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UBND TINH MOA BINH CONG HOA XA MOI CHU NGillA VIET NAMSC^ Y TE Doc lap - Tir do - Hanh phuc
S6: fin^/SYT- NVY Binh, ngay thang^nam 2018V/v gop y Du' lhao QuyStdinh sCra
d6i QD 3455/QD-BYT ngay16/9/201.3 cuaBYT
Ki'nh gu'i:- Cac benh vien trong tinh;- Trung tarn Y te cac huyen, thanh pho;
Thu'c hien Cong van so 2163/BYT-BH ngay 20/4/2018 cua Bo Y le vevice gop y Du' thao Quyet dinh sira doi QD 3455/QD-BYT ngay 16/9/2013 cuaBYT (pho to dinh kern)',
So Y t§ yeu clu cac dan vi nghien cuu noi dung Cong van va c6 y kiengop y gu'i ve Bo Y te trudc ngay 05/5/2018,/.
No/ nlian: \;J!giam d6c-Nlur iren:
- (jD Sa. PGD DT (de b/c);- l.im: VT.NVY^
DOC
,dn Buthmj
Bp YTfe
/BYT-BH
V/v gopy Dvt thSo Quyfit djnJi siia(16i Quyet djnh s6 3455/QD-DYT
ngay 16/9/2013 cuaB$Yte
KHAN
CpNG HOA XA HQl CHLI NGHU VI$T NAMSQc lap - Tu- do - Hanh piiuc
Ha N^i, ngayZOthdng 4mm 2018
SOY^E'TiNHHO^®"^^£,'s6LJ£HytlM Ng?.*Jl;„4.,/20U^Chuyw;LiAj tiogdso:
- SaYte cac tinh/thanh pho true thupc Irung ucmg; ^- Cac B?nh vien, Vi?n c6 giudng benh tr\rc thupc Bp Yte;- Cac Bpnh vipn: Quan y 108, Quan y 103, 19/8 Bp Cong an;^- Trung tarn Cong nghp thong tin; Trung tain Giam djnh bao hi6myte thanh loan da tu^^en khu virc phia BSc; Ban Thuc hienchinh sach bao hiltn ytS (thuoc Bao hidm xa hoi Viet Nam);- Tap doan VNPT, Viettel, FPT; Cong ty Hoan Chau.
^Sau day gpi chung la cac don vi)
Ngay 16/9/2013, Bp trucmg Bp Y16 da ban hanh Quyet djnh so _3455/QDjBYT (Sau day goi tat la Quyet djnh 3455) sua doi, bo sung Quyet dinh so517/QD-BYT ngay 23/02/2011 cua Bp truong Bp Yt6 ban hanh mau bang kc chiphi' kham benh, chua benh (KBCB) su dyng tai cac ca so KBCB. Tuy nliien, dennay, cac mlu bang ke chi phi KBCB ban h^h theo Quyet djnh 3455 da kliongcon phu hpp voi tinh hlnli thuc tien khi tri6n khai th\rc hipn tin hpc hoa trongKBCB bao hilm yte theo ykien chi dao cua Chinh phu, Thu tudmg Chlnlt phu.
Th^i gian qua, Bp Yl6 da ph6i hpp voi c&c ca quan,_dan vj c6_lien quanxay dimg va hodn thifn mau bang ke chi phi KBCB dir kien thay the cac maubSng ke ban hanh keni theo Quy6t dinh 3455. D6 lao thuan Ipi irong viec tiienkhai t6 chuc thuc hien va plui hpp v6i thpc tien, Bp Yle de nghj cac don vj cho yki6n gop ydOi'voi npi dung dp th^o Quy6t dinti thay the Quyet djnh 3455 ginkern theo Cong van nay. ^ , , . .i x. .
ki6n gop ycua cac don vj de nghj gui ve Bp Yte (Vp Bao hiem y^te)^ vagirl qua dja chi email: [email protected] iruoc ngay 05/5/2018 de tonghpp, bao cao Lanh dao Bp ky, ban h^inh. Sau thol gian noi tren, neu khong nhan ykien gop yciia don vi thi dupe hieu la d6ng yvoi npi dung du thao Quyet dinh.
Tran trong cam an./.TL. BO TRl/ONG
KT. vy tru"6'ng vy bao hi£m y rt•PHtrvsyTRirONG
AW iiJtOii.-
• Nhutren;. rr. Ph^m Le Tuin (dc b/c);- Vv trifong V\i BHYT(de b/c);• Luu: VT, DH.
Chiiiig ihu: YNgaykJ: 20/04/2018 16;2R:59lUlhintVOiTiccBaVTi
Dilmg pong Nam
BO_Y TE CONG HOA XA HOr CHU NGHIA VIET NAMDoc lap - Ty do - Hanli pink
So; /QD-BYT Ha Noi, ngay thdng nam20I8
QUYET DINH
BAN HANH MAU BANG KE CHI PIH KIIAM BENH, CHE A BENIISU' DUNG TAl CAC CO SO KHAM BENH, CHU A BENH '
BO TRETONG BO Y TE
Can cuLudl khdm benh, chua benh;
Can etc Lugl bdo hiem y te:
Can cuNghi dinh i'o 75/2017/HD-CP ngdy 20 thdng 6 ndm 2017 ci\a Ch'inhphu quydinh chuc ndng, nhiem vu, quyen hgn vd co can to chicc ciia Bo Yti:
Can cu Nghi dinh sS 166/2016/ND~CP ngdy 24 thdng 12 ndm 2016 cuaChinh phu quy dinh ve giao dichdien tu trong linh vuv bdo hiim xa hoi, bao hiimy te vd bdo hiem that nghiep:
Theo de nghi ciia Vu truang Vy Bao hidm y td, Cue tnc&ng Cue Qtian lykhdm, chua benh vd Vu tricang Vu Ke hogch - Tdi chinh,
QUYET DINH:
Dieu 1. Ban hanh kern theo Quy6t djnh nay Bang ke chi phi kham benh,chua benh su dung tai cac co so kham benh, chu'a benh (Sau day vilt tdt la Bangke chi phi) va Phu luc huang dan each ghi chep cac bang kc chi phi, bao gom:
1. Mau bang ke chi phi kham benh, chua benh;
2. Phu luc huang din each ghi chep bang ke chi phi kham benh, chua benh.Dieu 2. Quy dinh ap dung
1. mIli Bang ke chi phi kham benh, chua benh ap dung chung cho lat cacac CO sa kham benh, chua benh; ap dung cho ca kham benh, chu'a benh noi trukham benh, chua benh noi tru ban ngay va kham benh, chua benh ngoai tru.
2. Ca sa kham benh, chQ-a benh chi dugc lap 01 (mot) bang ke chi phikham benh, chua benh doi vai moi mot benh nhan trong mot dot dieu tri va phaidugc luu Cling vai ho sa kham benh, chua benh ciia benh nhan do.
3. Cac ca sa kham benh, chua benh chi ke nhung muc co phat sinh chi phiva giu' nguyen s6 thu tu ma Muc qui dinh trong mlu bang ke chi phi Idiam benh,chua benh.
f)ieu 3. Quydt dinh nay c6 hieii lu'c ke tu' ngay ky, ban hanh. Quyet djnhnay thay thi Quy^l dinh so 3455/OD-BYT ngay 16 lhang 9 nam 2013 ciia Botin'dng Bo Y tc v6 ban hanh mau Bang ke chi phi kham benh, chCra benh su dunglai cac co so kham benh, chua benh.
Dieu 4. To chu'c ihuc hicn
1. Cac CO sa gui du lieu dien tu va tiep nhan du' lieu dien tu ve chl phikham benh, chu-a benh c6 trach nhicm hoan thien phan mem de thuc hien lap,gtri, tiep nhan bang ke chi phi kham benh, chu'a benh theo dung quy djnh, huangdan lai Quyet dinh nay ke tu ngay 01 thang 6 nam 2018.
2. Trong qua trinh to chuc thyc hien Quyet djnh nay, ncu nhung van banneu trong Phu luc huong dSn ban hanh kem theo quyet dinh nay duoc thay thebang van ban moi thi thyc hien theo van ban moi ban hanh.
Dieu 5. Cac ong (ba): Chanh van phong Bo, Chanh Thanh tra Bp, Vutrudng Vu Bao hi8m y te. Cue trubng Cue Quan ly kham, chua benh, Vti truongVu Ke hoach - Tai chinh, Thu truong cac don vj thupc Bp Y te_, Giam doc So Yl6 cac tinh, thanh pho true thupc trung uong, Thu trudng y te cac Bp, nganh,Giam doc cac Benh vien va Vien co giuong benh true thupc Bp Y te va cac tochuc, don vj, ca nhan co lien quan chju trach nhiem thi hanh Quyet dinh nay./.
i\oi nhan:
' Nhu Dieu 5;
- Bo truaiig Bo Y ic (de b/cao);- Cac Tlu'r iruaiig Bo Y te;- Bp "I ai cliiiili;- BHXli Viet Nam;
- Cong lliong tin dien tir Bp Y te;-Lim: VT. Bll.
KT. BO TRU ONGTHU TRUONG
Pham Le Tuan
Mau bang ke chi phi kham benh, chfra benh(Ban hanh khn fheo Quyk dinh so /QD-BYTngay thdng ndm 2018 cua Bo trivcmg Bo Yti)
Bo Ytl/S6 Vte/V ih nganh: IVi|u ^6: 01/KBCBCor sd kham, chu^ benh: Ma s6 ngudi benh:
<Khoa thyc hien tfing ket ho so bfnh dn) (tuong ling MA BN trong XML)S6 kham benh:
BANG KE CHI PHI KHAM BENH, CHUA BENH...(1: Kham benh, 2: Dieu tri ngoai tru, 3: Dilu tri ngi tru, 4: Bilu tri ban ngay)I. PhSn Hanh chinh:
(1) Hp ten ngudi benh: ^gay, thang, nam sinh: / / ;-Gidi tinh:(2) Dia chi hien tai: (3) (Kl/ia/K3)(4) M3 the BHYT: j ] Gia trj td / din / /(5) Ntri DK KGB ban dau: .
(7) Den kham: gid phut, ngay / /
(8) Diiu tri npi trii tir: gid phut, ngay / /
(9) Ket thuc kham/dieu tri; gid phut, ngay / / Tdng so ngay didu tri:
(10)Capciru • (1!) Dung tuyin • Noi chuyin din: (!2) Thdng tuyin • (13)Trai tuyin •Tinh trang iuc vao vien • (1: DKKCBBD, 2; Cap cmi, 3: Chuyen tuyin, 4: Thdng tuyin (c3n liet ke ra cac tnidng hap thdng tuyin))
(14)Chan doan xac dinh: (15); Mabenh
(16) Benh kem iheo:
(17) Ma benh kem thso
(18) Thai diem dii 05 nSm lien tuctirngay: / / ; (19) Mien ci"ingchi tra trong nSm tir ngay: / /
H. Phan Chi phi kham benh, chOa b?nh: {Ma/ nid the BHYTse thong ke phdn chi khi kham benh, chica benh phdt sinh tirong ieng theo ma the do).Ma the BHYT: | \ ] ] | Qja tri tir..../ / den / / Mirc hudnsi
•
N^i dungfio'n vj
tinhSo lu-^ng
11
Ty Ifthanh
toan theo
dich vu
'(%) '
Thanh tien
BV
(Dongi
11 Tv lp
•Nguon thanh toan (dong)
Don gia BV{Sng}
Don gia BH(^ongj
Thanh tien
BH (36ng)thanh
toan
BHYTr%.i
Nguo'lQuy BHYT hciihciing
chitra
Ngu^iibenh
tu' tra
Kh^c
(1) (2) (2t (4) (5) i') (8) l9l (lOi ^ (ID (12) (1.))
Kham benh: 1
2. Ng^y giu-ft'ng:
2.1. Ngay giu-ong ban ng^y:
2.2. Ngay giu"6'ng chuyin khoa:
2.3. Ngay giu^ng luu: (Doi vai Tramyd luyenxa)
3. Xet nghicm:
4. Chan doan hinh anh:
G/iichii: S6 luana phim da tra...: So lirona phim niu- lai;...
5. Tham d6 chiic nang:
6.T
hii
thu
|t,
ph
auth
u^t
7.IV
ISu,
che
ph§
ni
mau
,t'a
nch
uy
enm
^u:
8.T
huoc
,djc
htr
uy
en
:
9.V
atlu
-yte
:i
50m
l,d
aytr
uye
Vdt
tuy
te1
djch
...)
khon
gdi
kem
i 'did
ich
vuky
thud
lri
do,
Vid
u:B
omch
oan
10.G
diva
ttu'
yte
:(Cd
cvd
r/try
ledi
kem
irong
mo!
Idn
/hue
hien
dich
vuky
thud
l.kh
ongg
hicd
cva
tluy
ledd
liiih
kitc
duiro
nggi
ddi
chvii
kyth
udld
o)
10
.1.G
6i
vat
tury
teI
(Gl u
kem
iheo
ten
dich
vuky
thud
lthi
cchi
en)
-T
en
VT
YT
I
-T
en
VT
YT
2
10
.2.
G6
iv
at
tu•y
te2
(Gl
ik
emth
eo
ten
dich
vuky
'thu
d!th
uchi
en)
-T
en
VT
YT
1
-T
en
VT
YT
2
lO.n
.G
6i
vat
tuy
ten
(Gl l
ik
emth
eo
tin
dich
vuky
thud
lih
iec
hi$n
)
-T
en
VT
YT
1
-T
en
VT
YT
2
11.
Van
chu
yen
ngu~
6'i
bei
lb:
12. Djch vu khac;
Cong:
T6ng chi phi Ian kham benh/ca dot didu tri (lam tron den dan vi dong): dong(Viet hang
Trong do, so lien do;
- Quy BHYT thanh loan: -
- Ngiroi benh tra, trong do:
+ Cung tra trong pham vi BHYT:
+ Cac khoan phai tra khac:
- Nguon khac:
NGl/OI LAP BANG KE
(ky. ghi rd ho ten)
XAC NHAN CIJA NGl/OI BENH(ky, ghi ro ho fen)
Ngay.... thdng... ndm...KE TOAN VIEN PHI
(ky, ghi ro ho ten)
Ngay.... thdng .... ndm ..GIAM DINH BHYT
(ky, ghi ro ho ten)
Ghi chu: Trirang hop kham benh, chira benh tai Tram ytd tuyen xa va trrong dirong: Thay the chu ky, ho ten cua Ke toan vienphi bing chu" ky, hp ten ciia nguoi phu tracfi don vi va phan ky xac nhan-eda Giam d[nh BHYT khong bat buoCrA
Mau bang ke chi phi kham benh, chua benh' ' r
(Ban hanh kem theo Quyet dinh so /QD-BYTngay thang nam 2018 cua Bo tneang Bo Yte)
Bo Y t£/S6'Y I6A' te ng^nh: Mau so: 01/KBCBCo so kham, chira benh: Ma so ngiioi benh:Khoa: (Khoa thi^ hien long ket h6 so benh an) (tuong ling MA_BN trong XML)M3 khoa: So kham benh:
BANG KE CHI PHI KHAM BENH, CHLTA BENH...(I: Kham benh, 2: Dieu tri ngoai tru, 3: Oieu tri noi trii, 4: Dieu tri ban ngay)
1. Phan Hanh chinh:
(1) Hi; ten ngiroi benh: ; Ngay, thang, nSm sinh: / / ; Gioi tinh:
(2) Dia chi hien tai: ;(3) Ma khu virc (K1/K2/K3) | |(4) Ma the BHYT; | | j | [Gia trj tir,.../ / den / /(5) Noi BK K.CB ban dk: - ; (6) Ma
(7) Den kham: gio phut, ngay / /
(8) Dieu tri noi tru tCr: gio phut, ngdy / /
(9) Kei thiic kham/diSu tri: gio phut, ngay / / T6ng s6 ng3y di6u tri;
(10)Cap ciru • (II)DungtuySn • Noi chuyen din: (12)Thong luycn • (13)Trai tuyin OTlnh trang liic vao vien • (1: DKKCBBD. 2: Cap ciiu, 3: Chuyen tuyen, 4: Thong tuyen (can Hot ke ra cac trirdng hop thong tuyen))
(14) Chan doan xac dinh: (15); Ma benh
(16) Benh kem theo:
; (17) Ma benh kem theo
(18) Thdi diem dii 05 nam lien tuc tir ngay: / / ; (19) Miln ciing chi Ira trong nam tir ngay: / /
H. Phan Chi phi kh^m bfnh, chira benh: (M6i ma the BHYTse thong kephdn chi kh!kham benh. chTea b4nhphdi sink licang I'fng theo ma the do).
Gidtrj tir..../ / din / / Mire huongMa the BHYT:I
N§i dung©en vj
tinhS6 lu'97ig
©on gia BV(ddnf[)
©on gii BH(dong)
Ty Ifthanh
toan thco
dich vu
'(%) '
Thanh tien
BV
(Ddng)
Thanh tien
BH mng)
Ty Ifthanh
todn
BHYT (%)
Nguon thanh todn (dSrtg)
Quy BHYTNguo'i
bfnh cungchi tra
Nguflibfnhtu' tra
Khac
(i) (21 (3) (41 (5) (61 0) (8) (9) (10) (II) (12) (13)
1. Kham benh:
2. Ngay giirong:
2.1. Ng^y giu'd'ng ban ngay:
2.2. Ngay giu'd'ng chuycn khoa:
2.3. Ngay giuong luai: (Dot v6i Tramy ti tuyen xa)
3. Xet nghifm: 1
4. Chan doan hinh anh: (1
Gliidiu: So luona phim da tra...: SA lirfm<> phim "ifr Ui-
5. Tham d6 chiit nang:1
6.T
hu
thu
St,
ph
auth
uat
:
7.M
du,c
hlph
3mm
^u,v
anch
uyen
mau
;
8.T
hufi
c,d
jch
tru
yen
:
9.V
3t
tu-y
tS:
tuy
lekh
dng
dike
rnv&
idic
hvu
^th
udl
ndo,
Vid
it:B
amch
oan
50m
l,d
aytn
iyen
dich
...)
10.G
6iva
llu
'yle
:(C
cicv
dln
tyte
dike
mtr
ong
mot
Idn
ihuc
hien
dich
vuky
thud
l,kh
dng
ghi
cdc
vati
iry
leda
tinh
ketc
antr
ong
gid
dich
vuth
uat
do)
10.1
.Goi
val
tuy
te1
(Ghi
kem
theo
ten
dich
vuky
thug
tth
uchi
gn)
-T
en
VT
YT
1
-T
en
VT
YT
2
10.2
.Goi
vat
tu'y
te2
(Ghi
kem
theo
ten
dich
vuky
thud
lthu
chi
gn)
-T
en
VT
YT
1
-T
en
VT
YT
2
lO.n
.Goi
vat
tiry
ten
(Ghi
kem
theo
ten
dich
vitk
ythu
gtth
uchi
en)
-T
en
VT
YT
1
-T
en
VT
YT
2
11.
V^n
chu
ycn
ngu'
o'i
ben
h:
•i t
12. Djch vu khsic:
C6ng:
Tong chi phi \hn kh^ benh/ca dot dieu tri (lam trdn din dan vi ding): ddng(Viet bang chit: ^Trong do, so tien do:
- Quy BHYTthanh toan:
- Ngirai benh tra, trong do:
+ Cung tra trong pham vi BHYT:
+ Cac khoan phai tra khac:
- Nguon khac:
NGLIOI LAP BANG KE(k)'. ghi ro ho ten)
XAC NHAN CUA NGUO'I BENH(ky. ghi ro ho ten)
Ngay.... thdng... ndm ...KE TOAn VIEN phi
(ky. ghi ro ho ten)
Ngay.... thdng.... nam ...GIAM DINH BHYT
(ky. ghi ro ho ten)
Trudng hop kham benh, chua benh lai Tram y tuyen xa va tuong dnong: Thay thS chu ky, ho ten cua kI toan vienphi bang chir ky, ho ten cua ngirdi phu trach dan vi va ph^ ky xac nhan cua Giam djnh BHYT khong bit buoc./.
