement the basic medical insurance to pay the costs in the budget management, total prepaid expenses management regulations to guarantee basic medical needs of the insured, regulate the use of health insurance funds.

    Seventh (redefine the designated qualification)

    Designated medical institutions to merge or institution, address, the number of approved beds of practice change, appointed retail drugstores of change of business address or business scope should be based on the relevant provisions of this city, to the designated municipal human resources and Social Security Bureau to apply for basic medical insurance eligibility and approval procedures.

    Eighth (designated medical institutions to provide services requested)

    Designated medical institutions should be based on the insured person's condition, according to basic medical insurance diagnosis and treatment project, the scope of medical services and prescription management, drug provision, reasonable choice clinic project, rational determination of drug use.

    Designated medical institutions providing medical services to insured persons shall abide by the basic medical insurance diagnosis and treatment projects, health services, medication range, payment standards and pricing departments to determine the charges, medical costs to insured persons settlement document.

    Nineth (appointed retail drugstores provide service request)

    Appointed retail drugstores in providing prescription drugs to insured persons outside and non-prescription drug purchases the services, does not meet the basic provisions of the Medicare drug prescription distribution, not for basic medical insurance costs; of non-prescription drugs provided to insured persons, shall not violate the basic medical insurance provisions on scope, variety and quantity of the drug.

    Designated retail pharmacy providing pharmacy services for insured persons shall comply with the provisions related to price management, provision of costs associated with the settlement documents to insured persons.

    Tenth (production and verification of basic medical insurance certificate)

    Insured persons registered at designated medical institutions, medical, examination, pharmacy, hospital, when settling medical expenses or appointed retail pharmacy dispensing, should take the initiative to show the basic medical insurance certificate.

    Basic medical insurance for insured persons shall not be lent to others.

    Designated medical institutions and appointed retail drugstores for insured personnel provide medical services or providing dispensing services, basic medical insurance certificate of insurance verification personnel.

    11th (supervision and inspection in a timely manner)

    The district (County) of human resources and Social Security Council, urban medical insurance should strengthen supervision and inspection of contracted medical institutions and the supervision and inspection of appointed retail drugstores.

    Fixed-point medical institutions of basic medical insurance billing charges beyond the budgetary targets and indicators in advance the larger, district (County) of human resources and social security, the Council for medical supervision and inspection should be carried out promptly by the insurance supervision and inspection.

    12th (real-time monitoring) Medical month should be insured by the insurance supervision and inspection personnel and emergency medical and real-time monitoring of the basic medical insurance costs.

    For insured personnel and emergency medical and basic medical insurance costs incurred outside the specified limits, you can temporarily change the fee for outpatient medical insurance billing settlement. Temporary change fee for outpatient medical insurance billing settlement measures, the city shall notify the insured person by the health insurance supervision and inspection, and hospitalization for review in a timely manner.

    Audit had found no violations of the provisions of basic medical insurance, should be in audit checking is done on that day, resumed its emergency medical insurance billing settlement.

    13th (supervision and inspection procedures required)

    The district (County), health insurance, human resources and Social Security Bureau, supervision and inspection on a daily basis and special supervision and inspection, shall be notified in advance in written form are checked for designated medical institutions or appointed retail drugstores, inform the supervision and inspection of the specific content and time.

    The district (County) of human resources and Social Security Bureau, city health when conducting supervision and inspection activities by the insurance supervision and inspection, supervisory and inspective personnel shall be not less than two, shall take the initiative to produce a certificate of administrative law enforcement.

    14th (supervision measures)

    The district (County) of human resources and social security, the Council for medical supervision and inspection activities carried out by the insurance supervision and inspection, you can take the following measures:

    (A) to inquire about, sound recording, video recording, photography or copied to collect relevant information and materials, and in the case of evidence might be destroyed or shifted register;

    (B) the requirements designated medical institutions, appointed retail drugstores and individuals related to the supervision and inspection of documents, and explanations and descriptions.

    Designated medical institutions, appointed retail drugstores, insurance or other individual shall, in accordance with the district (County), health insurance, human resources and Social Security Bureau, supervision and inspection requirements provide supervision and inspection-related documentation, data, and other materials.

    15th (matters related to entrusted)

    The district (County) of human resources and social security, the Council for medical supervision and inspection activities carried out by the insurance supervision and inspection may be entrusted with agencies and experts, to designated medical institutions, appointed retail drugstores, medical insurance fund usage for audit or verification, verify and provide advice on matters of basic medical insurance.

    16th (designated medical institutions, appointed retail drugstores under medical legal responsibility insurance)

    Designated medical institutions, appointed retail drugstores, one of the following acts, municipal human resources and Social Security Bureau shall be ordered to correct, the recovery has been paid for by the health insurance fund basic medical insurance, and can be punished with a warning or fined not more than 3000 Yuan and 100,000 yuan in serious cases, can also suspend its 1-6 months of basic medical insurance billing or cancel the qualification of the basic medical insurance appointed:

    (A) failing to verify the basic medical insurance certificate for basic medical insurance certificate violation of medical or pharmaceutical, medical insurance costs;

    (B) repeated for insured persons registered, repeat or indications for testing, inspection, treatment, factoring, or no indication in hospital or in other ways, fictional medical services or provide the necessary medical services and basic medical insurance costs;

    (C) in violation of the relevant provisions of the basic medical insurance, payment of the health insurance fund or any services outside the scope of diagnosis and treatment projects, medical expenses incurred for medical services, medical insurance costs;

    (D) violation of basic medical insurance treatment or use varieties requiring, to excessive drug use, repeated drug use, special restrictions on illegal use of drugs, or to break down, to change the prescription or any other means, for insured personnel approached, basic medical insurance costs;

    (E) to the insured person by repeated charging, decomposition collection, excessive payment of any fee or charge to set our own standards, basic medical insurance costs;

    (Vi) is not in accordance with the provisions of the basic medical insurance to pay for medical insurance costs;

    (VII) not in accordance with this article seventh point again for basic medical insurance requirements and approval procedures without authorization and implementation of networking of basic medical insurance costs.

    17th (designated medical institutions, appointed retail drugstores liability for serious violations of Medicare rules)

    Designated medical institutions, appointed retail drugstores, one of the following acts, municipal human resources and Social Security Bureau shall be ordered to correct, recovery of related medical costs have been paid for by the health insurance fund, and can be punished with a warning or fined not more than 30,000 yuan and 100,000 yuan in serious, should also suspend its 1-6 months of basic medical insurance billing or cancel the qualification of the basic medical insurance appointed:
(A) unauthorized and non-fixed-point medical institutions of implementation or retail pharmacy network, basic medical insurance costs;

    (B) to history of forged or altered records, prescriptions, accounting, medical expense receipts, upload data, etc, and basic medical insurance costs;

    (C) supplies, health tonics and other non-drug items serve as a medication drugs within the scope of basic medical insurance, basic medical insurance costs;

    (D) take the form of other medical insurance fund, medical insurance costs.

    18th (personal legal responsibility for violating the health insurance regulations)

    Parameter insurance personnel or other personal in medical or purchased drug process in the has following behavior one of of, city human resources Social Security Council should ordered its returned has by medical insurance fund paid of related basic medical insurance costs, and can sentenced warning or 100 Yuan above 2000 Yuan following of fine; plot serious of, sentenced 2000 Yuan above 10,000 yuan following of fine, also can on its take change basic medical insurance costs remember account settlement way 1-6 months of measures:

    (A) the basic medical insurance certificate will I lend them to others, or by transfer of medical credentials, the settlement documents, basic medical insurance costs;

    (B) the use of others ' basic medical insurance certificate or forged or altered certificate of basic medical insurance, basic medical insurance costs;

    (C) by repeating the visits, counterfeit, altered, altered history, prescription costs, reimbursement, medical documentation, medical insurance costs;

    (D) the sale by the costs of basic medical insurance and drug;

    (E) take the form of other medical insurance fund, medical insurance costs.

    19th (penalty standards)

    In accordance with the provisions of the present article 16th, to designated medical institutions, appointed retail drugstores fines, the amount of the fine in accordance with the following provisions:

    (A) the illegal settlement amount of up to 100,000 yuan, up to 3000 Yuan and 10,000 yuan fines;

    (B) illegal settlement amount of less than 100,000 yuan and 300,000 yuan, fined 10,000 yuan and 50,000 yuan fine;

    (C) illegal settlement amount of more than 300,000 yuan, fined 50,000 yuan and 100,000 yuan fine.

    20th (for violations of the health insurance provisions of other treatments)

    Appointed medical institution of appointed retail drugstores and Department or who violate the provisions of the basic medical insurance, municipal human resources and Social Security Bureau will suspend its basic medical insurance payment measure.

    21st (management liability of inspectors) Basic medical insurance management and supervisors and inspectors shall, in accordance with and the relevant provisions of this city, to perform the basic duties of medical insurance management and supervision and inspection shall not abuse, malpractice, neglect their duties. Violations of relevant personnel, human resources and Social Security Bureau, shall be given an administrative sanction; because it is causing loss of medical insurance funds, fees shall be recovered.

    Constitute a crime shall be investigated for criminal liability.

    22nd (date) These measures shall take effect on May 1, 2011.