Promulgated by: National Healthcare Security Administration.
Order No. 2 of the National Healthcare Security Administration.
The Interim Measures for the Administration of Medical Institutions as
Designated Medical Insurance Institutions were deliberated and adopted at the 2nd
Executive Meeting of the Administration on December 24, 2020, and are hereby
promulgated, to take effect on February 1, 2021.
Director: Hu Jinglin
December 30, 2020
Chapter 1 General Provisions
Article 1. These Measures are formulated in accordance with the Social Insurance Law of the People’s Republic of China, the Basic Medical and Health Care and Health Promotion Law of the People’s Republic of China, the Regulation on the Administration of Medical Institutions and other laws and regulations, in order to strengthen and standardize the administration of medical institutions as designated medical insurance institutions, improve the efficiency of the use of medical insurance funds, and better safeguard the rights and interests of the broad masses of insured persons.
Article 2. The administration of medical institutions as designated medical insurance institutions shall adhere to a people’s-health-centered approach, follow the principles of safeguarding the basics, fairness and impartiality, clear rights and responsibilities, and dynamic balance, strengthen the refined administration of medical insurance, promote the supply-side reform of medical institutions, and provide appropriate medical services to insured persons.
Article 3. The administrative department of medical security shall be responsible for formulating policies for the administration of medical institutions as designated institutions, and shall supervise the medical security handling agencies (hereinafter referred to as “handling agencies”) and designated medical institutions in the stages of designation application, professional evaluation, consultation and negotiation, conclusion of agreements, performance of agreements, and termination of agreements. The handling agency shall be responsible for determining designated medical institutions, signing medical security service agreements (hereinafter referred to as “medical insurance agreements”) with designated medical institutions, providing handling services, and carrying out the administration and assessment of medical insurance agreements. Designated medical institutions shall comply with the laws, regulations, rules and relevant policies of medical security, and provide medical services to insured persons in accordance with provisions.
Chapter 2 Determination of Designated Medical Institutions
Article 4. The administrative department of medical security in the overall planning area shall determine the allocation of resources for designated medical services in its overall planning area based on public health needs, administrative service needs, the revenue and expenditure of medical insurance funds, regional health planning, the planning for the establishment of medical institutions, and the like.
Article 5. The following medical institutions that have obtained a Medical Institution Practice License or a record-filing certificate for a traditional Chinese medicine clinic, as well as military medical institutions approved by the competent military department to have the qualification to serve the public, may apply for medical insurance designation:
(I) general hospitals, traditional Chinese medicine hospitals, hospitals integrating traditional Chinese and Western medicine, ethnic medicine hospitals, specialized hospitals, and rehabilitation hospitals;
(II) specialized disease prevention and treatment hospitals (institutes, stations) and maternal and child health hospitals;
(III) community health service centers (stations), central health centers, township health centers, sub-district health centers, outpatient departments, clinics, health stations, and village health rooms (offices);
(IV) independently established emergency centers;
(V) hospice care centers, hemodialysis centers, and nursing homes;
(VI) medical institutions established within elderly care institutions.
Internet hospitals may apply to sign supplementary agreements relying on their physical medical institutions, and the relevant expenses incurred by the medical services they provide that fall within the scope of medical insurance payment shall be settled in accordance with provisions by the handling agency of the overall planning area with the physical medical institution on which they rely.
Article 6. A medical institution applying for medical insurance designation shall simultaneously possess the following basic conditions:
(I) having been in formal operation for at least 3 months;
(II) having at least 1 physician who has obtained a Physician Practice Certificate, a Rural Doctor Practice Certificate, or a Traditional Chinese Medicine (Specialty) Physician Qualification Certificate and whose first place of registration is at the medical institution;
(III) the principal person in charge being responsible for medical insurance work, and being equipped with full-time (or part-time) medical insurance management personnel; medical institutions with 100 or more beds shall set up an internal medical insurance management department and arrange full-time staff;
(IV) having a medical insurance management system, financial system, statistical information management system, core medical quality and safety system and the like that meet the requirements of medical insurance agreement administration;
(V) having hospital information system technology and interface standards that meet the requirements of medical insurance agreement administration, achieving effective interface with the medical insurance information system, transmitting all relevant information of patients to the medical insurance information system as required, and providing direct online settlement for insured persons; establishing basic databases for medical insurance drugs, diagnosis and treatment items, medical service facilities, medical consumables, disease categories and the like, and using the unified national medical insurance codes in accordance with provisions;
(VI) meeting other conditions prescribed by laws and regulations and by the administrative departments of medical security at or above the provincial level.
Article 7. A medical institution shall file an application for medical insurance designation with the handling agency of the overall planning area, providing at least the following materials:
(I) the application form for a designated medical institution;
(II) a copy of the Medical Institution Practice License, the record-filing certificate for a traditional Chinese medicine clinic, or the license for a military medical institution to serve the public;
(III) the texts of internal management systems and financial systems corresponding to medical insurance policies;
(IV) materials related to the medical institution information system relating to medical insurance;
(V) a predictive analysis report on the use of medical insurance funds after being included as a designated institution;
(VI) other materials required to be provided by the provincial administrative department of medical security in accordance with relevant provisions.
Article 8. Where a medical institution files a designation application, the handling agency of the overall planning area shall accept it in real time. Where the content of the application materials is incomplete, the handling agency shall, within 5 working days from the date of receipt of the materials, inform the medical institution at one time of the supplements to be made.
Article 9. The handling agency of the overall planning area shall organize an evaluation team or entrust a third-party institution to carry out the evaluation in written, on-site and other forms. The members of the evaluation team shall be composed of professionals in medical security, medicine and health, financial management, information technology and the like. The evaluation time shall not exceed 3 months from the date of accepting the application materials, and the time for the medical institution to supplement materials shall not be counted within the evaluation period. The evaluation content includes:
(I) verifying the Medical Institution Practice License, the record-filing certificate for a traditional Chinese medicine clinic, or the license for a military medical institution to serve the public;
(II) verifying the practice information of physicians, nurses, pharmacists and medical technicians and other professional and technical personnel, and the first-place-of-registration information of physicians;
(III) verifying the basic facilities and instruments and equipment for diagnosis, treatment, surgery, hospitalization, drug storage and dispensing, examination and testing, radiology and the like that are commensurate with the service functions;
(IV) verifying the internal management systems and financial systems corresponding to medical insurance policies, and the results of the medical institution review by the health department;
(V) verifying whether the medical institution information system relating to medical insurance possesses the conditions for carrying out direct online settlement.
The evaluation results shall be classified as qualified and unqualified. The handling agency of the overall planning area shall report the evaluation results to the administrative department of medical security at the same level for the record. For those that pass the evaluation, they shall be included in the list of medical institutions with which agreements are to be signed, and this shall be publicized to the public. For those that fail the evaluation, the reasons shall be informed and rectification suggestions put forward. The evaluation may be organized again 3 months after the date on which the result is served; where the evaluation is still unqualified, no application may be filed again within 1 year.
The provincial administrative department of medical security may, on the basis of these Measures and in light of actual conditions, formulate specific evaluation rules.
Article 10. The handling agency of the overall planning area shall conduct consultation and negotiation with medical institutions that pass the evaluation, and where agreement is reached, both parties shall voluntarily sign a medical insurance agreement. In principle, the handling agency of an overall planning area at or above the prefecture and city level shall sign the medical insurance agreement with the medical institution and file it with the administrative department of medical security at the same level for the record. The medical insurance agreement shall specify the rights, obligations and responsibilities of both parties. Both parties signing the medical insurance agreement shall strictly perform the stipulations of the agreement. The term of the agreement shall generally be 1 year.
Article 11. The handling agency of the overall planning area shall make public to the public the information of designated medical institutions that have signed medical insurance agreements, including names, addresses and the like, for the selection of insured persons.
Article 12. Where a medical institution is in any of the following circumstances, its designation application shall not be accepted:
(I) its main scope of practice consists of non-basic medical services such as medical cosmetology, assisted reproduction, daily care, and dental implantation;
(II) its basic medical services do not implement the medicine and medical-services price policies formulated by the administrative department of medical security;
(III) it has not performed its administrative penalty responsibilities in accordance with the law;
(IV) it has applied for designation by fraud or other improper means, and less than 3 years have elapsed since the date of discovery;
(V) it has had its medical insurance agreement terminated due to violations of laws and regulations and less than 3 years have elapsed, or 3 years have elapsed but the administrative penalty legal liability has not been fully performed;
(VI) it has had its agreement terminated due to a serious breach of the stipulations of the medical insurance agreement and less than 1 year has elapsed, or 1 year has elapsed but the liability for breach has not been fully performed;
(VII) its legal representative, principal person in charge or actual controller previously caused the original designated medical institution to have its medical insurance agreement terminated due to serious violations of laws and regulations, and less than 5 years have elapsed;
(VIII) its legal representative, principal person in charge or actual controller has been included in the list of persons who have lost credit;
(IX) other circumstances prescribed by laws and regulations under which the application shall not be accepted.
Chapter 3 Operational Administration of Designated Medical Institutions
Article 13. A designated medical institution shall have the rights to obtain medical insurance settlement expenses after lawfully providing medical services to insured persons in accordance with provisions, to supervise the performance of the handling agency, and to put forward opinions and suggestions on improving medical insurance policies.
Article 14. A designated medical institution shall strictly perform the medical insurance agreement, conduct reasonable diagnosis and treatment, charge reasonably, strictly implement the catalogues of medical insurance drugs, medical consumables, medical service items and the like, give priority to equipping and using drugs in the medical insurance catalogue, control the proportion of patients’ self-paid expenses, and improve the efficiency of the use of medical insurance funds. A designated medical institution shall not provide medical insurance settlement for non-designated medical institutions.
Expenses not paid by the handling agency, the quality assurance deposit deducted from the designated medical institution in accordance with the stipulations of the medical insurance agreement, and the liquidated damages paid by it, and the like, shall not be treated by the designated medical institution as medical insurance arrears.
Article 15. A designated medical institution and its staff shall implement the provisions on real-name medical treatment and drug purchase administration, verify the valid identity certificates of insured persons, provide reasonable and necessary medical and pharmaceutical services in accordance with diagnosis and treatment norms, and truthfully issue expense bills and relevant materials to insured persons; they shall not split hospitalizations or maintain occupied beds, shall not, in violation of diagnosis and treatment norms, engage in excessive diagnosis and treatment, excessive examination, prescription splitting, over-prescription of drugs, or repeated prescription of drugs, shall not engage in repeated charging, over-standard charging, or itemized-splitting charging, shall not substitute drugs, medical consumables, diagnosis and treatment items, or service facilities, and shall not induce or assist others in seeking medical treatment or purchasing drugs under a false identity or fraudulently.
A designated medical institution shall ensure that the expenses paid by the medical insurance funds comply with the prescribed scope of payment; except in special circumstances such as emergency treatment and rescue, where it provides medical and pharmaceutical services outside the scope of payment of the medical insurance funds, the consent of the insured person or his or her close relatives or guardian shall be obtained.
Article 16. A designated medical institution shall formulate corresponding internal management measures and strictly grasp the indications for admission and discharge. It shall implement the medical-insurance total-budget indicators in accordance with the agreement, and implement payment methods such as payment by item, by disease category, by diagnosis-related groups, by bed-day, and by capitation. It shall not refuse to admit patients on the grounds of medical insurance payment policies.
Article 17. A designated medical institution shall implement the centralized procurement policy in accordance with relevant provisions, and give priority to using drugs and consumables selected through centralized procurement. Drugs and consumables paid for by medical insurance shall be procured on the platform prescribed by the administrative department of medical security in accordance with provisions, and the “incoming, sales and inventory” status and the like shall be truthfully recorded.
Article 18. A designated medical institution shall strictly implement the medicine and medical-services price policies formulated by the administrative department of medical security.
Article 19. A designated medical institution shall participate in publicity and training organized by the administrative department of medical security or the handling agency.
A designated medical institution shall organize and carry out training on systems and policies related to medical insurance funds, regularly inspect the use of medical insurance funds by its own entity, and promptly correct irregular conduct in the use of medical insurance funds.
Article 20. A designated medical institution shall hang a designated-medical-institution sign of a uniform style in a conspicuous location.
Article 21. A designated medical institution shall promptly report to the handling agency of the overall planning area, as required, information such as medical insurance fund settlement statements, including disease diagnoses and surgical operations, itemized settlement details of the expenses of drugs, medical consumables, and medical service items, and information on physicians, nurses and the like, and shall be responsible for the authenticity thereof. A designated medical institution shall truthfully report to the handling agency of the overall planning area, as required, the procurement prices and quantities of drugs and consumables.
A designated medical institution shall report to the medical security department the information required for the supervision and administration of the use of medical insurance funds and for agreement administration, and shall make public to the public information such as medical and pharmaceutical expenses and expense structures.
Article 22. A designated medical institution shall cooperate with the handling agency in carrying out the review, audit inspection, and performance assessment of medical insurance expenses and the like, accept the supervision and inspection of the administrative department of medical security, and provide relevant materials in accordance with provisions.
Article 23. A designated medical institution shall optimize the medical insurance settlement process, provide convenient medical services for insured persons, conduct direct settlement of medical insurance expenses in accordance with provisions, and provide expense settlement bills and relevant materials. It shall provide referral and transfer services for insured persons who meet the prescribed conditions. Insured persons may, in accordance with relevant provisions, purchase drugs at designated medical institutions or, on the strength of a prescription, purchase drugs at designated retail pharmacies.
Article 24. A designated medical institution shall do a good job in the security safeguard work of the information system relating to medical insurance, comply with the relevant systems for data security, and protect the privacy of insured persons. When a designated medical institution reinstalls its information system, it shall maintain the effective interface of the information system technical interface standards with the medical insurance information system, and promptly, comprehensively and accurately transmit to the medical insurance information system the relevant data required for medical insurance settlement and audit in accordance with provisions.
Chapter 4 Handling Administration and Services
Article 25. The handling agency shall have the right to grasp the operational administration status of designated medical institutions, and to obtain from designated medical institutions the information, data and other materials required for the audit and review of medical insurance expenses, performance assessment, financial bookkeeping and the like. Designated medical institutions shall be subject to territorial administration, and the handling agency shall bear the administrative service responsibilities for the medical services provided by the designated medical institutions within its territory to local and non-local insured persons.
Article 26. The handling agency shall improve the administrative processes for designation application, organizing evaluation and signing of agreements, performance of agreements, and alteration and termination of agreements, formulate handling procedures, and provide high-quality and efficient handling services for designated medical institutions and insured persons.
Article 27. The handling agency shall do a good job in the publicity and training of designated medical institutions on medical insurance policies, management systems, payment policies, and operating procedures, and provide medical security consultation and inquiry services.
Article 28. The handling agency shall implement medical insurance payment policies and strengthen the administration of medical insurance funds.
Article 29. The handling agency shall establish a sound internal control system, and clarify the post responsibilities and risk prevention and control mechanisms for the review, settlement, disbursement, and audit of expenses declared by designated medical institutions. It shall improve the collective decision-making system for major medical insurance expense expenditures.
Article 30. The handling agency shall strengthen the administration of medical insurance fund expenditures, and promptly review medical expenses by means of intelligent review, real-time monitoring, on-site inspection and the like. It shall conduct regular and irregular audits and reviews of designated medical institutions. It shall promptly and fully disburse medical insurance expenses to designated medical institutions in accordance with the stipulations of the agreement, and in principle shall disburse the medical insurance expenses that comply with provisions within 30 working days after the designated medical institution declares them.
Article 31. Where conditions permit, the handling agency of the overall planning area may, in accordance with State provisions, prepay a portion of medical insurance funds to designated medical institutions to relieve their capital operation pressure. In emergency situations such as a sudden epidemic, special funds may be prepaid in accordance with State provisions.
Article 32. Where a designated medical institution declares expenses in violation of provisions, and this is verified upon examination, the handling agency shall not make payment.
Article 33. The handling agency shall pay, in accordance with laws and regulations, the medical expenses incurred by insured persons at designated medical institutions, and provide medical insurance policy consultation for insured persons. Except for emergency treatment and rescue, the medical insurance funds shall not pay for the expenses incurred by insured persons seeking medical treatment at non-designated medical institutions.
Article 34. The handling agency shall make public to the public the data sets and interface standards of the medical insurance information system. Designated medical institutions shall independently select the operation and maintenance suppliers of the relevant information systems that interface with medical insurance. The handling agency shall not charge any fees in any name or designate suppliers.
Article 35. The handling agency shall comply with the relevant systems for data security, protect the privacy of insured persons, and ensure the security of medical insurance funds.
Article 36. The handling agency, or a qualified third-party institution it entrusts, shall conduct performance assessment of designated medical institutions and establish a dynamic administration mechanism. The assessment results shall be linked to the year-end settlement, the refund of the quality assurance deposit, the renewal of agreements and the like. The performance assessment measures shall be formulated by the national medical security department, the provincial medical security department may formulate specific assessment rules, and the handling agency shall be responsible for organizing implementation.
Article 37. For medical expenses of a designated medical institution that do not exceed the total-amount control indicators within the settlement period, the handling agency shall disburse them in full and on time in accordance with the agreement. It shall give appropriate compensation for the reasonable overruns of a designated medical institution caused by a substantial increase in the number of insured persons seeking medical treatment and the like.
Article 38. Where the handling agency discovers that a designated medical institution is in a circumstance of violating the stipulations of the agreement, it may, in accordance with the stipulations of the agreement, correspondingly adopt the following handling methods:
(I) conducting an interview with the legal representative, principal person in charge or actual controller of the medical institution;
(II) suspending or withholding the disbursement of expenses;
(III) refusing to pay or recovering the medical insurance expenses already paid;
(IV) requiring the designated medical institution to pay liquidated damages in accordance with the stipulations of the agreement;
(V) suspending the medical services involving the use of medical insurance funds of the relevant responsible personnel or the department to which they belong;
(VI) suspending or terminating the medical insurance agreement.
Article 39. Where the handling agency violates the medical insurance agreement, the designated medical institution shall have the right to request correction, or to request the administrative department of medical security to coordinate handling and urge rectification, and may also apply for administrative reconsideration or institute administrative litigation in accordance with the law.
Where the administrative department of medical security discovers that the handling agency is in a circumstance of violating the medical insurance agreement, it may, depending on the circumstances, correspondingly adopt the following handling methods: conducting an interview with the principal person in charge, ordering rectification within a time limit, circulating a notice of criticism, and giving sanctions to the relevant responsible personnel in accordance with laws and regulations.
Where the administrative department of medical security discovers that the handling agency violates relevant laws, regulations and rules, it shall handle the matter in accordance with laws and regulations.
Chapter 5 Dynamic Administration of Designated Medical Institutions
Article 40. Where major information of a designated medical institution, such as its name, legal representative, principal person in charge or actual controller, registered address, bank account, diagnosis and treatment subjects, institutional scale, institutional nature, grade and category, changes, the institution shall, within 30 working days from the date of approval by the relevant department, file an application for alteration with the handling agency of the overall planning area. Other general information changes shall be promptly notified in writing.
Article 41. A renewal shall be applied for by the designated medical institution to the handling agency 3 months before the expiry of the medical insurance agreement, or shall be uniformly organized by the handling agency. The handling agency of the overall planning area shall conduct consultation and negotiation with the designated medical institution on the renewal of the medical insurance agreement, and both parties shall decide whether to renew based on the performance of the medical insurance agreement and the performance assessment status and the like. Where consensus is reached, the medical insurance agreement may be renewed; where no consensus is reached, the medical insurance agreement shall automatically terminate upon expiry.
For designated medical institutions with good performance assessment results, a combination of a fixed medical insurance agreement and an annual medical insurance agreement may be adopted, with the fixed medical insurance agreement remaining relatively unchanged and the annual medical insurance agreement being adjusted each year according to specific circumstances, so as to simplify the signing formalities.
Article 42. Suspension of a medical insurance agreement means that the handling agency and the designated medical institution suspend the performance of the stipulations of the medical insurance agreement, and the medical insurance expenses incurred during the suspension period shall not be settled. Where, upon the end of the suspension period, the validity period of the medical insurance agreement has not been exceeded, the medical insurance agreement may continue to be performed; where the validity period of the medical insurance agreement has been exceeded, the medical insurance agreement shall terminate.
A designated medical institution may file an application for suspension of the medical insurance agreement, and upon the consent of the handling agency, the medical insurance agreement may be suspended, but the suspension period shall in principle not exceed 180 days; where a designated medical institution still fails to file an application to continue performing the medical insurance agreement after the suspension of the medical insurance agreement exceeds 180 days, the medical insurance agreement shall in principle automatically terminate. Where a designated medical institution is in any of the following circumstances, the handling agency shall suspend the medical insurance agreement:
(I) where, according to routine inspection and performance assessment, it is found that major risks may be posed to the security of medical insurance funds and the rights and interests of insured persons;
(II) where it fails to provide relevant data to the handling agency and the administrative department of medical security as required, or the data provided is untruthful;
(III) where the medical insurance agreement shall be suspended in accordance with the stipulations of the medical insurance agreement;
(IV) other circumstances under which suspension shall be made as prescribed by laws, regulations and rules.
Article 43. Termination of a medical insurance agreement means that the medical insurance agreement between the handling agency and the designated medical institution is terminated, the agreement relationship no longer exists, and the medical and pharmaceutical expenses incurred after the termination of the agreement shall no longer be settled by the medical insurance funds. Where a designated medical institution is in any of the following circumstances, the handling agency shall terminate the medical insurance agreement and make public to the public the list of medical institutions whose medical insurance agreements have been terminated:
(I) where, within the validity period of the medical insurance agreement, its medical insurance agreement has been suspended 2 times or more cumulatively, or it has failed to rectify as required or rectification has not been carried out to the required standard during the period of suspension of the medical insurance agreement;
(II) where it has applied for and obtained designation by fraud or other improper means;
(III) where it has been verified by the medical security department and other relevant departments to have engaged in fraudulent acts to defraud medical insurance;
(IV) where it has provided medical insurance expense settlement for a non-designated medical institution or a medical institution during the period of suspension of its medical insurance agreement;
(V) where it refuses, obstructs or fails to cooperate with the medical security department in carrying out intelligent review, performance assessment, supervision and inspection and the like, and the circumstances are egregious;
(VI) where it is found that major information has changed but the alteration of major information has not been handled;
(VII) where the designated medical institution has ceased business or suspended operations and failed to report to the handling agency in accordance with provisions;
(VIII) where the administrative department of medical security or other relevant departments, in the course of administrative law enforcement, discover that the designated medical institution has committed a major violation of laws and regulations that may cause a major loss to the medical insurance funds;
(IX) where its Medical Institution Practice License or record-filing certificate for a traditional Chinese medicine clinic has been revoked or canceled;
(X) where its legal representative, principal person in charge or actual controller is unable to perform the stipulations of the medical insurance agreement, or has committed acts of violating the law or losing credit;
(XI) where it has not performed in accordance with the law the administrative penalty decision made by the administrative department of medical security;
(XII) where the designated medical institution proactively files for termination of the medical insurance agreement and the handling agency consents;
(XIII) where the medical insurance agreement shall be terminated in accordance with the stipulations of the medical insurance agreement;
(XIV) other circumstances under which termination shall be made as prescribed by laws, regulations and rules.
Article 44. Where a designated medical institution requests to suspend or terminate the medical insurance agreement or to no longer renew the medical insurance agreement, it shall file an application with the handling agency 3 months in advance. Public medical institutions shall not proactively file for suspension or termination of the medical insurance agreement.
Where the handling agency of an overall planning area at or above the prefecture and city level in the place where the medical institution is located suspends or terminates the medical insurance agreement with a designated medical institution, the medical insurance agreements of that medical institution in other overall planning areas shall also be suspended or terminated at the same time.
Article 45. Where some personnel or departments of a designated medical institution violate the requirements of agreement administration, medical insurance settlement for such personnel or departments may be suspended or terminated.
Article 46. Where a dispute arises between a medical institution and the handling agency of the overall planning area over the signing, performance, alteration and termination of the medical insurance agreement, it may be resolved through self-negotiation, or the administrative department of medical security at the same level may be requested to coordinate handling, and administrative reconsideration or administrative litigation may also be instituted in accordance with the law.
Chapter 6 Supervision of Designated Medical Institutions
Article 47. The administrative department of medical security shall supervise the designation application, application acceptance, professional evaluation, conclusion of agreements, and performance and termination of agreements, and shall guide and supervise the construction of the internal control system of the handling agency and the review and disbursement of medical insurance expenses, and the like.
The administrative department of medical security shall, in accordance with laws and regulations, supervise, by means of on-site inspection, spot checks, intelligent monitoring, big-data analysis and the like, the performance of agreements by designated medical institutions, the use of medical insurance funds, medical service conduct, the purchase of third-party services involving the use of medical insurance funds, and the like.
Article 48. The administrative department of medical security and the handling agency shall broaden supervision channels and innovate supervision methods, and shall conduct social supervision of designated medical institutions by means of satisfaction surveys, third-party evaluations, the engagement of social supervisors and the like, keep the channels for reporting and complaints unobstructed, and promptly discover and handle problems.
Article 49. Where the handling agency discovers a breach of agreement, it shall promptly handle it in accordance with the agreement.
Where the handling agency makes a handling decision such as suspending the medical and pharmaceutical services involving the use of medical insurance funds of the relevant responsible personnel or the department to which they belong, or suspending or terminating the medical insurance agreement, it shall promptly report to the administrative department of medical security at the same level.
Where the administrative department of medical security discovers that a designated medical institution is in a circumstance of breach of agreement, it shall promptly order the handling agency to handle it in accordance with the medical insurance agreement, and the handling agency shall promptly handle it in accordance with the medical insurance agreement.
Where the administrative department of medical security, in investigating and dealing with violations of laws and regulations in accordance with the law, considers that the facts of the relevant illegal clues transferred by the handling agency are unclear, it may organize a supplementary investigation or require the handling agency to supplement materials.
Chapter 7 Supplementary Provisions
Article 50. The administration of medical security designation for basic medical insurance for employees, basic medical insurance for urban and rural residents, maternity insurance, medical assistance, serious illness insurance for residents and the like shall be carried out in accordance with these Measures.
Article 51. The handling agency referred to in these Measures is a functional institution that has statutory authorization to implement medical security administrative services, and is the principal body of medical security handling.
A designated medical institution refers to a medical institution that voluntarily signs a medical insurance agreement with the handling agency of an overall planning area to provide medical services to insured persons.
A medical insurance agreement refers to an agreement signed by the handling agency and a medical institution through consultation and negotiation, used to standardize medical service conduct and clarify the rights, obligations and responsibilities of both parties and other content.
Article 52. The administrative department of medical security of the State Council shall produce and periodically revise model medical insurance agreements, and the national medical security handling agency shall formulate handling procedures and guide localities in strengthening and improving the administration of medical insurance agreements. On this basis, the administrative departments of medical security and handling agencies at or above the prefecture and city level may, in light of actual conditions, respectively refine and formulate model medical insurance agreements and handling procedures for their own regions. The content of the medical insurance agreement shall be consistent with adjustments and changes in laws, regulations, rules and medical security policies; where the administrative department of medical security adjusts the content of the medical insurance agreement, it shall solicit the opinions of the relevant designated medical institutions.
Article 53. These Measures shall be interpreted by the administrative department of medical security of the State Council, and shall come into force on February 1, 2021.