Notice of the General Office of the Ministry of Finance of the Office of the National Medical Insurance Administration on the implementation of the pilot work for direct settlement of outpatient chronic diseases related treatment costs across provinces

General Office of the Ministry of Finance, Office of the National Medical Insurance Administration

General Office of the Ministry of Finance, Office of the National Medical Insurance Administration

Regarding the cost of outpatient treatment of chronic diseases

Regarding the cost of outpatient treatment of chronic diseases

Notice on the pilot work of inter-provincial direct settlement

Notice on the pilot work of inter-provincial direct settlement

Medical Insurance Office Letter (2021) No.
4

Medical Insurance Office Letter (2021) No.
4

All provinces, autonomous regions, municipalities directly under the Central Government and Xinjiang Production and Construction Corps medical security bureaus, financial departments (bureaus):

In order to implement the deployment of the 2021 Government Work Report on the promotion of direct settlement of outpatient expenses across provinces, and to further solve the problem of "difficult and worrying" problems encountered by the people in settlement of medical treatment in different places across provinces, we are accelerating the promotion of direct settlement of ordinary outpatient medical expenses.
On the basis of settlement, it was decided to launch a pilot project for direct settlement of outpatient chronic diseases related treatment costs across provinces
.

The relevant matters are hereby notified as follows:

1.
Pilot objectives

1.
Pilot objectives

Before the end of 2021, each province (autonomous region, municipality directly under the Central Government, including Xinjiang Production and Construction Corps, hereinafter collectively referred to as the province) will select at least one coordinating area to carry out a pilot program for direct settlement of outpatient chronic disease-related treatment costs across provinces, which can provide hypertension, diabetes, and malignant tumors.
Outpatient radiotherapy and chemotherapy, uremic dialysis, and anti-rejection treatment after organ transplantation are directly settled across provinces for treatment costs related to chronic diseases in five outpatient clinics
.

Combining the pilot situation, paying attention to the needs of the masses and personal interests, effectively solving the problems of direct settlement policy, handling management and informatization of chronic and special diseases in outpatient clinics, and forming a reproducible and popularized experience

2.
Scope of the pilot

2.
Scope of the pilot

(1) The scope of the pilot population
.

Those who have completed the above five outpatient treatment qualifications for chronic and special diseases in the insured place, and have gone through the procedures for inter-provincial and remote medical treatment according to the insured place, are included in the scope of the pilot population
.

The insured agency must upload the information on the outpatient chronic special disease treatment qualification certification information of the remote medical records personnel in a timely manner on the information platform of the National Medical Insurance Bureau, so that the designated medical institutions in the medical treatment area can obtain relevant information and carry out corresponding diagnosis and treatment settlement services

(2) The name and code of chronic diseases in outpatient clinics
.

In order to be compatible with the differences in the scope of disease types, referring to the outpatient chronic disease type code and disease type name in the national medical security information business coding standard, this pilot disease type includes hypertension, diabetes, malignant tumor outpatient radiotherapy and chemotherapy (corresponding to the business coding standard Outpatient treatment for malignant tumors in China), uremic dialysis (corresponding to dialysis in the business coding standard), anti-rejection treatment after organ transplantation (corresponding to the anti-rejection treatment of kidney transplantation, bone marrow transplantation anti-rejection treatment in the business coding standard, Heart transplantation anti-rejection therapy, liver transplantation anti-rejection therapy, lung transplantation anti-rejection therapy, liver and kidney transplantation anti-rejection therapy) and other outpatient chronic idiopathic diseases (see attachment for details)
.

(3) Scope of designated medical institutions
.

In pilot areas, among the designated medical institutions that have opened direct settlement of general outpatient medical expenses across provinces, priority is given to selecting high-level diagnosis and treatment, standardized management, and completing medical insurance disease diagnosis, medical insurance drugs, medical service items, medical consumables, outpatient chronic diseases, etc.
The designated medical institutions for the implementation of the medical security business code carry out a pilot program.
After necessary system transformation and full testing, the designated medical institution information and the opened outpatient chronic and special disease information are uploaded to facilitate the agencies and the insured personnel of the insured area.
Choose
.

3.
Pilot content

3.
Pilot content

(1) Standardize cross-provincial direct settlement policies
.

When the outpatient chronic disease-related treatment costs are directly settled across provinces, the national unified outpatient chronic disease disease code and disease category name are used, and the payment method is temporarily settled according to the project payment method.
The payment scope and relevant regulations of the medical place are implemented (basic medical insurance) The scope of payment for medicines, medical service items and medical consumables) shall be implemented in accordance with relevant regulations such as the minimum payment standard, payment ratio, and maximum payment limit of the medical security fund of the insured area
.

Where there is a corresponding outpatient chronic and special disease that limits the scope of payment, the payment scope of the hospital is implemented; if there is no corresponding outpatient chronic and special disease, the designated medical institution and the receiving physician shall follow the relevant disease diagnosis and treatment specifications and medication regulations for reasonable diagnosis and treatment
.

If the insured person enjoys the treatment of multiple outpatient chronic diseases at the same time, the insured place shall determine the treatment calculation rules according to local regulations

(2) Unified medical settlement rules
.

When designated medical institutions provide cross-provincial direct settlement services for insured persons who are eligible for outpatient chronic and special disease treatment, they should treat specific diseases, use drugs rationally, and separately settle the outpatient chronic and special disease-related treatment costs
.

After dividing the cost of each item according to the local payment scope and regulations, the medical place will transmit it to the insured place together with the outpatient chronic disease code of the insured person

Other medical expenses incurred at the same time that are not related to the treatment of chronic diseases in outpatient clinics shall be settled separately according to ordinary outpatient expenses
.

After the conditional designated medical institutions have successfully settled, the type of medical expenses (general outpatient clinic or outpatient chronic disease) of this settlement will be displayed on the bills, checklists and other vouchers

(3) Improve the construction of information system
.

Pilot areas should do a good job in the implementation of a unified national medical insurance information platform, and in accordance with the requirements of the "Inter-provincial Remote Medical Management Subsystem Interface Specification (V2.
0)", realize the direct settlement of outpatient chronic diseases related treatment costs across provinces
.

The pilot areas should complete the upgrade and transformation of the information systems of medical insurance agencies and designated medical institutions as soon as possible, and do a good job in the comparison and compatibility of the local outpatient chronic and special disease code to ensure the smooth operation of the pilot work

(4) Implementing medical supervision responsibilities
.

The medical treatment agency is responsible for medical insurance management and services.
It should bring the medical personnel from different places into the local unified management, improve the medical insurance agreement of the designated medical institution, and guide the designated medical institution of the medical treatment to provide direct settlement services for the outpatient treatment of chronic diseases
.

Implement the supervision responsibilities of medical treatment places, innovate supervision methods, guide designated medical institutions to regulate diagnosis and treatment behaviors, severely crack down on medical insurance fraud and insurance fraud, and prevent fund risks

(5) Do a good job of prepayment and liquidation of funds
.

The outpatient chronic disease-related treatment costs are directly settled across the provinces and the medical security fund payment part is prepaid and then settled
.

In principle, the advance payment comes from the medical insurance fund of the insured area
.
The medical security fund shall pay the part of the outpatient chronic disease-related treatment expenses, which shall be uniformly prepaid and cleared by referring to the direct settlement management process of inter-provincial treatment and hospitalization medical expenses in different places
.

Four, work requirements

Four, work requirements

(1) Strengthen organization and leadership
.
Promoting the direct settlement of medical treatment across provinces and other places is one of the important tasks put forward in this year’s "Government Work Report".
The medical insurance departments of all provinces must raise awareness, strengthen leadership, decompose at different levels, and compact responsibilities, and make this a key task.
Complete the task without compromise
.
The medical insurance departments in the pilot areas should increase their political positions, implement them in a solid and effective manner, and make direct settlement of outpatient chronic and special disease costs across provinces as a key measure of "doing practical things for the masses" to ensure that the pilot work achieves practical results
.

(2) Actively promote pilot projects
.
Provincial medical insurance departments should standardize and unify policy measures for insured persons to apply for outpatient treatment for chronic diseases in different places, and provide medical regulations, guide the pilot areas to formulate pilot implementation plans based on local conditions, clarify pilot objectives, work measures, schedule arrangements and supporting policies, and proceed in a steady and orderly manner.
Pilot work
.
Submit the list of pilot areas and designated medical institutions to the National Medical Insurance Bureau for the record before September 30, 2021; submit the outpatient medical insurance policy and access application for chronic and special diseases in the pilot area before November 15, 2021
.

(3) Do a good job of propaganda and guidance
.
The medical insurance departments in the pilot areas should strengthen publicity and training, and positively guide public opinion
.
Use the Internet, newspapers, television, radio and other media to do a good job in policy propaganda and interpretation, respond to the concerns of the masses in a timely manner, and reasonably guide social expectations
.

During the pilot implementation process, if there are major problems, timely feedback to the National Medical Insurance Bureau and the Ministry of Finance
.

Attachment: Outpatient Chronic Special Disease Related Treatment Expenses Cross-province Direct Settlement Pilot Disease Code Table

Office of the National Medical Security Administration

Office of the Ministry of Finance

September 7, 2021

Appendix:

Outpatient chronic disease related treatment costs across provinces

Outpatient chronic disease related treatment costs across provinces

Direct settlement pilot disease code table

Direct settlement pilot disease code table

Remarks: In order to take into account regional differences, the pilot area can use the pilot disease code according to the local outpatient chronic and special disease medical insurance policy.
Among them, the malignant tumor outpatient radiotherapy and chemotherapy and other related outpatient treatment can be transmitted according to the M00500 code, hemodialysis, peritoneal dialysis, uremia Dialysis related treatments can be delivered in accordance with M07801
.