Circular No. 48/2017/TT-BYT on the extraction and transfer of electronic data in the management and settlement of medical examination and treatment costs under health insurance

CIRCULAR

REGULATIONS ON THE EXTRACTING AND TRANSFERRING OF ELECTRONIC DATA IN MANAGEMENT

AND PAYMENT OF HEALTH INSURANCE EXPENSES FOR MEDICAL EXAMINATION AND TREATMENT

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

Based on Decree No. 1Decree No. 66/2016/NĐ-CP dated December 24, 2016 of the Government on electronic transactions in the social insurance and health insurance sectors and occupational injury insurance sector; health insurance andsocial health insurance;medical establishments;health insurance;

At the proposal of the Director of the Health Insurance Department;3. Data format:

The Minister of Health issues this Circular regulating the extracting and transferring of electronic data in management and payment of expenses for medical examination and treatment under health insurance. is a document or information successfully sent, received, and stored on the System, including: This Circular regulates electronic data, format of electronic data, procedures, methods, time of transferring electronic data, and feedback on receiving electronic data for management and appraisal, payment of expenses for medical examination and treatment under health insurance. Common directoryincludes information about technical services, medicines, medical supplies, blood and its products, disease names, medical examination and treatment facilities, and other relevant information related to medical examination and treatment activities that have been coded and divided into directories (Common Directory Code Table) by the Minister of Health, applicable in medical examination and treatment facilities under health insurance and agencies implementing appraisal and payment of expenses for medical examination and treatment under health insurance throughout the country..

PART I

GENERAL PROVISIONS

Article 1. Scope of Regulation

Information technology infrastructure

Article 2. Interpretation of Terms

In this Circular, the following terms are understood as follows:

1. consists of computing devices (servers, workstations), peripheral devices, network connection devices, auxiliary devices, internal networks, wide area networks, information technology applications, and other equipment. XML

2. is an abbreviation for the English term "eXtensible Markup Language," meaning Extensible Markup Language, created with the purpose of sharing electronic data between different information technology systems. 4. UTF-8 is an 8-bit Unicode conversion format.

3. Article 3. Principles of transferring and receiving electronic data 1. Electronic data must meet the requirements stipulated in this Circular.

2. Extracting and transferring electronic data and receiving electronic data must ensure transparency, honesty, equality, security, confidentiality, efficiency, and compliance with legal regulations on electronic transactions.

EXTRACTING AND TRANSFERRING OF ELECTRONIC DATA

Article 4. Input data and output data in management and appraisal, payment of expenses for medical examination and treatment under health insurance

1. Electronic data used in management and appraisal, payment of expenses for medical examination and treatment under health insurance include: input data and output data.

Chapter II

2. Input data and output data are built based on and must comply with the provisions of the Common Directory Code Table issued by the Minister of Health, meeting the requirements for connecting and interlinking electronic data to serve management and appraisal, payment of expenses for medical examination and treatment under health insurance.

3. Format of electronic data:

a) Using XML language to format electronic data; using UTF-8 character encoding table to represent characters in the Unicode set.

b) Each XML file may contain one or more health insurance medical examination and treatment records, each record containing information about one episode of medical examination and treatment for a patient, including cases where a patient has two or more health insurance cards during one episode of medical examination and treatment.

a) Use the XML language to format electronic data; use the UTF-8 character encoding table to represent characters in the Unicode character set.

b) Each XML file may contain one or more medical examination and treatment records for health insurance, including each record containing information about a medical examination and treatment session of a patient, which includes cases where a patient has two or more health insurance cards in one medical examination and treatment session.

b) Each XML file may contain one or more medical examination and treatment records under health insurance, wherein each record includes information about a single medical examination and treatment session of a patient, including cases where the patient has two or more health insurance cards for a single medical examination and treatment session.

Article 5. Methods for transferring electronic data

1. Methods for transferring electronic data include:

a) Method 1: Connection via web service;

b) Method 2: Synchronizing electronic data from desktop software;

c) Method 3: Direct data entry;

d) Method 4: File transfer using FTP (File Transfer Protocol).

2. Medical examination and treatment facilities have the right to choose one of the methods for transferring electronic data specified in Clause 1 of this Article but must ensure the accuracy of the data and achieve the same results as the output data.

Article 6. Procedure for sending electronic data and feedback on receipt of electronic data for managing medical examinations and treatments under health insurance

1. Time for sending electronic data for managing medical examinations and treatments under health insurance:

Medical examination and treatment facilities shall send electronic data to the Data Reception Portal of the Health Insurance Claim Information System of the Vietnam Social Security (hereinafter referred to as the Claim Information Portal) immediately after the completion of a medical examination session or outpatient treatment session or inpatient treatment session for patients, except in cases stipulated in Article 8 of this Circular.

2. Feedback on receipt of electronic data for managing medical examinations and treatments under health insurance

a) Upon receiving information from medical examination and treatment facilities regarding the verification of the status and health insurance card information of patients seeking medical care, the Claim Information Portal must provide feedback on the status and health insurance card information of such individuals, while also providing a complete history of their medical examinations and treatments with minimum information, including: time of medical examination and treatment, main diseases suffered and accompanying diseases (if any) according to ICD-10 or traditional medicine codes, and the status of medical examination and treatment in the last six months.

b) After receiving electronic data from medical examination and treatment facilities regarding the completion of a medical examination session or outpatient treatment session or inpatient treatment session for patients, the Claim Information Portal must notify the medical examination and treatment facilities that the electronic data has been received.

3. The transfer of electronic data after the completion of an outpatient medical examination session or outpatient treatment session or inpatient treatment session for patients to the Claim Information Portal for managing medical examinations and treatments under health insurance does not require electronic data authentication.

Article 7. Procedure for sending electronic data and feedback on receipt of electronic data for requesting claim review and payment of medical examination and treatment costs under health insurance

1. Within seven working days from the date of completion of medical examinations and treatments for patients, medical examination and treatment facilities must perform:

a) Checking and comparing to adjust electronic data if there are discrepancies with reality and supplement missing information or remove unsuitable information before sending electronic data for requesting payment of medical examination and treatment costs under health insurance;

b) Authenticating electronic data for requesting claim review and payment of medical examination and treatment costs under health insurance before sending the data to the person assigned the task or authorized person;

c) Sending electronic data to the Ministry of Health's Medical Data Reception Portal and the Claim Information Portal, except in cases stipulated in point d of Clause 1 of this Article.

d) Sending electronic data for requesting claim review and payment of medical examination and treatment costs under health insurance arising at the end of the month, quarter, or year to the Ministry of Health's Medical Data Reception Portal and the Claim Information Portal before the fifth day of the following month.

2. Feedback from the Ministry of Health's Medical Data Reception Portal: Immediately upon receiving electronic data transferred from medical examination and treatment facilities, the Ministry of Health's Medical Data Reception Portal must notify the medical examination and treatment facilities that the electronic data has been received.

3. Feedback from the Claim Information Portal:

a) Immediately upon receiving electronic data for requesting claim review and payment of medical examination and treatment costs under health insurance transferred from medical examination and treatment facilities, the Claim Information Portal must provide feedback to the medical examination and treatment facilities on the result of sending and receiving the electronic data;

b) Within seven working days from the date of receiving electronic data for requesting claim review and payment of medical examination and treatment costs under health insurance, the Claim Information Portal must provide detailed notification of the result of reviewing the electronic data for requesting claim review and payment of medical examination and treatment costs under health insurance;

c) In cases where the electronic data for requesting claim review and payment of medical examination and treatment costs under health insurance is flagged or rejected for payment or both flagged and rejected for claim review and payment, the Claim Information Portal must provide detailed notifications of the flagged errors or rejection errors according to each field of each XML table for the medical examination and treatment facilities to be aware and promptly complete.

Article 8. Cases of Sending Electronic Data Late Than the Specified Time

1. Electronic data serving management and appraisal, payment of medical examination and treatment costs under health insurance may be sent late compared to the provisions of this Circular in the following cases:

a) Due to objective incidents or force majeure causing the information technology infrastructure system to fail to meet the requirements for extracting or receiving electronic data.

b) The information technology infrastructure system fails to meet the requirements for extracting or receiving electronic data due to lack of electricity or internet connection.

2. When objective incidents or force majeure as stipulated in point a, Clause 1 of this Article occur from the side of the medical examination and treatment facility sending electronic data or from the side of the agency receiving electronic data, the party causing the incident shall immediately notify the other party of the cause of the incident. Notification shall be made by telephone, email, or written form. Electronic data shall continue to be sent and received immediately after the incident has been repaired and resolved.

3. In cases where the reasons are as specified in point b, Clause 1 of this Article, the method and time of sending electronic data shall be decided by the head of the medical examination and treatment facility and the head of the social insurance agency that signed the medical examination and treatment contract under health insurance with such medical examination and treatment facility, and must be clearly recorded in the medical examination and treatment contract under health insurance. At the same time, the heads of the medical examination and treatment facilities and the social insurance agency have the responsibility to report in writing to the direct supervisory agency.

Article 9. Confidentiality and Management of Data

1. The sending, transmission, receipt, response, exchange, and management of electronic data as prescribed in this Circular must be kept confidential and managed according to the regulations of laws on information technology, network security, medical examination and treatment, and other relevant laws.

2. In addition to implementing the provisions of Clause 1 of this Article, agencies, organizations, and individuals participating in the sending, transmission, receipt, response, exchange, and management of electronic data have the responsibility to:

a) Ensure the safety, confidentiality, accuracy, and integrity of electronic data and use electronic data within their functional responsibilities, duties, and authorities; cooperate with related agencies, organizations, and individuals to implement necessary technical measures to ensure the authenticity of data, confidentiality, and security of the system;

b) Comply with legal regulations and procedures for ensuring the privacy of healthcare information on the network.

Chapter III

RESPONSIBILITIES FOR IMPLEMENTATION

Article 10. Responsibilities of the Ministry of Health

1. Direct, guide, and inspect the extraction and transfer of electronic data for medical examination and treatment under health insurance and appraisal, payment of medical examination and treatment costs under health insurance for Departments of Health, health departments of ministries and sectors, medical examination and treatment facilities under health insurance, and agencies receiving and managing electronic data.

2. Take the lead and coordinate with the Vietnam Social Security and related agencies, organizations, and individuals in:

a) Building, updating, adjusting, revising, and supplementing the Common List, format, and output data standards and other relevant regulations to organize and implement this Circular;

b) Prescribing the extraction and transfer, receipt, response, and appraisal of electronic data for medical examination and treatment under health insurance for some special cases;

c) Building a related information system for managing medical examination and treatment under health insurance and issuing guiding documents for implementation;

d) Receiving and resolving any difficulties and issues arising during the implementation process.

3. Ensure the reception, management, exploitation, and use of medical examination and treatment data under health insurance and other data serving state management at the Ministry of Health's Medical Data Reception Portal.

4. Assign Departments, Bureaus, and units related to the Ministry of Health to carry out tasks to meet the needs of management and appraisal, payment of medical examination and treatment costs under health insurance.

Article 11. Responsibilities of the Vietnam Social Security

1. Ensuring human resources, infrastructure systems including server machines, workstations, network connections, software components, health insurance card database, and the Health Insurance Claim Verification Information Portal to meet the requirements for searching medical examination and treatment information under health insurance, managing medical examination and treatment routes, and promptly receiving, responding to, and securing electronic data requests for claim verification and payment of medical examination and treatment costs from healthcare facilities sent to the social security agency accurately and completely.

2. Applying correctly and fully the common code catalogues and regulations on standards and data formats for output data issued by the Minister of Health, meeting the requirements for receiving and managing electronic data from healthcare facilities sent for claim verification and payment of medical examination and treatment costs under health insurance.

3. Providing the common catalogues that the Vietnam Social Security has developed or proposed to develop and supplement, for issuance by the Minister of Health.

4. Establishing, issuing, and announcing the health insurance card database, electronic claim verification procedures and rules on the software system to ensure the connection and interoperability between the claim verification and cost payment system and the software management system for medical examination and treatment under health insurance at healthcare facilities, and being responsible for the status, accuracy, security, safety, and cybersecurity of the health insurance card information database and electronic data of patients seeking medical examination and treatment under health insurance that have been transferred to the Health Insurance Claim Verification Information Portal of the social security agency.

5. Directing lower-level social insurances to implement this Circular; timely and fully paying medical examination and treatment costs under health insurance to healthcare facilities according to the law.

6. Cooperating with the Ministry of Health in the implementation of digitalization of medical examination and treatment under health insurance and sharing all necessary information to serve the state management functions of the Ministry of Health and the tasks assigned to the Vietnam Social Security.

Article 12. Responsibilities of the Departments of Health of provinces and centrally-administered cities and health departments of ministries and sectors

1. Organizing the implementation, directing, guiding, inspecting, and urging the use of the common code catalogues and standards, and data format outputs issued by the Minister of Health, ensuring the extraction and transfer of electronic data serving the management of medical examination and treatment and claim verification and payment of medical examination and treatment costs under health insurance at healthcare facilities under their management, ensuring compliance with the provisions of this Circular.

2. Exploiting and using the electronic database on the Health Insurance Claim Verification Information Portal and the Medical Data Reception Portal of the Ministry of Health to serve management functions according to assigned responsibilities and decentralization. During the exploitation and use of the electronic database, it must ensure the confidentiality of patient medical examination and treatment information according to laws on information technology, network security, medical examination and treatment, and other relevant laws.

3. Taking the lead and coordinating with related agencies to resolve any issues arising during the implementation of this Circular. In cases where resolution is not possible, they shall promptly report to the competent authority for consideration and resolution.

Article 13. Responsibilities of medical examination and treatment facilities

1. Implement the use of the Common Item Code Set; Data standards and output formats; Electronic authentication issued by the Minister of Health to ensure timely, complete, and accurate electronic data transfer reflecting the true process of medical examination and treatment at the facility for management purposes and medical examination and insurance payment.

2. Retrieve information on health insurance cards of patients seeking medical examination and treatment under health insurance to ensure the rights of all parties as prescribed by law.

3. Bear responsibility for the accuracy of medical examination and treatment data and the confidentiality of such information and data according to legal regulations.

4. Report to the managing authority and social insurance agency when there are changes regarding authorized personnel for electronic management and authentication, use of assigned accounts related to electronic data transfer for medical examination and treatment management and insurance payment.

5. Comply with directives, inspections, audits, and supervision by competent authorities as prescribed by law.

6. Sign off on medical examination and treatment costs under health insurance at the medical examination and treatment facility when the patient or their representative does not proceed with the insurance payment procedures. The head of the medical examination and treatment facility shall bear legal responsibility for signing off and sending electronic data.

7. Immediately transfer electronic data as stipulated in Articles 6 and 7 of this Circular on the next working day following the completion of a medical examination session, outpatient treatment period, or inpatient treatment period for patients during non-standard medical examination and treatment days (on holidays, public holidays, or festivals).

8. Send electronic data for medical examination and treatment cost review and payment simultaneously with data sent for medical examination and treatment management if the medical examination and treatment facility can do so.

9. Be permitted to adjust previously submitted electronic data for medical examination and treatment cost payment requests upon discovery of discrepancies, but must clearly state the reasons and reach agreement with the social insurance agency.

10. Establish and implement regulations for providing, using, and storing healthcare information in medical examination and treatment activities, insurance payment processes, and other healthcare activities conducted via the internet at the medical examination and treatment facility without contravening legal provisions.

Chapter IV

IMPLEMENTING PROVISIONS

Article 14. Effective Date

This Circular takes effect from March 1, 2018.

Article 15. Transitional Provisions

Medical examination and treatment facilities that cannot connect to the Ministry of Health's Healthcare Data Reception Portal and the Health Insurance Examination Information Portal due to objective conditions are exempted from applying this Circular's provisions.

During implementation, if difficulties arise, relevant agencies, organizations, and individuals are advised to promptly report to the Ministry of Health (Health Insurance Department) for consideration and resolution./.