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Tianyi Yongning insurance claims process
Step 1: Scan the QR code and follow the official account of Tianyi Yongningbao WeChat.

Step 2: Click Service Center → Personal Center → Login or Registration.

Step 3: After logging in or registering, click "Online Claim" → "Medical Expense Report". If you have not done real-name authentication before, you need to do real-name authentication first.

Step 4: Fill in the information of the applicant, the insured and the bank.

Step 5: Upload the information, click the box at the bottom, and then click to read the personal information collection and use authorization, anti-insurance fraud tips, authorization and statement. Click × in the upper right corner after reading it.

Step six: Click "Submit" to complete the report.

First, enjoy the treatment conditions

According to the regulations, the insured persons of basic medical insurance for urban workers and basic medical insurance for urban and rural residents in Ningbo who have paid the premiums in full in Tianyi Yongning Insurance enjoy the benefits of "Tianyi Yongning Insurance" on the basis of overall social medical insurance in Ningbo (including but not limited to basic medical insurance and serious illness insurance, the same below).

Second, important tips

(a) tips on the proportion of compensation for patients with previous diseases.

The proportion of all expenses paid by this product to patients with previous diseases is halved. Patients with past diseases refer to the insured who meet the following conditions at the time of insurance:

(1) During the period of 2019-2022, enjoy the treatment of serious illness insurance in Ningbo;

(2) During the period of 2065438+09-2022, if the medical insurance for special diseases was approved and the processing time was earlier than the first application for "Tianyi Yongning Insurance", the original "Citizen Insurance" and "Yonghui Insurance" participants will be regarded as participating in "Tianyi Yongning Insurance" regardless of the enrollment record before the interruption;

(two) tips on the responsibility of self-funded medical expenses in hospitals.

The out-of-pocket medical expenses of hospitalization of Responsibility 1 refer to the expenses of medicines, medical services and medical consumables that occurred in the designated medical institutions of basic medical insurance and can be settled by Zhejiang "Smart Medical Insurance" system, a national medical security platform, which do not belong to the catalogue of basic medical insurance in Ningbo and should be paid by individuals, and the expenses within the scope of liability exemption are not included. Out-of-hospital prescription adjustment expenses do not belong to the scope of in-hospital self-funded medical expenses. The above expenses include the expenses that are included in the reimbursement scope of this scheme or deducted from the family economic account by using the surplus funds in the personal account of medical insurance over the years. Self-funded medical expenses do not include personal commitment in Ningbo's basic medical insurance policy, personal out-of-pocket expenses (excluding expenses exceeding the price limit in the basic medical insurance catalogue), personal out-of-pocket medical expenses, compliance medical expenses in serious illness insurance, medical expenses of Zhejiang Province's rare disease drug guarantee mechanism, and expenses exceeding the limited scope of medical insurance in the basic medical insurance catalogue.

(three) the use of basic medical insurance responsibility tips.

During the insurance period, the medical expenses that the insured has not been reimbursed by the basic medical insurance for employees in Ningbo and the basic medical insurance for urban and rural residents are not included in the reimbursement scope of this product.

(four) the second kind of malignant tumor at their own expense drug cost tips.

The self-funded drug expenses for malignant tumors refer to the drug expenses that meet the following conditions at the same time:

(1) The indication specified in the drug instructions is malignant tumor;

(2) The drug expenses that are not covered by the relevant catalogues and policies of Ningbo basic medical insurance and serious illness insurance shall be paid by individuals.

(5) Tips for seeking medical treatment in different places.

(1) Responsibility 1 Expenses incurred by hospitals in Zhejiang Province (excluding Ningbo City) shall be included in the cumulative adjustment by 85%; The expenses incurred by hospitals outside Zhejiang Province are included in the cumulative adjustment by 75%.

(2) Liability II and Liability III are limited to prescriptions issued by specialists in designated hospitals in Ningbo and drugs purchased in designated medical insurance pharmacies in Ningbo, and drugs not issued by hospitals designated by this insurance or purchased by designated medical insurance pharmacies in Ningbo will not be paid.

(six) tips on medical insurance for cost compensation.

This product is a medical expense compensation type, and the overall compensation principle is for all parties (including but not limited to basic medical insurance, serious illness insurance, medical assistance, free medical care, work unit, infringer or infringer, commercial insurance institution, etc.). ) The aggregate payment shall not exceed the self-paid medical expenses actually paid by the insured.

Three. exonerate

The insurance company shall not be liable for the medical expenses incurred by the insured under any of the following circumstances.

(1) Matters not paid according to the provisions of relevant laws, regulations, policies and documents of People's Republic of China (PRC); Medical expenses incurred by the insured in violation of laws and regulations;

(two) should be paid by the industrial injury insurance fund, should be borne by the third party, should be borne by the health department;

(3) The medical expenses that the insured has not been reimbursed by Ningbo basic medical insurance for employees and basic medical insurance for urban and rural residents during the insurance period are not included in the reimbursement scope of this product;

(4) Receiving medical treatment or incurring medical expenses in Hong Kong Special Administrative Region, Macao Special Administrative Region, Taiwan Province Province or overseas;

(five) the use of drugs that have not been registered and approved by the drug supervision and administration department of China; Medical expenses incurred in clinical diagnosis and treatment of designated medical institutions that do not conform to the principle of treating diseases, and medical expenses that do not conform to the indications, usage and dosage of drug instructions approved by the state drug supervision and administration department; Relevant medical data cannot prove that the insured's illness conforms to the characteristics of using specific drugs; Hospital take-away drugs or prescriptions are adjusted for each part of the drug expenses for more than one month (if the relevant government departments have other provisions on chronic disease adjustment, the relevant provisions shall prevail);

(6) Use the following drugs that are not paid for in the national basic medical care, industrial injury insurance and maternity insurance drug list applicable to Ningbo basic medical insurance: nutritional supplements, immune function regulating drugs and Chinese herbal pieces;

(seven) the cost of oral materials, artificial joints, artificial joint accessories, artificial lenses, contraceptive materials, assisted reproductive materials, cochlear implants, breast fillers and other medical consumables; Bed fee, rehabilitation, oral and maxillofacial surgery, correction, plastic surgery, consultation and other related medical services;

(eight) social medical insurance will not be reimbursed for surgery or hospitalization, such as all kinds of beauty, plastic surgery, non-functional orthopedics, weight loss, freckle removal, mole removal, skin care, tooth cleaning, glasses, artificial eyes, artificial limbs, hearing AIDS and other expenses;

(9) Non-disease treatment items, such as various health check-ups, premarital check-ups, travel check-ups, occupational check-ups, exit check-ups and other expenses;

(10) Various diagnosis and treatment items for infertility (pregnancy) and sexual dysfunction (such as male infertility and female infertility, and examination and treatment fees for identifying sexually transmitted diseases), as well as various teaching, scientific research and clinical verification diagnosis and treatment items;

(1 1) Special medical care (newborn birth record, laser myopia treatment technology, appointment of outpatient service and special outpatient service, blood degreasing, storage cost of autologous umbilical cord blood hematopoietic stem cell bank, autologous blood preservation, medical plastic surgery service (including orthodontics), oral implant, special optional physical examination service, special care for newborns, advanced special wards including family wards, warm delivery rooms, and inter-hospital consultation services.

(twelve) during the insurance period, the drugs newly included in the basic medical insurance, serious illness insurance and rare disease drug protection in Zhejiang Province, and the expenses incurred since the date of inclusion;

(13) The expenses of the same kind of drugs incurred by the insured who meets the application conditions for charitable relief drugs because the insured fails to submit the relevant application or the submitted application materials are incomplete; The expenses of similar drugs purchased by the insured at the designated medical insurance pharmacy in Ningbo because he passed the rescue audit for personal reasons but did not receive the rescue drugs;

(fourteen) the disease status of the insured, after examination, to determine the cost of drug resistance; (Note: Drug resistance refers to one of the following two situations: (a) solid tumor lesions have made progress according to the criteria for evaluating the efficacy of solid tumors (RECIST); B) Non-solid tumors (including malignant tumors such as leukemia, multiple myeloma, myelofibrosis, lymphoma, etc.) often have no definite masses or small masses that are difficult to find clinically. After standardized treatment, according to the guidelines of Chinese Society of Clinical Oncology (CSCO), Hematology Branch of Chinese Medical Association, Hematology Committee of Chinese Anti-Cancer Association, National Health Commission, National Comprehensive cancer network (NCCN) and other professional institutions, the patients were evaluated for bone marrow morphology, flow cytometry and histology. )

(15) War, military conflict, riot or armed rebellion, nuclear explosion, nuclear radiation or nuclear pollution.

Four. Claim application and acceptance

(a) Responsibility for "one-stop" settlement

In Zhejiang Province, the expenses that meet the first responsibility can be settled in real time through the basic medical insurance in medical institutions, that is, they can be settled simultaneously with the basic medical insurance.

(II) Responsibility 1 "Sporadic Reimbursement" Settlement

For the medical expenses incurred by the insured who do not meet the "one-stop" settlement situation of swiping the card or scanning the code and meet the claim conditions, sporadic reimbursement claims will be implemented. Under the premise of complying with the relevant policies and regulations of Ningbo social medical insurance, if the insured fails to handle the online settlement of medical insurance in time in this city or other places due to special reasons, it needs to go to the window designated by the insurance institution.

(3) Responsibility 2. Responsibility three. Responsibility four. Claim application process

Please pay attention to the official account of "Tianyi Yongningbao" WeChat, and upload the claim application materials according to the online prompts in "Service Center-Personal Center-Online Claim". After approval, the case with compensation amount less than 10000 yuan will be paid directly, and the case with compensation amount greater than 10000 yuan will be sent to the designated place of Ningbo Pratt & Whitney Insurance Service Center, and the payment will be initiated after verification.

(D) Responsibility II, Responsibility III Drug Direct Payment Process

On the basis of the above-mentioned claim application process, after the rationality of drug use for Liability II and Liability III of this product is approved, the service specialist will call the insured to confirm the method and time of receiving and purchasing drugs, as follows:

1. Take medicine at the store: the service specialist will contact the insured by telephone, confirm the address of taking medicine, and send the medicine purchase voucher. The insured shall bring prescriptions, purchase vouchers and other relevant materials to the designated pharmacy for collection. After confirming that the materials are complete and correct, the insured only needs to pay the drug expenses that need to be borne by the individual.

2. Apply for home delivery: The service specialist will contact the insured by telephone to confirm the home delivery information and send the shopping voucher. The insured shall submit relevant materials when receiving medicines. After confirming that the materials are complete and correct, the insured only needs to pay the drug expenses that need to be borne by himself.

Verb (abbreviation of verb) materials needed for claim settlement

(1) Responsibility 2: Drug guarantee for out-of-pocket prescriptions for malignant tumors, and Responsibility 3: Drug guarantee for specific rare diseases.

The beneficiary shall apply and provide the following certificates and materials:

1. Drug invoice and detailed list of drugs issued by designated medical insurance pharmacies in Ningbo (drug name, specification, unit price and quantity are required). If the name of the drug only shows the generic name, it is necessary to provide the trade name (or manufacturer), specifications, unit price and quantity of the drug and affix the official seal of the designated retail pharmacy. If the name of the drawer is incomplete (if there is no specific name of the chain store), the official seal of the designated retail pharmacy should also be stamped on the invoice or drug list;

2. Pathological diagnosis reports, inspection reports and diagnosis certificates related to indications; Copy of electronic prescription for external use; Immunohistochemical/genetic test report, etc. ;

3. Medical records, including but not limited to outpatient medical records, admission records, discharge summaries, etc. ;

4. Other certificates and materials that can be provided to confirm the nature and cause of the insured accident;

5. Valid identity documents and bank account information of the insured.

(2) Responsibility 4: Guarantee of proton and heavy ion medical expenses.

The beneficiary shall apply and provide the following certificates and materials:

1. Original medical expense bills issued by hospitals with proton and heavy ion diagnosis and treatment qualifications;

2. Medical expenses settlement list;

3. Medical records, including but not limited to outpatient records, discharge summaries, medical history descriptions, inspection reports, drug details and prescriptions;

4. Other certificates and materials that can be provided to confirm the nature and cause of the insured accident;

5. Valid identity documents and bank account information of the insured.

(4) Other special materials

1. If the insured is a minor, the identity certificate and relationship certificate of the guardian shall also be provided;

2. If the insured dies, it shall also provide medical death certificate, beneficiary relationship certificate and identity certificate; As the insured's inheritance, insurance money also needs to provide relevant rights documents that can prove the legal inheritance right.

3. If the insured entrusts others to apply for claim settlement, it shall sign a power of attorney, which shall be signed by the insured, and indicate the scope or matters of authorization, and provide the identity documents of the entrusting parties;

Six, other matters needing attention

(1) The guardian shall guarantee the legal custody of the minor insured, ensure the authenticity and validity of the information of the minor insured, and undertake the obligation of paying insurance premiums for the minor insured and handling the creditor's rights; If there is any falsehood, the guardian shall bear all legal consequences.

(2) If the insured incurred expenses before the start date of the insurance liability period (2023, 65438+ 10/), the insurance company will not be liable for the payment of insurance benefits. Legal basis: