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How does an insurance participant see doctors and settle their medical expenses during a review period?
(02.21.2008)

During a review period, an insurance participant is still under the coverage of Basic Medical Insurance, but their clinical expenses shall be settled in cash instead of by their Individual Medical Account. Simultaneously, the Shanghai Health Insurance Bureau shall officially notify the insurance participant of changing the settlement method of the clinical expenses.

An insurance participant with

- more than 15 clinical treatments accumulated in one month,

- 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,

should bring his/her medical insurance certificate, ID card, clinical record and medical expense receipt(s) in order to go through the procedures of revalidating the settlement account of medical expenses, clarify the situation and support the review in the Shanghai Medical Insurance Supervision Office or the dedicated district/county Medical Insurance Affairs Office. This should be done within 15 weekdays from the date of changing the clinical expenses settlement method.

If the participant’s clinical expenses are settled in cash the insurance participant shall bring his/her medical insurance certificate, ID card, clinical record and medical expense(s) receipt(s) to handle the procedures of reimbursement in the dedicated district/county Medical Insurance Affairs Center.