BAO mtm xx HoI VIET NAM CQNG HOA XA HQI CHU NGHIA VIET NAM DOc lap - Tv do - Hanh phtic StS: /BHXH-DVT V/v htrang clan thanh toan chi phi VTYT theo Th

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1 BAO mtm xx HoI VIET NAM CQNG HOA XA HQI CHU NGHIA VIET NAM DOc lap - Tv do - Hanh phtic StS: /BHXH-DVT V/v htrang clan thanh toan chi phi VTYT theo Th8ng to so 04/2017/TT-BYT Ha Noi, ngay 04 tiding 6 nain 2017 Kinh giri: - Bao hiem xa hoi cac tinh, thanh ph6 true thuoc trung uang; - Bao hiem xa hoi BO Qu6c ph6ng; - Bao hiem xa hoi Cong an nhan dan. (sau clay goi chung la BHXH cac tinh) BO Y t6 ban hanh Thong tu s6 04/2017/TT-BYT ngay 14/4/2017 ban hanh Danh muc va ts, le, dieu kien thanh toan doi vai vat to y t6 (VTYT) thu6c pham vi dtro.c hiring cua ngued tham gia bao hiem y to (sau day goi la Thong tu 04) va Quyet dinh so 2192/QD-BYT ngay 31/5/2017 ye viec dinh chinh Thong tu so 04. De th6ng nhdt thirc hien, Bao hiem xa hoi (BHXH) Viet Nam hung dan BHXH cac tinh ph6i hop vai ca sa kham benh, chua benh (KB, CB) bao hiem y to (BHYT) trien khai nhu sau: 1. Can cir xay dung danh muc VTYT sir dung tai ca so KB, CB lam ca so thanh toan chi phi VTYT BHYT: Thuc hien theo Khoan 1, Dieu 2, Thong tu 04. Trong do km Si nguyen tac lua chon cac loaf VTYT dap ims nhu eau kham benh, china benh, phi' hop yeti kha nang chi tra cua quy bao hiem y t6; uu tien vat tu y to san xudt trong nuac CO chat lucmg va gia thanh hop Vr. 2. Ca so. KB, CB co trach nhiem cung cap cho ca quan BHXH de lam ca sa giam dinh va thanh toan chi phi VTYT cac tai lieu sau: a) Bang ke danh muc VTYT (bang van ban gidy va bang van ban dien tir dinh clang excel) theo mau tai Phu luc 02 hoac Phu luc 03 (doi yeti cac, ca son KB, CB ngoai ding lap chon ap dung mua VTYT theo quy dinh cila Dieu 52 Luat ddu thau) ban hanh kern Thong tu 04: - Bang ke danh muc VTYT chi bao g6m cac VTYT &roc thanh toan rieng, chua &roc tinh chi phi vao gia cua Bich vu ky thuat, kham benh, ngay gitrong dieu tri hoac thu tron goi theo tn.rong hop benh sir dung tai ca so KCB. - Ca so KB, CB ghi r6 thoi diem bat dl ap dung d6i vai Danh muc VTYT nay de lam ca sa thanh toan vai ca quan BHXH. - Trat tu VTYT trong Bang ke danh muc VTYT duoc sap xep nhu sau : I. Vat to y te khong quy dinh tst le, khong quy dinh mire thanh toan, khong tai sir dung, khong sir dung theo dinh mire II. Vat tu y t6 quy dinh muc thanh toan III. Vat to y to quy dinh ts, le thanh toan 1

2 IV. Vat tu y to tai s* dung V. Vat tu y t6 sir dung theo dinh mirc VI. Vat tu y to do co so. KB, CB tu san x at - Co so. KB, CB ghi ma dm dich vu thuat (DVKT) tuong irng vai Danh muc VTYT duoc s* dung de thvc hien DVKT tai cot ghi chit (cot so 15) cita Phu luc 02 Thong tu 04; truong hop co 46. KB, CB sir dung Phu luc 03 Thong to 04, co sa KB, CB 1)6 sung cot ghi c I t\tk it (la cot so 21, tiep theo cot so 20) va thvc hien ghi ma dm dich vu ky thuat (D T) vao cot nay. b) Quyet dinh phe duyet ke hoach Iva chon nha thau, Quyet dinh phe duyet ket qua Iva chon nha thau cung irng VTYT (bang van ban giay va bang van ban dien dr dinh clang excel). c) Thong bao bang van ban dinh mirc sir dung cac loai VTYT kilo dinh luting. d) Thong bao bang van ban ai vai VTYT tai sir dung: - Se ran sir dung to'i da cua tirng loai VTYT. - Gia thanh toan VTYT cho moi IAn sir' dung can cir theo quy dinh tai Khoan 1, Khoan 2 Dieu 5 dm Thong tu 04. d) Thong bao bang van ban del vai VTYT do co sa KB, CB to san xuat gin kern theo cac tai lieu ve quy trinh san xuat, gia thanh san pham do Giant doe co so. KB, CB phe duyet ding co cau chi phi cau thanh san pham. e) Cung cap hoa don, chimg tir mua VTYT doi vai cac VTYT chua dtrov tinh chi phi vao gia cua dich vu ky thuat, kham benh, ngay gitremg dieu tri ho4c thu tron goi theo twang hop benh trong cac dcyt iant dinh, thanh tra, kiem tra chi phi kham benh, chua benh bao hiem y te; 3. Co quan BHXH thvc hien giam dinh va thanh toan chi phi VTYT: 3.1. Sau khi nhan day dit he so tai lieu TYT do,co sa KB, CB,giri cho co quan BHXH tai diem 2 neu tren, co quan HXH kiem tra, del chieu, giam dinh danh muc va gia VTYT, be sung vao h so Hop deng KCB BHYT cua tirng co sa KB, CB vai co quan BHXH; Truen4 hop phat hien co,van,de bat hop 1/, co. quan BHXH th6ng bao bang van ban chd co sa KB, CB de ph6i hop thvc hien, b6 sung day dit ho so tai lieu VTYT theo quy dinh Phi hop vai co so. KB, CB cai d4t4 khai bao, quan ly co sot du lieu teen phan mem thanh toan vien phi doi voi VTYT sir dung tai co so. KB, CB, lam can c* giam dinh thanh toan chi phi KCB BHYT theo quy dinh Giam dinh va thanh toan chi phi VTYT a) Can cir giam dinh thanh toan chi phi V - VTYT phai co trong Danh mix Phu luc 1 va Bang ke danh muc VTYT do co so. KB, CB 14p theo Phu luc 02 hoac Phu luc 03 Thong tu 04; - VTYT chua ducyc tinh chi phi vao gia cua dich vu ky thuat, kham benh, ngay giuong diet' tri hoc thu tron goi theo truong hop b'enh (dugc ghi chit cu the doi vai tirng dich vu ky thuat y to tai Thong to 37/2015/TTLT-BYT-BTC ngay 29/10/2015 dm lien BO Y te, BO Tai chinh quy dinh thong nhat gia dich vu KB, 2

3 CB BHYT gifra cac benh vien ding hang tren toan qu6c); - S6 luting VTYT thuc to dirge chi dinh, sir dung cho nguai benh; Gia VTYT mua vao cua ca so' KB, CB theo quy dinh cua phap 101 ve dau thau; doi yeti VTYT c6 gia mua vao cao hon muc thanh toan quy dinh tai cot 5 Danh muc VTYT tai Phu luc 01 Thong tu 04, thi thanh toan bang mix thanh toan quy dinh tai cot 5; - Dieu kien, ts7 le thanh toan, muc thanh toan quy dinh tai cot 5 Danh muc VTYT tai Phu luc 01 Thong tu 04; - Pham vi va mirc lux6mg theo quy dinh cua phap lust ve bao hiem y b) Mirc thanh toan tong chi phi VTYT cho mot lan sir dung dich vu ky thust kh6ng vuot qua 45 thang luting co. so theo muc hung cua tong nhom doi Wong tham gia BHYT (100%, 95%, 80%). D6i voi VTYT da duoc quy dinh ts, le thanh toan tai cot 5 Danh muc vat tu y to tai Phu luc 01 Thong tu 04 thi khong ap dung quy dinh nay; 4. Viec thanh toan VTYT trong cac tnrerng hqp cu the nhu sau: a) D6i ttron tham gia BHYT co thoi gian tham gia BHYT lien tuc du 5 nam tra len tinh den theari diem sir dung DVKT (trir tnxong hop tu di kharn benh, chfia benh khong dung tuyen), se &roc quy BHYT chi tra toan b6 phan cang chi tra vuot qua 6 thang luting co so, t6i da la 45 thang Krung co sa, theo quy dinh tai diem c Khoan 1 Dieu 22 Luat BHYT sira doi. Ph&n ding chi tra chi phi VTYT cua ngtroi benh, ducic xac dinh theo ts7 le ding chi tra (0%, 5%, 20%) d6i vai tong chi phi VTYT, sir dung cho mot 1An thkrc hien DVKT, thuoc pham vi thanh toan cua quy BHYT (bao gom VTYT thuc to sir dung va muc gia thanh toan terng VTYT theo gia mua vao theo quy dinh phap lust ye dau than; mire thanh toan doi vai VTYT c6 quy dinh mire thanh toan tai cot 5, Phu luc 01 Thong tu 04; theo gia thanh toan VTYT cho m6i lan sir dung doi yeti VTYT tai sir dung; theo gia thanh toan VTYT cho m6i an sir clung d6i vbi VTYT c6 dinh mix sir dung; theo gia VTYT tu san xuat do Giarn d6c co so. KB, CB phe duyet). PhAn chi phi VTYT do gia mua vao vuot mire gia thanh toan quy dinh tai cot 5 oh Phu luc 01 Thong tu 04 va do vuot 45 thang luting ca so khong &roc xac dinh la ph'an chi phi VTYT thuoc pham vi thanh toan cua quy BHYT va thuoc trach nhiem chi tra cua nguai benh BHYT. b) D6i vai tnrong hop dat Stent dong mach vanh phai sir dung nhieu hon mot stent phu thuoc: thkrc hien theo quy dinh tai diem c Khoan 2 Dieu 3 Thong tu 04 va Quyet dinh so 2192/QD-BYT dinh chinh Thong tu so 04, trong d6 luu nhu sau: - D6i vbi stent thir hai: guy BHYT thanh toan them mot phan hai (1/2) chi phi dm stent thir hai theo gia mua vao dm co. so. KB, CB nhung khong cao hon (fang, 'thong phu thuoc vao muc huang cua nguad benh (100%, 95%, 80%) va khong phu thuoc vao thoi gian tham gia BHYT cim nguoi benh. c) Cac d6i tu9ng quy dinh tai Diem b Khoan 1 Dieu 4 Nghi dinh s6 105/2014/ND-CP ngay 15/11/2014 va Dieu 2 Nghi dinh so 70/2015/ND-CP 3

4 ngay 01/9/2015 ctila Chinh - Kh6ng ap dung quy dinh "T6ng chi p i VTYT cho mot Fan s* dung dich vu ky thuat khong vuot qua 45 thang Won ca so". - Kh6ng ap dung ty le thanh toan d6i voi cac VTYT c6 quy dinh t5, le thanh toan quy dinh tai cot 5 Phu luc 01 Thong to Ap dung mirc thanh toan doi voi cac V YT c6 quy dinh mire thanh toan quy dinh tai cot 5 Phu luc 01 Thong tu Ap dung dieu kien thanh toan d6i vai c c VTYT c6 dieu kien thanh toan quy dinh tai cot 5 Phu luc 01 Thong tu 04. d) D61 vai VTYT c6 nhieu chung loai, ieu mirc gia khac nhau: De dam bao quyen lgi, han the viec ph4i chi tra chi phi chenh Lech cho nguai benh, co so. KB, CB c6 trach nhiem hoach mua sam VTYT dam bao chat luting c6 gia ca ph* hop, dap An* you Icau diet' tri, d6ng thoi thong bao vai nguai benh gia cac loai dugc mua sam, mire thanh toan theo quy dinh de nguiyi benh hra chon. Tr&mg hop nguai benh de nghi s* dung loai VTYT co gia cao han mirc thanh toan, nguai benh to chi tra han chi phi chenh Lech giira gia mua vao va mire thanh toan. d) VTYT kho dinh luting khi sir dung, t i Khoan 3 Dieu 4 Thong tu 04: Twang hop theo chi dinh chuyen mon, guai benh chi sir dung mot phan cua VTYT ma co sa KB, CB mua vao, phan c' n lai khong the s* dung dugc (vi du: khong c6 nguai benh sir dung, phan can lai khong du de sir dung, qua thai han sir dung) thi quy BHYT thanh toan chi phi 'heo gia mua vao cua VTYT. Ca so. KB, CB thong bao cu the danh ach nguai benh, loai VTYT va DVKT da dugc chi dinh sir dung cho ca quan HXH de doi chieu h6a don mua VTYT lam co so giam dinh, thanh toan. e) Doi vai VTYT co the tai sir dung: Co so KB, CB thong bao cho ca quan HXH danh muc, s6 Fan sir dung, gia thanh toan cua tirng loai VTYT lam can cir giam dinh thanh toan theo huong dan tai Dieu 5 Thong tu 04. Cuei nam, ca quan BHXH doi chieu s6 luting VTYT theo hoa dan mua, so nguai benh da.dugc ca so KCB chi dinh sir flung thanh toan doi vori tirng loai DVYT tucmg img, de xac dinh thuc to so lan Sir dung trung binh ctia tirng loai VTYT lam ca sa xac dinh, th6ng nhat vai co so KCB dieu chinh chi phi VTYT tai sir dung trong nam. Throng hop co. s6. KB, CB mai tri6n khai, co quan BHXH thong bao cho ca so KB, CB so Ian sir dung trung binh cua cac loai VTYT da duce cac ca so KB, CB khac dang thuc hien (theo Danh muc VTYT tai sir dung dinh kern theo Cong van nay va dugc cap nhat tren cong ng tin dien to cua BHXH Viet Nam) de tham khao tri'en khai, thuc hien. g) D6i voi'vtyt c6 dan vi tinh la "b0" hanh toan theo quy dinh tai diem 4 Khoan 4 Thong tu 04: - Can cir.thuc to nhu cau chuyen mon, so KB, CB xay dung ke hoach 4

5 dau thau mua sam cung irng VTYT theo "be"; chi tiet dm "be" de phi.' hap vai viec sir dung tai dan vi, tranh xay,ra lang phi. - Co KCB ra,soat ca cau gia cac DVKT c6 sir dung VTYT duac tinh theo be, thong nhat yen ca quan BHXH cach thirc thanh toan VTYT trong cac DVKT, dam bao khong thanh toan tang. - Truong hop VTYT duac mua sam theo "be" nhung thuc to chi sir dung met hoc met so be phan trong "be": thanh toan ton goi theo be khi cac be phan con lai khong the sir dung duac. Ca sa KB, CB thong ke cac be phan dm be VTYT con lai khong sir dung dirge va thong bao bang van ban vai ca quan BHXH de doi chieu h6a dan mua VTYT lam ca sa giam dinh, kiem sok, thanh toan. h) Huang dan thanh toan met s6 VTYT cu the: - VTYT sir clung trong DVKT cay/dlat may tao nhip, ma s6 37.8D tai 'Thong to so 37/2015/TTLT-BYT-BTC: duac quy BHYT thanh toan VTYT, Om "may tao nhip (bao gom may va he thong day), ma N va kim tham do, ma NO VTYT "Meroches va cac loai x6p mui, tai, xoang cac loai, cac co." c6 ma so N tai Thong to 04, bao,gom cac loai, cac c43. meroches (miii, tai, xoang, vach ngan) va cac loai, cac c6." xop mui, tai, xoang. - VTYT "Ong th& 2 nong khi quail cac loai, cac ca", thanh toan theo ma s6 N "Ong noi khi quart sir dung met ran cac loai, cac (bao gam ong nei khi quan,canlene) tai Thong tu so 04. De nghi BHXH tinh phoi. hap vai ca so. KB, CB thong nhat cac twang hop chi dinh sir dung cu the de thanh toan, dam bdo hieu qua, sir dung quy BHYT. 5. DOi vori cac ca sa y to ngodi cong Ca sa KCB ngodi cong lap tix t6 chirc dau thau theo quy dinh cua phap luat ye dau thau hoc chon ap dung mua VTYT theo quy dinh dm Dieu 52 Ludt &Au thau theo huong dan tai Khodn 6 Dieu 3 Thong to so 04; - BHXH cac tinh kiem tra, d6i chieu, giant dinh, xac dinh chi phi VTYT thanh toan theo quy dinh. 6. BHXH cac tinh chit' dong tham gia Tau thau cung img yd. quart 1.$, chi phi VTYT tai cac ca so KB, CB: 6.1. Chit Ong tham gia qua trinh Kira ch9n nha thau mua sam VTYT tap trung va rieng le trong cac co. so. KB, CB, dam bdo nguyen tac sau: a) Ddm bdo an town, hap ly, tiet kiem, dap img nhu cau KB, CB ; b) Phu hop vai kha. Wang chi tra. cua quy BHYT ; c) Lru tien Iva chon VTYT san xuat trong nu& co chit Kral-1g, gia thanh h9p ly nhu quy dinh tai Khoan 1 Dieu 2 Thong tu so 04 ; d) Doi vai cac VTYT c6 mirc thanh toan quy dinh tai OA 5 Phu luc 01 ban hanh kern Thong tu so 04, khi lap, tham dinh, phe duyet k'e hoach lua chon nhd thau hoc khi lap ice hoach mua sam (d6i vai ca sa KB, CB ngodi cong lap ch9n 5

6 a dung mua VTYT theo quy dinh cita Dieu 52 Luat Dau thau) can tru tien mua sam nhfing loci VTYT c6 ding tieu chi chat lu g nhung c6 gia thap,hon hoc bang mire thanh toan de berth nhan lua chon, h the thanh toan tir tien titi. dm nguoi berth BHYT Tap trung phan tich, so sanh gia VTYT trung thau tai cac co sa KB, CB teen dia ban, voi cac co s6 KB, CB cila cab dia phucmg khac (theo dit lieu cong khai ten cong thong tin dien tir dm BHXH Viet Nam), phat hien gia VTYT cao bat hop ly, BHXH tinh c6 Y kien vai So. Y te, SO. Tai chinh va cac co. so KB, CB de c6 giai phap khac phuc, dieu chinh gia VTYT; d6ng thai xac dinh nguyen nhan, giai phap khac phuc trong ky dau thau VTYT tiep theo ThuOng xuyen kiem tra, danh gia tinh hinh sir dung VTYT thuc te tai cac co set KB, CB, phat hien cac bat thtrong, xac dinh cac nguyen nhan va de xuat giai phap dam bao viec lua chon, sir dung VTYT tai cac co s6 KCB hop ly. 7. Che do bao cao: BHXH cac tinh thuc hien the do bao cao theo quy dinh cila Tong Giam doc BHXH Viet Nam, dong thoi giri ye BHXH Viet Nam (Ban Duqc va VTYT) cac tai lieu tai diem a, b.!, c, d, d, e diem 2 Cong van nay (ban scan va file excell) khi c6 phat sinh. 8. Viec thanh toan VTYT trong giai doan chuyen tiep: - Thuc hien theo quy dinh tai Dieu 7 Tho g tir so DOi v6i Danh muc VTYT sir dung tru6 ngay 1/6/2017 ma tiep tuc dugc co so. KB, CB sir dung tir ngay 1/6/2017, de nghi cac co. sec KB, CB ra sok, dieu chinh, chuyen ma VTYT theo quy dinh tai Phu luc so 02, Phu luc so 03 Thong tir 04, thong bao cho co quan BHXH de lam co sg quan 1Y, thanh toan VTYT. - DOi yen cac VTYT c6 trong Thong tu so 27, dirge thanh toan rieng ngoai gia DVKT nhung khong thuc pham vi thanh tpan BHYT theo Thong tu 04, co. so. KB, CB tong hop so lugng tong loci VTYT da trung thau va dal dugc co soy KB, CB ky hop dong voi nha cung img truac ngay ThOng tu 04 do hieu luc giri co. quan BHXH truac ngay 15/6/2017 de lam cjo so giam dinh, thanh toan theo quy dinh (kern theo hop dong cung img, so lugrig VTYT ton den thai diem ngay 1/6/2017); Nhan dugc cong van nay, de nghi BHXI- cac tinh khan,trucmg thuc hien. Trong qua trinh to chirc thuc hien, neu c6 kho khan, vuang mac, cac don vi bao cao BHXH Vie Nam (Ban Duqc va VTYT) de kip thoi c6 hu6ng clan chi dao giai quyet./. Noi nh(111: - Nhu ten; - BO Y te; - TOng Giam doc (a b/c); - Cac Pho TOng Giant doc; - Sar Y to cac tinh, TP trtrc thuc TW; - Cac Benh vien,vien có gitrerng berth thuc BO Y t& - Cue Quan Y-BQP; Cue Y te-bca; Cue Y te-bo GT-VT; - Cac don vi: CSYT, TCKT, TTKT, KTNB; GDB; GDN; - COng thong tin dien tir BHXH VN; - Luu: VT, DVT (06b). van, 6 KT. TONG GIAM DOC PHO TONG GIAM DOC

7 sir dung va so lan sir dung trung binh co' KCB nam 2016 /BHXH-DVT ngay.0114 /2017 cida BHXH Viet Nam Ma A theo.1' Don vi SO Ian sir dung STT nhom (tai TT Ten VTYT tinh trung binh 04) 1 NO Barn ap luc a barn b6ng nong dong mach Cai 1,2 vanh 2 NO Kim choc vach lien nhi Cai 10 3 N Catheter chin down (di8n cue chin down) Cai 3 4 Catheter dot loan nhip (trong bo dung cu N ,, Cai 2 dieu tri roi loan nhip tim bang RF) 5 Ong thong trg giup can tlii8p (Guiding Cai 1,2 N Catheter) 6 N Catheter ta giup can thi8p Ong mach vdnh Cai 1,2 7 N Dau dao cat gan sieu am Cai 3 8 N BO Sheath dai dung trong can thi8p mach chi (Long sheath) BO 1,5 9 N BO 6ng thong (Sheath hoac delivery BO 1,5 system) 6 tha db. dung 18 thong lien nhi 10 N BO ma duang vao mach mall Cai 1,5 11 N Bong Inoue d6 nong van hai la Cai BO tha dii (Jong 18 thong lien nhi, 6ng dong N BO 1,2-2 mach, thong li8n that 13 N Bong do duong kinh 18 thong lien nhi Cai 1,5 14 N Bong nong dong mach varih Cai 1, N B6ng nong van dong mach phi 4 16 N Dung cu lay di vat (multi-snare) trong tim C'Zii mach 17 N Dau cat dich kinh Cai 4 18 N Dung cu khau cat not thing (noi soil m6 mo) Chik 4