Chương V Nghị định 146/2018/NĐ-CP: Hợp đồng khám bệnh, chữa bệnh bảo hiểm y tế

Chapter V

HEALTH INSURANCE-COVERED SERVICE CONTRACTS

Article 16. Health insurance-covered service contracts

1. In case of a first-time health insurance-covered service contract, documents shall include:

a) Request form for signing the contract, prepared by the requesting healthcare establishment;

b) Duplicate of the healthcare license, issued by a competent regulatory authority to the requesting healthcare establishment;

c) Internally stamped duplicate of the decision on ranking of hospitals made by a competent regulatory authority (if any) or the decision on medical level issued by a competent regulatory authority with respect to non-public healthcare establishments;

d) List of medical technology services, medicines, chemicals or medical supplies, approved by a competent regulatory authority (whether in the written or electronic form).

2. In case where a healthcare establishment obtains a competent regulatory authority’s approval of supplementation of functions, duties, scope of professional practices and hospital ranking, that healthcare establishment shall be responsible for informing a competent social insurance agency of adding the abovementioned information to the health insurance-covered service contract. Within duration of 10 working days of receipt of the written document stating approval from the healthcare establishment, the receiving social insurance agency shall be responsible for completely signing on appendices to the contract or entering into a new contract.

Article 17. Contractual terms and conditions, requirements for eligibility of a healthcare establishment for signing a health insurance-covered service contract with

1. Contractual terms and conditions shall be established by using the Form N0.7 of the Appendix to this Decree. Depending on conditions of a healthcare establishment, a social insurance agency and that healthcare establishment shall agree on supplements to contractual terms and conditions without committing any violation against legislative regulations on health insurance.

2. Requirements for eligibility of a healthcare establishment for signing a health insurance-covered service contract shall be comprised of the followings:

a) Fully meet requirements for conformance to medical practicing regulations in accordance with laws on healthcare services and have obtained a competent regulatory authority’s medical service license;

b) Ensure provision of medicines, chemicals and medical supplies are in line with the scope of functions of that healthcare establishment.

Article 18. Conclusion of health insurance-covered service contracts

1. In case of entering into a health insurance-covered service contract for the first time:

a) A healthcare establishment sends 01 set of documents referred to in Article 16 hereof to a social insurance agency;

b) Within duration of 30 days of receipt of all required documents (based on the postmark date of received document), a social insurance agency must complete the processing of submitted documents and contract signing. In case of refusal to sign a health insurance-covered service contract, a written response clearly stating reasons for such refusal must be sent.

2. Validity period of a health insurance-covered service contract:

a) The validity period of a contract shall range from January 1 to end of December 31 of each year, but shall be restricted to 36 months;

b) In case of the health insurance-covered service contract signed for the first time, the validity period of this contract shall start from the signature date to end of December 31 in the year on which the contract expires, but shall not exceed 36 months;

c) In case of signing a health insurance-covered service contract on an annual basis, a healthcare establishment and a social insurance agency shall completely conclude the contract of the following year before December 31 of that year.

10 days before the contract expires, if the healthcare establishment and the social insurance agency agree on the contract extension and negotiate about the implementation of the contract based on an appendix to that contract, that appendix shall have legal value, unless otherwise agreed upon.

3. If a policyholder receives medical services prior to January 1, but is discharged from a healthcare establishment ahead of January 1, his/her medical costs shall be subject to the following regulations:

a) In case where that healthcare establishment continues to sign a health insurance-covered service contract, such medical costs shall be taken into account as the following year's medical costs;

b) In case where that healthcare establishment decides not to continue to sign a health insurance-covered service contract, such medical costs shall be taken into account as that year's medical costs.

4. A health insurance-covered service contract shall clearly specify the method for payment of health insurance-covered medical costs where relevant to actual conditions of that healthcare establishment.

5. Contracting parties shall be responsible for assuring rights and interests of patients holding health insurance cards under laws on health insurance and preventing any suspension of medical services provided for patients holding health insurance cards.

Article 19. Contracts for health insurance-covered medical services performed at commune- or ward-level health stations, public maternity homes, regional general clinics and healthcare establishments of public service entities and educational institutions

1. With respect to commune- or ward-level health stations, public maternity homes and regional general clinics

a) A social insurance agency shall sign a contract with a district-level healthcare center or hospital or other healthcare establishment approved by the provincial-level Department of Health to provide medical services at a commune- or ward-level health stations, maternity homes and regional general clinics for health insurance policyholders;

b) The healthcare establishment signing the health insurance-covered medical service contract prescribed in point a of this clause shall be responsible for providing medicines, chemicals and medical supplies for commune- or ward-level health stations, public homes, regional general clinics and paying costs incurred from use of patient beds (if any) and medical technologies within the scope of its medical functions; concurrently, making monitoring, supervisory and consolidated reports for the purpose of making payments to social insurance agencies.

2. With respect to healthcare establishments of entities or educational institutions (except those receiving state budget allocations funding primary care services as prescribed in clause 1 of Article 34 hereof), social insurance agencies shall be authorized to sign health insurance-covered medical service contracts directly with entities and educational institutions.

Article 20. Rights and responsibilities of social insurance agencies for implementation of health insurance-covered medical service contracts

1. Rights of social insurance agencies:

a) Implement regulations laid down in Article 40 of the Law on Health Insurance;

b) Request healthcare establishments to carry out the transfer of electronic data for evaluation and payment of health insurance-covered medical costs under regulations promulgated by the Minister of Health.

2. Responsibilities of social insurance agencies:

a) Implement regulations laid down in Article 41 of the Law on Health Insurance;

b) Within duration of 10 first days of the first month in the validity period of a contract, provide healthcare establishments with the list of holders of health insurance cards submitting an electronic or signed and stamped written application for registration of primary care services by using the Form No. 8 of the Appendix to this Decree at the beginning of each quarter;

c) Ensure compliance with laws on medical examination and treatment, regulations on management of medical records in accordance with regulations promulgated by the Minister of Health;

d) Cooperate with healthcare establishments in receiving and checking procedures for health insurance-covered medical services; revoke and temporarily impound health insurance cards and take actions within their jurisdiction against any violation; give information technology support for evaluation of health insurance-covered medical costs and payment thereof to healthcare establishments;

dd) Protect rights and interests of health insurance policyholders; deal with claims or complaints related to health insurance benefits under their jurisdiction;

e) Establish a perfect system for evaluating and ensuring the continuous receipt of electronic data and results of evaluation of health insurance-covered medical services, and the timely response upon receipt thereof to healthcare establishments under regulations promulgated by the Minister of Health.

Article 21. Rights and responsibilities of healthcare establishments for implementation of health insurance-covered medical service contracts

1. Rights of healthcare establishments:

Implement regulations laid down in Article 42 of the Law on Health Insurance.

2. Responsibilities of healthcare establishments:

a) Implement regulations laid down in Article 43 of the Law on Health Insurance;

b) Ensure provision of medicines, chemicals or medical supplies and medical technology services is in line with their level of medical practices as regulated by the Minister of Health;

c) Send electronic data for the purpose of performing the task of management of health insurance-covered medical services immediately after completion of each medical examination or completion of each outpatient treatment or completion of each inpatient treatment of a patient under regulations of the Minister of Health;

d) Send electronic data on health insurance-covered medical costs to request payments made not later than 7 working days from the date of completion of medical examination and treatment of patients in accordance with the regulations of the Minister of Health.

Article 22. Contract amendment and supplementation

1. In the course of implementation of a health insurance-covered medical service contract, if there is any party requesting amendments or supplements to contractual terms and conditions, they must inform the other party in writing for at least 30 days in advance of which terms and conditions subject to amendment or supplementation in that contract.

2. In case where both parties agrees on which terms and conditions are amended or supplemented, amendment and supplementation shall be carried out by bearing their signatures on appendices or entering into a new contract.

3. In case where both parties fail to reach agreement on amendment or supplementation, the existing contract shall remain valid for implementation.

Article 23. Cases of contract termination

1. A contract shall be terminated in case the contracting healthcare establishment is subject to business closure, dissolution, bankruptcy or revocation of its license.

2. A contract shall be terminated in case both parties agree on contract termination in accordance with laws.

3. In the course of implementation of a health insurance-covered medical service contract, if a social insurance agency, entity, organization or individual discovers that any healthcare establishment commits any violation against the contract, they must inform the provincial Department of Health, the Ministry of Health or a health authority of a ministry or sectoral administration with respect to the healthcare establishment under its respective control (hereinafter referred to as regulatory authority).

Within duration of 5 working days of receipt of the notification, the regulatory authority shall be responsible for sending the defaulting healthcare establishment a written request for submission of a written explanation for matters relating to the allegation of violations.

After receipt of the written explanation from the regulatory authority, the healthcare establishment shall be responsible for sending the regulatory authority the written explanation, enclosing evidences (if any).

After receipt of the written explanation from the defaulting healthcare establishment, the regulatory authority shall be responsible for cooperating with the same-level social insurance agency in carrying out review, verification and judgement of the allegation of violations. The judgement must clearly conclude whether or not the healthcare establishment at question commits any violation and may suggest remedial actions (if any).

4. In the course of implementation of a health insurance-covered medical service contract, if an entity, organization or individual discovers that a social insurance agency commits any violation against the contract, a notification of such violation must be sent to the regulatory authority.

Within duration of 05 working days of receipt of the abovementioned notification, the regulatory authority shall be responsible for sending the social insurance agency a written explanation for matters relating to the allegation of violations.

After receipt of the written request for explanation from the regulatory authority, the social insurance agency shall be responsible for sending the regulatory authority the written explanation, enclosing evidences (if any).

After receipt of the written explanation from the social insurance agency, the regulatory agency shall be responsible for cooperating with the same-level social insurance agency (in the event that the same-level social insurance agency is the body reported for violations, the higher-level social insurance agency is invited to cooperate with the regulatory authority) in carrying out the review, verification and judgement of the allegation of violations. The judgement must clearly conclude whether or not the social insurance agency at question commits any violation and may recommend remedial actions (if any).