Interim Measures for the administration of designated medical insurance institutions (Draft for comments)

In order to adapt to the new situation, new environment and new tasks faced by the medical security industry, standardize the designated management of medical security of medical institutions and retail pharmacies, improve the efficiency of the use of medical security funds, and provide high-quality medical services for the insured, the State Medical Security Bureau has studied and drafted the Interim Measures for the designated management of medical security of medical institutions (Draft for comments) and Interim Measures for fixed point management of medical security of retail pharmacies (Draft for comments): Chapter I general provisions of Interim Measures for fixed point management of medical security of medical institutions (Draft for comments) Article 1 [objective basis] these measures are formulated in accordance with the social insurance law, regulations on the administration of medical institutions and other laws and regulations in order to standardize the designated management of medical security of medical institutions, improve the efficiency of the use of medical security funds, and provide high-quality medical services for the insured Article 2 [principles] the fixed-point management of medical security of medical institutions should adhere to the principle of people's health as the center, follow the principles of basic security, fairness and justice, clear rights and responsibilities, dynamic balance, strengthen the fine management of medical security, promote the supply side reform of medical institutions, and provide appropriate medical services for the insured and the relief objects Article 3 [Responsibilities] the administrative department of medical security is responsible for formulating the management policies of designated medical institutions, and supervising the medical security agencies and medical institutions in the links of designated evaluation, negotiation and agreement implementation The medical security agency is responsible for determining the designated medical institutions, signing service agreements with the designated medical institutions and providing the handling services The designated medical institutions shall abide by the relevant policies of medical insurance and provide medical services to the insured in accordance with the service agreement Chapter II Determination of designated medical institutions Article 4 [designated scale] the administrative department of overall planning of regional medical security shall determine the scale layout of designated medical institutions within its jurisdiction according to the balance of medical insurance revenue and expenditure, combined with the allocation of regional medical and health resources, medical needs of the insured, etc Article 5 [scope of application institutions] the following medical institutions that have obtained the practice license of medical institutions, as well as the military medical institutions with medical service qualification for the people approved by the competent military department, may apply for medical security fixed points: (1) general hospitals, traditional Chinese medicine hospitals, integrated Chinese and Western medicine hospitals, national hospitals, and specialized hospitals （2） Special disease prevention and treatment hospital (Institute, station), maternal and child health care hospital （3） Community Health Service Center (station), Central Health Center, township health center, street health center, outpatient department, clinic, health center (station), village health office (station) （4） First aid center, first aid station （5） Anning treatment center, hemodialysis center （6） There are medical institutions in the elderly care institutions （7） Internet hospitals can rely on their physical hospitals to apply for fixed points As a third-party service provider, clinical test center, medical laboratory, pathological diagnosis center and medical imaging diagnosis center can sign an agreement with the designated medical institutions and report to the local agency for filing, and then provide relevant services for the designated medical institutions The relevant expenses shall be settled by the regional agency and the designated medical institution as a whole Article 6 [application conditions] the medical institutions applying for medical security fixed points shall meet the following basic conditions: (1) formal operation for more than three months （2） There shall be at least one doctor who has obtained the doctor's practice certificate or the village doctor's practice certificate （3） Provide full-time (Part-time) medical insurance management personnel, and the main responsible comrades of medical institutions are in charge of medical insurance work Medical institutions with more than 100 beds shall have a medical security office with full-time staff （4） It has medical insurance management system, financial system, statistical information management system, medical quality and safety core system that meet the requirements of medical insurance （5） It should have perfect hospital information system technology and interface standard, realize effective docking with medical insurance information system, and provide direct online settlement for the insured Establish basic databases of medical insurance drugs, diagnosis and treatment projects, medical service facilities, medical consumables, disease types, medical insurance doctors, etc., and use the unified national medical insurance code according to regulations （6） Meet other requirements stipulated by provincial medical security administrative department and relevant laws and regulations Article 7 [submission of application materials] medical institutions shall voluntarily apply for designated medical insurance to the agencies in the overall planning area, and at least provide the following materials: (1) application form for designated medical institutions （2） Copy of medical institution practice license (original and duplicate) （3） Department setting and practice information of medical staff （4） Internal management system and financial system corresponding to medical insurance policy （5） Information system related materials related to medical insurance （6） Included in the predictive analysis report of the impact on the medical insurance fund after designated （7） Other materials required by the provincial administrative department of medical security Article 8 [instant acceptance] qualified medical institutions can submit fixed-point applications at any time, and the regional agency for overall planning shall accept them immediately If the application materials are insufficient, the handling agency shall inform the medical institution for supplement within 5 working days from the date of receiving the materials Article 9 [organization evaluation] the regional handling organization shall organize the evaluation team or the entrusted third party organization to carry out the evaluation in writing, on-site and other forms The members of the assessment team are composed of medical security, medical health, financial management, information technology and other professionals The evaluation time shall not exceed 3 months from the date of acceptance of application materials The evaluation results are divided into qualified and unqualified The overall regional agency shall report the evaluation results to the administrative department of medical security at the same level for the record For those who fail to pass the evaluation, the reason shall be informed and rectification shall be made within a time limit The application can be submitted again 3 months after the rectification from the date of result notification Article 10 [signing the agreement] coordinate the negotiation between the regional agency and the qualified medical institution If an agreement is reached, both parties shall sign the service agreement voluntarily The term of the agreement is generally one year The agency shall publicize to the public the list of medical institutions that have signed the service agreement At the end of publicity, the service agreement signed by the agency and the designated medical institution shall be reported to the administrative department of medical security at the same level for filing Article 11 [agreement content] the responsibilities, rights and obligations of both parties shall be clearly defined in the service agreement signed between the regional agency and the designated medical institution Both parties signing the service agreement shall strictly implement the agreement Article 12 [publication of results] the agency of the overall planning area shall publicize the information of the designated medical institution signing the service agreement to the society, including the name, address, etc., for the choice of the insured The designated medical institutions in each overall planning area shall recognize each other and shall not apply separately Article 13 [inadmissibility] medical institutions shall not accept fixed-point applications in case of any of the following circumstances: (1) non basic medical services such as medical cosmetology, assisted reproduction, life care, tooth planting and tooth planting as the scope of practice （2） Failing to implement the government guidance price for basic medical services （3） The penalty period of the medical insurance department has not ended or the economic penalty has not been paid up （4） Applying for a designated place by means of fraud or other improper means and less than 3 years have elapsed since the date of discovery （5） The medical institution has been terminated for less than 3 years due to violation of relevant laws and regulations of medical insurance, or the agreement has been terminated for more than 3 years, but has not been paid off due to economic punishment by the medical insurance department （6） The original designated medical institution terminates the agreement due to the serious violation of laws and regulations by the legal representative, the main person in charge and the actual controller, and establishes a new medical institution within 5 years （7） The legal representative, the principal person in charge and the actual controller are included in the list of dishonest persons （8） Other inadmissible cases prescribed by the provincial administrative department of medical security Chapter III operation and management of designated medical institutions Article 14 [rights] designated medical institutions have the rights to obtain medical insurance settlement fees after providing medical services for the insured, propose to change, suspend or terminate the agreement, conduct social supervision on the performance of the agency, and put forward opinions and suggestions on improving the medical insurance policy Article 15 [medical service] designated medical institutions shall strictly implement the service agreement, make reasonable diagnosis and treatment, charge reasonable fees, strictly implement the catalog of medical insurance drugs and diagnosis and treatment projects, control the use of self funded medical projects, and improve the use efficiency of medical insurance funds Article 16 [payment policy] designated medical institutions shall strictly implement the budget indicators of the total amount of medical insurance, the payment methods and payment standards by project, disease, DRG, bed day and head Formulate corresponding internal management measures, define the admission and exit standards, and do not reject patients on the basis of medical insurance payment policy Article 17 [bidding procurement] designated medical institutions shall implement the centralized procurement policy in accordance with the relevant provisions, give priority to the use of drugs and consumables selected in the centralized procurement, purchase drugs and consumables on the platform recognized by the administrative department of medical security, and truly record the "purchase, sale and storage" situation Article 18 [price implementation] the designated medical institutions or departments included in the designated medical insurance departments shall strictly implement the price policies formulated by the medical insurance departments Article 19 [publicity and training] designated medical institutions shall participate in the publicity and training organized by the administrative departments and agencies of medical security Learning and training of policies and regulations related to medical insurance should also be organized within designated medical institutions Article 20 [signs] the designated medical institutions shall hang the signs of the designated medical institutions in a uniform format at a prominent position Article 21 [information submission] designated medical institutions shall timely and truthfully submit medical insurance information submission list, medical service information, medical insurance settlement list, charging details, drugs and consumables and other "purchase, sale, storage" data, financial and cost data, doctors and nurses' practice information, etc to the overall regional agencies as required, and shall be responsible for their authenticity Article 22 [accept examination and supervision] the designated medical institutions shall cooperate with the agencies to carry out cost examination, audit, performance evaluation and other work, accept the supervision and inspection of the administrative department of medical security, and provide the required materials as required Article 23 doctors with prescription right in designated medical institutions shall become doctors under medical insurance agreement Doctors under medical insurance agreement shall strictly implement the relevant policies and regulations of medical insurance, fulfill the contents of service agreement and standardize medical service behaviors Article 24 designated medical institutions shall optimize the medical insurance settlement process and provide convenient medical insurance services for the insured When providing medical services, it is necessary to check the valid certificates of the insured or the rescue object, so as to make sure that the certificates are consistent with each other, and provide them with direct settlement of medical insurance or rescue expenses and expense settlement documents To provide medical insurance services for the insured or the assisted persons who meet the requirements The insured and the rescued can decide to purchase drugs in the designated medical institutions or hold the prescription to the designated retail drugstores Article 25 [information security management] designated medical institutions shall do a good job in information system security related to medical insurance, abide by relevant data security systems, and protect the privacy of the insured When a designated medical institution reinstalls the local information system, it must be filed with the agency Chapter IV designated handling management service article 26 [rights] handling