Chapter III
FACILITIES THAT PROVIDE MEDICAL SERVICES TO POLICYHOLDERS OF HEALTH INSURANCE (Hereinafter referred to as healthcare providers)
Article 6. Healthcare providers, registration for medical services covered by health insurance and hospital transfer
1. According to the Law on Medical Examination and Treatment, healthcare providers shall execute a contract for provision of medical services to policyholders (hereinafter referred to as the contract for medical services) with the social insurance organization.
2. Registration for medical services at primary healthcare providers, and hospital transfer shall be done according to the regulations by the Ministry of Health.
Article 7. Contract for medical services covered by health insurance
1. General principles:
a) The social insurance organization shall be responsible for contracting with medical facilities. The contract for medical services shall be drafted according to the provisions set out in the Appendix 03 enclosed herewith. Depending on conditions of the medical facility, the social insurance organization and the medical facility shall be unanimous in supplementing some terms and conditions to the contract without going against the Law on Health Insurance;
b) The term of validity of the contract shall conform to the fiscal year, starting from January 01 to December 31 of the same year; for any contract what is made for the first time, the term of validity of the contract shall start from the day of signing to December 31 of the same year;
c) Expense for medical services provided to insured patients before January 01 but discharged since January 01, shall be set as follows:
- In case the healthcare provider continues to sign a contract for medical services, the expenses shall be transferred to the succeeding year;
- In case the healthcare provider discontinues signing a contract for medical services, the expenses shall be included in the preceding year;
2. Documents for entering into the contract for medical services:
a) With respect to any healthcare provider that signs a contract for the first time:
- Healthcare provider’s official offer for signing the contract;
- Healthcare provider’s operation license;
- Hospital classification decision issued by competent agencies (if any); with respect to non-public healthcare providers, it is required to have the decision on professional and technical healthcare network issued by competent agencies.
b) With respect to any healthcare provider that signs a one-year contract annually:
Supplement functions, duties, scope of profession, hospital level approved by competent agencies (if any).
3. Procedures for entering into the contract for medical services:
a) With respect to any healthcare provider that signs the contract for the first time:
- The healthcare provider must submit a dossier as regulated in Point a, Clause 2 of this Article to the social insurance organization decentralized by the Vietnam Social Security;
- Within 30 days since the receipt of adequate documentation, the social insurance organization must complete the examination of the documentation and signing the contract; in case of refusal, the social insurance organization must make a written notice and state the reasons.
b) With respect to any healthcare provider that signs a one-year contract annually: Both the healthcare provider and the social insurance organization must complete the signing of the contract for the succeeding year before December 31.
4. The contract for medical services signed with commune-level healthcare provider and medical facilities that belong to agencies, organizations and schools:
a) Commune-level healthcare providers:
- The social insurance organization shall sign a contract with the district-level hospital or medical center where the district-level hospital is not yet separated, or other primary healthcare providers approved by the Services of Health for providing medical services at the commune-level medical facility:
- Within the assigned fund, the district-level hospital or the medical center at district level, or other healthcare providers as approved by the Services of Health shall be responsible for providing medicine, chemicals, medical materials, hospital beds (if any), medical technical services to the commune-level medical facility within its own scope of specialty, and at the same time carrying out surveillance and finalizing payment with the social insurance organization.
- Total expenditure for medical services provided at the commune-level medical facility must range between 10 per cent and 20 per cent of the fund for medical services to outpatients calculated on the number of individuals registering with primary healthcare providers at commune-level as defined in Point a, Clause 4, Article 11 hereof.
- The time for retaining patients for treatment at the commune-level medical facility should not exceed 03 days, or 05 days with respect to any commune-level medical facility in the area facing socio-economic difficulties, or in island districts, communes.
b) For medical facilities that belong to agencies, organizations and schools (except agencies, organizations and schools that are granted expenditure for initial medical services as defined in Points b, c, Clause 1, Article 6 of the Decree No. 105/2014/NĐ-CP):
Agencies, organizations and schools managing the medical facility that contracts with the social insurance organization shall be responsible for providing medicine, chemicals, medical materials, technical medical services to meet demand for medical services. In case agencies, organizations and schools managing the medical facility at the same level as commune-level medical facility fail to provide medicine, chemicals, medical materials, technical medical services to meet demand for medical services, the social insurance organization shall contract with the district-level hospital or medical center.
5. For general clinics affiliated to the district-level hospital or medical center, apply the same as every ward of the district-level hospital or medical center. Based on the stipulations on specialty and pricelist of medical services as approved by competent agencies, the social insurance organization and the district-level hospital or medical center shall be unanimous in the contract for medical services provided at the general clinics.
Article 8. Procedures for access to medical services covered by health insurance
1. Participants that go for medical examination and treatment must present a health insurance card with photo; in case the health insurance card has no photo, some papers proving identity of such person must be presented.
2. Children under six who go for medical examination and treatment shall present health insurance cards only. Presentation of notice of birth or birth certificate is required in case the participant receives medical services without health insurance cards; in case the treatment to the participant takes place right after birth without notice of birth, head of the medical facility, parents or guardian to the child shall confirm the medical records as foundation for payment as stipulated in Clause 2, Article 13 hereof and shall be responsible for such confirmation.
3. Participants that go for medical examination and treatment must present an appointment note or some papers proving identity of such person while pending replacement of the health insurance card by the social insurance organization.
4. Participants as body organ donors going for medical examination and treatment must present some papers as defined in either Clause 1, Clause 2, or Clause 3 of this Article. In case the donor is brought for medical treatment right after donation without health insurance card, the donor still enjoys the benefits as a policyholder; Head of the medical facility where body organs are taken, the donor or his/her relatives must confirm the medical records as foundation for payment as stipulated in Clause 3, Article 13 hereof and be responsible for such confirmation.
5. In case of transfer for medical facilities, participants must present some papers as defined in either Clause 1, Clause 2, or Clause 3 of this Article and transfer papers as stipulated by the Ministry of Health.
6. In case of emergency, participants shall be entitled to go to any medical facility provided that such papers as defined in either Clause 1, Clause 2, or Clause 3 of this Article must be presented before being discharged. After the stage of emergency, the participant shall be transferred to other wards or medical treatment rooms for further surveillance, treatment or transfer to other medical facilities as required.
When a patient is discharged from hospital, any medical facility that does not contract with the social insurance organization must provide to the patient the documents related to pathological state and other vouchers for medical services as foundation for payment with the social insurance organization as stipulated in Articles 14, 15 and 16 hereof.
7. Participants on a follow-up visit to medical facilities at upper level without going to primary healthcare providers must present papers as defined in Clause 1, Clause 2, or Clause 3 of this Article enclosed with a medical appointment note. Every medical appointment note shall become ineffective once used. Based on the patient's conditions and technical requirements, the doctor shall decide a follow-up visit for the patient.
8. Participants going for medical examination and treatment (not in the case of emergency) while on a business trip, doing ambulatory job; attending the concentrated training course shall be granted health insurance covered by primary healthcare providers at the same professional and technical level as or similar to the medical facility noted on the health insurance card and must present such papers as defined in either Clause 1, Clause 2 or Clause 3 of this Article, together with one of the following documents: work order, decision on appointment for study, and other papers registering for temporary residence.
9. Medical facilities and the social insurance organization are not permitted to prescribe additional administrative procedures in provision of medical services besides the procedures set out in this Article. In case the medical facility and the social insurance organization need to copy the health insurance card, hospital transfer note and other papers concerning medical services for their own management, they must do it by themselves and should not ask patients to pay for this.
Article 9. Health insurance appraisal
1. The social insurance organization shall carry out the appraisal of health insurance and be responsible for results of appraisal according to the provisions set out in the Law on Health Insurance.
2. Content of health insurance appraisal comprises:
a) Examine procedures for medical services provided to policyholders according to the provisions set out in Article 8 hereof;
b) Examine and assess treatment, use of medicine, chemicals, medical materials and technical medical services within the scope of policyholders’ entitlement to benefits and number of days of hospital stay.
c) Examine, assess and determine expenses for medical services:
- Preparation of a payment bill to patients and a list of expenses for medical services to inpatients, outpatients must be in conformity with the expenses and forms as regulated;
- Examine expenses requested for payment by medical facilities.
d) Collaborate with health workers at the medical facility on handling difficulties in procedures for medical services, rights and responsibilities of policyholders; explain and disseminate policies on health insurance to patients at wards and medical treatment rooms.
3. Appraisal of health insurance shall be done concurrently or after the patient is discharged from hospital and must ensure accuracy, transparence and openness. Results of appraisal shall be made in writing and notified to the medical facility.
4. Content of health insurance appraisal must ensure unanimous agreement between medical facilities and the social insurance organization. In case it is not unanimously agreed, opinions or comments from both sides must be clearly stated and notified to agencies at upper level for handling.
5. The Vietnam Social Security shall provide specific guidance on the content and procedures for health insurance upon receipt of approval from the Ministry of Health.
Tìm kiếm
Thông tư liên tịch 41/2014/TTLT-BYT-BTC (Bản Word)
Thông tư liên tịch 41/2014/TTLT-BYT-BTC (Bản Pdf)