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In order to do a good job in the management of medical insurance payment for medical services in internet plus, Tianjin, the Municipal Medical Insurance Bureau has formulated the Measures for the Management of Medical Insurance Payment for Medical Services in internet plus, Tianjin, which clarifies the medical insurance payment policy for Internet medical services and other contents, and the measures will be implemented from November 1, 222.
The full text is as follows
Measures for the Administration of Medical Insurance Payment for Medical Services in internet plus, Tianjin
Chapter I General Provisions
Article 1 In order to strengthen and standardize the management of medical insurance payment for medical services in internet plus, according to Opinions of General Office of the State Council on Promoting the Development of Internet+Medical Health, Guiding Opinions of National Medical Insurance Bureau on Actively Promoting Medical Insurance Payment for Medical Services in internet plus, etc.
article 2 the term "internet plus" medical service and medical insurance payment management as mentioned in these measures refers to that the designated medical institutions of medical insurance that have approved the establishment of internet hospitals or the internet diagnosis and treatment activities in this city provide "internet plus" medical services for the insured, and the institutions involved in medical insurance work apply for signing contracts, medical insurance payment policies, medical insurance settlement, agreement management, management and supervision.
article 3 the municipal medical insurance bureau is responsible for the management of medical services in internet plus, and determines the conditions that designated medical institutions should have to carry out medical services in internet plus, the procedures for applying for signing contracts, and the policies on the price and payment of medical services in internet plus.
the district medical security bureau is responsible for the supervision and management of medical services and medical insurance payment in internet plus within its jurisdiction.
the municipal medical insurance fund management center and its branches in various districts shall organize and implement the management of the "internet plus" medical service medical insurance agreement according to their duties.
the municipal medical insurance fund settlement center is responsible for the audit and settlement of medical insurance payment fees in internet plus.
the municipal medicine procurement center is responsible for improving the procurement platform, and supporting the designated medical institutions to carry out the online procurement of medicines required for medical services and medical insurance payment in internet plus.
entrusted by the municipal medical insurance bureau, the municipal medical insurance fund supervision and inspection office is responsible for the supervision and inspection of the implementation of medical insurance laws, regulations and rules by designated medical institutions, medical insurance service physicians and insured persons in the medical insurance payment of "internet plus".
Chapter II Application for Signing by Institutions
Article 4 The designated medical institutions for medical security in this Municipality that are legally approved to set up Internet hospitals or to carry out Internet diagnosis and treatment activities may, on a voluntary basis, apply to the Medical Insurance Sub-center by their entity medical institutions for signing a supplementary agreement for medical services in internet plus. If the entity medical institution is a non-designated medical institution, it may apply for the "internet plus" medical service supplementary agreement at the same time when applying for signing the designated medical insurance agreement.
Article 5 A medical institution applying for the internet plus Supplementary Agreement for Medical Services shall meet the following basic conditions:
It shall have the conditions of docking with the national unified medical insurance information business code, and basic information databases such as drugs, medical consumables, diagnosis and treatment items, medical service facilities and diseases;
It has the conditions for data exchange with the medical insurance information system, and realizes the mobile payment of medical insurance in combination with the construction of a national unified medical insurance information platform, and can provide patients with electronic bills, electronic invoices or paper bills in time;
relying on medical insurance electronic certificate to carry out real-name authentication to ensure that the insured persons use their real identities;
Information such as electronic medical records, electronic prescriptions, drug purchase records and medical records with definite diagnosis provided by patients during the diagnosis and treatment of insured persons can be completely preserved, and the whole process of diagnosis and treatment, prescription and dispensing can be traced back;
Be able to verify that the patient is a follow-up patient and master the necessary medical information;
the information system of medical institutions should be able to distinguish offline medical services, medical services in different places and medical services in internet plus;
complete the transformation of internet plus's medical insurance network settlement system according to the relevant requirements of the state and the city's medical insurance information platform management;
other conditions as required.
Article 6 A medical institution applying for a supplementary agreement on medical services in internet plus shall provide the following materials:
An application for signing a supplementary agreement on medical services in internet plus;
a copy of the license issued by the competent department to approve the establishment of an Internet hospital or to carry out Internet diagnosis and treatment activities;
information system-related materials related to medical insurance payment of "internet plus" medical service;
List of physicians related to medical insurance payment in internet plus;
other materials required according to relevant regulations.
article 7 a medical institution shall apply to the medical insurance sub-center for signing the supplementary agreement of "internet plus" medical service, and the medical insurance sub-center shall accept it immediately. If the application materials are incomplete, the medical insurance sub-center will inform the medical institution to supplement them once within 5 working days from the date of receiving the materials.
Article 8 The medical insurance sub-center shall organize an evaluation team to evaluate the medical institutions that have applied for signing the internet plus Supplementary Agreement on medical services in written form or on-site. Since the date of acceptance of the application materials or the signing of the medical insurance agreement by the entity medical institution, the evaluation time shall not exceed 2 months, and the time for supplementary materials of the medical institution shall not be included in the evaluation period. The evaluation contents include:
checking the license of the competent department to set up an Internet hospital or carry out Internet diagnosis and treatment activities;
check the medical institutions "internet plus" medical insurance network settlement and national medical insurance electronic certificate, mobile payment system docking and other information systems;
check the medical institutions "internet plus" medical service medical insurance payment related doctors;
Check whether the medical service of the medical institution "internet plus" can verify that the patient is a follow-up patient and master the necessary medical information of the patient;
check whether the medical service of the medical institution "internet plus" can completely retain the electronic medical records, electronic prescriptions, drug purchase records and other information during the diagnosis and treatment of the insured;
check other materials that medical institutions should provide according to relevant regulations.
article 9 _ evaluation of qualified medical institutions, the municipal medical insurance center or medical insurance sub-center shall sign a supplementary agreement with the medical institutions within 5 working days, and the term of the supplementary agreement shall be consistent with the designated medical institutions of the entities they rely on. If the assessment is unqualified, the medical insurance sub-center shall inform the reasons in writing and put forward rectification suggestions.
chapter iii medical insurance payment policy
article 1 the establishment of "internet plus" medical service projects by medical institutions shall be implemented in accordance with the national and municipal "internet plus" medical service prices and medical insurance payment policies. Designated medical institutions to provide in line with the provisions of the "internet plus" medical follow-up service, according to the public hospital general outpatient service project price charges and payments. The drug expenses incurred shall be paid according to the payment standards and policies stipulated by offline medical insurance.
Article 11 The "internet plus" medical follow-up service provided by designated medical institutions for the insured shall be within the scope of medical treatment subjects of offline entity medical institutions, and shall not exceed the scope of Internet medical treatment subjects. Internet diagnosis and treatment services provided by designated medical institutions for the insured are limited to the follow-up visits of common diseases and chronic diseases that can be independently completed online.
Article 12 The prescriptions for "internet plus" medical follow-up provided by designated medical institutions for insured persons shall comply with the relevant provisions of Internet diagnosis and treatment and prescription management of health departments. Online prescriptions purchased in our hospital or in designated retail pharmacies must be electronically signed by doctors and uploaded to the medical insurance settlement system according to regulations after being reviewed by pharmacists.
article 13 if the medical expenses and drug expenses incurred by the insured in the medical institutions designated for medical services in internet plus city meet the scope of medical insurance payment, they shall be paid in accordance with the relevant provisions of medical insurance in this city. The expenses borne by the individual can be paid by the employee's medical insurance personal account according to the regulations. The cost of providing drug distribution services is not included in the scope of medical insurance payment.
chapter iv medical insurance settlement
article 14 the municipal medical insurance center shall promptly publish the interface specification for medical insurance settlement management of "internet plus" medical services. Designated medical institutions that carry out "internet plus" medical services should transform their internal systems according to the interface specifications, and maintain effective docking with the medical security information platform of this Municipality as required to realize online settlement of medical insurance. Designated medical institutions independently choose the operation and maintenance suppliers of relevant information systems connected with medical insurance. Medical insurance agencies shall not charge any fees and designate suppliers in any name.
Article 15 The insured shall complete the settlement of medical insurance expenses of "internet plus" medical service through mobile payment after relying on the real-name authentication of medical insurance in electronic certificate.
the insured shall activate the medical insurance electronic certificate through the third-party channel authorized by the National Health Insurance Bureau.
article 16 the internet plus medical service consultation fees provided by designated medical institutions and the drug expenses incurred by the institutions providing internet plus medical services or the third-party institutions designated by them shall be paid by the medical insurance fund according to the regulations, and the medical insurance agency shall directly settle with the entity designated medical institutions. "internet plus" medical follow-up prescription circulation to the designated retail pharmacies in the city of drug costs, according to the provisions should be paid by the medical insurance fund, by the medical insurance agencies and designated retail pharmacies settlement.
Article 17 Designated medical institutions shall declare the medical expenses paid by "internet plus" medical service and medical insurance as required, and distinguish them from offline medical expenses. City medical insurance settlement center according to the requirements of the relevant provisions of the administrative department of medical security, the administrative department of health and market supervision departments, take the method of combining intelligent audit and manual key audit, according to the responsibility of "internet plus" medical service medical insurance payment of medical expenses for legality and rationality audit. Pay the fees that meet the requirements, and do not pay the fees that have been examined and verified for the illegal declaration.
Article 18 The designated medical institutions that carry out "internet plus" medical services and their offline entities are regarded as the same management service subject, and their medical insurance payment management shall be implemented in accordance with the current relevant regulations such as the total budget management of this Municipality's regional point method, fixed payment by disease type, total payment by head, and payment by project.
Chapter V Agreement Management
Article 19 The designated medical institutions that provide "internet plus" medical services shall abide by the medical insurance agreement of the designated medical institutions in this Municipality and the supplementary agreement of "internet plus" medical services. Medical insurance agencies shall, according to the requirements of the agreement, 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 plus" medical services, and urge the designated medical institutions to announce to the public the main service contents and charging prices of "internet plus" medical services. ___
Article 2 Medical insurance service doctors shall obtain the corresponding qualifications of medical practitioners in accordance with the law, have more than three years of independent clinical work experience, and shall abide by the relevant contents of this Municipality's medical insurance agreement, the additional agreement for medical insurance service doctors and the supplementary agreement for medical services in internet plus.
Article 21 The medical insurance agency or the third-party agency entrusted by it shall regularly carry out performance appraisal on the medical institutions providing "internet plus" medical services and the entity medical institutions it relies on. Establish an evaluation index system centered on the use of medical insurance funds, the quality of medical services, and the satisfaction of patients taking medicines. The assessment results are linked to the signing of medical insurance agreement and medical insurance payment.
article 22 the municipal medical insurance center shall improve the contents of the supplementary agreement on medical services in internet plus, establish an exit mechanism, and suspend or terminate the supplementary agreement according to regulations. The entity designated medical institutions are suspended or terminated, and the supplementary agreement for providing "internet plus" medical services is suspended or terminated at the same time; Medical institutions that provide "internet plus" medical services are suspended or terminated, and the medical insurance agency shall decide whether to suspend or terminate the corresponding fixed-point agreement according to the fixed-point agreement of the entity medical institutions.
Chapter VI Management and Supervision
Article 23 Designated medical institutions shall establish an online prescription review system and a medical service behavior supervision mechanism, upload electronic medical records, online electronic prescriptions, drug purchase records, real-name authentication records and other information to the medical security information platform in real time, and gradually implement drug traceability code scanning sales, properly preserve relevant electronic information such as medical treatment, make the whole process of diagnosis and treatment, prescription, transaction and distribution traceable, and realize information flow, capital flow and distribution.
article 24 medical insurance agencies should strengthen the responsibility of cost audit, comprehensively use big data, the internet and other technical means, and use the medical insurance intelligent audit monitoring system to conduct real-time supervision on the details of medical service fee settlement, drugs, consumables, medical service items and outpatient medical records of internet plus. Use audio and video to test the authenticity of the doctors attending the "internet plus" medical service. Comprehensive grasp of the insured medical information and medical institutions to check the follow-up behavior of the relevant records. Refuse to pay the examination fees and drug fees that do not meet the requirements, and deal with them according to the agreement.
Article 25 The urban two-level medical security departments shall, according to their duties, bring the internet plus medical services provided by designated medical institutions and their medical insurance service physicians into the scope of supervision, strengthen big data analysis through medical insurance intelligent audit and real-time monitoring system in accordance with medical insurance laws, regulations and service agreements, and severely crack down on illegal behaviors of medical insurance payment for internet plus medical services.
Article 26 The urban two-level medical security departments shall, in accordance with the relevant provisions, disclose to the public the illegal cases of designated medical institutions, medical insurance service physicians and insured persons in internet plus, and notify the health and market supervision departments, and incorporate them into the national credit information sharing platform, law enforcement supervision platform and other credit management platforms, and implement joint punishment for dishonesty according to law.
Article 27 If the designated medical institutions, their medical insurance service physicians and the insured persons who accept the medical service of internet plus violate these administrative measures and belong to the contents stipulated in the medical insurance agreement, the municipal medical insurance center or the medical insurance sub-center shall deal with them according to the agreement; Belonging to the scope of administrative punishment prescribed by laws, regulations and rules, the medical security department shall give administrative punishment according to law; If a crime is constituted, criminal responsibility shall be investigated according to law.
if the medical security departments at all levels abuse their powers, neglect their duties or engage in malpractices for selfish ends in the management of medical insurance payment in internet plus, the directly responsible person in charge and other directly responsible personnel shall be punished according to law; If a crime is constituted, criminal responsibility shall be investigated according to law.
Chapter VII Supplementary Provisions
Article 28 Medical security departments at all levels should do a good job in the network security of data related to medical insurance payment of "internet plus" medical services to prevent data leakage and ensure the information security of medical insurance system. Designated medical institutions and their medical insurance service physicians shall strictly implement the relevant provisions of the state and this Municipality on information security to ensure the safety of insured persons and medical insurance data and information.
Article 29 The designated medical institutions mentioned in these Measures refer to designated medical institutions and designated retail pharmacies.
medical insurance 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 medical insurance agencies and medical institutions through negotiation, which is used to standardize medical service behavior and clarify the rights, obligations and responsibilities of both parties.
Article 3 These Measures shall be implemented as of November 1, 222 and shall be abolished on October 31, 227.