Order and procedures for medical examination and treatment covered by health insurance in certain specific cases for health insurance participants
How are the latest procedures for medical examination and treatment covered by health insurance according to Decree 75/2023/ND-CP?
Based on the regulations in Section A on Administrative Procedures issued with Decision 4384/QD-BYT in 2023, the latest procedures for medical examination and treatment covered by health insurance are as follows:
Step 1: For health insurance participants
(1) Health insurance participants when arriving at medical examination and treatment facilities must present:
+ Health insurance card with a photo or a citizen identification card;
+ In case of presenting a health insurance card without a photo, they must present one of the personal identification documents with a photo issued by a competent agency or organization, or a certificate by the commune-level police, or other documents certified by the educational institution managing the students;
+ Other legal identity documents or electronically named documents at level 2 according to Decree 59/2022/ND-CP;
- Note: For children under 6 years old, only the health insurance card is required.
(2) In case of emergency, health insurance participants are allowed to receive medical examination and treatment at any medical facility and must present the health insurance card along with the documents specified in (1) before discharge.
(3) In case of treatment referral, health insurance participants must have a referral letter for medical examination and treatment covered by health insurance and the referral documents from the medical facility.
(4) In case of follow-up examination as required for treatment, health insurance participants must have a return appointment letter from the medical facility.
(5) In case the technical capabilities are exceeded, the health insurance medical facility is responsible for promptly transferring the patient to another health insurance medical facility according to the regulations on technical expertise transfer.
Step 2: For medical facilities
- Organize medical examination and treatment ensuring quality with simple and convenient procedures for health insurance participants.
- Admit patients with health insurance cards into the medical facility for diagnosis and treatment.
Procedures for medical examination and treatment covered by health insurance in some specific cases for health insurance participants? (Image from the Internet)
Guidelines for medical examination and treatment procedures covered by health insurance in some specific cases for health insurance participants?
In Section A on Administrative Procedures issued with Decision 4384/QD-BYT in 2023, the procedures for medical examination and treatment covered by health insurance in some specific cases for health insurance participants are clearly stated as follows:
(1) Health insurance participants when arriving at medical examination and treatment facilities must present:
+ Health insurance card with a photo or a citizen identification card;
+ In case of presenting a health insurance card without a photo, they must present one of the personal identification documents with a photo issued by a competent agency or organization, or a certificate by the commune-level police, or other documents certified by the educational institution managing the students;
+ Other legal identity documents or electronically named documents at level 2 according to Decree 59/2022/ND-CP;
(2) Children under 6 years old arriving for medical examination and treatment only need to present the health insurance card.
- In case the child has not been issued a health insurance card, a copy of the birth certificate or birth registration certificate must be presented;
- In case immediate treatment is required after birth and no birth certificate is available, the head of the medical facility and the child's parent or guardian sign to confirm in the medical record as the basis for payment according to Clause 1, Article 27 Decree 146/2018/ND-CP and take responsibility for this confirmation.
(3) Health insurance participants awaiting replacement or renewal of the health insurance card must present:
- The participation declaration and information adjustment for social insurance, health insurance according to Form TK1-TS (Issued with Decision 490/QD-BHXH in 2023) and a type of personal identification document.
(4) Individuals who have donated organs, upon arriving for medical examination and treatment, must present:
+ The documents specified in point (1) or point (3) above.
+ In case immediate treatment is required after donation, the head of the medical facility where the organ was taken and the patient or the patient's relative sign to confirm in the medical record as the basis for payment according to Clause 2, Article 27 Decree 146/2018/ND-CP and take responsibility for this confirmation.
(5) In case of medical referral
- Health insurance participants must present the referral documents from the medical facility and the Referral Letter according to Form Number 6 of the Appendix issued with Decree 75/2023/ND-CP.
The referral letter is valid until December 31 of the calendar year, but if the treatment session has not ended, the referral letter can be used until the end of the treatment session.
In case of follow-up examination as required for treatment, health insurance participants must have a return appointment letter from the medical facility according to Form Number 5 of the Appendix issued with Decree 75/2023/ND-CP.
(6) In case of emergency, health insurance participants are allowed to receive medical examination and treatment at any medical facility and must present the following documents:
- The documents specified in Clause 6, Article 1 of Decree 75/2023/ND-CP or Clause 2 or Clause 3, Article 15 of Decree 146/2018/ND-CP before discharge. After the emergency phase is over, the patient is transferred by the medical facility to another department for further monitoring and treatment or transferred to another medical facility which is considered as the correct medical referral.
- After the emergency phase is over, the patient is transferred by the medical facility to another department for further monitoring and treatment or transferred to another medical facility which is considered as the correct medical referral.
(7) Health insurance participants during business trips, mobile work, concentrated training forms, training programs, and temporary residence are allowed initial medical examination and treatment at the medical facility of the same specialization or equivalent to the initial registered medical facility on the health insurance card and must present the documents specified in Clause 6, Article 1 of Decree 75/2023/ND-CP or Clause 2 or Clause 3, Article 15 of Decree 146/2018/ND-CP and one of the following documents:
- Business trip letter
- Decision to be sent for training
- Student card
- Temporary residence registration document
- School transfer letter
What does the latest health insurance medical examination and treatment dossier include?
In Section A on Administrative Procedures issued with Decision 4384/QD-BYT in 2023, the latest health insurance medical examination and treatment dossier includes:
- Health insurance card and personal identification document; for children under 6 years old, only the health insurance card is required.
- Copy of birth certificate or birth registration certificate for children under 6 years old.
- Participation declaration and information adjustment for social insurance, health insurance according to Form TK1-TS (Issued with Decision No. 490/QD-BHXH on March 28, 2023, by Vietnam Social Security).
- Form Number 5: Return appointment letter.
- Form Number 6: Health insurance referral letter.
- Referral documents from the health insurance medical facility.
Number of dossiers: 01 set.
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