Shanghai Serious Illness Medical Insurance Reimbursement Process
(1) material
1, "Shanghai Basic Medical Insurance Medical Expenses Allocation Application Form"
2, "Shanghai basic medical insurance transfer and emergency registration form"
3. Identity card (or citizen card)
4. Medical records
5. Original receipt of medical expenses
6. Detailed list of expenses (including treatment and examination expenses, unit price and quantity of western medicine and Chinese patent medicine, prescriptions of Chinese herbal medicines, etc.). )
7, discharge summary, medical institutions grade certificate and other relevant information needed for the audit.
(2) Process
1, receive and fill in the Application Form for Sharing Medical Expenses of Shanghai Basic Medical Insurance, in which the unit must be stamped with the official seal of the unit when participating in the insurance.
2, to the municipal medical insurance agency window for materials.
3. Reimbursement payment:
① "Cash payment" method: get reimbursement at the financial window with the audited and printed statement and my ID card (or citizen card) signed by the leader.
② "Company Transfer" method: transfer the reimbursement to the company through financial transfer.
legal ground
Measures of Shanghai Municipality on Improving the Outpatient Security Mechanism of Basic Medical Insurance.
second
(1) Improve the personal account calculation and payment method. From July 1 day, 2023, all the basic medical insurance premiums paid by employees will be included in my personal medical account, and the inclusion standard is 2% of my insured payment base, and all the basic medical insurance premiums paid by the unit will be included in the overall fund. Individual accounts of retirees are allocated by the overall fund according to the quota, and the specific standards are under 74 years old 1680 yuan/year, and over 75 years old 1890 yuan/year.
(two) to enhance the outpatient service * * * economic security function. We will improve the medical insurance outpatient expense guarantee mechanism for employees, and adjust the outpatient and emergency standards from July 2023 1.
1. On-the-job employees: the standard of self-supporting part of outpatient and emergency departments is adjusted to 500 yuan. The excess is paid by the overall fund according to the following standards: 80% of the outpatient and emergency departments of first-class medical institutions are paid by the overall fund; Secondary medical institutions outpatient emergency, pooling funds to pay 75%; Third-level medical institutions outpatient emergency, pooling funds to pay 70%.
2. Retirees:
(1)200 1 1 after retirement, the outpatient and emergency standards are adjusted to 300 yuan. The excess is paid by the overall fund according to the following standards: 85% is paid by the overall fund for outpatient and emergency departments of first-class medical institutions; Secondary medical institutions outpatient emergency, co-ordination fund to pay 80%; Third-level medical institutions outpatient emergency, pooling funds to pay 75%. (2) For retirees who retired before 65438+February 3/KLOC-0 in 2000, the standard of outpatient and emergency services was adjusted to 200 yuan. The excess is paid by the overall fund according to the following standards: 90% of the outpatient emergency of the first-class medical institutions is paid by the overall fund; Secondary medical institutions outpatient emergency, co-ordination fund to pay 85%; Third-level medical institutions outpatient emergency, the overall fund to pay 80%.
(3) Standardizing the scope of use of personal accounts. Personal accounts are mainly used to pay out-of-pocket expenses of insured persons within the policy scope of designated medical institutions or designated retail pharmacies. From July 2022 1, the scope of personal accounts will be gradually expanded. Personal accounts can be used to pay the medical expenses incurred by the insured and their spouses, parents and children in designated medical institutions, as well as the expenses incurred by individuals in purchasing medicines, medical devices and medical consumables in designated retail pharmacies. Explore the personal accounts of spouses, parents and children participating in the basic medical insurance for urban and rural residents. Personal accounts shall not be used for public health expenses, physical fitness or health care consumption and other expenses that are not covered by the basic medical insurance.
(four) to enhance the supplementary guarantee function of local additional funds. The local additional medical insurance premiums paid by the employer are all included in the local additional fund and accounted for separately. From June 65438+1 October1day in 2023, the outpatient and emergency medical expenses will be included in the payment scope of the overall fund, and will no longer be paid by local additional funds. Local supplementary funds continue to pay all kinds of burden reduction expenses, including the overall burden reduction of employees' medical insurance, as well as medical expenses above the maximum payment limit of some overall funds. Explore the multi-channel financing and supplementary guarantee functions of local additional funds in coping with the aging population.
(5) Strengthen supervision and management. Improve the management service measures, innovate the system operation mechanism, guide the rational use of medical resources, ensure the stable operation of medical insurance funds, and give full play to the guarantee function. Strictly implement the budget management system of medical insurance fund, and strengthen the construction of fund audit system and internal control system. Further improve the dynamic management mechanism of the whole process of personal accounts and strengthen the audit of the use and settlement of personal accounts. Strengthen the supervision of medical behavior and medical expenses, improve the supervision system of administrative law enforcement at the municipal and district levels, continue to carry out special actions to crack down on fraud and insurance fraud, strengthen joint supervision across departments, strengthen social supervision, and accelerate the construction of intelligent supervision system. Accelerate the construction of the primary medical service system, improve the contract service of family doctors, standardize the long-term prescription management, and guide the insured to seek medical treatment at the primary level.
(six) improve the payment mechanism that is suitable for outpatient service. Strengthen the linkage of "three doctors" and promote the deepening of the reform of the medical and health system. We will continue to deepen the reform of payment methods of medical insurance, promote the system of payment by disease (DIP) and the system of payment by disease diagnosis (DRG) under the general budget management, and provide better medical services for the masses and reduce their burden of medical treatment. Scientifically and reasonably determine the payment standard of medical insurance, and guide the active use of drugs with definite curative effect and reasonable price. In addition, eligible "internet plus" medical services will be included in the scope of payment.