Joint Circular No. 39/2011/TTLT-BYT-BTC guiding procedures for settling medical examination and treatment costs for insured persons involved in traffic accidents under health insurance

JOINT CIRCULAR

Guidelines for procedures to settle costs for medical examination and treatment

for insured persons involved in traffic accidents

_________________________

Pursuant to the Health Insurance Law dated November 14, 2008;

On the basis of Decree No. 86/2012/NĐ-CP dated October 19, 2012, issued by the Government detailing and guiding implementation of certain provisions of the Metrology Law;

Pursuant to the Railway Law dated June 14, 2005;

Pursuant to the Law on Waterway Traffic dated June 15, 2004;

Pursuant to Decree No. 62/2009/NĐ-CP dated July 27, 2009 of the Government detailing and guiding the implementation of certain provisions of the Health Insurance Law,

The Ministry of Health and the Ministry of Finance issue guidelines for procedures to settle costs for medical examination and treatment for insured persons involved in traffic accidents as follows:

Article 1. General Principles

1. Insured persons involved in traffic accidents, who have not yet sufficient evidence to determine that the cause of the accident was due to their violation of traffic laws, shall enjoy health insurance benefits according to regulations when seeking medical examination and treatment.

2. When there is sufficient evidence to determine that the cause of the traffic accident was due to the insured person's violation of traffic laws or in cases where the insured person is involved in a traffic accident but does not fall within the scope of payment by the health insurance fund, the insured person shall not be entitled to health insurance benefits and shall be responsible for fully reimbursing all medical examination and treatment costs to the health insurance fund.

3. Cases eligible for health insurance medical examination and treatment benefits without having to undergo the process of determining traffic law violations as stipulated in Article 2 of this Circular:

Point a. Children under 14 years old;

b) Elderly persons aged 80 years or older.

Article 2. Procedures, formalities, and responsibilities in determining traffic law violations

1. For insured persons involved in traffic accidents:

When insured persons involved in traffic accidents seek medical examination and treatment, in addition to presenting general health insurance examination and treatment procedures, they must provide healthcare facilities with relevant information, including: Full name; date of birth; place of residence; time and location of the accident and cause of the traffic accident (if known).

In cases where the injured person is unconscious and unable to provide the above information, relatives or those bringing the injured person to the hospital must provide the information they know about the traffic accident involving the injured person.

If any of the documents specified in Article 3 of this Circular are available, the injured person or their relatives must immediately provide them to the healthcare facility as the basis for settling health insurance examination and treatment costs according to the prescribed regime.

2. For healthcare facilities receiving injured persons:

Daily, healthcare facilities compile a list of insured persons involved in traffic accidents seeking medical examination and treatment or emergency care on the same day (according to Form No. 01 attached to this Circular) to transfer to the Social Insurance Authority or social insurance staff permanently stationed at the healthcare facility.

3. For the Social Insurance Authority:

a) Within two working days from the date of receipt of the list of persons holding health insurance cards involved in traffic accidents transferred by healthcare facilities, the Social Insurance Authority has the responsibility to send a request for verification of traffic law violations by the injured person to traffic police forces or criminal investigation units dealing with public order offenses (hereinafter referred to collectively as the police force) of the location where the traffic accident occurred (according to Form No. 02 issued together with this Circular). If the injured person or their relatives have provided any of the documents specified in Article 3 of this Circular to the healthcare facility or the Social Insurance Authority, or if the injured person has previously been requested for verification by the Social Insurance Authority, there is no need to resend a request for verification.

b) In cases where three months have passed since the Social Insurance Authority sent the verification request as stipulated in point a of this clause but still have not received a notification from the police force or received a notification stating that the situation could not be verified, the Social Insurance Authority will proceed to settle and finalize the costs of medical examination and treatment used as if the accident did not involve a violation of traffic laws.

b) In case, within three months from the date the Social Insurance agency sends the request for verification as prescribed in point a of this Clause but has not yet received a notification from the police authority or has received a notification stating that there was no verification or that the traffic law violation could not be verified, the Social Insurance agency shall process the settlement of medical examination and treatment costs as if the accident did not involve a traffic law violation.

Article 3. Basis for payment or non-payment of medical examination and treatment costs under the regime for persons participating in health insurance who have been involved in traffic accidents.

The Social Insurance Agency shall base its decision to pay or not to pay medical examination and treatment costs for persons participating in health insurance who have been involved in traffic accidents on one of the following documents:

1. A copy of the traffic accident resolution record issued by the public security agency.

2. A copy or excerpt from the investigation conclusion on the cause of the traffic accident, confirmed by the public security agency handling and resolving the traffic accident.

3. A copy or excerpt from the final conclusion of the court's judgment on the traffic accident (confirmed by the court), provided by the person involved in the accident or their relatives.

Article 4. Payment of medical examination and treatment costs in cases of violation of traffic laws.

When there is sufficient basis to determine that the cause of the traffic accident was due to the violation of traffic laws by the person involved in the accident, the Social Insurance Agency shall implement payment as follows:

1. In the case where the person involved in the accident is still being treated at a medical facility: the Social Insurance Agency shall directly inform the person involved in the accident or their relatives (biological father, mother; spouse; biological children aged 18 years or older) about the fact that the person involved in the accident has violated traffic laws and will not be eligible for medical examination and treatment cost reimbursement from the health insurance fund.

2. In the case where the person involved in the accident has been discharged from the hospital: the Social Insurance Agency shall recover the medical examination and treatment costs paid by the health insurance fund according to the provisions of Article 5 of this Circular.

3. In the case where the person involved in the accident has died: the Social Insurance Agency shall settle the medical examination and treatment costs with the medical facility according to the health insurance regime (without recovering the medical examination and treatment costs already paid in this case).

Article 5. Recovery of medical examination and treatment costs paid by the health insurance fund.

1. The Social Insurance Agency shall have the responsibility to notify the person involved in the accident or their relatives of the results of the traffic law violation determination by the public security agency and request the person involved in the accident or their relatives to fulfill the obligation to repay the health insurance fund for the medical examination and treatment costs paid by the Social Insurance Agency (according to the form attached as Appendix No. 03 issued together with this Circular).

2. After 30 days from the date of sending the first request for repayment, if the person involved in the accident or their relatives do not repay the costs, the Social Insurance Agency shall continue to send a reminder letter.

3. If, after three months from the date of notification and reminder as stipulated in Clause 2 of this Article, the person involved in the accident or their relatives still do not repay, the lower-level Social Insurance Agency shall report to the higher-level Social Insurance Agency for consolidation and reporting to the Vietnam Social Security.

4. At the end of the fiscal year, the Vietnam Social Security shall compile the medical examination and treatment costs for persons participating in health insurance who have been involved in traffic accidents but cannot be recovered and submit them to the Ministry of Health to take the lead and coordinate with the Ministry of Finance to request the Prime Minister's approval to settle these unrecovered amounts into the health insurance fund.

Article 6. Effectiveness

1. This Circular takes effect from December 26, 2011.

2. Abolish Clause 3 of Article 8 of the Joint Circular No. 09/2009/TTLT-BYT-BTC dated August 14, 2009 of the Ministry of Health and the Ministry of Finance guiding the implementation of health insurance when this Circular takes effect.

Article 7. Implementation Organization

1. Entrust the Vietnam Social Security to issue a consolidated form and report on cases where recovery of costs as stipulated in Clause 3 of Article 5 of this Circular cannot be achieved, and guide the Social Security agencies at all levels to organize implementation.

2In the case of a participant of health insurance who was involved in a traffic accident before this Circular took effect but is still undergoing treatment at a medical 1. Ensure all material conditions, equipment, and human resources to implement the approved technical examination and treatment catalog. facility, it shall be implemented according to this Circular.

During implementation, if there are any difficulties, please promptly report to the Ministry of Health and the Ministry of Finance for research and resolution./.