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according to the website of the State Medical Security Bureau, the State Medical Security Bureau and the Ministry of Finance issued the “notice on promoting the pilot work of cross provincial direct settlement of outpatient expenses”. According to the notice, by the end of 2020, the pilot experience of Beijing Tianjin Hebei, Yangtze River Delta and southwest five provinces, which can be replicated and popularized, will be further expanded by relying on the trans provincial and remote medical treatment management subsystem of the state medical insurance administration, and the pilot scope of cross provincial direct settlement of outpatient expenses will be further expanded, and a unified system, operation mechanism and implementation path of cross provincial direct settlement of outpatient expenses will be explored.

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according to the notice, Beijing, Tianjin, Hebei, Shanghai, Jiangsu, Zhejiang, Anhui, Chongqing, Sichuan, Guizhou, Yunnan and Tibet are pilot areas for cross provincial direct settlement of outpatient expenses. At the same time, provinces with the following conditions can apply for the national pilot project:

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. The provincial people’s government attaches great importance to and supports the cross provincial direct settlement of outpatient expenses. The medical insurance department and the financial department work together to carry out the direct settlement and settlement of cross provincial hospitalization. The provincial medical security administrative departments have the ability to undertake the national pilot task, take the lead in formulating local supporting policies, and promote the pilot projects as a whole; the provincial medical security agencies have strong organization ability and management service ability.

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are relatively unified in terms of policy standard, management service and information system of outpatient service in the whole province, and the direct settlement of outpatient expenses in the province has been basically realized. With a unified online filing service channel, the filing service is convenient and fast.

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can complete the interface transformation of cross provincial direct settlement of outpatient expenses with high quality according to the national pilot task and time schedule (the interface standard will be issued separately).

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about the pilot content, the notice is clear, and the transfer out process of remote medical treatment is unified. According to the national unified “Regulations for handling cross provincial direct settlement of outpatient expenses” (Trial Implementation), the pilot work of cross provincial direct settlement of outpatient expenses is carried out. The personnel who have handled the direct settlement and filing of medical expenses for cross provincial and non local medical treatment of basic medical insurance shall simultaneously open the service of direct settlement of outpatient expenses, without additional filing. Other personnel who need to go to other places for outpatient treatment shall go through the medical record in different places according to the management requirements of different places. The insured places can provide online self-service service and open the service of remote medical record. The insured choose the designated medical institutions which open the cross provincial direct settlement service in the registered medical places.

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standardize the settlement process and treatment policy of medical treatment in different places. When the outpatient expenses of insured personnel are directly settled across provinces, the agency of the medical treatment place will divide the expenses of each expense according to the payment scope and regulations of the medical treatment place, and then transmit it to the insured place in real time through the national and provincial medical settlement system, calculate the personal burden of the insured and the amount paid by various medical insurance funds according to the policy of the insured place, and return the results to the medical treatment place Order medical institutions.

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refer to the payment scope and relevant provisions (payment scope of basic medical insurance drugs, medical service items and medical consumables) stipulated by the place of medical treatment in principle. The basic medical insurance fund payment standard, payment proportion, maximum payment limit, outpatient chronic diseases and other reimbursement policies shall be implemented in accordance with the provisions of the insured place.

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outpatient chronic disease qualification and medical insurance management services. The cross provincial direct settlement of outpatient expenses for chronic and special diseases starts from the outpatient chronic diseases which involve a large number of people, such as hypertension and diabetes, and is gradually expanded to other outpatient chronic diseases. The state medical insurance bureau is responsible for the formulation of national unified disease name and disease code. The agencies in the insured areas are responsible for the qualification certification and personnel filing information management of outpatient chronic diseases. The local agencies are responsible for the management and service of medical insurance, improve the medical insurance agreement of designated medical institutions, guide the designated medical institutions to do a good job in the settlement service of outpatients with chronic and special diseases in different provinces and provide the same management services as the local insured patients.

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should strengthen the supervision of medical places. The local agency should incorporate the medical personnel from other places into the local unified management, provide the same standard service and management as the local insured in the aspects of the determination of designated medical institutions, medical information record, medical behavior monitoring, medical expense audit and audit, and make it clear in the agreement management with the designated medical institutions. The medical treatment agencies should strengthen business collaborative management, crack down on medical insurance fraud, and timely report the illegal and illegal behaviors of medical personnel in different places to the insurance agencies.

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strengthen the management of funds for medical treatment in different places. Outpatient expenses are directly settled across provinces, and the payment part of medical insurance fund is paid in advance and then settled. In principle, the advance payment comes from the medical insurance fund of the insured area. The management of advance payment and clearing fund for cross provincial direct settlement of outpatient expenses refers to the management process of direct settlement of hospitalization expenses for cross provincial medical treatment.

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create convenient and efficient medical settlement services in different places. Conditional pilot areas can combine with the pilot work of cross provincial direct settlement of outpatient expenses, simultaneously promote the self-service opening of remote medical settlement service and the realization of convenient services such as medical treatment and drug purchase with the help of medical insurance electronic voucher, and actively promote the information business such as the classification and code of medical insurance disease diagnosis and surgical operation, medical service items, medical insurance drug classification and code, and chronic and special diseases in medical insurance outpatient department Coding standards are applied.