ORDER OF FEDERAL COMPULSORY HEALTH INSURANCE FUND OF THE RUSSIAN FEDERATION

of February 28, 2019 No. 36

About approval of procedure for the organization and monitoring procedure of amounts, terms, quality and conditions of provision of medical care on compulsory medical insurance

According to part 1 of article 40 of the Federal Law of November 29, 2010 No. 326-FZ "About compulsory medical insurance in the Russian Federation" (The Russian Federation Code, 2010, No. 49, Art. 6422; 2011, No. 49, Art. 7047; 2012, No. 49, Art. 6758; 2013, 27, of the Art. 3477) I order to No.:

1. Approve the enclosed Procedure for the organization and monitoring procedure of amounts, terms, quality and conditions of provision of medical care on compulsory medical insurance (further - the Procedure).

2. Recognize invalid:

the order of Federal Compulsory Health Insurance Fund of December 1, 2010 No. 230 "About approval of the Procedure for the organization and monitoring procedure of amounts, terms, quality and conditions of provision of medical care on compulsory medical insurance" (registration No. 19614) is registered by the Ministry of Justice of the Russian Federation on January 28, 2011;

the order of Federal Compulsory Health Insurance Fund of August 16, 2011 No. 144 "About modification of the Procedure for the organization and monitoring procedure of amounts, terms, quality and conditions of provision of medical care on compulsory medical insurance approved by the order of Federal Compulsory Health Insurance Fund of December 1, 2010 No. 230" (registration No. 22523) is registered by the Ministry of Justice of the Russian Federation on December 9, 2011;

the order of Federal Compulsory Health Insurance Fund of July 21, 2015 No. 130 "About modification of the Procedure for the organization and monitoring procedure of amounts, terms, quality and conditions of provision of medical care on compulsory medical insurance approved by the order of Federal Compulsory Health Insurance Fund of December 1, 2010 No. 230" (registration No. 38182) is registered by the Ministry of Justice of the Russian Federation on July 27, 2015;

the order of Federal Compulsory Health Insurance Fund of December 29, 2015 No. 277 "About modification of the Procedure for the organization and monitoring procedure of amounts, terms, quality and conditions of provision of medical care on compulsory medical insurance approved by the order of Federal Compulsory Health Insurance Fund of December 1, 2010 No. 230" (registration No. 40813) is registered by the Ministry of Justice of the Russian Federation on January 27, 2016;

the order of Federal Compulsory Health Insurance Fund of February 22, 2017 No. 45 "About modification of the Procedure for the organization and monitoring procedure of amounts, terms, quality and conditions of provision of medical care on compulsory medical insurance approved by the order of Federal Compulsory Health Insurance Fund of December 1, 2010 No. 230" (registration No. 46609) is registered by the Ministry of Justice of the Russian Federation on May 4, 2017.

3. To heads of territorial funds of compulsory medical insurance and medical insurance companies to use the enclosed Procedure under the organization and monitoring procedure of amounts, terms, quality and conditions of provision of medical care on compulsory medical insurance.

Appendix

to the Order of Federal Compulsory Health Insurance Fund of the Russian Federation of February 28, 2019 No. 36

Procedure for the organization and monitoring procedure of amounts, terms, quality and conditions of provision of medical care on compulsory medical insurance

I. General provisions

1. This Procedure for the organization and monitoring procedure of amounts, terms, quality and conditions of provision of medical care on compulsory medical insurance (further - the Procedure) No. 326-FZ "About compulsory medical insurance in the Russian Federation" is developed according to Chapter 9 of the Federal Law of November 29, 2010 <1> (further - the Federal Law "About Compulsory Medical Insurance in the Russian Federation") and determines rules and the procedure of the organization and carrying out by medical insurance companies and funds of compulsory medical insurance of control of amounts, terms, quality and conditions of provision of medical care by the medical organizations in amount and on conditions which are established by the territorial program of compulsory medical insurance and the contract for rendering and payment of medical care for compulsory medical insurance.

--------------------------------

<1> Russian Federation Code, 2010, No. 49, Art. 6422; 2011, No. 25, Art. 3529, No. 49, Art. 7047, 7057; 2012, No. 31, Art. 4322, No. 49, Art. 6758; 2013, No. 7, Art. 606, No. 27, Art. 3477, No. 30, Art. 4084, No. 39, Art. 4883, No. 48, Art. 6165, No. 52, Art. 6955; 2014, No. 11, Art. 1098, No. 28, Art. 3851, No. 30, Art. 4269, No. 49, Art. 6927; 2015, No. 51, Art. 7245; 2016, No. 1, Art. 52, No. 27, Art. 4183, 4219; 2017, No. 1, Art. 12, 13, 14, 34; 2018, No. 27, Art. 3947, No. 31, Art. 4857, No. 49, Art. 7497, 7509; 2019, No. 6, Art. 464.

2. The purpose of this Procedure - regulation of the actions directed to realization of the rights of insured persons in the sphere of compulsory medical insurance including on providing at the expense of means of compulsory medical insurance of guarantees of free rendering medical care to insured person in case of loss occurrence within the territorial program of compulsory medical insurance and the basic program of compulsory medical insurance, creation of conditions for ensuring availability and quality of the medical care provided within programs of compulsory medical insurance.

II. Purposes of control of amounts, terms, quality and conditions of provision of medical care on compulsory medical insurance

3. Actions for check of compliance to the medical care provided to insured person to amount and conditions which are established by the territorial program of compulsory medical insurance and the contract for rendering and payment of medical care for compulsory medical insurance belong to control of amounts, terms, quality and conditions of provision of medical care on compulsory medical insurance (further - control).

4. Object of control is the organization and delivery of health care to insured person for compulsory medical insurance.

5. Subjects of control are the territorial funds of compulsory medical insurance, medical insurance companies and the medical organizations performing activities in the sphere of compulsory medical insurance <2>.

--------------------------------

<2> According to part 1 of Article 14 and part 1 of article 15 of the Federal law "About Compulsory Medical Insurance in the Russian Federation".

6. Control purposes:

1) ensuring free rendering medical care to insured person in amount and on conditions which are established by the territorial program of compulsory medical insurance and the contract for rendering and payment of medical care for compulsory medical insurance;

2) protection of the rights of insured person to free delivery of health care in case of loss occurrence within the territorial program of compulsory medical insurance and the basic program of compulsory medical insurance in the medical organizations performing activities in the sphere of compulsory medical insurance taking into account survey results of insured persons about quality and availability of medical care;

3) the prevention of the violations in case of delivery of health care which are result:

discrepancies to the provided medical care to the state of health of insured person in case of loss occurrence, taking into account extent of defeat of bodies and (or) systems of organism or violations of their functions, caused by disease or condition or their complication;

failures to carry out, untimely or inadequate accomplishment of preventive, diagnostic and (or) medical actions, surgeries necessary for the patient according to procedures for delivery of health care, on the basis of clinical recommendations, taking into account standards of medical care;

non-compliance with terms of expectation of the medical care provided in planned form including terms of expectation of delivery of health care in stationary conditions, carrying out separate diagnostic inspections and consultations of specialists doctors, including in the medical organizations providing medical care on an outpatient basis, providing planning solutions of the internal spaces providing comfort of stay of patients including the organization of open registry with the infomat, electronic board with the schedule of acceptance of doctors, call center, system of navigation, zone of comfortable stay in halls and equipment of entrance automatic doors>;

--------------------------------

<3> the Order of the Ministry of Health and Social Development of the Russian Federation of May 15, 2012 No. 543n "About approval of the Regulations on the organization of rendering primary health care to adult population" (it is registered by the Ministry of Justice of the Russian Federation on June 27, 2012, registration No. 24726) with the changes made by orders of the Ministry of Health of the Russian Federation of June 23, 2015 No. 361n (registration No. 37921) is registered by the Ministry of Justice of the Russian Federation on July 7, 2015, of September 30, 2015 No. 683n (registration No. 39822) is registered by the Ministry of Justice of the Russian Federation on November 24, 2015, of March 30, 2018 No. 139n (registration No. 51917) is registered by the Ministry of Justice of the Russian Federation on August 16, 2018, of March 27, 2019 No. 164n (No. 54470) is registered by the Ministry of Justice of the Russian Federation on April 22, 2019.

4) check of execution by the medical organizations of obligations for rendering necessary medical care to insured person within the territorial program of compulsory medical insurance and medical insurance companies of obligations on payment of the medical care provided according to the specified program;

5) expense optimization, connected with payment of medical care in case of loss occurrence, and decrease in insurance risks in compulsory medical insurance.

7. Control is exercised by carrying out medico-economic control, medico-economic examination, examination of quality of medical care.

8. For the purpose of control of the medical care provided to insured person on the oncology profile the medical insurance company by means of information resource of territorial fund of compulsory medical insurance (further - territorial fund) keeps the personified account of data on the medical care provided to insured person in cases of suspicion of oncological disease or the established diagnosis of oncological disease, on for the first time to the revealed disease or the continuing treatment, providing collection, processing, transfer and storage of data on the provided medical care in the chronological sequence by dates of rendering the finished cases of treatment and/or medical services <4>.

--------------------------------

<4> The order of the Ministry of Health and Social Development of the Russian Federation of January 25, 2011 No. 29n "About approval of the Procedure for conducting the personified accounting in the sphere of compulsory medical insurance" (it is registered by the Ministry of Justice of the Russian Federation on February 8, 2011, registration No. 19742) with the changes made by orders of the Ministry of Health of the Russian Federation of December 8, 2016 No. 941n (No. 45494) is registered by the Ministry of Justice of the Russian Federation on February 1, 2017, of January 15, 2019 No. 12n (No. 53618) is registered by the Ministry of Justice of the Russian Federation on January 29, 2019.

III. Medico-economic control

9. Medico-economic control according to part 3 of article 40 of the Federal law "About Compulsory Medical Insurance in the Russian Federation" - establishment of compliance of data on amounts of the provided medical care to insured persons based on the account registers provided for payment by the medical organization to conditions of contracts for rendering and payment of medical care on compulsory medical insurance to the territorial program of compulsory medical insurance, payment methods of medical care and rates for payment of medical care.

10. Medico-economic control is exercised by specialists of medical insurance companies and territorial funds within three working days after submission of account registers by the medical organizations on payment of medical care in terms, the established stipulated in Article 39 Federal Laws "About Compulsory Medical Insurance in the Russian Federation" by the contract for rendering and payment of medical care on compulsory medical insurance.

11. In case of medico-economic control control of the medical care rendered and given on payment for the account of means of compulsory medical insurance on each insured event is carried out for the purpose of:

1) verifications of account registers on compliance to established procedure of information exchange in the sphere of compulsory medical insurance <5>;

--------------------------------

<5> The order of Federal Compulsory Health Insurance Fund of April 7, 2011 No. 79 "The general principles of creation and functioning of information systems and procedure for information exchange in the sphere of compulsory medical insurance" (further - the order No. 79) with the changes made by orders of Federal Compulsory Health Insurance Fund of September 9, 2016 No. 169, of November 17, 2017 No. 323, of March 23, 2018 No. 54, of September 28, 2018 No. 200, of December 13, 2018 No. 285 (according to the letter of the Ministry of Justice of the Russian Federation of July 27, 2018 No. 01/99744-YuL the order No. 79 was not subject to submission on state registration to the Ministry of Justice of the Russian Federation).

2) identifications of person insured by specific medical insurance company;

3) checks of compliance to the provided medical care:

to the territorial program of compulsory medical insurance;

to terms of the contract on rendering and payment of medical care on compulsory medical insurance;

the current license of the medical organization on implementation of medical activities;

4) checks of justification of application of rates for payment of medical care at the expense of means of compulsory medical insurance, their compliance to the payment methods of medical care established by the tariff agreement, the stipulated in Article 30 Federal Laws "About Compulsory Medical Insurance in the Russian Federation" and to the contract for rendering and payment of medical care on compulsory medical insurance;

5) establishments of lack of excess by the medical organization of the amounts of medical care which are subject to payment for the account of the means of compulsory medical insurance established by the decision of the commission on development of the territorial program of compulsory medical insurance created in the subject of the Russian Federation according to part 9 of article 36 of the Federal law "About Compulsory Medical Insurance in the Russian Federation" (further - the commission on development of the territorial program of compulsory medical insurance);

6) identifications of cases of non-inclusion or untimely inclusion in group of dispensary observation of insured persons which by results of holding preventive actions or rendering other medical care for the first time establishes diagnoses in case of which dispensary observation, and also non-compliance with the established frequency of surveys of the citizens included in groups of dispensary observation, according to procedure and frequency of carrying out dispensary observation and the list of the researches <6> included in them is provided.

--------------------------------

<6> The order of the Ministry of Health of the Russian Federation of March 29, 2019 No. 173n "About approval of procedure for carrying out dispensary observation of adults" (No. 54513) is registered by the Ministry of Justice of the Russian Federation on April 25, 2019.

12. The violations revealed in account registers are reflected in the act of medico-economic control in form according to appendix 1 to this Procedure <7> with indication of the amount of reduction of the account on each record of the register containing data on violations in case of delivery of health care.

--------------------------------

<7> According to part 9 of article 40 of the Federal law "About Compulsory Medical Insurance in the Russian Federation".

13. According to parts 9 and 10 of article 40 of the Federal law "About Compulsory Medical Insurance in the Russian Federation" the results of medico-economic control which are drawn up by the act, the stipulated in Item 12 presents About are the basis for application of measures, the stipulated in Article 41 Federal Law "About Compulsory Medical Insurance in the Russian Federation", terms of the contract on rendering and payment of medical care on compulsory medical insurance and the list of the bases for refusal in payment of medical care (reduction of payment of medical care) (appendix 8 to this Procedure), and also can be the basis for conducting medico-economic examination; organizations and conducting examination of quality of medical care; carrying out repeated medico-economic control, repeated medico-economic examination and examination of quality of medical care by territorial fund or medical insurance company on the instructions of territorial fund.

Disclaimer! This text was translated by AI translator and is not a valid juridical document. No warranty. No claim. More info