Re: guide to basic medical insurance for urban residents in Ji'nan
(yuan) resident medical insurance fund
proportion (%) per individual burden
(%) maximum payment limit
(yuan)
level medical institution
(including society) District medical institutions) 2007030
(the annual maximum payment limit is yuan)
two level medical institutions 4006040
three level medical institutions 7005050
note: in a medical year, the second hospitalization start standards are 20% lower than the previous one. From the third hospitalization, the start payment standards are not carried out. The standard of outpatient service is only one time in a medical year, with a standard of 200 yuan.
eight, urban residents' medical settlement process
(1) a designated community health service outpatient medical treatment, settlement process
a medical year, the insured person is in the outpatient of a designated community health service institution that meets the requirements of the residents' basic medical insurance fund. No more than 200 yuan will be paid by the fund according to the standard of 20%, and the excess will be paid by personal cash. The insured should pay medical insurance cards when they seek medical service at the designated community health service institutions.
(two) hospitalization, settlement process
1, ordinary hospitalization
(1) inpatient registration: the insured person is in hospital for illness, and the medical insurance management department of the designated medical institution can handle the hospitalization with the medical insurance card and the ID card after the medical insurance management department of the designated medical institution.
(2) deposit collection: when the insured person is hospitalized in a designated medical institution, the hospital may collect a certain amount of deposit first, but it may not exceed the individual's own part of the insured.
(3) discharge settlement: when the insured person is discharged from hospital, the insured should settle the part of the personal burden with the designated medical institution in time (the part outside the catalogue, the first part of the catalogue, the proportion in proportion within the scope of the overall payment, the part above the maximum payment limit). The designated medical institutions should print the inpatient invoices and the list of the hospitalization expenses of the basic medical insurance participants in the urban residents of Ji'nan, and the settlement of the hospitalization expenses of the participants in the designated hospitals of the urban residents in Ji'nan.
2, emergency hospitalization,
to stay in the hospital in the same designated medical institution, the medical expenses and the hospitalization expenses during the period of their stay are calculated; no need to be admitted to the hospital and be treated in the outpatient department.
the critical patient is invalid in emergency emergency treatment. The emergency expenses in accordance with the prescribed emergency expenses shall be paid by the resident medical insurance fund in accordance with the relevant regulations of the hospital, and the starting and payment standards are not carried out.
3, municipal referral transfer hospital
has been admitted to the hospitalized patients, the hospital because of equipment or technology limited diagnosis and treatment of difficulties, should be provided for the patient to transfer the hospital. When a insured person transfers to a higher level hospital, he should make up the difference between the standard transferred to the hospital. The transfer of the hospital to the next level will not be refunded. The condition of
4,
transfer hospital in a foreign transfer hospital:
(1) the city is limited to the critical and difficult conditions that can not be treated by technical and equipment conditions;
(2) is still unconfirmed by inspection and expert consultation in the three class designated medical institutions of the city or the specialist hospital at the level of the municipal level;
(3) the level of diagnosis and treatment in the receiving hospital is higher than that in the city;
(4) the admission hospital is limited to three grade A hospitals in Beijing, Shanghai or Tianjin.
Special referral program:
when the insured person really needs a special referral to the transfer hospital, we should organize the consultation and fill in the report of the medical insurance of the Ji'nan urban residents' basic medical insurance referral transfer hospital. The office is put on record.
the proportion of personal burden of medical expenses increased by 10 percentage points, and the medical insurance fund of residents will not be paid without the medical expenses. Emergency treatment for critically ill patients, such as
5, emergency non scheduled hospitalization
, can be hospitalized in nearby non designated medical institutions. However, within 3 days from the date of hospitalization, it shall report to the medical insurance agency of the district. After the condition is allowed, the medical insurance fund should be transferred to the designated medical institution for treatment; the medical insurance fund of the residents shall not pay if there are no justifiable reasons for overdue report or if it is not found to be a critically ill patient.
(three) family sickbed opening, settlement process
conforming to the following conditions, the designated community health service institutions can set up a family bed for them on the basis of application:
(1) the loss of all or most of the ability of stroke and the condition of hospitalization; < br / > (2) the advanced action of malignant tumor is difficult.
(3) serious cardiopulmonary disease conforms to the hospitalization conditions, and the hospitalization is difficult;
(4) other conditions conform to the hospitalization conditions, because the hospitalization is difficult and suitable for the family treatment.
when the insured person applies for a family sickbed, it should first submit a written application to a designated community health service. After a preliminary opinion on the condition of the insured, the designated community health service hold the application form for the establishment of the basic medical insurance family bed for urban residents in Ji'nan and the recent medical records of the insured and the inspection and inspection. Go to the medical insurance agency alone for the record.
family sickbed treatment cycle is generally 90 days, because the illness is really necessary to extend, should be reported to the district medical insurance agencies for record, but in a medical year the longest no more than 150 days. The medical expenses of the family sickbeds are subject to quota management. The average medical cost per person's daily medical insurance fund is 60 yuan per person. The expenses within the quota shall be settled according to the prescribed proportion after the audit, and the residents' medical insurance funds beyond the limit will not be paid. Family beds should be cleared up before hospitalization due to hospitalization due to illness. Those who still need family beds after discharge should be re declared.
(four) the insured persons under the age of 18 or under the age of 18, the medical treatment and settlement process of the insured persons, children and the other insured persons under the age of 18 are required for emergency treatment for accidental injury, and the medical expenses will be paid by the individual. After the end of treatment, reimbursement procedures will be processed by the outpatient medical records, the original documents and the cost list.
accidental injury refers to an external, unexpected, unintentional and non physical objective event that causes bodily injury.
(five) the medical expense cash reimbursement process
cash reimbursement range: foreign referral transfer hospital, foreign emergency hospitalization, local emergency non fixed-point hospitalization, outpatient emergency death, students and children under 18 years old and under emergency injury, inpatient cash reimbursement.
after the medical termination of the insured person, we should carry the first page of the medical records and the copy of the medical orders, the original medical records of the outpatient department, the discharge diagnosis, the effective bill and the bill of expenses. (the case of the transfer Hospital of the medical insurance of Ji'nan city residents should also be carried on the record of the transfer Hospital of the medical insurance participants in the city of the city of the city of the city) before 10 days of the month. The medical insurance agency in the region handles the cash reimbursement formalities. The district medical insurance agency inquires the status of the payment and record of the insured, and confirms the authenticity and completeness of the material, and collect the material after it is unmistakable. After the audit and settlement, the cost of reimbursement is put into the medical insurance card financial area of the insured person through the resident medical insurance bank.
(six) the outpatient provision of medical treatment, settlement process
outpatient provision of medical treatment, with the "gate certificate", "medical insurance card" to the designated hospital of the designated hospital set "outpatient specified disease window", and extract my "outpatient specific medical records of medical records bag", the door gauge card It is temporarily registered and preserved by the medical staff of the window. Outpatients prescribe sick patients with "outpatient prescriptions special case history bag" to the relevant departments for treatment, and take two prescriptions to take medicine. After the visit, the special medical records, double prescriptions, cost documents and the related examination and treatment materials should be loaded into the medical personnel of the special medical records of the prescribed diseases in the outpatient department, and the medical staff of the window should be returned to the medical staff at the same time. The
outpatient stipulates that the patient should pay only part of the personal burden when the patient is hospitalized at a designated medical institution, and the rest is settled by the designated medical institution and the municipal medical insurance agency.
nine, the medical expenses in the range of
insured by the basic medical insurance fund of the urban residents shall not be paid by the resident medical insurance fund:
(1) the injury caused by the violation of the relevant legal provisions;
(two) suicide self disability (except for mental illness) or drunkenness Deaths and injuries;
(three) birth and related surgery;
(four) plastic, cosmetic, correction and other treatment;
(five) rehabilitation treatment;
(six) have third liability;
(seven) other non compliance with the coverage of medical insurance coverage.
medical expenses of insured persons in foreign countries and in Hongkong, Macao Special Administrative Region and Taiwan area, and the residents' medical insurance fund will not be paid.
ten, ten, city, district medical insurance agency
organization name and address telephone
Ji'nan city staff medical insurance management office city six li Mountain Road 46 80698660
No. 23 86983714
No. Medical insurance office in the Middle District of the city??? 53 82078668
Huaiyin District medical insurance office in the Middle District of the city?????? No. 24 87956068
Tianqiao District medical insurance office in the North Xiaoxinzhuang West Street of Huaiyin District??? No. 31, 85872990?
in Tianqiao District, 85872990?
the medical insurance office of the city district Huayuan Road 2 - 1, 88066042? 1, 88066042???
high and new zone medical insurance office???? No. 304, room 28, No. 28, industrial South Road, room 304, Changqing district medical insurance office, Changqing District, the middle section of Shui Ming Street, the middle section of water sounding street, the basic medical insurance of Ji'nan city residents Insurance policy advisory telephone: 80698508
detailed policy and business content can be viewed by the Ji'nan medical insurance network "medical insurance column for urban residents"
address: http://www.jnyb.com.cn
Office of medical insurance management in Ji'nan