When is Referral Permitted for Healthcare and Medical Treatment Covered by Health Insurance?

Circular 40/2015/TT-BYT clearly stipulates 6 cases for patient transfer as follows:

1. People with health insurance cards (BHYT) who register for initial medical examination and treatment (KCB) at commune-level healthcare facilities, general clinics, or district hospitals are allowed to receive KCB at commune-level health stations, general clinics, or district hospitals within the same province;
2. People with BHYT cards who register for initial KCB at commune-level healthcare facilities are transferred to district hospitals, including district hospitals classified as Grade I, Grade II, and provincial traditional medicine hospitals (YHCT) if the district hospital does not have a traditional medicine department, such as:
   1. Transfer from commune health stations (level 4 in terms of technical expertise) to provincial Grade III YHCT hospitals (level 3 in terms of technical expertise);
   2. Transfer from commune health stations (level 4 in terms of technical expertise) to provincial Grade II or Grade I YHCT hospitals if the district hospital does not have a traditional medicine department.
3. People with BHYT cards are transferred from district hospitals, including hospitals classified as Grade I, Grade II, and general hospitals, specialized hospitals, specialized institutes, and provincial-level specialized centers to provincial-level specialized centers or general hospitals, specialized hospitals, specialized institutes of the same grade or lower.
4. For emergency cases such as:
   1. Patients are treated at any healthcare facility. The doctor or physician receiving the patient assesses, determines the emergency status, and records it in the patient’s medical records.
   2. After the emergency treatment phase, the patient is admitted for inpatient treatment at the healthcare facility where they received emergency care or transferred to another healthcare facility for continued treatment according to professional requirements or returned to their initial KCB registration place after stabilization.
5. If a patient is transferred for KCB and has other accompanying diseases that were discovered or arose outside of those listed on the referral letter, the receiving healthcare facility will treat these diseases within their professional scope.
6. BHYT participants who go on business trips, study, work temporarily or reside for less than 12 months in another locality are entitled to receive KCB at healthcare facilities in that locality equivalent to the level of their initial KCB registration facility listed on the BHYT card. If there is no equivalent healthcare facility in that locality, BHYT participants can choose another facility that provides initial KCB with BHYT.

For cases of KCB not following the referral system according to the amended 2014 Health Insurance Law, BHYT holders will only be reimbursed 40% of inpatient treatment costs at central-level hospitals and 60% of inpatient treatment costs at provincial-level hospitals.

Special attention should be paid to cases using Referral Letters and Re-examination Appointment Letters in BHYT KCB, especially for patients with diseases, groups of diseases stipulated in Appendix 01 issued with the Circular.

According to Circular 40, initial BHYT KCB facilities are classified as follows:

- Commune-level and equivalent initial BHYT KCB facilities- Commune, ward health stations, and commune-level town health stations;- Clinics, health stations, health departments of agencies, units, organizations;- Independent private family doctor clinics;- Military-civilian health stations, military-civilian clinics, military medical units at battalion level, and other healthcare facilities as prescribed by the Minister of National Defense.- District-level and equivalent initial BHYT KCB facilities- General hospitals of districts, towns, district-level cities, and provincial cities;- District health centers with health examination and treatment functions; district health centers with general clinics;- General clinics; regional general clinics;- Grade III, Grade IV, and ungraded general hospitals of Ministries, Sectors or units under Ministries, Sectors;- Private general hospitals equivalent to Grade III, Grade IV, or ungraded equivalent;- Private traditional medicine hospitals equivalent to Grade III, Grade IV, or ungraded equivalent;- Health departments, Infirmaries under the Ministry of Public Security, Provincial Public Security Infirmaries, and centrally controlled provincial cities;- Military-civilian health centers, military infirmaries, military-civilian infirmaries, Grade III, Grade IV, or ungraded military hospitals, Grade III, Grade IV, or ungraded military-civilian hospitals, and other healthcare facilities as prescribed by the Minister of National Defense.- Provincial-level and equivalent initial BHYT KCB facilities:- General hospitals of provinces and centrally controlled provincial cities;- Grade I, Grade II general hospitals of Ministries, Sectors, or units under Ministries, Sectors;- Specialized hospitals, Specialized institutes, Specialized Centers, Provincial preventive health centers with general clinics;- Children's Hospitals, Obstetrics - Pediatrics hospitals of provinces, centrally controlled provincial cities;- Private general hospitals equivalent to Grade I, Grade II;- Traditional medicine hospitals of provinces, centrally controlled provincial cities, Ministries, Sectors;- Private traditional medicine hospitals equivalent to Grade I, Grade II;- Clinics under the Committee for Health Care and Protection of Provincial Officials and centrally controlled provincial cities;- Grade II hospitals of National Defense Ministry, Grade II military-civilian hospitals, and other healthcare facilities as prescribed by the Minister of National Defense.- Central-level and equivalent initial BHYT KCB registration facilities- General hospitals under the Ministry of Health, except for hospitals stipulated in Clause 3 of this Article;- Specialized hospitals, Specialized institutes under the Ministry of Health with general clinics;- Huu Nghi Hospital, C Da Nang Hospital, and Thong Nhat Hospital under the Ministry of Health;- Special-grade hospitals, Grade I military hospitals under the Ministry of National Defense, Military Traditional Medicine Institute, and other healthcare facilities as prescribed by the Minister of National Defense.

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