(a) medical expenses audit of designated medical institutions

1. Declaration and registration

(1) The registration post accepts the application materials of medical expenses submitted by designated medical institutions and confirms that the application materials are true, accurate and effective. Fill in the "Declaration and Handover Form for Medical Expenses" in duplicate. After both parties sign it, one copy will be kept and the other will be handed over to the designated medical institution.

(2) according to the application materials submitted by designated medical institutions, check the data information uploaded by the information system and complete the preliminary examination within the specified time.

Designated medical institutions are required to provide Urumqi Maternity Insurance Medical Expense Declaration Summary, Urumqi Maternity Insurance Prenatal and Postnatal Examination Expense Declaration Summary, Urumqi Maternity Insurance Outpatient Medical Expense Declaration Summary, Urumqi Maternity Insurance Hospitalization Medical Expense Declaration Summary and Urumqi Maternity Insurance Complications Hospitalization Expense Declaration Form.

The application materials include:

1 Maternal hospitalization: copy of birth medical certificate, original discharge certificate or diagnosis certificate, unified bill for settlement of hospitalization expenses, and maternal discharge statement (stamped with special seal for hospital).

2. Obstetric outpatient service: the original unified bill for hospital outpatient service, the corresponding details of the unified bill for hospital outpatient service, and the settlement sheet for obstetric outpatient service (stamped with the special seal for hospital).

3. Maternity complications: original discharge certificate or diagnosis certificate, original unified bill for settlement of hospitalization expenses, list of hospitalization expenses and hospitalization medical records.

(3) classify and register the application materials and submit them to the treatment review post for review.

2. Cost audit

(1) The fertility audit post carefully checks the information uploaded by medical institutions in the social security system according to the information declared by designated medical institutions; In strict accordance with the "autonomous region basic medical insurance drug list, diagnosis and treatment directory, service facilities directory" scope and standard audit insured medical expenses, hospitalization days, cost details and other data information. If there is no objection to the audit, the corresponding medical expenses payment audit account shall be established; If there is any doubt about the audit, submit it to the department for discussion or notify the audit department in writing to assist in field verification.

(2) For the expenses paid upon examination and approval, print the Medical Expenses Audit Sheet in duplicate, which shall be signed by the auditor and stamped with the "Maternity Insurance Benefits Audit Chapter", and submit the Medical Expenses Audit Sheet and application materials to the Work Injury and Maternity Insurance Benefits Audit Section for examination. If the audit is unqualified, communicate with the designated medical institutions in time to understand the situation. For truly illegal expenses, fill in the Notice of Refusal of Medical Expenses and treat it as refusal.

(3) according to the reporting unit to establish the corresponding medical expenses audit account, and make records at the same time. In the audit, it is required that the data such as the declared summary amount, the amount of refusal to pay and the amount of settlement payment of each medical expense correspond to each other one by one.

(two) personal cash medical expenses audit

The medical expenses such as hospitalization and outpatient service declared by the insured unit, trusteeship unit or individual shall be declared and accepted if they meet the conditions of preliminary examination by reviewing the data and querying the relevant information in the system. Those who do not meet the conditions for cash declaration will not be accepted and informed of the policy. For abnormal medical expenses and other expenses that do not fully meet the reimbursement policy, they shall be submitted to the fertility expert meeting for determination after declaration. Medical expenses that meet the requirements shall be paid and settled in accordance with the reimbursement regulations and handling procedures.

1. Register. The declaration and registration post examines the medical invoices and corresponding lists, hospitalization invoices, expense lists, discharge diagnosis certificates, insurance claims, medical records and other materials submitted by the management unit or the applicant. If the procedures are complete and meet the requirements, the audit department of work-related injury and maternity insurance benefits shall handle them in time.

2. Cost audit. The fertility audit post will review the application materials, establish an audit ledger for the medical expenses that meet the scope of the Birth Catalogue, and submit the medical expenses in question to the department for discussion or submit them in writing to the joint meeting of fertility experts for determination. Print the "Medical Expense Audit Sheet" in duplicate, which shall be signed by the auditor and stamped with the seal of treatment audit, submitted to the registration post for registration, and submitted to the treatment audit department of work-related injury and maternity insurance together with the application materials. If the audit is unqualified, fill in the Notice of Refusal of Medical Expenses, return the application materials to the management unit, community or individual, and explain the reasons for refusal.

Two, maternity insurance benefits review

(1) Review and accept maternity allowance

Work-related injury and maternity insurance benefits audit department shall audit the maternity expenses certification materials submitted by the audit department, and if there is any error in the audit, the relevant documents shall be returned to the treatment audit department for re-audit. The audit contents are as follows:

1. Whether the application materials of the insured are complete; Whether the declaration has exceeded the time limit; Whether the personal information of the application materials is consistent with the personal information of the social security information system.

2 check whether the declared reproductive medical expenses overlap with the paid records; Whether the medical institution for medical treatment is a designated medical institution for childbirth; Whether the personnel who reimburse maternity medical expenses conform to the policy scope; There is no approval basis for reimbursement of maternity expenses under special circumstances.

3. Check whether the Audit Sheet of Maternity Medical Treatment and the Summary of Maternity Insurance Hospitalization Medical Expenses are signed and sealed by the auditors.

(2) the audit of maternity medical expenses

1. The treatment review post reviews the Declaration and Handover Form of Maternity Medical Expenses, the Summary Form of Maternity Insurance Hospitalization Medical Expenses, the Maternity Medical Treatment Review Form and the application materials, checks the authenticity of the categories of fertility and family planning operations indicated in the basic information, invoices and diagnosis certificates of fertility personnel, and confirms that the voucher materials are correct.

2. The auditor of the treatment audit post shall sign the Maternity Treatment Medical Audit Form and the Maternity Insurance Hospitalization Medical Expense Summary Form, make a payment plan, print the Maternity Treatment Medical Payment Plan Form in duplicate, and be signed by the auditor and the section chief and stamped with the special seal for maternity insurance treatment audit. Submit the payment plan and treatment audit form to the designated medical institution for settlement.

3. Work-related injury and maternity insurance benefits audit department shall complete the audit within 20 working days, and designated maternity medical institutions shall go to the work-related injury and maternity insurance benefits audit department to handle the financial settlement business from 20th to 30th of each month.

(3) the audit of maternity allowance

1. According to the Notice on Issues Related to Maternity Insurance Treatment and Expense Settlement for Urban Workers in Urumqi (Wulao [2009] 119), the maternity insurance office, audit office and audit office were assisted by1to sub-district offices, social security branches and designated maternity medical service institutions. Every month 10.

2. Transfer and batch audit according to the maternity allowance batch audit sheet submitted by the Work Injury and Maternity Insurance Treatment Audit Section. After confirming the basic information of maternity personnel, unit payment, unit base of the previous year and other information according to the batch audit list of maternity allowance, the auditor signs the batch audit list of maternity allowance, establishes the payment plan, and prints the batch payment plan of maternity allowance in duplicate.

3. Submit the birth allowance batch payment schedule to the fund management department for batch payment, and submit the payment schedule and treatment audit sheet to the unit or individual for retention.

(d) data voucher transfer and internal audit document management

1. After registering the maternity payment plan, batch review of maternity allowance, maternity medical review and related application materials, the review post will be handed over to the department archivist.

2. The archive management post shall conduct internal audit on the archive materials, and hand them over to the archive management section on time after the internal audit is correct and binding.

3. The monthly treatment review post and the treatment review post check the number of people enjoying maternity treatment and the amount of payment, and reconcile with the fund management department, establish a maternity insurance treatment payment account, and do a good job in the balance of maternity insurance payment for the month.

(5) Payment and settlement

The payment and settlement (payment) post of the Fund Management Section shall make payment and settlement of maternity insurance benefits according to the batch summary table of payment plan or maternity payment schedule and medical payment schedule submitted by the Work Injury and Maternity Treatment Audit Section. Print "Handover Sheet" or "Handover Summary Sheet" in duplicate, and submit the payment and settlement of maternity allowance only after it is signed by the manager and section chief and reported to the competent leader.