Policy Guidelines for Diagnosis and Treatment of Severe (Chronic) Diseases in Medical Insurance Outpatients of Urban and Rural Residents in Wuhan
I. Policy basis
Outpatient treatment of severe (chronic) diseases, payment ratio and annual payment limit are all implemented in accordance with the Notice on Adjusting Relevant Policies of Outpatient Treatment of Severe (chronic) Diseases in Basic Medical Insurance (No.2017).
Second, the reimbursement standard
1, reimbursement diseases: outpatient treatment of 32 kinds of severe (chronic) diseases by residents; 20 19 phenylketonuria was included in the scope of serious (chronic) diseases in outpatient department.
2. Reimbursement ratio: 50% for the basic medical insurance fund and 70% for phenylketonuria;
3. Reimbursement limit:
(1) The annual payment limit of the basic medical insurance fund is 4,000 yuan to 1.5 million yuan.
(2) The insured who has undergone radiotherapy and chemotherapy for malignant tumor (including leukemia), dialysis treatment for chronic renal failure, anti-rejection after kidney transplantation and anti-rejection after liver transplantation can pay a maximum of 300,000 yuan.
Second, the handling process:
1. Statement: Insured residents (colleges and universities) suffering from specified diseases carry the original medical records of recent continuous treatment of related diseases, relevant inspection reports, discharge summary and other materials. And report to the medical insurance agency in the jurisdiction.
2. Audit: After the medical insurance agency in the jurisdiction accepts it, it will complete the preliminary examination of medical records within 3 working days. If the audit does not meet the requirements or the information is incomplete, it should be returned or notified to the reporting community (university) in time to supplement the relevant information; Those who pass the preliminary examination will be issued the Examination and Approval Form for the Identification of Some Severe (Chronic) Diseases in Urban Basic Medical Insurance Outpatients in Wuhan (hereinafter referred to as the Registration Form for Examination and Approval), and the insured residents will fill in the corresponding columns as required.
3. Appraisal: The insured residents who have passed the preliminary examination shall go to the hospital designated by the medical insurance agency in their jurisdiction for relevant examination with the approval registration form, so as to identify the confirmed illness and put forward treatment suggestions.
4. Examination and approval: After the insured residents are appraised in the designated hospitals, the insured residents (colleges and universities) will report the examination and approval registration form and my recent five one-inch or two-inch bareheaded photos to the medical insurance agency in the jurisdiction. After receiving the appraisal feedback, the medical insurance agencies in the jurisdiction should complete the examination and approval within three working days, do a good job in registration and filing in the medical insurance system, and fill out the special medical records for the treatment of some serious diseases in the outpatient department of the basic medical insurance for urban residents in Wuhan (hereinafter referred to as the serious medical records).
After the application is approved, the insured person will go to the designated doctors, hospitals, grassroots designated medical institutions (follow-up visits) and designated pharmacies for medical treatment with the social security card (college students holding ID cards) and critical illness medical records.