1, non-basic medical insurance directory. According to the medical insurance catalogue, the drugs and medical treatment items paid by themselves or only by the industrial injury insurance fund or only by the maternity insurance fund are included in the reimbursement scope of basic medical insurance for review (the drugs and medical insurance items of maternity insurance are not reviewed by urban and rural residents);

2, in violation of the limited indications (conditions) medication. Review the indications of drugs with clear indications and limited use conditions;

3. Limit the level of hospital types. According to the notes of drugs in the medical insurance catalogue, for example, if there are "secondary and above medical institutions", check the hospital (which hospital is specifically designated), type (comprehensive or specialist) and level (primary, secondary and tertiary hospitals);

4. Children only. Review the drugs and items paid by medical insurance when the three major catalogues of medical insurance are limited to newborns and children (medical insurance for urban and rural residents is not reviewed);

5. Limited gender review. Review the drugs and articles with gender use characteristics in the three catalogues of medical insurance.

6. Do not review the expense date during hospitalization. Audit the occurrence date of detailed expenses other than the hospitalization date, or upload detailed expenses at one time;

7. Exceeding the limited frequency. Check whether the use frequency of diagnosis and treatment items in a certain time interval is in compliance.

Medical insurance intelligent audit process:

1, expense settlement Designated medical institutions apply to the medical insurance agency for settlement of hospitalization expenses last month from 1 to 10 every month. Medical insurance agencies should complete the audit, review and approval of settlement information in the medical insurance information system before 14 every month;

2. Push the settlement data to the medical insurance information system, and automatically push the settlement data information to the intelligent audit system on 15 at 0: 00 every month;

3. The intelligent file preliminary examination system extracts data from every June 16 for computer preliminary examination. Before June 17, Zhonggong.com staff will check the preliminary examination data and push the problem documents that have completed the preliminary examination to the publicity and representation system of audit results of medical institutions. 18 -20, the medical insurance agency enters the data of the proposed refusal of payment of the manual audit fee package into the intelligent audit system, and generates audit opinions according to the preliminary examination data and the manual audit data;

4. Designated medical institutions shall negotiate 2 1 month. Medical institutions check the audit results of medical materials in our hospital in the system of publicity and representation of audit results. If there is any objection to the problem documents audited by suspicious rules, they will be represented in the intelligent auditing system before the next month 15. If they fail to give feedback within the specified time, they will be considered as having no objection.

5. Review, final review and deduction The medical insurance agency will manually review the representations submitted by medical institutions in the intelligent review system from May to 27th every month. Those who meet the policy requirements will be repaid in the intelligent review system, and those who do not meet the requirements will be reviewed and deducted.

To sum up, the illegal rules of medical insurance intelligent audit include non-basic medical insurance catalogue, violation of limited indications (conditions), limitation of hospital type and level, limitation of children, limitation of gender audit, absence of expense date audit, and over-limit times.

Legal basis:

"Measures for the Administration of Knowledge Base and Rule Base for Intelligent Audit and Monitoring of Medical Security Fund (Trial)" Article 3

The measures referred to in intelligent audit and monitoring of medical insurance funds refer to the supervision and management mode that medical insurance departments conduct real-time dynamic monitoring of the use of medical insurance funds in the whole process based on relevant laws and regulations and relevant industry standards and norms, relying on the national unified medical insurance information platform, using information means and using big data, and conducting agreement management and administrative supervision according to the monitoring results.

Knowledge base is a collection of knowledge and foundation needed for intelligent audit and monitoring of medical insurance funds.

Rule base is a collection of logic, parameters, reference threshold and judgment level based on knowledge base, which is used to judge the legality and compliance rationality of related behaviors of supervised objects.