reimbursement process for medical expenses of insured persons

Review and scope of review: (1) Medical expenses incurred by transferring to medical institutions outside the city for the record with the approval of the Municipal Medical Insurance Center;

(2) Medical expenses incurred by persons who live or work in different places for hospitalization and outpatient service in designated medical institutions at their places of residence and work;

(3) Medical expenses incurred by people who are on business trips or visiting relatives who are hospitalized in local public hospitals due to sudden illness;

(4) Medical expenses incurred in outpatient treatment and medication for those who enjoy some outpatient subsidies for chronic diseases;

(5), with the consent of the medical insurance office of the designated medical institution in the city, the expenses incurred in conducting special examinations in the outpatient department;

(6) Medical expenses incurred by special treatment in outpatient department with the consent of the municipal medical insurance center;

(7) Other medical expenses that meet the reimbursement requirements.

audit methods: (1) medical expenses incurred by the insured in hospitalization due to illness can be accompanied by their medical insurance calendar, discharge summary, detailed list of expenses, hospital invoices and copies of doctor's orders within 1 days after the end of medical treatment (those who are on business or visiting relatives should attach the unit certificate; Foreign residents in different places should attach a medical declaration form for foreign residents; Referral medical personnel should be attached to the referral application form) and other audit materials to the municipal medical insurance center handling department for cost audit registration procedures. The expenses incurred by the insured for special inspection in the outpatient clinic due to illness shall go through the examination and registration formalities in the next month with the medical record of the outpatient clinic, special inspection form, medical insurance prescription and medical insurance invoice. The expenses incurred by the insured for special treatment in the outpatient clinic due to illness shall go through the examination and registration formalities at the municipal medical insurance center every 2 months with the medical record of the medical insurance outpatient clinic, the special treatment list, the medical insurance prescription, the checklist and the medical insurance invoice. The expenses incurred by the insured who enjoy the subsidy for chronic diseases in outpatient treatment and medication shall go through the examination and registration formalities at the municipal medical insurance center in June and December each year with outpatient medical records, medical insurance prescriptions and medical insurance invoices.

(2) When the insured goes through the registration formalities of expense audit, the handling department will check whether the audit materials are complete on the spot and issue an acceptance receipt. When the materials are not uniform, inform the insured of the materials that still need to be paid at one time. Insured personnel should be filled within 1 working days.

(3) The handling department shall, in accordance with the relevant provisions of the "Three Catalogs" of the State, complete the cost review of all accepted materials in the current month, and provide a list of items that cannot be reimbursed and bear the expenses in proportion in each accepted material. For medical expenses that need to be investigated and verified, the audit time shall be appropriately extended, but the longest time shall not exceed 6 working days from the date of acceptance of the materials.

expense settlement: (1) the 15th to 2th of the month following the examination and registration is the expense settlement time (postponed in case of holidays). During this period, the insured can go to the handling department of the municipal medical insurance center for cost settlement. Special circumstances shall be notified by the municipal medical insurance center in advance by telephone.

(2) At the time of settlement, the handling department shall provide a list of reimbursement components of medical expenses, including overall reimbursement amount, out-of-pocket expenses amount, out-of-pocket expenses classification composition and out-of-pocket expenses list, so as to ensure that the insured personnel can clearly settle accounts.

(3) The insured must hold the original ID card and perform the signing and settlement procedures. If I can't go to the municipal medical insurance center for reimbursement and withdrawal for some reason, I can entrust others to handle it on my behalf. The client should show the original ID cards of myself and the client, and provide a copy for retention and future reference.

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