Notice on Printing and Issuing the Implementation Program of Networked Settlement and Reimbursement of Expenses Occurred when Accessing Medical Service in a Place other than the Resident Region in the National New Rural Co-operative Medical System (Issued
To the Population and Family Planning Commissions and Financial Departments or Bureaus of all provinces, autonomous regions and municipalities, as well as that of the municipalities with independent planning status, and the Budget Management Hospital of the National Health and Family Planning Commission:
In order to implement the requirements of the 2016 Government Work Report on accelerating the work of national networking of basic medical insurance and settlement over accessing medical service in a place other than the resident region, and the spirit of Guiding Opinion on Doing a Good Job in Check and Settlement of Medical Expense Incurred in Cross-province Medical Treatment in the New Rural Cooperative Medical System (issued by Guo Wei Ji Cheng (2015) No. 46) of the National Health and Family Planning Commission and the Ministry of Finance, and comprehensively promote the networking, settlement and reimbursement work over accessing medical service in a place other than the resident region in the National New Rural Co-operative Medical System (including the basic medical insurance of urban and rural residents that the health and family planning department is responsible for), the National Health and Family Planning Commission, together with the Ministry of Finance developed an Implementation Program of Networked Settlement and Reimbursement of Expenses Occurred when Accessing Medical Service in a Place other than the Resident Region in the National New Rural Co-operative Medical System (see below).
National Health and Family Planning Commission of PRC, Ministry of Finance
Implementation Program of Networked Settlement and Reimbursement of Expenses Occurred when Accessing Medical Service in a Place other than the Resident Region in the National New Rural Co-operative Medical System
To accelerate the work of realizing networked settlement and reimbursement of expenses occurred when accessing medical service in a place other than the resident region with basic medical insurance is an important content of promoting the construction of health China. It is of great significance to deepening the reform of medical and health system, implementing hierarchical diagnosis and treatment, completing the construction of the basic medical insurance system and improving the sense of access of urban and rural residents. In order to carry out requirements put forward in the 2016 Government Work Report on accelerating promotion the work of realizing networked settlement and reimbursement of expenses occurred when accessing medical service in a place other than the resident region with basic medical insurance, and comprehensively promote the networked settlement and reimbursement work of expenses occurred when accessing medical service in a place other than the resident region in the new rural cooperative medical system (hereinafter referred to as NCMS, including basic medical insurances for urban and rural residents that the Health and Family Planning Department is responsible for, similarly hereinafter), the program is here developed.
1. Work Objectives
The work objective is to establish an effective operation and management mechanism on accessing medical service in a place other than resident region through the improvement of compensation management policy on accessing medical service in a place other than resident region, information system function and service network, and gradually realize nationwide networked settlement and reimbursement when seeking for cross-province medical service in NCMS. In 2016, we shall perfect the national and provincial NCMS information platforms, basically complete the establishment of the NCMS remote medical treatment information system, realize direct settlement and reimbursement of expenses occurred when accessing medical service in the same province, and carry out settlement and reimbursement pilots for NCMS in-patients transferred in designated cross-province hospitals for treatment. In 2017, we shall basically realize settlement and reimbursement of NCMS transferred in-patients seeking for cross-province medical treatment in designated hospitals.
2. Basic Principles
(1) Adhere to being people-oriented. Start from maintaining the vital interests of the masses participating in the New Rural Cooperative Medical Insurance, take bringing convenience for the masses as the starting point and ending point of promoting the remote medical treatment settlement and reimbursement work, and practically improve convenience and timeliness for the insured in settlement and reimbursement when seeking for medical service in other places.
(2) Adhere to boosting with hierarchical diagnosis and treatment at the same time. The remote medical treatment settlement and reimbursement service is mainly for standard transfer patients, gives play to the basic medical insurance’s guiding and regulating roles in the flow direction of patients, and promotes the formation of a reasonable medical service seeking order.
(3) Adhere to being medical treatment place management-based. In principle, cross-province patients shall implement the relevant policies of the place where they seek for medical service. The provincial management and handling institution in the place where the patients seek for medical service shall be responsible for the management of and service for cross-province patients on behalf of the insurance-participating region.
(4) Adhere to classification guide. By combining the progress of NCMS information construction in all places, the medical institutions dock with the National New Rural Cooperative Medical System Information Platform (hereinafter referred to as the National Platform) through different channels to ensure the formation of smooth information exchange channels and effective working mechanism. In accordance with the principle of “Making it Mature in a Province (Autonomous Region, Municipality), Connect a Province (Autonomous Region, Municipality), and Implement in a Province (Autonomous Region, Municipality)”, we shall promote the work actively.
3. Main Measures
(1) Build and improve the remote medical treatment information system.
1. Improve the national and provincial remote medical treatment settlement and reimbursement network. According to the requirements of the Notice on Comprehensively Promoting the Construction of National NCMS Information Platform (Guo Wei Ban Ji Cheng Han (2015) No. 870) issued by the National Health and Family Planning Commission, we shall speed up promoting the construction of the national platform and provincial NCMS information platform (hereinafter referred to as provincial platform) in accordance with the general framework and top-level design of population health information construction, and build the national NCMS trans-provincial medical service access data exchange channel based on the national e-government network or virtual private network. The national platform should give play to a pivotal role and be responsible for exchanging data on trans-provincial referral settlement, reimbursement and so on. The provincial platform shall be responsible for connecting the designated networked medical institutions in the province, uploading the patients’ information in its province transferred to hospitals of other provinces immediately, collecting and uploading settlement and reimbursement related data of patients transferred from other provinces to the designated networked medical institutions in the province. The medical institution connects with the national platform via the provincial platform in the principle of running by the local authorities. Budget management hospitals, third-level provincial (regional and municipal) medical institutions not with connection conditions connect with the national platform directly.
2. Establish a remote medical treatment information system and improve the function. On the basis of perfecting the national and provincial platforms, we shall speed up the establishment of the NRM remote medical treatment information system and enable the system to have the referral, settlement and other management functions. All provincial platforms are responsible for the settlement and reimbursement of trans-provincial treatment. For those provincial platforms with imperfect functions, they can alloy their provincial compensation schemes on the national platform and have the national platform complete settlement and reimbursement. For regions where the provincial platform has not been built, they can build a remote treatment information system based on their provincial (regional and municipal) population health information platform. For provinces (autonomous regions and municipalities) that have handed over NCMS to other departments for management, they should make full use of the built NCMS information platform, provide patients transferred from other provinces with referral settlement, reimbursement and other management service work, or coordinate with the urban health insurance departments to do related work well.
All coordinating areas also can be based on the actual situation and select medical institution to carry out trans-provincial medical treatment settlement and reimbursement in advance through the method of point-to-point contract signing in the place where workers concentrate. The remote medical treatment settlement and reimbursement work within the province can be planned and arranged by all provinces according to their actual situations.
3. Realize interconnection and data sharing of remote medical treatment information systems. We shall realize the wide interconnection of information systems between medical institutions and coordinating areas. The networked medical institution should, in accordance with the Notice of the National Health and Family Planning Commission on Printing and Issuing the National New Rural Cooperative Medical System Information Platform Connection Technology Program (trial) (Wei Ban Nong Wei Han (2013) No. 456), generate standard data exchange content and submit to the national or provincial platforms. Medical institutions adopting disease diagnosis grouping payment should generate data exchange content according to the standard format.
4. Unify data exchange frequency. Trans-provincial referral, in-patient registration and hospital discharge settlement and reimbursement information should be exchanged in real time; in-hospital diagnosis and expense information should be uploaded daily in principle; information on the home page of the hospital discharge record should be uploaded within 5 working days after the patient leaves hospital; advanced payment returning application and disbursement information should be exchanged monthly on a regular basis.
(2) Develop remote medical treatment settlement and reimbursement policies.
1. Standardize the compensation policies for remote medical treatment. All provinces (autonomous regions and municipalities) should standardize relatively unified compensation policies for remote medical treatment within the province or outside the province, realize unification in terms of medication catalog, diagnosis and treatment items and other aspects, and standardize remote medical treatment operation flow. For patients seeking medical service in a province other than the resident province, the reimbursement application policy should be implemented on the basis of the fixed-point agreement. On the premise of ensuring the smooth operation of funds, you can refer to the reimbursement catalog of the place for medical treatment, but the payment proportion shall still refer to the regulations of the place where the patient participates in the NCMS. You can also select to implement the unified policy formulated by the province (autonomous region, municipality) where the patient participates in the NCMS.
2. Establish a referral system for remote medical treatment. To establish and perfect a hierarchical diagnosis and treatment system is the foundation to do the remote medical treatment settlement and reimbursement work well, so all provinces (autonomous regions, municipalities) should establish a referral system for NCMS remote medical treatment. NCMS-participating patients in line with conditions seek medical treatment outside the province after applying for referral record in the NCMS-participating place, the operating institution in the NCMS-participating place should submit the standardized referral information to the provincial or national platform immediately, and the medical institution obtains the patient’s referral information through the national or provincial NCMS platform and provides corresponding service. It is encouraged that all places takes resident health card as the main certificate for identifying the patient’s NCMS participating identity as well as the certificate for settlement and reimbursement when he/she is accessing medical service outside his/her resident province.
3. Implement seeking medical service in designated and networked hospitals. All provinces (autonomous regions, municipalities) should confirm the networked medical institutions under their administration carrying out trans-provincial medical treatment settlement and reimbursement according to the service ability of the medical institutions, service patient objects and the connection situation of NCMS platform in the area under their administration. Networked medical institutions should include general and specialized hospitals at all levels, especially medical institutions providing more service for patients from other places. There should be third-level medical institutions that can meet the referral patients’ demand for difficult miscellaneous diseases, but also several second-level hospitals making it convenient for people to seek medical service nearby or seek emergency treatment as well as some basic medical institutions with certain in-patient conditions. The National Health and Family Planning Commission Budget Management Hospitals and all provincial (regional, municipal) people’s hospitals (provincial hospitals) and hospitals of traditional Chinese medicine should take the lead in carrying out trans-provincial medical treatment settlement and reimbursement. All provinces (autonomous regions, municipalities) submit the name list of networked medical institutions with trans-provincial settlement conditions to the National Health and Family Planning Commission and then the name lists shall be released for selection by all places via the web portal of the National NCMS Information Platform.
All places should select their designated hospitals for patients in their provinces (autonomous regions, municipalities) for trans-provincial medical treatment from the name list of the networked medical institutions published on the national platform and sign agreements with them, and then carry out trans-provincial referral settlement and reimbursement work comprehensively on the basis of pilots. When promoting networked settlement and reimbursement for remote medical treatment, all places shall plan and consider the docking work with critical illness insurance, medical assistance, target poverty relief, etc.
(3) Standardize the remote medical treatment settlement mechanism.
1. Implement management service duties. For trans-provincial referrals, they should be docked with province (autonomous region, municipality) as the unit in principle, based on treatment place management and coordinated by the NCMS-participating place. The provincial NCMS management and operating department in the treatment place shall be responsible for the settlement and reimbursement management and service work; and the provincial NCMS management and operating department in the NCMS-participating place shall be responsible for relevant coordination and cooperation work.
For provinces that hand over the NCMS work to other departments for management, they should undertake the settlement, reimbursement and relevant settlement management work of NCMS patients of other provinces transferred to the designated networked medical institutions of their provinces. The health and family planning administration department should actively coordinate with the basic medical insurance management and operating department to bear corresponding management and service responsibilities. The work mentioned above can also be entrusted to the health, insurance or financial institutions and be docked with the National Health and Family Planning Commission well.
2. Set up a settlement center. The National Health and Family Planning Commission entrusts the Chinese Academy of Medical Sciences (the National Platform Construction Unit) to undertake the national remote medical treatment settlement management function, to be responsible for the trans-provincial medical treatment information technology guide, the daily operation and maintenance of the information system, and to coordinate with and handling the nationwide trans-provincial medical treatment settlement and reimbursement work. It should have certain settlement function. The provincial health and family planning administration department should identify the institution undertaking the provincial settlement function (hereinafter referred to as the Provincial Settlement Center) as soon as possible by increasing settlement function for the provincial operating institution or by designating a relevant unit to assume the function, etc.
We should give full play to the role of market mechanism and mobilize the social force to participate in the basic medical insurance handling service. We should encourage financial insurance and other third-party institutions to participate in the construction of national and provincial settlement centers, encourage all places to entrust the commercial insurance and other institutions to handle remote medical treatment settlement and reimbursement management and service work. Commercial insurance institutions undertaking NCMS critical illness insurances can use their existing settlement channels to provide service for remote medical treatment settlement. We should also actively promote one-stop settlement and reimbursement of NCMS, critical illness insurances and medical assistance; encourage financial institutions to give play to the role of credit guaranty and advance the personal self-pay part expense.
3. Standardize the settlement process. Patients transferred to designated networked medical institutions outside the province according to standard procedures only need pay the self-pay part amount before hospital discharge; the NCMS fund payment part shall be advanced by the medical institution first and the medical institution shall apply for returning the advanced fund to the provincial settlement center it is in on a regular basis; and the settlement center checks the returned money application materials and appropriates the checked amount to the medical institution monthly. The provincial settlement center in the NCMS-participating place conducts fund settlement with the provincial settlement center of the medical treatment place and is responsible for fund settlement with all coordinating regions in the province.
For those areas that do not have the condition for direct settlement and reimbursement, they should coordinate with the designated networked medical institution to provide remote referral medical treatment service and cooperate with the work of settlement. After the NCMS-participating patient accesses medical service in a designated networked hospital, the hospital should submit the standard treatment information and hospital discharge settlement information to the national or provincial platform within 5 working days. The operating institution in the NCMS-participating place shall combine the medical expense information provided by the national platform, calculate the compensation fees according to the local policy and remit the compensation fee to the patient’s resident health card or bank account directly.
4. Schedule
By the end of June 2016, all provinces (autonomous regions, municipalities) should improve the intra-provincial remote medical treatment settlement and reimbursement policy and ensure the implementation of the policy.
By the end of July 2016, all provinces (autonomous regions, municipalities) should develop trans-provincial remote medical treatment settlement and reimbursement work program, submit the name list of networked medical institutions that can provide trans-provincial medical treatment settlement and reimbursement service in the area under their administration, and submit the implementation situation of intra-provincial remote medical treatment.
By the end of August 2016, all provinces (autonomous regions, municipalities) should improve the provincial platform information system and have the system have the functions of referral, settlement, reimbursement, etc.; should develop national network settlement and reimbursement related data exchange interface, and realize connectivity among the national and provincial platforms and medical institution information systems.
By the end of October 2016, all provinces (autonomous regions, municipalities) should build a provincial settlement center or entrust relevant units to undertake the trans-provincial medical treatment settlement function; and fully realize intra-province remote medical treatment settlement and reimbursement. All provinces (autonomous regions, municipalities) should select at least two prefecture-level cities and several networked medical institutions outside the province, sign relevant agreements with them, and carry out trans-provincial medical treatment networked settlement pilot work. In the mean time, all provinces (autonomous regions, municipalities) also should select several networked medical institutions inside the province to provide service for patients transferred from other provinces.
In the principle of “Connecting a Province (Autonomous Region, Municipality), Publishing a Province (Autonomous Region, Municipality)”, the progress in the trans-provincial NCMS medical treatment settlement and reimbursement work in all provinces (autonomous regions, municipalities) should be published timely. The National Health and Family Planning Commission shall work together relevant departments to supervise and check the trans-provincial treatment settlement and reimbursement work in all provinces. For places whose progress is slow, the National Health and Family Planning Commission shall urge them through appointment, notification or other forms, so as to ensure them complete their task on time.
5. Work Requirements
(1) Strengthen organization and leadership. The health and family planning administrative departments at all levels should take NCMS remote medical treatment settlement and reimbursement work as an important task for deepening the reform of the medicine and health system, bring it into the medical reform targets, carry out assessment and management, plan and organize carefully, coordinate in promotion, overcome difficulties and ensure to fully achieve the task objects.
The provincial health and family planning administration department should be responsible for the organization, leadership, supervision and management work of NCMS remote medical treatment settlement, actively strive for support from relevant departments, and coordinate to develop trans-provincial medical treatment settlement and reimbursement work program. This department should also practically fulfill its localized management duties, strengthen supervision over the service behavior and quality of the designated networked medical institutions, control the growth of unreasonable expense, and coordinate with the returning of remote medical treatment settlement and reimbursement funds. Provinces (autonomous regions, municipalities) that have handed over NCMS to other departments for management should also set up an awareness of serving the NCMS-participating patients of other provinces, actively coordinate with, supervise and urge designated networked medical service institutions in the area under their administration to provide trans-provincial medical treatment settlement and reimbursement services.
All planning areas’ operating institutions of NCMS should create conditions and provide convenience for trans-provincial medical treatment settlement and reimbursement, and actively cooperate with the NCMS operating institutions and designated medical institutions in the medical treatment place to handle settlement, reimbursement and liquidation work.
The Medical Information Institute of the Chinese Academy of Medical Sciences shall cooperate with all levels of health and family planning departments to implement the trans-provincial medical treatment settlement and reimbursement work, develop relevant system standard application, user privilege management, data security protection and relevant technical specifications, do technical support and training work well, strengthen tracing and guidance to experimental units in all places, summarize and publish progress in all places at regular intervals.
(2) Clarify the responsibility of medical institutions. Medical institutions at all levels should attach great importance to the trans-provincial medical treatment settlement and reimbursement work and actively create conditions to become a designated and networked trans-provincial medical institution. Third-level medical institutions, especially commission-level budge management hospitals, should actively play a leading role, take the initiative to participate in, and provide trans-provincial settlement and reimbursement service for the patient.
Designated networked medical institutions should reform their hospital management information systems, connect each other with the national population health information platform (NCMS information platform) and transmit each other the data. They should also enhance internal management, improve the relevant working mechanism, optimize the medical treatment settlement and reimbursement process, and earnestly improve the service level. They should give priority and provide medical services for the referrals based on online referral information. Moreover, they also should set up designated trans-provincial medical service windows, do a good job in patient identity recognition and hospital discharge settlement and reimbursement, and exchange trans-provincial medical treatment data timely.
(3) Do a good job in policy link-up for other people. Long-term migrant workers that have established stable labor contract relations should participate in urban worker medical insurance in accordance with the law and enjoy corresponding reimbursement. The elderly living together with their children or other people living in a place other than his/her hometown for a long time can handle a residence permit in the living place according to the Temporary Regulations on Residence Permit, participate in urban and rural resident medical insurance in the living place and enjoy corresponding treatment. People that cannot participate in the basic medical insurance of the working place or living place can make a record in the NCMS-participating place and then enjoy corresponding settlement and reimbursement treatment according to the referral standard.
(4) Do a good job in publicity and guidance. All places should use various forms to conduct vigorous propaganda, so that the NCMS-participating residents can understand the policy and practices of trans-provincial medical treatment settlement and reimbursement and actively cooperate with the relevant work. All places should do a good job in information disclosure, publish the telephone number and other contact information timely, making it easy for the NCMS-participating patients in inquiry, consultation, complaints and supervision.
(5) Focus on information security. All levels of health and family planning departments, NCMS operating departments, settlement centers and medical institutions should attach great importance to the information security and privacy protection of patients seeking medicine service in remote places, improve their security management systems, operating procedures and technical specifications in strict accordance with the requirements of the national information security level protection system and the Population Health Information Management Measures (Trial) published by the National Health and Family Planning Commission. The health and family planning departments of county- or higher level shall assume the responsibilities of the competent department; and all levels and all kinds of medical and health service institutions as responsible organizations should practically strengthen information security management and personal privacy protection.