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What are the applicable post-review rules for different cases?
(02.21.2008)

The Shanghai Health Insurance Bureau shall complete the review in 90 days after the date of changing the settlement method of the insurance participant’s clinical expenses. After the review is completed, the bureau will apply the rules for different cases:

(1) For an insurance participant with:

more than 15 clinical treatments accumulated in one month;

or more than 30 clinical treatments accumulated in three consecutive months;

or more than RMB 5,000.00 accumulatively paid for in one clinic in one month,

if he/she has handled the procedures of registration properly and has been found to breach no Basic Medical Insurance rules by the review, his/her settlement account of medical expenses shall be revalidated from the 30th weekday after the registration date.

If he/she has been found to possibly breach the Basic Medical Insurance rules after the review, the Shanghai Health Insurance Bureau shall perform an additional review. If no breach is found by the second review, his/her settlement account of medical expenses shall be revalidated from the 90th weekday after the date of changing the clinical expenses settlement method. If any breach is found by the second review, the Shanghai Health Insurance Bureau shall undertake legal action, and then revalidate his/her settlement account of medical expenses after the appropriate legal action.

For an insurance participant that has not handled the procedures of registration, if no breach of the Basic Medical Insurance rules is found by the review, the settlement of his/her account of medical expenses shall be revalidated from the 90th weekday after the date of changing the clinical expenses settlement method. If any breach of the Basic Medical Insurance rules is found by review, the Shanghai Health Insurance Bureau shall undertake legal action, and revalidate his/her settlement account of medical expenses after the legal procedure.

(2) For an insurance participant that has spent more than RMB 20,000.00 on clinical expenses in their dedicated medical institution in Shanghai in one sole Medical Insurance Year, if no breach of the Basic Medical Insurance rules is found by the review, the settlement of his/her account of medical expenses shall be revalidated from the first weekday of the next Medical Insurance Year to the end date of the review. If the end date of the review goes into the next Medical Insurance Year, the settlement of his/her account of medical expenses shall be revalidated from the end date of the review.

If any breach of the Basic Medical Insurance rules is found by the review, the Shanghai Health Insurance Bureau shall undertake legal action, and revalidate his/her settlement account of medical expense from the first weekday of the next Medical Insurance Year after the end date of the legal procedure. If the end date of the legal procedure goes into the next Medical Insurance Year, his/her settlement account of medical expenses shall be revalidated from the end date of the legal procedure.

(3) In the case of a clinical expense needing to be settled in cash by the review, the Shanghai Health Insurance Bureau retains the decision of settling the clinical expense in cash.

(4) In the case of an insurance participant being found to violate other requirements stated in the Shanghai Municipal Procedures of Basic Medical Insurance for Urban Employees, the Shanghai Health Insurance Bureau shall undertake legal action.

(5) In the case of an insurance participant possibly participating in criminal activities, the Shanghai Health Insurance Bureau may act without limitation by the above rules, and shall turn over the participant to the police.