How to go to the social security center for reimbursement of the

1. Shanghai medical insurance processing guide
reimbursement proportion
outpatient and emergency department of insured personnel
the initial payment standard is set for the medical expenses of outpatient and emergency department of insured personnel (including family beds). The part of medical expenses exceeding the initial payment standard within one year shall be paid by urban and rural residents' medical insurance fund according to a certain proportion, and the rest shall be borne by indivials
the starting payment standard is: 300 yuan for people aged
60 or above, severely disabled people, primary and secondary school students and infants
500 yuan for those over 18 years old and under 60 years old
the proportion of medical insurance fund payment for urban and rural residents is:
70% for outpatient and emergency services in community health service centers (or first-class medical institutions); 60% for outpatient and emergency treatment in secondary medical institutions; In the third level medical institutions outpatient emergency, pay 50%
the medical expenses incurred by the insured in the village clinic are not included in the starting payment standard, and 80% of them are paid by the urban and rural residents' medical insurance fund
hospitalization of the insured
the starting payment standard is set for the medical expenses of each hospitalization of the insured (including observation in the emergency observation room). The part exceeding the minimum payment standard shall be paid by the urban and rural residents' medical insurance fund according to a certain proportion, and the rest shall be borne by indivials
the minimum payment standard is:
50 yuan for first-class medical institutions, 100 yuan for second-class medical institutions and 300 yuan for third-class medical institutions
the proportion of medical insurance fund payment for urban and rural residents is as follows:
90% for those aged 60 or above and those with severe disability who are hospitalized in community health service centers (or primary medical institutions), 80% for those hospitalized in secondary medical institutions and 70% for those hospitalized in tertiary medical institutions
for people under the age of 60, 80% of them are hospitalized in community health service centers (or primary medical institutions), 75% in secondary medical institutions and 60% in tertiary medical institutions<
reimbursement range
1 employees
2% of their monthly salary (unit: 11%) pay for medical insurance. When looking after the outpatient and emergency department, you need to use the amount included in the medical insurance in the current year first, and then enter the self financing section. The self financing amount is 1500 yuan
in-service employees are hospitalized
if they need to be hospitalized, as long as they pay the medical insurance, most of the medical expenses can be borne by the medical insurance
first of all, you should be responsible for the starting line expenses of 1500 yuan, and the expenses beyond the starting line can be reimbursed by medical insurance in proportion. If it exceeds the maximum payment limit, it can also be paid by the supplementary fund in proportion< More detailed information: 2016 latest medical insurance policy of Shanghai: reimbursement standards and scope of Shanghai Medical Insurance, The following medical expenses are not included in the payment scope of medical insurance fund for urban and rural residents:
(1) those that should be paid from the instrial injury insurance fund< (2) it should be borne by a third party< (3) it should be borne by public health< (4) seeking medical treatment abroad
medical expenses shall be borne by a third party according to law. If the third party does not pay or cannot determine the third party, the medical insurance fund for urban and rural residents shall pay in advance. After the medical insurance fund of urban and rural residents is paid in advance, they have the right to recover from the third party
reimbursement conditions
1. Insured and paid normally (it means that they are still in the status of insured and paid at the time of discharge) and the treatment audit period has expired (insured and paid as a unit for 30 days and paid as an indivial for 6 months)
2. The disease type conforms to the "directory of inpatient diseases of basic medical insurance"
3 The data are complete
reimbursement materials
outpatient and emergency medical expenses reimbursement
to apply for outpatient and emergency medical expenses reimbursement, the insured should bring valid documents (ID card, household register, etc.), social security card or medical insurance card, special receipts for outpatient medical expenses, special receipts for emergency medical expenses, relevant medical history data and copies The attached page and of the outpatient and emergency medical records (the medical relationship is the medical expenses incurred by the personnel of the city in the designated medical institutions of the city's medical insurance). If the medical insurance card is damaged, the medical insurance card damage notice should also be provided
reimbursement of hospital stay and observation expenses
to apply for reimbursement of hospital stay and observation expenses in the emergency observation room, the insured should provide the special receipt of medical expenses, the list of medical expenses ring hospitalization (list of hospital stay and observation expenses in the emergency observation room) and copies, and the summary and copies of discharge (observation)
sporadic reimbursement of out-patient medical expenses for serious diseases
to apply for sporadic reimbursement of out-patient medical expenses for serious diseases, the insured should provide special receipts for out-patient medical expenses, disease diagnosis certificate and copies, and relevant inspection reports and copies< The insured can entrust others to handle the reimbursement. The client should also bring the valid certificates (ID card, household register, etc.) of himself and the insured
reimbursement location
Pudong New Area medical insurance affairs center
address: 3059 Zhangyang Road, Pudong New Area
Tel: (021) 50353961
Minhang District medical insurance affairs center
address: 530-546 Shuiqing Road, Minhang District (near Baochun...
Tel: (021) 54135063
Changning medical insurance center
address: 702 Wuyi Road, Changning District
Tel: 021-52065400
address: 021-52065400 Medical insurance affairs center of Xuhui District
address: No. 999, Nanning Road
medical insurance affairs sub center of Pudong New Area, Shanghai
address: No. 168, Hongshan Road, Pudong New Area (near Pudong South Road)
Tel: 021-50567061
Tel: 021-64164870
medical insurance affairs center of Huangpu District, Shanghai
address: 1 / F, Hualong building, No. 343, South Suzhou Road, Huangpu District (near Sichuan middle road)
Tel: 021-63215132
Putuo District medical insurance affairs center
address: 1711 Dahe road
Tel: 021-52804754
Hongkou District medical insurance affairs center -
address: 352-356 Chifeng Road
Tel: 021-55888140
Yangpu District medical insurance affairs center
address: 1118 Lanzhou Road, Yangpu District
Tel: 021-65890960
Shanghai Medical Insurance Center < B R / > address: 805-807, Kangding Road
Tel: 021-62554838
if you have any other insurance questions, please come to obaoyu to talk about insurance!,

2. This is not OK, because if you go to the social security department to register at your own expense when you are in hospital, you will not be able to apply for reimbursement after discharge, because there is the possibility of insurance fraud

3. The reimbursement process of Shanghai medical insurance is as follows:
1
2
3
4. Indivials pay part of the advance payment for hospitalization and go through the hospitalization proceres
5. Fill in the approval form for special examination, treatment and valuable drugs (self funded project agreement) according to the patient's condition
6. When going through the discharge proceres, the medical staff and the indivial should settle the part of the amount at their own expense and at their own expense
7. The reimbursement amount of basic medical insurance is settled by the hospital and the district medical insurance center

in the case of out of city referral application and hospitalization expenses reimbursement, the situation is as follows:
1. Required information:
(1) original ID card or social security card
(2) the original receipt of hospitalization charges of the unified financial and tax medical institutions
(3) the original of the detailed list of hospitalization expenses printed by the hospital computer
(4) the original of the disease diagnosis certificate
(5) original and of discharge summary
(6) the original and copies of the application form for external referral of insured employees in Shanghai
(7) the original ID card of the agent shall be provided< (1) the doctor above the deputy director of the third level hospital of the city applies for the application, which is approved by the chief of the medical section and signed by the president of the hospital
(2) approved by the medical insurance benefits audit department of the social insurance agency
3. If the applicant is approved to seek medical treatment outside the city, his / her medical expenses will be paid by himself / herself in advance, and he / she will be reimbursed by the municipal medical insurance agency with the required information after discharge
4. The applicant should bring all the required information to the social security agency for reimbursement. If the information is complete and meets the requirements, it should be handled immediately
5. Precautions
(1) those who apply for referral outside the city can only go to the designated hospitals at the provincial level
(2) those who have been transferred to another hospital for more than 60 days must go to the medical insurance Department of the social security fund management center to handle the extension proceres with the brief introction of the patient's condition.

4.

Self expense refers to the medical expenses that are not included in the scope of basic medical payment, and indivial self expense refers to all the expenses that are borne by indivials outside the scope of reimbursement. According to different ages, there will be a period of conceit

self conceited segment: 900 yuan under 45 years old; 600 yuan from 45 years old to retirement; 300 yuan after retirement

if the accumulated amount of self financing is reached, the reimbursement can be made according to the corresponding proportion. The specific proportion is as follows: 25% for outpatients in tertiary hospitals and 75% for medical insurance fund; 14% of the on-the-job outpatients in community hospitals took personal responsibility; 8% for retirees and 86% and 92% for medical insurance fund respectively; In other hospitals, 20% of the medical expenses are paid by indivials and 80% by medical insurance fund

extended data:

medical insurance refers to social medical insurance. Social medical insurance is a social insurance system established by the state and society according to certain laws and regulations to provide basic medical needs for the workers within the scope of insurance. The basic medical insurance fund is composed of overall fund and indivial account. All the basic medical insurance premiums paid by the employees are included in their personal accounts; The basic medical insurance premium paid by the employer is divided into two parts, one is transferred into the indivial account, and the other is used to establish the overall planning fund

it has the characteristics of "low level, wide coverage". The payment is subject to the expenses that the vast majority of low-level units and indivials can bear. It covers all units and employees in cities and towns, and employees of different types of units can enjoy the right of basic medical insurance. The insured can enjoy it for life after completing the payment period. Secondly, the basic medical insurance has the characteristics of "the burden of both sides, the combination of unified accounts"; It is based on the principle of "determining expenditure by revenue and balancing revenue and expenditure"

5. tolerable. All expenses are divided into self expense, class A, class B, etc. the total expenses, except the part of self expense and class B expenses, after 10% of the first self payment, exceed the hospital medical insurance threshold fee, enjoy the proportion of overall payment. Different levels of hospitals have different threshold fees, and the proportion of overall payment is also different. The proportion of medical insurance for employees is more than 80%

it doesn't need to be calculated by yourself or by the hospital

when Medicare is hospitalized, show the Medicare card, read the card into the Medicare system, pay the deposit (generally threshold fee), and enter the expenses incurred into the system. The system automatically classifies them into self funded, class A, class B, etc. class B pays 10% first, and then enters the basic medical care. According to the number of hospitalizations per year (more than one time, the threshold fee is halved), the hospital level (different threshold fee and different proportion of overall planning), the number of hospitalizations per year (more than one time, the threshold fee is halved), the number of, The computer calculates how much the hospital should pay and how much the hospital will settle with the medical insurance center of social security.

6.

If the medical insurance has been paid for more than one year, the inpatient medical expenses can be reimbursed

in the reimbursement of medical insurance, class a drugs can enjoy full reimbursement, class C drugs need to pay all the expenses, while class B drugs need to pay 80% and 20% of the expenses. Self funded medicine is not reimbursable, bed fee is limited. Generally speaking, it is about 70%

the reimbursement process of medical insurance hospitalization is as follows:

first of all, at the beginning of hospitalization, it is necessary to explain with the hospital that they are reimbursed by medical insurance, but they have to pay medical expenses in advance, and then they can take the invoice to the medical insurance settlement window for reimbursement

the medical insurance card personal account should be used to pay the hospitalization expenses, and the settlement staff of the hospital should be informed before discharge settlement, and the normal card swiping proceres should be followed. Self funded projects can not be paid with indivial account of medical insurance card

the service item settlement method of post payment was adopted in the settlement of hospitalization expenses

(1) reimbursement scope:
A. drug expenses: auxiliary examination: electrocardiography, X-ray fluoros, film making, laboratory test, physical therapy, acupuncture, CT, MRI and other examination expenses are limited to 200 yuan; Operation expenses (according to the national standard, those over 1000 yuan will be reimbursed as 1000 yuan)
B. the elderly over 60 years old are hospitalized in Xingta town health center, and the compensation for treatment and nursing expenses is 10 yuan per day, with a limit of 200 yuan

(2) reimbursement rate: 60% in township hospitals; The reimbursement rate of secondary hospitals was 40%; The reimbursement rate of tertiary hospitals is 30%
the following are not included in the scope of social security reimbursement:

1. Self medical treatment (no designated hospital or referral form), self purchased drugs, drugs that cannot be reimbursed according to public medical regulations and medical expenses that do not conform to family planning

2. Outpatient treatment expenses, visiting expenses, hospitalization expenses, board expenses, accompanying expenses, nutrition expenses, blood transfusion expenses (except those with family blood storage, which shall be reimbursed according to relevant regulations), cooling and heating expenses, rescue expenses, special care expenses and other expenses

7. Medical insurance card has no money, can you still claim reimbursement? The truth is here<

school information
quick number | 05-07 13:16
the payment of medical insurance is more and more convenient, including seeing a doctor, buying medicine, outpatient and emergency department, hospitalization, etc., but we don't understand many problems of medical insurance, such as the money in the account of medical insurance card (in fact, it has been unified as social security card, but for the habit of everyone's name, we will continue to call it medical insurance card), How to pay for medical treatment? Do you need to pay out of your own pocket

it is estimated that many people, like Xiaobian, have such questions. So will it affect it? Xiao Bian specially arranged it... Let's have a look

if the medical insurance card is out of money, can it be reimbursed? How to apply for reimbursement with medical insurance card? What's the ratio? 1、 Medical insurance card has no money, can you still claim reimbursement
medical insurance is one of the social security, which belongs to the social welfare of the whole people. It is mainly used for reimbursement of medical expenses such as going to the hospital for treatment and buying medicine. According to the difference of the insured population, medical insurance can be divided into three types: urban workers' medical insurance, urban and rural residents' medical insurance and new rural cooperative medical insurance

the payment objects of medical insurance are two parties, one is ourselves, the other is the unit or the government

we pay our own money into the personal account of medical insurance. Personal account is the balance in the medical insurance card that we usually see. It can be used to buy medicine in the designated drugstore, and can be used to pay the outpatient expenses and the indivial self paid part of the hospitalization expenses

the money paid by the unit or the government goes into the co-ordination account of medical insurance. The overall account is mainly responsible for medical reimbursement. For example, as long as the reimbursement conditions are met, the money will be transferred directly from the overall planning account to the hospital

therefore, when the balance of your medical insurance card is 0, it does not affect the medical reimbursement. Even if there is no money in the medical insurance card, as long as the medical insurance is in a normal state, you can continue to enjoy the medical reimbursement, but the self paid part can only be paid in cash, and can not be paid in advance from the medical insurance card. Reimbursement involves the money in the co-ordination account

will the money in the co-ordination account run out? In fact, the health insurance co-ordination account belongs to the social fund and will not be used up, because there are financial subsidies, but the amount allocated to each person is limited. The maximum payment limit is the maximum amount that the overall planning fund can pay. In principle, it is controlled at about 4 times of the average annual salary of local employees

it should be noted that although the urban and rural residents' medical insurance and new rural cooperative medical system have indivial payment, the money goes into the overall planning account< How to apply for reimbursement of medical insurance card? What's the ratio
the treatment expenses of medical insurance reimbursement are mainly limited in the medical insurance catalog, and can only be reimbursed for the hospitals, drugs and treatment items specified in the medical insurance. The most common scene in the actual use of medical insurance is to see outpatient and inpatient. The specific reimbursement methods of medical insurance are generally divided into these two situations:

outpatient reimbursement: after the outpatient expenses reach a certain amount (subject to the local medical insurance policies), the excess part can enjoy medical reimbursement. There is no other proceres, direct real-time settlement with medical insurance card, users only need to pay the expenses after reimbursement

inpatient reimbursement: when hospitalized in a designated hospital of medical insurance, a medical insurance card is issued to let the unified medical insurance settlement system read the information of the insured and handle the inpatient number. When discharged from the hospital, the hospital will settle with the social security center and automatically dect the reimbursement amount. Patients only need to pay other personal expenses after reimbursement

because the reimbursement proportion of medical insurance varies from place to place, please refer to the local policy. Take Shenzhen as an example to introce the proportion of medical insurance reimbursement<

outpatient treatment:

inpatient treatment:

in addition to the specified reimbursement proportion, medical insurance reimbursement has a certain range, and the part of medical insurance reimbursement is above the starting line and below the capping line, decting the self paid part and self paid part The relationship between medical insurance and commercial insurance can be summarized in one sentence: medical insurance is the foundation and commercial insurance is the supplement. Whether it's the new rural cooperative medical system in rural areas, or the residents' medical insurance and employees' medical insurance in cities and towns, these basic medical insurance are the welfare of the state and must be allocated

however, considering the limited role of medical insurance in the face of serious illness, if conditions permit, we should choose "payment type" commercial medical insurance with higher cost performance to rece "hidden loss" and obtain more comprehensive protection<

Xiaobian would like to recommend some kinds of insurance that can be used when "medical insurance can't help":

serious disease insurance: if you are diagnosed with a serious disease within the scope of insurance, you can pay in advance. For example, the protection of the flagship version of comfort insurance is divided into three parts: serious disease, moderate disease and mild disease, which can be paid for many times, and the premium can be exempted. And for patients with severe illness, the "payment type" characteristics of severe illness insurance can play a very good role in income compensation

million medical insurance: low price and high coverage. Medical treatment, medicine purchase, treatment technology and other aspects are basically "willful", such as Allianz zhenai medical insurance (Thanksgiving version), the dectible of this proct is 10000 yuan, and the part over 10000 yuan can be reimbursed. It can be paid monthly by stages to rece the economic pressure. It also supports the advance payment of treatment costs. It also covers the external use of social security drugs and proton heavy ion data technology, which has a solid guarantee

cancer insurance: it's specially for malignant tumors. It's also cheap and has high coverage. Moreover, the health information is quite loose. People with high, high and diabetes can also be insured. For example, enjoy life-long cancer medical insurance, 2 million cancer medical insurance benefits, continuous insurance for first-time cancer, no waiting period for insurance transfer, direct payment for cancer hospitalization in China, including reimbursement for targeted drugs outside hospital, and expanded coverage for medical expenses incurred by proton heavy ion radiotherapy in Shanghai proton heavy ion hospital. The compensation ratio is 100% regardless of whether social security is applicable.

8.

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