The implementation object of medical settlement management in different places shall meet the following conditions:

1. Participate in the medical insurance for employees in this city, and enjoy the basic medical insurance and local supplementary medical insurance benefits normally (excluding those who enjoy the preferential policies of disabled soldiers medical insurance from Grade 1 to Grade 6, those who enjoy Medicaid for civil servants and retirees who implement overall management of medical expenses);

2 long-term residence in the administrative area of this Municipality.

[Including five cities: (Changshu, Zhangjiagang, Taicang, Kunshan and Wujiang); Seven districts (Jinchang District, Canglang District, Pingjiang District, Wuzhong District, Xiangcheng District, Suzhou Industrial Park and Suzhou High-tech Zone (huqiu district)), but the insured place and residence are not in the same social insurance co-ordination area;

3. Have gone through the registration formalities for going abroad for medical treatment;

4. Did not go through the formalities for outpatient specific projects.

PS: The settlement management of medical treatment in different places is not implemented among the urban overall planning scope, Wuzhong District, Xiangcheng District and industrial park, that is, the insured person's insured place and residence are all within the urban administrative area (including seven districts), and they are not included in the implementation object of settlement management of medical treatment in different places.

Second, the handling process

1. Eligible insured persons hold their medical insurance card, fill out the Application Form for Settlement of Medical Treatment in Different Places, and apply for settlement of medical treatment in different places to the social security agency in the insured place.

2. After the insured goes through the registration formalities, the medical expenses incurred in the designated medical institution at the place of residence shall be settled in cash first, and then the above application form, resident ID card, original invoice, medical record, detailed list of expenses and other materials shall be presented to the social security agency at the place of medical treatment for settlement and reimbursement.

3. The social security agency in the medical co-ordination area will review the medical expenses according to the drug list and diagnosis and treatment services in the co-ordination area, determine the expenses that meet the requirements of medical insurance settlement, and calculate and determine the reimbursable amount according to the provisions of medical insurance treatment settlement for employees in the insured area through the "Suzhou settlement platform for medical treatment in different places" and pay it directly to the insured.

Third, matters needing attention

1. After the insured goes through the registration formalities for settlement of medical treatment in different places, the social security agency in the insured place will no longer accept the reimbursement of medical expenses; For enterprise retirees among them, the payment of personal accounts of medical insurance will be stopped from the following year.

2. The insured shall go to the social security agency of the medical place to handle the reimbursement procedures for medical expenses in different places within the settlement year specified by the social security agency of the insured place; Cross-settlement year, medical expenses shall be treated as expenses incurred in the settlement year, and the settlement and payment procedures shall be handled in accordance with the provisions on settlement and payment of medical insurance for employees in the insured area in that year.

3. If the insured person needs to cancel the settlement of medical treatment in different places, or needs to change the place of medical treatment because the registered permanent residence moves into other overall planning areas of this Municipality, he shall apply to the social security agency of the insured place for canceling the settlement of medical treatment in different places or changing the application procedures. After the insured cancels the settlement of medical treatment in different places, it shall be implemented according to the provisions of medical insurance for going abroad for medical treatment; If you live in the insured place, you must also go through the cancellation procedures for going out for medical treatment.

4. Due to various reasons, the medical insurance status of the insured employees is interrupted or the relationship is terminated, and the medical insurance benefits of the employees are suspended or stopped, and the settlement of medical treatment in different places is suspended or stopped accordingly.

5. If the insured person needs to be transferred, he can directly go through the transfer registration formalities at the social security agency in his place of residence. Insured persons who meet the conditions of hospitalization expenses or emergency medical expenses transfer payment shall be audited and paid by the social security agency at the place of residence.

6. If the insured person needs to apply for a specific outpatient service, he/she shall go through the registration confirmation formalities with the social security agency of the insured place with the relevant diagnosis certificate and his/her medical card, and cancel the settlement of medical treatment in different places.

7. If the insured person is the object of real-time medical assistance, and has completed the declaration and registration procedures of assistance qualification in the social security agency of the insured place, the real-time medical assistance treatment can be settled in different places together with the medical insurance treatment.

Who needs medical treatment in different places for the record?

1. Resettlement of retirees in different places: refers to those who have settled in different places after retirement and moved into their place of residence.

2. Long-term residents in different places: refers to people who live in different places and meet the requirements of the insured place.

3. Resident in different places: refers to the personnel who are sent by the employer to work in different places and meet the conditions of the insured place.

The above three types of personnel are referred to as "expatriates". At the same time, the settlement function of Suzhou social security citizen card in the insured place will be suspended, and the filing and cancellation procedures can only be handled after 60 days of filing.

4. Referral personnel from different places: refers to those who have been diagnosed by hospitals at or above the county level with referral qualifications and cannot be diagnosed due to limited medical technology and equipment in this city, and need to be transferred to other hospitals for treatment. Referral personnel need to go through referral procedures in medical institutions with referral qualifications in this Municipality, and the filing period is valid for one year.

Suzhou guide to reimbursement for medical treatment in different places

I. Scope of treatment

The following expenses shall be paid by the insured in advance, and shall be audited and settled by the social security agency according to regulations:

1. According to the type of medical treatment in different places, the medical expenses that meet the medical insurance settlement conditions but cannot be directly settled by the insured who have gone through the formalities of medical treatment in different places;

2. Failing to go through the filing procedures for referral to a different place for medical treatment according to the regulations, and directly going to a different place outside the insured place for medical treatment, resulting in medical expenses that meet the provisions of medical insurance settlement and payment;

3. Medical expenses incurred due to sudden acute, dangerous and serious diseases without using social security cards;

4. The anti-rejection drug treatment after organ transplantation that has completed the registration and confirmation procedures for specific outpatient items meets the prescribed medical expenses;

5. Medical expenses incurred by the insured students in the original domicile or the current place of study;

6. Medical expenses incurred by freshmen who participated in urban residents' medical insurance for the first time from September to 65438+February of the year of enrollment;

7. Medical expenses incurred at the end of the month when the newborn goes through the formalities of residents' medical insurance from the date of birth to three months after birth;

8. Medical expenses incurred during the period from the date of approval of the land requisition compensation and resettlement plan to the end of the month when the land requisition expenses are allocated to the medical insurance premiums of landless farmers who enjoy the medical insurance benefits of residents according to regulations;

9. Other expenses that meet the requirements of medical insurance for urban residents and need to be reimbursed.

Second, submit materials.

1. social security card;

2. My bank card account number (limited to ICBC, China Bank, Bank of Communications, China Construction Bank, Agricultural Bank, Postal Savings Bank, Jiangsu Bank and Suzhou Bank);

3. Medical bills and detailed lists, outpatient medical records and discharge records;

4 for emergency medical treatment, should carry emergency diagnosis certificate (emergency medical records); Trauma, should bring trauma related documents;

5. If an agent is entrusted, the agent shall also provide the original resident identity card.

Third, the handling procedures

1. The insured shall go through the audit and settlement procedures with the above materials at the social security agency.

2. After the social security agency has passed the pre-examination, print the "Suzhou Social Basic Medical Insurance Medical Expenses Sporadic Reimbursement Acceptance Form" and submit it to the insured person for signature and confirmation.

3. The social security agency shall examine and determine the amount that can be paid by the medical insurance fund within 30 days from the date of acceptance, and pay the reimbursement settlement amount to the designated bank card account declared by me through "online payment".

Fourth, matters needing attention

1. When the insured goes through the reimbursement procedures for sporadic medical expenses in the social security agency, the reimbursement settlement amount can be calculated according to the settlement standard of the treatment type at the time of reimbursement settlement according to the applicable medical insurance treatment type at the time of each expense (hospitalization medical expenses are calculated according to the discharge date); If the medical expenses are reimbursed and paid across the year, the expenses shall be included in the year when the reimbursement and payment procedures are handled.

2. All kinds of medical expenses that need to be reimbursed by the insured person sporadically shall be reviewed and reimbursed within this settlement year (April to March of the following year for non-employed residents, 1 to12 for students and children); Under special circumstances, it can be extended by 12 months.

3 for long-term medical treatment in the field of insured sporadic reimbursement of medical expenses.

4. If the insured fails to go through the referral procedures for medical treatment in different places in accordance with the regulations and goes directly to other places outside the insured place for medical treatment, the medical expenses that meet the provisions of medical insurance settlement payment shall be paid by the residents' basic medical insurance pooling fund in accordance with the regulations, and 80% of the settlement payment proportion shall be reimbursed according to the original provisions.

5. Freshmen who participate in urban residents' medical insurance for the first time, who meet the requirements of medical insurance settlement and payment from September of the year of enrollment to 65438+February, must be reimbursed and settled from/kloc-0 to June 30th of the following year.

6. For newborns who have gone through the formalities of residents' medical insurance within three months of birth, if the time of first insurance and the date of birth span the settlement year, they shall go through the formalities of insurance and pay the residents' medical insurance fee in the year of birth before they can reimburse the medical expenses from birth to the end of the year.

7. If the insured person needs to settle the detailed list, he can take the Acceptance Form and his/her (or agent's) resident ID card to the social security agency for collection within six months; You can also log on to the website of Suzhou Social Security Center, and self-query and print by the acceptance form number in the column of "Print sporadic reimbursement settlement form".

8. The insured college students who have not used the social security card or paid the general outpatient medical expenses in cash due to emergency or returning to their original residence can be directly reimbursed at the designated medical institutions in the school; If there is no designated medical institution in the school, the designated department of the school will arrange a special person to collect and summarize social security cards, medical bills and detailed lists, outpatient medical records, discharge records and bank card account numbers, and then go through the audit and settlement procedures at the social security agency. Among them, for the insured college students who have gone through the registration procedures of medical treatment in different places, specific outpatient programs or real-time medical assistance, their outpatient medical expenses must be paid by the school or by the social security agency.