淮北市医疗工伤生育保险管理服务中心内部控制实施细则（The detailed rules for the implementation of internal control of Huaibei City medical injury maternity insurance management service center）

淮北市医疗工伤生育保险管理服务中心内部控制实施细则（The detailed rules for the implementation of internal control of Huaibei City medical injury maternity insurance management service center） 淮北市医疗工伤生育保险管理服务中心内部控制实施细则(The detailed rules for the implementation of internal control of Huaibei City medical injury maternity insurance management service center) Detailed rules for the implementation of the internal control of the medical injury insurance management service center in Huaibei Chapter 1 General Provisions The first is the internal management and supervision to strengthen our city medical care, work injury and maternity insurance management services, to prevent and resolve operational risks, adjust and standardize medical care, work injury and maternity insurance management and service work, to ensure the safe operation of the fund, according to the Anhui provincial human resources and social security department "on the issuance of the" Anhui province social insurance notice of the detailed rules for the implementation of "internal control mechanism" (labor agency 2008 No. 35) the spirit of the document, the implementation rules are formulated. Second the implementation details of the alleged internal control refers to the Huaibei City medical insurance management service mechanism of injury fertility center and its staff engaged in medical care, work injury and maternity insurance management services and business conduct standardized, monitoring, error correction and evaluation methods, procedures and measures. Internal control consists of organization control, business operation control, fund financial control, information system control and so on. Third the construction of the internal control objectives: to establish a standardized operation, scientific management, effective monitoring, evaluation and correction of the strong strict internal control system, the whole process of supervision on the business, medical, work injury, maternity insurance service management mechanism, each link of each post, improve medical care, work injury and maternity insurance policies and regulations and the rules of execution, to ensure the safety and integrity of the funds, safeguard the legitimate rights and interests of the insured. The fourth internal control should follow the following principles: (1) legality. The contents of internal control are standardized and unified, which is in line with the requirements of national and provincial medical insurance policies and regulations concerning medical injury, childbirth and maternity insurance. (two) integrity. Each business management behavior has the corresponding system stipulation and the surveillance restriction. All departments, posts and personnel, all business projects and operation links are within the scope of internal control. (three) checks and balances. From the organization setting, the responsibilities and powers of each department and post are clear and restricted, and the blind spots and weaknesses in the internal control can be eliminated through effective checks and balances. (four) validity. On the basis of three levels of internal control management mode in post, department and unit, a scientific and reasonable decision-making mechanism, execution mechanism and supervision mechanism of internal control are formed. Establish reasonable internal control procedures to ensure effective implementation of internal control management. (five) adaptability. The specific work system and process should be combined with the actual management services, according to the needs of timely adjustment, modification and improvement, to adapt to changes in human resources and social security management services. (six) persistence. Keep internal control sustainable, not because of institutional adjustment, personnel replacement and careless mistakes. Fifth supervision and inspection personnel to carry out supervision and inspection of internal control work, strictly abide by the objective, fair and confidentiality principle. The supervision and inspection personnel shall avoid the matter of supervision and inspection, and be subject to the objects of supervision and inspection or the items of supervision and inspection. The second chapter, organization control The sixth is to establish a perfect organizational decision-making control system. Medical insurance agencies should make specific and explicit provisions on internal institutions, post settings, decision-making procedures, legal person authorization, meeting minutes, approval, filing and other aspects. The seventh is to establish a scientific personnel management system. In addition to the personnel management system of institutions and institutions that comply with each other, the provisions of post setting and responsibilities, staffing and use, learning and training, assessment and rewards and punishments should be stipulated. The eighth is to establish a clear leadership authorization system. Detailed regulations are made on the restriction and supervision of authorized personnel and scope, rights, job rotation or division of labor, routine audit and outgoing audit. Ninth, establish effective internal control evaluation system. The assessment of the risk control and the accountability of violation of the provisions of the provisions of the provisions of the provisions. Tenth, establish a joint meeting system. The designated medical service institutions of basic medical insurance in the operation of the entry and exit, the health insurance fund (must) pre review and supervision of internal control system implementation is performed, the disbursement of funds and large financial and commercial insurance cooperation and other important aspects and events, held a joint meeting by the discipline inspection and supervision, medical insurance, fund supervision administrative departments and medical care, work injury and maternity insurance management service center responsible comrades together to participate in the discussion. Eleventh business managers shall not the same person, the fund financial departments and audit departments and internal audit department of the unit in charge of the leadership principle; not the same treatment issued by the Department and settlement costs units in charge of the leadership principle. Right, Twelfth issued by the fund financial audit, internal audit treatment and information technology work should be located in different departments, and the work of the relevant departments above shall not be the same person as. Thirteenth according to the needs of work and personnel situation, key position of middle-level cadres center should be timely rotation, in the same position for 3 to 5 years should be rotation. Fourteenth the establishment of expert triage system, from medical and pharmaceutical experts set up basic medical insurance management expert database, each quarter of the settlement of medical records and medical institutions of medical records were randomly selected in the amount of 5%, found the problem, to the hospital after the confirmation, in accordance with the provisions of treatment and investigation. The fifteenth center should be equipped with appropriate audit staff, and requires the necessary professional knowledge. The third chapter business operation control Sixteenth medical and occupational injury and maternity insurance work by the medical insurance management department, management department, special cases of occupational injury and maternity insurance management department, finance department and other department and settlement shall be handled in accordance with the division of responsibilities, an important subject matter of research agency leadership decision. Examination and payment of medical expenses sporadic reimbursement of insured persons. The insured special disease outpatient medical expenses, in non designated medical institutions for medical expenses, hospital emergency referral referral inpatient medical expenses, relocation of retirees in local hospitals and hospital outpatient special disease audit fees, medical insurance in Huaibei city implementation of the relevant provisions. The auditors examine the relevant bills and materials provided by the insured or medical institutions according to the law, and review the cases by the department heads and report the payment procedures after the examination and approval of the person in charge of the agency. Seventeenth urban residents medical treatment audit, examination and approval system. (1) the examination of sporadic reimbursement of medical insurance and medical expenses for the insured. Medical expenses reimbursement of medical insurance management department of sporadic data receiving personnel insured, for the trial in strict accordance with the provisions of the system of payment scope, payment standard audit, no person shall change the payment and payment standards. The medical insurance management department personnel, fill out the "medical expense examination", stating the audit will not pay for the project name and amount, and signature confirmation, and then review and relevant documents to the single transfer payment settlement department. Hospital expense reimbursement should be submitted as follows: treatment cost invoice; disease diagnosis certificate; outpatient medical record (detailed record of diagnosis and treatment); discharge summary; expense detailed list; (two) medical expenses audit of two appointed institutions. The audit fee list of designated medical institutions and pharmacies, medical insurance management department audit monthly 15 days before according to the designated hospitals, pharmacies last month, expense reports, medical records of first instance, and to develop "designated hospitals, pharmacies cost audit" list, and then by the Department responsible for the review, special organization of medical experts the Commission staff review. Check and review after review by the leaders in charge, director of the center for approval after the transfer to the settlement department. The medical insurance management department carries out off-site monitoring and unscheduled spot checks on medical expenses in designated hospitals and designated drugstores through computer networking, and the abnormal expenses should be confirmed by on-site inspection. Treatment and management of special diseases for eighteenth insured persons According to the special disease identification results of the insured patients and the allowance limit for chronic diseases, the special case management staff should approve the quota of the special fund for the special medical personnel, Making Huaibei medical insurance for chronic diseases outpatient card. For cancer, uremia, organ transplant, special case management department personnel according to the information provided by the insured patients, the Department responsible for the review, the maintenance of patient specific disease information and timely tracking management. Nineteenth insured medical insurance medical expenses settlement The relocation of personnel, emergency personnel of chronic diseases, medical expenses settlement, settlement, according to the medical insurance management department provides insured medical insurance for medical expenses reimbursement and payment related to sporadic review documents, issued by the "Huaibei city urban workers' medical expenses reimbursement", determine the amount paid, together with the relevant documents after the approval by the director of the center the finance department to pay. With the designated hospitals and designated pharmacies cost settlement monthly settlement. 18 days before the month, director of the center for settlement department after issuing the audit fee settlement of single cross financial payment. Settlement with designated medical institutions and designated retail pharmacies is not allowed to be settled in cash through bank transfer. Twentieth industrial injury insurance management procedures and audit, approval system. First, industrial injury treatment 1, workers must to work-related injury insurance designated medical institutions for treatment, emergency medical institutions may be the nearest rescue and immediately report the insurance agencies, to be a relatively stable condition, must be transferred to industrial injury insurance designated medical institutions to continue treatment, refused to, agencies will not pay the cost of treatment. 2, workers because of illness need referral referral treatment, by the advice of the hospital physician, by inductrial injury insurance department hospital signed opinions, reported the work-related injury insurance department for referral referral examination and approval procedures. 3, for the follow-up or old injury recurrence need to continue treatment of injured workers should first put forward the treatment application to the center, after approval, to the designated hospital for consultation and treatment. Two, industrial injury insurance payment (1) medical treatment (rehabilitation) treatment audit and payment. The treatment of audit personnel according to the applicant by the qualification of the "treatment of inductrial injury insurance application form", according to the medical workers fill in the table (Kang Fu) and other related costs approved bills, certificates and other information for the trial, at the same time, the occurrence of medical expenses according to the provisions of the audit, through the audit, in the approved form. Fill out the audit opinions and audit amount, the Department is responsible for the review and approval agencies, establish and record the relevant information, to pay the Department in accordance with the provisions of payment review. Fixed point medical insurance system for industrial injury insurance. 1, the insured units shall promptly after the accident in the staff to the municipal labor and Social Security Bureau for related injuries, to be issued after the decision related injuries and medical workers to end or stable condition, and then to the center for medical treatment payment, and submit the following materials: industrial injury identification decision; inductrial injury medical treatment, hospital outpatient medical records a list of expenses, disease certificate, discharge summary; a copy of my ID card. 2, personnel according to the medical records provided by the medical insurance unit, the identification results of inductrial injury worker entry work injury insurance information system, at the same time, fill in the "Huaibei city industrial injury insurance reimbursement of medical expenses audit" (table thirteen), reported work-related injury insurance for work-related injury insurance review, tube leadership approval, pay the settlement department audit audit department is responsible for review, after the settlement, in charge of leadership for approval after the settlement of medical expenses, give the settlement personnel into the computer by the charge of fund settlement, leadership approval, the financial department to pay benefits. (two) examination and payment of auxiliary equipment expenses. The treatment of audit personnel according to the applicant by the qualification of the "work injury insurance application form", "workers of assistive devices for the application form", the relevant proof of the applicant's information for the trial, according to the standard calculation of auxiliary appliance for the installation and configuration of the applicant (more change) amount, and fill out the audit opinions and audit amount in the application form, the Department is responsible for review, approval agencies, establish and record relevant information, Pay the fee according to the regulations after the payment department review. (three) disposable disability treatment and long-term treatment 1, workers who work disability, identified by the Municipal Committee of labor ability appraisal to reach the level of disability of the insured unit apply for disability benefits, should fill in the "Huaibei city to the center because workers disability treatment application and approval form" (table fourteen) four copies, at the same time must attach the original labor ability appraisal conclusion to the center. 2, the above information provided by staff received insurance units, should be carefully audit, through the audit, the disability treatment of injured workers into the work-related injury insurance information system, at the same time to fill out the "Huaibei city workers disability caused by work-related injury treatment application and approval form (this table for the internal approval form") (table fifteen), and send the work-related injury insurance management division is responsible for the review, in charge of work-related injury insurance fund in charge of examination and approval, and finally by the leadership of approval, the financial department shall pay. 3, handling personnel to enjoy long-term disability benefits shall be issued, for the first time to fill in the "Huaibei workers, because workers disability benefits application approval table (the table for the internal approval form") (table fifteen) to copy and send the fund in charge of leadership for approval, to financial department to pay benefits. (four) the examination and payment of disability and death treatment. The treatment of audit personnel according to the applicant by the qualification of the "treatment of inductrial injury insurance application form", the relevant proof of the applicant's information for the trial, the calculation of injured workers in accordance with the provisions of the one-time disability benefits, disability allowance and nursing fee amount, one-time grants workers killed, funeral subsidies and enjoy every dependent relatives pension the amount of audit opinions and audit, and fill in the amount in the application form, the Department is responsible for the review and approval agencies, establish and record the relevant information, to pay the Department review and payments according to the provisions. 1, the injured workers died due to work, the insured units apply for treatment of workers, should fill in "Huaibei staff death insurance benefits declaration form" (table sixteen), and to the center to provide the following relevant materials: (1) the residence booklet, ID card and living proof of dependents; (2) proof of no living source issued by the relatives of the street office and the township (town) people's government; (3) civil affairs departments to prove to the elderly or uncultured orphans; (4) adoption certificate for foster children; (5) the students who are supported by relatives should be provided with the proof of reading issued by the school where they are present. 2, the above information provided by staff received insurance units, conducted the first trial, and then to the local units, workers living residence investigation, confirm the support for relatives of the qualification, the treatment of inductrial injury worker deaths entry work-related injury insurance information system, Huaibei city workers who died form "with the approval of the treatment when" (table sixteen), and send the work-related injury insurance management department responsible person in charge of the review, the work-related injury insurance fund in charge of examination and approval, and finally by the leadership of approval, the financial department shall pay. Two, medical treatment payment In charge of urban residents audit personnel need to check the insured medical invoices and related auxiliary materials, according to the provisions of medical insurance policy review, in charge of the leadership review, submit financial accounting, financial leaders signed after payment. Twenty-first maternity insurance declaration and other operating procedures and audit, approval system. First, the filing procedure of maternity insurance 1, female workers should be insured within three months of pregnancy, birth control surgery within 30 days prior to the "Huaibei City maternity insurance for urban workers registration form" and the reproductive health services card, marriage certificate, a copy of ID card, one inch photo (2) letter of introduction, family planning operation (by the employee street the office or unit) to the center for registration, "birth insurance pregnancy prenatal care table", "Huaibei urban maternity insurance certificate". Two, maternity insurance medical expenses payment 1, hospitals in 10 per month before the insured workers "Huaibei urban maternity insurance certificate", discharge invoices, hospital records, medical fees, order a copy of the birth insurance responsible for the audit, in charge of the maternity insurance fund is in charge of the leadership for approval, and finally by the leadership after the approval of the financial sector, to be hospitals and agencies pay. The fourth chapter fund financial control Twenty-third financial management according to laws and regulations. The fund financial management strictly establishes the definite accounting operation rules according to the national laws, regulations, policies and social insurance fund financial and accounting system, and implements the supervision over the whole process of the financial treatment. Twenty-fourth strict accounting control. According to the financial system of social insurance fund and the accounting system of social insurance fund, the accounts should be set up according to different types of insurance, and the mutual funds, individual funds and individual insurance accounts should not be taken out of each other. The setting of accounting items is accurate, standard, accounting processing meets the requirements of financial accounting. The original vouchers and vouchers for bookkeeping are legal and effective, and the contents of vouchers and account books are accurate, which can clearly reflect the content of the business. To correct the accounting records, the necessary examination and approval procedures should be carried out with detailed records. Twenty-fifth clear job responsibilities. The financial department of the fund must set up accounting positions, accounting, cashier and other financial positions, and define the scope of responsibilities of each post. The examination and approval of financial revenue and expenditure shall be carried out by graded authorization, and the post office shall not be permitted without authorization. The cashier shall not be concurrently in charge of auditing, accounting records and income and expenditure and debt account login; account seal, blank receipt bill, implementation of personnel management and business registration, payment required by a person in custody shall not seal. The accounting personnel rotation or transfer, must perform handover procedures strictly. The twenty-sixth is to establish a reasonable system of separation of responsibility. The money, securities custody and account treatment phase separation; important blank vouchers keeping phase separation and the use of funds; budget approval and specific operations for phase separation; information data processing and business processing and accounting separation. The twenty-seventh is to perfect the checking system of social insurance fund account, and to check the different accounts regularly, so that the account, account, certificate, account, account, account, financial account are consistent with the business account. The financial department of the fund should appoint a special person to check the monthly income of the fund, the household and the financial account bank. Monthly collection amount levied by the feedback department. Fund financial departments should audit, analyze and deal with accounts differences. Fund financial departments should regularly check, check, register and manage cash, notes, certificates of deposit, bonds and other securities. The fund's financial department shall review and check the approved expenditure after the business is approved. The fifth chapter is information system control The twenty-ninth center must make full use of computer technology to standardize business operation procedures, reduce the human factors in the operation process, and realize the automation of internal control to the maximum extent. The thirtieth strictly in accordance with the Ministry of human resources and social security department on social insurance information system construction standards, standardize business systems and database construction, formulate a clear operation process and management system. According to the business process and business system function, the functions of each department and post are divided, and the responsibilities and authority of the business operators and system maintenance personnel are defined, and the corresponding management system is established. Thirty-first, establish the routine system of computer monitoring business operation. The business system should be set up between the data logical relationship detection function, the correctness of the business data logic relationship between the business department and audit department regularly or not regularly check, and then to supervise the handling of business. The thirty-second business systems must establish linkage and containment relations to related businesses, and set warning and control functions to prevent false operations. The responsibility and authority of the thirty-third business system R & D personnel and business system maintenance operators must be separated and not be held concurrently by the same person. The business system developer is responsible for the business system programming, Business data can not be operated directly; business system maintenance operator according to the program compiled by R & D personnel business system maintenance operations, not to assume the business system programming. The operation system maintenance operator should be the center personnel. The thirty-fourth set of data entry, modify, access, use, security and maintenance of the authority management system, clear operation according to the data valid documents and must fulfill the formalities of examination and approval, to strengthen the monitoring of the data information system. Through the computer background to modify the business data of the business system, it should set up three levels (including three levels) operation privileges. In accordance with the requirements of higher authorities, gradually improve the medical injury maternity insurance database, establish remote backup mechanism to ensure data security. Thirty-fifth business systems should be set up business operations, system maintenance records and can be checked. All operations on a business system must have records (traces) that are malleable and can be checked. Business departments and audit departments should regularly check or check operation records, business system maintenance technical documents should be archived as long-term archives. Thirty-sixth, establish effective feedback mechanism of information exchange. The business data and other information management, communication and feedback made clear regulations, to ensure that the management to timely understand the business processes and comprehensive data. Thirty-seventh business systems and the Internet must achieve physical isolation, to prevent tampering through the network business system data behavior. For classified information need to be encrypted on the network transmission, to strengthen network and computer virus protection, to ensure network security. Thirty-eighth, strengthen password management, at least once a year to replace the operation password, job changes should be at any time to replace the operation password, to ensure the safety of passwords and fingerprints use. The sixth chapter is the supervision and inspection of internal control The forty-first business departments should check the business process of the Department once a month. Forty-fourth, establish reward and punishment system. Commend and reward the departments and individuals who have good internal control work. If the central staff fails to comply with the internal control system and causes adverse consequences, the relevant administrative responsibility shall be investigated according to the seriousness of the case, and the corresponding punishment shall be given; if the circumstances are serious enough to constitute a crime, the criminal responsibility shall be investigated according to law. The seventh chapter supplementary provisions The forty-fifth detailed rules are explained and revised by the management and service center of maternity injury insurance in Huaibei. The forty-sixth implementing rules will come into force on the date of promulgation.