Chapter I General Provisions

Article 1 In order to protect the medical rights and interests of the insured persons of basic medical insurance, standardize the service behavior of designated medical institutions, promote the rational purchase of medicines by the insured persons, and improve the efficiency of the use of the basic medical insurance fund, these measures are formulated in accordance with the relevant provisions of the state and the province and combined with the actual situation of this Municipality.

Article 2 These Measures shall apply to the insured persons of basic medical insurance in this Municipality.

Article 3 The insured person shall follow the principle of "first consultation at the grass-roots level, two-way referral, rapid and slow division and treatment, and linkage between the upper and lower levels" when seeking medical treatment.

Article 4 When seeking medical treatment, the insured shall present his Zhuhai Social Security Card (hereinafter referred to as the Social Security Card) as a medical treatment settlement voucher.

Article 5 The designated medical institutions in this Municipality shall strictly implement the basic medical insurance service agreement, and treat the insured due to illness, make reasonable examination and use drugs rationally.

Chapter II Designated Medical Care

Article 6 The basic medical insurance shall be subject to designated medical management, and the insured shall go to the designated medical institutions in this Municipality for medical treatment and medicine purchase according to the following provisions:

(a) the insured can purchase drugs in the designated retail pharmacies in this city.

(two) the insured should choose the city's basic medical insurance 1 general outpatient designated medical institutions (hereinafter referred to as the general outpatient designated institutions) as their general outpatient medical institutions. The insured person shall go through the transfer procedures in the designated institutions of outpatient co-ordination with his social security card.

(3) Insured persons who enjoy the treatment of outpatient specific diseases (hereinafter referred to as outpatient diseases) choose 1-3 designated medical institutions in this city (at least 1 of them are community health service institutions in this city) as their outpatient disease expense settlement institutions. The insured person shall go through the selection procedures at the designated medical institutions with the social security card.

(IV) Insured persons who are identified as outpatients with hypertension and diabetes (hereinafter referred to as "two diseases") can voluntarily sign a "two diseases" management service agreement with the three departments of outpatient co-ordination designated institutions by virtue of their social security cards, and seek medical treatment in outpatient co-ordination designated institutions.

"Two diseases" outpatient disease insured and outpatient co-ordination of the three teams, designated institutions signed the "two diseases" management service agreement, no longer according to the outpatient disease management.

(five) the insured should go to the designated hospital in this city for medical treatment.

Article 7 The designated outpatient co-ordination institutions and outpatient disease expense settlement institutions selected by the insured shall not be changed within the same social security year. If the insured person needs to make changes in the next social security year, he should go through the change formalities with the social security card at the newly selected designated medical institution from April to June every year, which will take effect on July 1 day; Those who have not gone through the formalities for change shall be regarded as continuing to choose the original designated medical institution.

Article 8 In case of any of the following circumstances during the social security year, the insured may go through the change procedures at the newly selected designated medical institution with the social security card and related materials:

(a) the work unit or home address changes.

(two) the new outpatient diseases need to change the outpatient disease expense settlement institution.

(three) the selected outpatient medical institutions have suspended the basic medical insurance service, and the basic medical insurance service agreement has been terminated or terminated.

Relevant information includes transfer notice, labor contract, real estate license, house lease certificate, outpatient disease audit notice, etc.

Chapter III General Outpatient Medical Management

Ninth insured to the selected outpatient co-ordination designated institutions for medical treatment, outpatient medical expenses after approval, according to the provisions of the network settlement.

Article 10 If the insured person needs to be referred for medical treatment in the designated outpatient co-ordination institution, the attending physician of the institution shall apply, and after the approval of the institution's seal, he shall be transferred to the designated hospital that signed an agreement with the institution, and the referral certificate shall be valid at that time. Outpatient medical expenses approved by the outpatient department will be reimbursed to the designated outpatient co-ordination institution selected by the individual after cash payment.

Eleventh insured persons who have been approved to go through the formalities of permanent medical treatment in different places shall, from the next social security year, pay the personal use part in one lump sum according to the amount paid by the per capita fund of the outpatient service in the previous year.

Article 12 After college students are insured in our city, the general outpatient medical expenses incurred outside the city during the winter and summer vacations, suspension from school and internship shall be reimbursed by the selected outpatient co-ordination and designated institutions according to the regulations, based on the medical information and related expense documents.

Article 13 If the insured person is in the emergency department of other outpatient co-ordination designated institutions in the city, he shall promptly inform the selected outpatient co-ordination designated institutions, and the medical expenses approved by the outpatient department shall be reimbursed to the selected outpatient co-ordination designated institutions according to the regulations after personal cash payment. The basic medical insurance fund will not pay the non-emergency outpatient medical expenses.

Chapter IV Disease Management of Medical Outpatients

Fourteenth insured persons who enjoy the treatment of outpatient diseases go to the selected outpatient disease expense settlement institution for medical treatment, and the approved outpatient disease medical expenses are settled online according to the regulations.

Article 15 If the outpatient disease expense settlement institution selected by the insured person has no corresponding examination, treatment items or drugs, and needs to go to other designated medical institutions in this Municipality for examination, treatment or drug purchase, the relevant medical expenses can be reimbursed according to the provisions on the basis of the application issued by the outpatient disease expense settlement institution.

Article 16 If the insured person of outpatient disease fails to seek medical treatment in the selected outpatient disease expense settlement institution due to the emergency of outpatient disease, the approved outpatient disease medical expenses shall be reimbursed to the municipal social insurance agency according to relevant information.

Seventeenth "two diseases" outpatient serious illness insured and its outpatient co-ordination designated institutions belonging to the three divisions team signed the "two diseases" management service agreement, according to the provisions of Article 9, Article 10 and Article 13 of these measures for medical treatment.

Article 18 If the insured person for outpatient diseases leaves the city for a short period of time (1 month to 6 months) due to work, visiting relatives, visiting friends, traveling, etc., he/she can go to the municipal social insurance agency for short-term going out for the record with his/her social security card, which can only be handled once a year.

The insured shall go to the local basic medical insurance designated hospital for medical treatment during his short-term outing. If you return to this city in advance, you should go through the cancellation procedures in time.

Nineteenth insured referral, emergency or short-term medical treatment, the medical expenses approved by the outpatient diseases, according to the provisions of the network settlement; In this city, medical institutions have not achieved instant online settlement, and personal cash payment shall be reimbursed to the municipal social insurance agency according to regulations.

Twentieth insured referral, emergency, short-term outing, other hospitalization, treatment or drug purchase and other conditions for medical treatment, the medical expenses approved by the outpatient diseases, paid by individuals in cash, to the municipal social insurance agencies to apply for reimbursement should provide the following information:

(1) My social security card or ID card.

(two) the original medical bills printed by finance and taxation or the proof that the public, procuratorial and legal departments received the original bills.

(3) Detailed list of expenses.

(4) outpatient medical records.

(five) in other hospitals for examination, treatment or drug purchase, it is necessary to provide an application for examination, treatment or drug purchase in other hospitals issued by the outpatient disease cost settlement institution.

Chapter V Hospitalization Management

Twenty-first insured people need hospitalization, medical treatment according to the following provisions:

(a) the insured person to the designated hospitals in the city, according to the provisions of hospitalization procedures. Due to trauma, the insured person or his family members need to sign the admission record, and the hospitalization medical records are uploaded by the designated hospitals, and paid by the basic medical insurance pooling fund after being audited by the municipal social insurance agency, and settled online according to regulations.

(II) If the insured person needs to go to other designated medical institutions in the city for examination, treatment or drug purchase due to illness or other reasons during his hospitalization in the designated hospitals in the city, the designated hospitals in the hospital shall issue an application for examination, treatment or drug purchase in other hospitals, and the approved medical expenses shall be settled online according to the regulations or reimbursed by the municipal social insurance agency.

(3) If the insured meets the discharge standard after hospitalization, they shall go through the discharge formalities in time, and the approved medical expenses incurred in hospitalization shall be settled online according to the regulations; Refused to leave the hospital, the basic medical insurance fund for follow-up medical expenses will not be paid.

(IV) Due to objective reasons such as the failure of the basic medical insurance settlement system, unpaid medical insurance premiums, and expenses borne by the third responsible person, if the insured fails to make online settlement in the designated hospitals in the city, after confirmation by the designated hospitals, they shall be reimbursed to the municipal social insurance agency in accordance with the regulations.

Twenty-second insured persons were hospitalized in non-designated hospitals in this city for emergency treatment, and those whose condition was stable after rescue should be transferred to designated hospitals in this city for treatment. The approved medical expenses for emergency hospitalization shall be paid by individuals in cash and reimbursed by the municipal social insurance agency according to regulations.

Chapter VI Management of Medical Treatment Outside the City

Twenty-third insured persons who meet the following conditions and need to be treated in designated medical institutions outside the city may apply for referral procedures outside the city:

(a) the critically ill need to be referred for rescue.

(two) after many inspections and consultations, the diagnosis is still unclear.

(three) specialist diseases, medical institutions in the city are difficult to diagnose and treat due to conditions.

(four) due to illness, it is necessary to do the examination or treatment projects that have not been carried out in this Municipality.

Twenty-fourth insured persons shall go through the referral procedures outside the city according to the following provisions:

(a) by the city's tertiary hospital deputy director and above doctors to apply, approved by the medical insurance office seal, and upload information, approved by the municipal social insurance agencies, transferred to the designated medical institutions outside the city. Mental illness, AIDS, tuberculosis and other specialized diseases are handled by specialized hospitals according to regulations.

(II) Special critical cases that need to be transferred to designated medical institutions outside the city for rescue may be transferred to other hospitals first, and the referral procedures shall be completed within one week according to the provisions in the first paragraph of this article.

(three) referral outside the city in principle to the designated medical institutions outside the province. Due to the limited conditions for transferring to designated medical institutions, it is necessary to refer to designated medical institutions outside the province, and the relevant deputy chief physician and above of the designated medical institutions shall apply, and the medical department (department) of the hospital agrees to seal it.

(four) the referral is valid for one year, in which the referral certificate of drug purchase or one-time inspection in designated medical institutions outside the city is valid.

Twenty-fifth insured referral, emergency or unauthorized hospitalization outside the city, the medical expenses approved by the hospital in accordance with the provisions of the network settlement; If the medical institution fails to realize instant online settlement in this city, the personal cash payment shall be reimbursed to the social insurance agency in this city according to the regulations.

Twenty-sixth insured persons to the municipal social insurance agencies to apply for reimbursement of their cash payment of hospitalization approved medical expenses, need to provide the following information:

(1) My social security card or ID card.

(two) the original bill of hospitalization medical expenses printed by finance and taxation or the proof that the public, procuratorial and legal departments received the original bill.

(3) Detailed list of hospitalization expenses.

(4) discharge summary.

In case of emergency or trauma hospitalization, relevant information such as admission records should be provided.

Chapter VII Management of Residents' Medical Treatment in Different Places

Twenty-seventh basic medical insurance level insured person meets the following conditions, you can apply for permanent medical treatment in different places:

(1) The employee is sent by the employer to work in a different place.

(two) flexible employees work or live in different places after the insurance.

(three) retirees can apply for permanent residence in different places:

1. Live where you were born.

I bought my own house in my place of residence.

3. Take refuge in immediate family members in different places.

4. Go to a different place to start a business.

Twenty-eighth basic medical insurance second insured (except urban and rural residents, students and minors) 1 year, in line with the provisions of Article 27 of these measures, can apply for permanent residence in different places.

Twenty-ninth insured persons in accordance with the provisions of article twenty-seventh, article twenty-eighth, in accordance with the following provisions to the municipal social insurance agencies for permanent medical procedures:

(1) When the insured chooses 1-3 designated medical institution for basic medical insurance as the local medical institution in the place where his permanent residence is located, he shall provide the following information in addition to the Zhuhai Permanent Medical Insurance Application Form:

1. Employees dispatched by the employing unit to different places shall provide relevant dispatch certificates issued by the unit.

2. Flexible employees provide permanent residence permits or permanent business licenses.

3 retirees provide one of the following materials:

(1) account book.

(2) I have proof of real estate in the place where my permanent residence is located.

(3) Proof of kinship of immediate family members.

(4) Business license of permanent residence.

(5) proof of labor relations.

(two) shall not be changed or cancelled within one year after handling the formalities for permanent medical treatment in different places; If you return to work or live in this city, you should go through the cancellation procedures in time.

(three) if the insured person living in a different place leaves his permanent residence for a short time, he shall go through the short-term filing formalities with reference to the provisions of Article 18 of these Measures.

Thirtieth permanent residents in different places need to be transferred for treatment due to illness. In principle, it should be transferred to a local superior hospital or a specialized hospital. The application is made by the deputy director of the relevant specialized hospital and above, and the medical department (department) agrees to seal it.

When the insured person really needs to be transferred to a hospital or specialized hospital outside his permanent residence due to illness, the medical department (room) agrees to apply with the seal of the deputy director and above of the local tertiary hospital or specialized hospital.

Thirty-first approved medical expenses incurred by insured persons living in different places shall be settled online according to regulations; If the medical institutions in this Municipality fail to realize instant online settlement, they shall be reimbursed in accordance with the provisions of Articles 20 and 26 of these Measures after being paid by individuals in cash.

Chapter VIII Supplementary Provisions

Article 32 According to the requirements of regional integration of Pearl River Delta and Jiangyang in Guangdong Province, medical institutions that have signed service agreements with Zhongshan, Jiangmen and Yangjiang are regarded as designated medical institutions in this Municipality.

Thirty-third drugs, medical treatment items and medical service facilities in the three catalogues of basic medical insurance should be included in the basic medical insurance coverage. When the designated medical institutions provide medical services for the insured, they must obtain the consent and signature of the insured or their families before they can use drugs, diagnosis and treatment items, medical service facilities and expensive medical consumables at their own expense.

Thirty-fourth municipal social insurance agencies shall manage the basic medical insurance business files in accordance with the Provisions on the Administration of Social Insurance Business Files, in which the medical registration data shall be kept for 10 years.

Thirty-fifth approach by the municipal social insurance administrative department is responsible for the interpretation of.

Article 36 These Measures shall be implemented as of September 1 year 1 day. Where the original provisions are inconsistent with these measures, the provisions of these measures shall prevail.