1. Confirm whether reimbursement is possible. In order to be reimbursed smoothly, it is necessary to seek medical treatment in a medical institution stipulated by outpatient medical insurance. The treatment items are within the scope of outpatient medical insurance reimbursement, and the treatment expenses should exceed the deductible line of outpatient medical insurance reimbursement.
If the relevant certification materials meet the conditions for outpatient medical insurance reimbursement, it is necessary to find the attending doctor to issue medical records, diagnosis certificates and other materials, and need information such as diagnosis and treatment time, condition description and medical expenses;
2. The hospitalization time shall be counted from the date of hospitalization to the date of discharge. Deliberately delayed discharge, hospital stay beyond the provisions of the hospital is not included in the scope of reimbursement;
3. After the signature and seal of the medical institution and other related materials are issued, it is necessary to find the person in charge of the medical institution above the deputy chief physician for signature confirmation. After the signature of the person in charge, he will also go to the medical department of the medical institution to affix his seal to prove the authenticity and authority of the materials;
4. After the institutional audit materials are fully prepared, the insured individual or the relevant personnel of the unit can go through the reimbursement procedures at the medical insurance agency, and after the examination and approval, they can receive the corresponding proportion of reimbursement.
There are two kinds of outpatient medical insurance reimbursement, and the reimbursement standards are as follows:
1, residents' medical insurance:
In an insurance year, if the general outpatient expenses of insured residents in designated outpatient medical institutions are less than 100 yuan, the residents' medical insurance fund will pay 30%, and individuals will pay 70%; Personal consumption exceeds 100 yuan.
2, medical insurance for urban workers:
Not all the personal accounts on the medical insurance card of the insured person insured by the unit are paid by themselves. Since last year, the medical insurance card of flexible employees has also had a personal account, with a monthly amount of 15 yuan, which can be used to pay the outpatient expenses, which is equivalent to the outpatient reimbursement of the insured, unless the insured belongs to a civil servant or the unit has another reimbursement policy.
Medical insurance hospitalization, show medical insurance card, read the card into the medical insurance system, and pay the deposit is generally a threshold fee. The expenses incurred are entered into the system, and the system automatically classifies them as self-funded, Class A, Class B, etc. Class B pays 65,438+00% first, and then enters the basic medical care. If the number of hospitalizations per year is greater than 1, the threshold fee will be halved, and the proportion of overall planning will be different for different hospital levels. The computer figured out how much it should pay.
To sum up, after preparing the required materials, you can apply to the relevant departments of the local social security center. After examination, if the materials are complete and meet the requirements, you can apply immediately. When applying for reimbursement of outpatient medical expenses, the applicant should first deduct the amount allocated to the personal account of medical insurance in this social security year, and then verify the amount to be reimbursed.
Legal basis:
Article 28 of People's Republic of China (PRC) Social Insurance Law
Medical expenses that meet the basic medical insurance drug list, diagnosis and treatment items, medical service facilities standards and emergency rescue shall be paid by the basic medical insurance fund in accordance with state regulations.
Article 29
The medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by social insurance agencies, medical institutions and pharmaceutical business units.
The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.