Circular No. 09/2019/TT-BYT guides the assessment of conditions for signing contracts for initial health check-ups and medical treatment under health insurance, transferring the implementation of clinical support services, and direct payment of costs in certain special cases.

CIRCULAR

GUIDELINES FOR THE REVIEW OF CONDITIONS FOR SIGNING HEALTH INSURANCE PRIMARY HEALTH CARE CONTRACTS, TRANSFER OF IMPLEMENTATION OF CLINICAL SUPPORT SERVICES, AND DIRECT PAYMENT OF FEES IN CERTAIN CASES OF HEALTH INSURANCE HEALTH CARE

Pursuant to the Health Insurance Law on November 14, 2008, amended and supplemented by certain articles according to the Health Insurance Law on June 13, 2014;

Pursuant to Decree No. 146/2018/NĐ-CP dated October 17, 2018 of the Government detailing and guiding methods for implementing certain provisions of the Health Insurance Law;

Pursuant to Decree No. 75/2017/NĐ-CP dated June 20, 2017 of the Government stipulating the functions, tasks, powers, and organizational structure of the Ministry of Health;

The Minister of Health issues this Circular to guide the review of conditions for signing health insurance primary health care contracts, transfer of implementation of clinical support services, and direct payment of fees in certain cases of health insurance health care.

Article 1. Scope of Regulation

This Circular guides the organization and implementation of health insurance health care regarding:

1. Reviewing the conditions of healthcare facilities to sign health insurance primary health care contracts.

2. Transfer of implementation of clinical laboratory testing, diagnostic imaging, and functional examinations (hereinafter collectively referred to as clinical support services).

3. Direct payment of health insurance health care costs for other special cases as stipulated in Point c Clause 1 Article 31 of the Health Insurance Law, amended and supplemented according to Law No. 46/2014/QH13.

Article 2. Review of Conditions for Healthcare Facilities Signing Health Insurance Primary Health Care Contracts

1. The review of conditions for healthcare facilities to sign health insurance primary health care contracts for healthcare facilities announced by the Department of Health in accordance with Article 13 of Circular No. 40/2015/TT-BYT dated November 16, 2015 of the Minister of Health on registration for health insurance primary health care and transfer of health insurance health care only applies to the following cases:

a) First time requesting to sign a health insurance primary health care contract;

b) After termination of a health insurance primary health care contract.

2. Content of the review:

a) Comparing the contract registration dossier for the first time signing a health insurance primary health care contract with the provisions of Clause 1 Article 16 of Decree No. 146/2018/NĐ-CP dated October 17, 2018 of the Government detailing and guiding methods for implementing certain provisions of the Health Insurance Law (hereinafter referred to as Decree No. 146/2018/NĐ-CP);

b) Comparing information about the list of personnel registered to practice at healthcare facilities with the list published on the Ministry of Health's Electronic Information Portal or the Department of Health's Electronic Information Portal.

3. The Social Security of provinces and centrally-administered cities shall be responsible for reviewing according to the contents prescribed in Clause 2 of this Article within the time limit specified in Point b Clause 1 Article 18 of Decree No. 146/2018/NĐ-CP.

1. The transfer of implementation of clinical support services shall be carried out in accordance with the principle of suitability with the requirements of professional technical expertise in health care, ensuring the rights of health insurance participants, and according to the following list:

a) Clinical support services belonging to the list of medical techniques approved by competent state authorities for healthcare facilities and currently being implemented at healthcare facilities but at the time of prescribing for patients, those healthcare facilities cannot implement them;

b) Clinical support services not included in the list of medical techniques approved by competent state authorities for healthcare facilities to implement but are actually necessary for professional activities as stipulated by the Minister of Health on management, diagnosis, and treatment in health care.

2. Healthcare facilities may only transfer patients or samples to receiving facilities that have been approved by competent authorities to meet the conditions for implementing clinical support services and must sign a general agreement with the facility providing clinical support services (the agreement includes the content of agreeing that the social security agency where the health insurance health care contract is signed will inspect the clinical support services received and implemented at the clinical support service facility).

3. The receiving facility for patients or patient samples to perform ancillary medical services shall not further transfer patients or patient samples to a third party (different facility).

4. Coding of Clinical Support Services:

The healthcare facility transferring patients or samples (hereinafter referred to as the transferring facility) shall code as follows: XX.YYYY.ZZZZ.K. WWWWW, wherein:

a) XX.YYYY.ZZZZ is the code for ancillary medical services;

b) K is a character indicating that the ancillary medical service is performed at another facility;

c) WWWWW is a character indicating the code number of the ancillary medical service provision facility issued by the Ministry of Health.

5. Payment of costs:

a) Payment for the cost of implementing clinical support services shall be carried out in accordance with Clause 6 Article 27 of Decree No. 146/2018/NĐ-CP and according to the price of the receiving facility but shall not exceed the price of health care services prescribed in Circular No. 39/2018/TT-BYT dated November 30, 2018 of the Minister of Health on unified prices for health insurance health care services between hospitals of the same level nationwide and guidance on applying prices and paying costs for health insurance health care in certain cases.

In the case of an ancillary medical service being performed at multiple receiving facilities in the same prescription, the health insurance fund shall only pay for one performance of that ancillary medical service.

b) The receiving facility providing ancillary medical services shall not charge additional fees for diagnosis and ancillary medical services for patients.

Article 4. Direct payment of medical examination and treatment costs for other special cases as provided for in Point c Clause 1 Article 31 of the Health Insurance Law amended and supplemented according to the provisions of Law No. 46/2014/QH13.

1. In addition to the cases of direct payment of medical examination and treatment costs as stipulated in Points a and b Clause 2 Article 31 of the Health Insurance Law amended and supplemented according to the provisions of Law No. 46/2014/QH13, persons holding health insurance cards shall be entitled to direct payment of medical examination and treatment costs in the following cases:

b) Cases where health insurance card data is not provided or inaccurately provided regarding health insurance card information;

2. The Social Insurance agency receiving the application for direct payment shall be responsible for paying the health insurance medical examination and treatment costs for the cases specified in Clause 1 of this Article within the scope of benefits of health insurance participants.

Article 5. Effective Date

This Circular takes effect from August 1, 2019.

Article 6. Reference Provisions

In cases where referenced documents in this Circular are replaced or amended, the replaced or amended documents shall apply.

During the implementation process, if there are difficulties or obstacles, it is recommended that organizations, entities, and individuals promptly report to the Ministry of Health (Health Insurance Department) for consideration and resolution./.