Decree No. 2015-770 29 June 2015 Concerning The Modalities Of Implementation Of The Third Party Paying For The Beneficiaries Of Supplementary Universal Health Coverage And Payment Of Supplementary Health Insurance Assistance

Original Language Title: Décret n° 2015-770 du 29 juin 2015 relatif aux modalités de mise en œuvre du tiers payant pour les bénéficiaires de la couverture maladie universelle complémentaire et de l'aide au paiement d'une assurance complémentaire de santé

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Summary pursuant to article 41 (I: 4 ° and 5 °) of Act No. 2014 - 1554 22 December 2014.
Keywords Social Affairs, health, social security, CODE DE LA SÉCURITÉ SOCIALE, CSS, insured SOCIAL, social PROTECTION, cover disease universal supplementary, CMU - C, third PAYANT, supplementary health insurance, CSA, helps payment, beneficiary, contract of insurance disease further, caller one, health professional, health insurance organization, organization of insurance supplementary health, organization of insurance disease further, organization of security social JORF n ° 0149 June 30, 2015 page 11025 text no. 51 order No. 2015-770 29 June 2015 on detailed rules of implementation of the third party paying for the beneficiaries of supplementary universal health coverage and the payment of supplementary insurance of health NOR aid: AFSS1513049D ELI: https://www.legifrance.gouv.fr/eli/decret/2015/6/29/AFSS1513049D/jo/texte Alias: https://www.legifrance.gouv.fr/eli/decret/2015/6/29/2015-770/jo/texte interested Publics: insured beneficiary of supplementary universal health (CMU - c), insured coverage beneficiary of aid to the payment of a supplementary health insurance (ACS) and who have subscribed a contract among the offers selected, mandatory health insurance agencies, agencies of complementary insurance, health professionals, health institutions, health centres.
Subject: determination of the modes of implementation of the third party paying for the beneficiaries of the ACS, where the health care professional wishes to have a single point of contact, and updating of these terms and conditions for the beneficiaries of the CMU - c.
Entry into force: the text comes into force the day following its publication.
Notice: this order is intended to update the modalities of implementation of the third party paying for the beneficiaries of the CMU - c and determine the terms of the third party paying for health professionals wishing to have a single point of contact, when the insured is the recipient of the ACS and that endorsed a supplementary health insurance contract selected. The text stipulates, to this effect, procedure between health professionals and insurance providers, on the one hand, and the applicable between complementary health insurance agencies and insurance agencies, other hand References: the provisions of the social security code amended by this decree can be found in their issue drafting of this amendment , the site of Légifrance (http://www.legifrance.gouv.fr).
The Prime Minister, on the report of the Minister of Social Affairs, health and rights of women, given the code of social security, particular articles L. 861 - 3 and L. 863-7-1;
Pursuant to law n ° 2003 - 1199 of December 18, 2003, from financing social security for 2004, including section 33;
Pursuant to law n ° 2013 - 1203 December 23, 2013, financing of social security for 2014, including section 56;
Having regard to the opinion of the Council of the National Fund of insurance illness of employees dated June 2, 2015;
Having regard to the opinion of the central Board of Directors of social mutuality agricultural dated June 11, 2015;
Having regard to the referral to the Council of the National Union of the insurance funds as of May 21, 2015, enacts as follows: Article 1 more on this article...

Title VI of Book VIII of the social security code is amended as follows: 1 ° it is thus titled: «complementary Protection in health and aid to the payment of a supplementary health insurance»;
2 ° it is composed of the following three chapters: has) a chapter I, entitled: "Provisions relating to the supplementary health coverage" including articles D. 861 - D. 861 1 - 8;
b) a chapter II, entitled: 'Financial provisions relating to the Fund's financing of the additional protection of the universal coverage of the disease risk' and composed:-d' a section 1: "General provisions", including article D. 862 - 1;
-d' an section 2: "Provisions relating to supplementary health insurance agencies", comprising articles D. 862 - 2 to D. 862 - 4; and -d ' a section 3: "Provisions relating to social security bodies", comprising articles D. 862 - 5 to D. 862 - 7;
c) a chapter III, entitled: 'Aid to the payment of a supplementary health insurance' includes articles D. 863 - 1 and D. 863 - 2;
3 ° sections D. 861 - D. 861 2 - 6 are replaced by the following: «art.» D. 861-2.-to qualify for the third paying provided for in article L. 861 - 3, the care recipient must submit to the professional or the establishment of health insurance referred to in article L. 161 - card 31. In the event of impossibility of reading the map or absence of update of the latter, the beneficiary may submit the proof of law issued by the organization that benefits of the health insurance database. An order of the Minister in charge of social security determines the content of the certificate.
"The payment to the professional or the health of the acts or services facility under the provisions referred to in article L. 861 - 3 is guaranteed, subject to the General conditions of support acts or services concerned and on the condition that map the beneficiary health insurance care not be listed on the list of opposition referred to in article R. 161-33-7 on the day of the issuance of these acts or services or. in the cases provided for in the preceding paragraph, on joint submission of certification of right valid and insurance card.
«Art.» D. 861-3.-when the agencies for the care recipient of the basic health insurance scheme and the supplementary benefits are different, third paying is done according to the rules laid down in articles D. 861 - 4 to D. 861-7.
"By way of exception, professionals and health institutions can sign agreements with insurance mandatory or complementary providers defining the terms of the paying third parties other than those mentioned in the preceding paragraph. When agencies serving a base of health insurance plan benefits are not signatories to these conventions, they are informed of their content by the signatory parties.
«Art.» D. 861-4.-for the acts and benefits provided by the health professionals and for those that do not fall within the scope of the annual allocation of funding health institutions mentioned in article L. 174 - 1, exemption from advance fee involving a single contact provided for in article L. 861 - 3 is carried out according to the following procedure: "1 ° Professional or health facility forward to the body serving as the basis of health insurance benefits. , under the conditions laid down in articles R. 161 - 47 and R. 161 - 48, the documents referred to in article R. 161 - 40 for the recognition of care and conditioning the opening of the right to reimbursement;
«2 ° the body serving as the base of liquid health insurance plan benefits the share of expenditures supported respectively by the basic scheme and the supplementary health insurance agency. It makes the payment to the professional or the establishment of health of all the amounts taken in charge. It shall send a statement of benefits common to the organization used the basic plan benefits and supplementary health insurance agency;
«3 ° the exchange of information between agencies serving insurance base pension benefits and supplementary health insurance agencies are carried out electronically and shall comply with the technical specifications defined by the specification of the open standard of exchange between disease and external stakeholders, prepared by caisses national insurance after consultation with supplementary health insurance agencies;
"The amounts owed to the organization used the benefits of the basic scheme by the supplementary health insurance agency are paid within a period of five days from the date of the invoice by compulsory health insurance.
"The payment by the Agency of supplementary health insurance is accompanied by the sending of an electronic payment voucher.
"The service provided by the sickness insurance institution is charged the Organization of supplementary health insurance under conditions fixed by Decree.
«Art.» D. 861-5.-for benefits other than those referred to in article D. 861 - 4 issued by health institutions mentioned in the L. 174 - 1, exemption from advance fee practised on its support by the Organization of supplementary health insurance is done according to either of the two methods below:

1 ° the establishment of health address a demand for payment electronically to its pivot which shall forward it without delay to the Agency for the care recipient benefits from the plan of health insurance database. When cloud sending is impossible, the establishment directly address the claim on paper serving Agency for the recipient of care benefits from the plan of health insurance database. This organization makes the payment of the amount corresponding to the health facility on behalf of the Organization of supplementary health insurance and sends to the health facility a statement of benefits paid by the supplementary health insurance agency. Relations between the serving Agency to the beneficiary of the benefits of basic care and serving as additional benefits are determined in accordance with 3 ° of article D. 861-4;
"2 ° the establishment address his request for payment directly to the body of supplementary health insurance. This provides, under its responsibility, the liquidation of the benefit, the payment to the establishment of the corresponding amount and the sending of a statement of the benefits supported.
«Art.» D. 861-6.-except in the case of rejection duly motivated and brought to the attention of the persons concerned by the agencies using a base plan benefits, payments to professionals or health institutions mentioned in article D. 861 - 4 and the 1 ° of article D. 861 - 5 are carried out within a time limit of: "1 ° seven days from the date of the acknowledgement of receipt referred to in the sixth paragraph I of article R. 161-47. , in the case of use of an electronic healthcare sheet;
«2 ° twenty-one days from the date of dispatch by the professional or health care facility, in the event of use of a sheet of care on paper. '' This period is extended by 15 days when the sheet of care on paper was addressed to a different health insurance organization from that used for the care recipient benefits from the plan of health insurance database. » ;
5 ° chapter I is supplemented by the following two articles: «art.» D. 861-7.-an order fixed the content of statements of benefits directed to professionals and health institutions as well as the modalities for the exchange of information between agencies serving a base of health insurance plan benefits and supplementary health insurance agencies.
«Art.» D. 861-8.-to qualify for the third paying under the ninth paragraph of article L. 861 - 3, the recipient must submit to the professional or the establishment of health insurance referred to in article L. 161 - card 31 and the third paying certificate issued by its body used the benefits of health insurance database. » ;
6 ° to chapter III, are created the following articles: «art.» D. 863-1.-in the context of the implementation of the third paying the supplementary health insurance body transmits insurance compulsory health, within a period of 48 hours, each new membership, subscription, renewal or termination of a contract selected by a beneficiary of the deduction provided for in article L. 863 - 2. To this end, he mentioned the dates of beginning and end of the contract as well as the type of contract signed by the beneficiary as provided in the second subparagraph of article R. 863 II - 11.
«Art.» D. 863-2.-to qualify for the third paying provided for in article L. 863-7-1, the care recipient presents the professional card of insurance referred to in article L. 161 - 31. In the event of impossibility of reading the map or absence of update of the latter, the beneficiary may submit the certificate of third party paying full issued by the organisation used the benefits of health insurance database.
"Payment to the professional of the acts or services carried out in the context of the provisions referred to in article L. 863-7-1 is guaranteed, subject to the General conditions of support acts or services concerned and on the condition that the recipient of care health insurance card is not registered on the list of opposition referred to in article R. 161-33-7 on the day of the issuance of these acts or services or. in the cases provided for in the preceding paragraph, on joint presentation of the certificate of third party paying valid and insurance card.
' When health care professional wishes to benefit from a single point of contact, it is implementing the third paying according to the conditions defined in articles D. 861 - 4, D. 861 - 6 and D. 861 - 7. '


Article 2 more on this article...

Decree No. 99 - 1079 of 21 December 1999 on detailed rules for the application of the exemption in advance of costs of health care and amending the social security code is repealed.


Article 3 read more on this article...

By derogation to article D. 861 - 4 of the code of social security in its preparation resulting from this Decree and for acts and services that do not fall within the scope of the staffing annual funding of the health institutions mentioned in article L. 174 - 1 of the code, the third paying apply from the dates laid down in the last paragraph I of article 33 of Act No. 2003 - 1199 of December 18, 2003, from funding from the social security for 2004. Before these dates, the provisions of article D. 861 - 5 of the code shall apply.
Where application is made one-third pay provided for in article 863-7-1 of the same code, the provisions of the second sentence of the 2 ° of article D. 861 - 4 apply, between 1 July 2015 and December 31, 2015, to height of the minimum levels of decision-making support expenses fixed by the Decree mentioned in article L. 863 - 6 of the same code , in the version resulting from article 56 of law No. 2013 I - 1203 December 23, 2013, financing of social security for 2014.


Article 4 more on this article...

The Minister of finance and public accounts, the Minister of Social Affairs, health and rights of women and the Secretary of State for the budget are responsible, each in relation to the implementation of this Decree, which shall be published in the Official Journal of the French Republic.


Made June 29, 2015.
Manuel Valls by the Prime Minister: the Minister of Social Affairs, health and rights of women, Marisol Touraine the Minister of finance and public accounts, Michel Sapin Secretary of State in charge of the budget, Christian Eckert

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