Medical services and OMS. Free medical care

The government of Moscow
Department of Health
Moscow City Fund
mandatory health insurance

ON APPROVAL OF THE PROCEDURE AND CONDITIONS OF PROVIDING MEDICAL ASSISTANCE UNDER THE MOSCOW CITY CHI PROGRAM

In accordance with the Law Russian Federation"On medical insurance of citizens in the Russian Federation", Rules of compulsory medical insurance of the population of the city of Moscow, Territorial program state guarantees providing the population of the city of Moscow with free medical care and in order to improve the organization of the provision of medical care within the framework of the Moscow City Compulsory Medical Insurance Program, we order:

1. Approve the Procedure and conditions for the provision of medical care under the Moscow city compulsory medical insurance program (Appendix).
2. Heads of health departments of administrative districts of Moscow, heads of medical institutions to bring this document to the attention of subordinate medical institutions and structural divisions for leadership and execution.
3. The Moscow City Compulsory Medical Insurance Fund shall ensure that the population of Moscow is informed about the procedure and conditions for the provision of medical care under the Moscow City Compulsory Medical Insurance Program.
4. Consider invalid the order of the Moscow Health Committee and the Moscow City Compulsory Medical Insurance Fund No. 352/75 dated July 12, 2002 "On Approval of the Procedure and Conditions for the Provision of Medical Assistance under the Moscow City Compulsory Medical Insurance Program".
5. Control over the execution of this order shall be entrusted to the First Deputy Head of the Department of Health of the City of Moscow Polyakov S.V. and Deputy Executive Director of the Moscow City Compulsory Medical Insurance Fund Yuryev T.I.

Head of the Department of Health of the city of Moscow A.P. Seltsovsky
Executive Director of the Moscow City CHI Fund A.V. Reshetnikov

APPENDIX TO THE ORDER
Department of Health of the city of Moscow
and the Moscow City Compulsory Medical Insurance Fund
of November 14, 2008 N 931/131

PROCEDURE AND CONDITIONS FOR PROVIDING MEDICAL ASSISTANCE
ON THE MOSCOW CITY CHI PROGRAM

1. Medical care under the Moscow City Compulsory Medical Insurance Program (CHI) is provided by medical institutions operating in the CHI system of Moscow to citizens subject to compulsory health insurance:

• citizens insured under compulsory medical insurance in Moscow;
• citizens insured under compulsory medical insurance in the territory of other constituent entities of the Russian Federation (hereinafter referred to as "nonresident citizens");
• patients who, for objective reasons, have not been identified (due to compulsory medical insurance policy) when providing them with primary health care for emergency indications, in a polyclinic or hospital (hereinafter referred to as "unidentified patients").

2. Citizens insured under compulsory medical insurance in Moscow receive medical assistance upon presentation of the compulsory medical insurance policy (when you first apply to a medical institution, in addition to the compulsory medical insurance policy, you must present a passport).

In the absence of a compulsory medical insurance policy for patients (in case they apply on an emergency basis), medical institutions take measures to identify the patient in order to identify the insurer or classify him (according to his passport) as a non-resident citizen or unidentified patient.

Planned inpatient medical care for citizens insured under compulsory medical insurance in Moscow is provided at the direction of the outpatient clinic to which they are attached for medical care.

Medical assistance to citizens insured under compulsory medical insurance in Moscow in departmental and non-state medical institutions participating in the implementation of the Moscow city compulsory medical insurance program is provided taking into account the volumes (types) of medical care planned by the medical institution and approved by the Moscow City Health Department.

3. For non-resident citizens, planned medical care in the scope of the Moscow city CHI program is provided at medical institutions of the Moscow Department of Health upon presentation of a territorial CHI policy and a passport (in the absence of a CHI policy for objective reasons, only a passport, and for children - a passport of one of the parents or other legal representatives ).

Planned inpatient medical care for nonresident citizens is provided on the basis of referrals issued by the Moscow Department of Health, the health departments of the administrative districts of Moscow (in accordance with the subordination of the institution), as well as referrals issued by outpatient clinics, if nonresident citizens are attached to them on medical service.

When providing medical care to children and pregnant women - residents of the Russian Federation who have a territorial compulsory medical insurance policy and are registered at the place of stay in Moscow, they are attached to a medical institution on the basis of a written application addressed to the chief physician, followed by entry into the register of the attached population of the medical preventive institution (Order of the Department of Health of the City of Moscow dated 06.06.2007 N 254 ​​"On the procedure for providing medical care to children and pregnant women - residents of the Russian Federation in medical and preventive institutions of the Department of Health").

4. Diagnostic examinations and advisory assistance are carried out according to medical indications and are prescribed by the attending physician.

The attending physician selects specialists for consultations and selects medicines, materials and medical products.

If the standard workload of a specialist and/or medical institution receiving consultative-diagnostic and planned medical care under the compulsory medical insurance program is carried out in order of priority.

5. The implementation of the right of citizens insured under compulsory medical insurance in Moscow to choose a medical institution in the compulsory medical insurance system of Moscow is carried out on the basis of a written application addressed to the head physician, in accordance with the resource capabilities of the institution: capacity, staffing of medical personnel and the Organizational Procedure medical care of the population according to the district principle, approved by order of the Ministry of Health and Social Development of Russia dated 04.08.06 N 584.

Home care is provided by medical workers of institutions located in the territory of actual residence of citizens.

Realization of the right of those insured under MHI to choose a doctor, including a family doctor and a doctor, is carried out subject to his consent.

6. Medical institutions provide citizens with free and accessible information:

• on the types of medical services provided free of charge within the framework of targeted programs for the development of the capital's health care and the Territorial Program of State Guarantees for the Provision of Free Medical Care to the Population of the City of Moscow, which include the Moscow City Program of Compulsory Medical Insurance;
• on the types of medical services provided by a medical institution at the expense of personal funds citizens or other sources of funding within the framework of voluntary medical insurance;
• on the possibilities of a medical institution to provide services at the request of citizens for a fee, at prices that reflect the full cost of a medical service, and (or) provide services for an additional fee (without payment full cost medical service);
• on the conditions for the provision and receipt of paid services;
• about benefits for certain categories citizens.

7. The insurance medical organization that issued the CHI policy considers the appeals of the insured in order to ensure and protect their rights to receive medical care under the Moscow City CHI program. If the application contains the insured under compulsory medical insurance of a citizen claims to the organization and (or) quality of medical care provided, the insurance medical organization is obliged to organize an examination of the quality of medical care in the manner and within the time limits provided for by the Regulations on medical and economic control of the volume and examination of the quality of medical care provided under the compulsory medical insurance program.

If necessary, the insurance medical organization takes measures to provide certain types of medical care to the insured under compulsory medical insurance in other medical institutions that are in contractual relations with it.

8. Citizens insured under MHI in Moscow, citizens from other cities and unidentified patients, when receiving free medical care, have the rights established by the Fundamentals of the Legislation of the Russian Federation on the Protection of Citizens' Health and the Law of the Russian Federation "On Medical Insurance of Citizens in the Russian Federation".

In case of violation of the rights, the patient can contact:

• directly to the head or other official of the medical institution in which he received medical care;
• to the health department of the corresponding administrative district of Moscow;
• to the Department of Health of the city of Moscow;
• to the insurance medical organization that issued the compulsory medical insurance policy to the insured and assumed obligations to protect his interests;
• to the City Arbitration Expert Commission (GAEC) in case the patient's claims have already been considered by the insurance medical organization and the requirements of the insured have not been satisfied (applications for transfer to the GAEC are accepted by the Office of the CHI Organization of the Moscow City Compulsory Medical Insurance Fund);
• to court.

Note.

1. In accordance with Decree of the Government of Moscow dated 04.03.2008 No. 145-PP, the Moscow City Health Department issues a referral for hospitalization (consultation), including those insured under compulsory health insurance in the city of Moscow and on the territory of other constituent entities of the Russian Federation, within the framework of the Territorial Program state guarantees for the provision of free medical care to the population of the city of Moscow to citizens, as well as citizens living in the territory of the CIS countries, at the expense of the Healthcare sector within the framework of existing intergovernmental agreements (contracts) that determine the procedure for interaction in the field of healthcare.
2. In accordance with Decree of the Government of the Russian Federation No. 546 dated September 1, 2005, emergency medical care for foreign citizens is provided by medical institutions of the state and municipal health care system in case of conditions that pose an immediate threat to their lives or require urgent medical intervention free of charge (at the expense of the budget) . After exiting from these states, foreign citizens can be provided with planned medical care on a paid basis. If an international treaty of the Russian Federation establishes a different procedure for the provision of medical care to foreign citizens, the rules of the international treaty shall apply.

The compulsory medical insurance program was created to provide free medical care to citizens of the Russian Federation, to protect and prevent their health. Under this program, insured persons have the right to receive a certain set of medical services. What is a medical service? Who has the right to provide medical services and what regulation regulates this right? What assistance can be provided under the CHI program? We will answer these questions in this article.

What is a medical service?

Article 2 federal law No. 323 of November 21, 2011 "On the Fundamentals of Health Protection in the Russian Federation", a medical service is a specific medical intervention or a set of such interventions that are aimed at diagnosis and treatment, medical rehabilitation and prevention. According to paragraph 1, article 5 of the same law, activities that are an integral part of medical services must be carried out on the basis of recognition, protection and observance of the rights of citizens, in accordance with regulations international law and generally accepted principles.

In general, a medical service consists of certain medical actions - medical care. object civil rights is a medical service, respectively, it has commodity form with a certain value and can be the subject of sale. A feature of the medical service is its professional variety, moreover, the performers are subject to high requirements in terms of qualifications, for example, only a certified doctor of the relevant specialization has access to medical practice.

Who is eligible to provide medical services under the CHI program?

As part of the state guarantee for the provision of free medical care, the Russian Federation has a compulsory medical insurance program, which is regulated by Federal Law No. 326 of November 29. 2011 "On CHI in the Russian Federation". Within the framework of this law, two programs for the provision of medical services have been developed: basic and territorial. Participate in the implementation of the basic and territorial programs compulsory medical insurance medical organizations with any form of ownership are eligible, while they must meet certain criteria. Medical organizations that meet the following requirements are entitled to participate in the compulsory medical insurance program:

• Must be accredited and have relevant documents for the provision of medical care;
• Provide an appropriate material and technical, personnel and medicinal base for the provision of medical care of the proper quality;
• Have technical and software tools for maintaining personalized records of the medical care provided to the insured, protecting personal data and exchanging information in the information field;
• Comply with the sanitary-epidemiological and medical-protective regime;
• To be ready to provide medical assistance in the conditions of liquidation of emergency consequences;
• Be prepared to take anti-epidemic measures and submit extraordinary reports in accordance with the regulations of the federal and territorial Department of Health and the Rospotrebnadzor;
• Be ready to provide emergency medical care;
• Comply with the procedure for hospitalization of planned and emergency patients in accordance with the requirements of the Department of Health;
• Have information tools (including on the Internet) to inform the insured persons about the working hours of the medical organization, the conditions and types of services provided, etc.

Requirements for medical organizations that have the right to provide medical services in the CHI system are regulated by Federal Law No. 323 of November 21, 2011 on health protection in the Russian Federation and Federal Law No. 326 of November 29, 2010 on CHI in the Russian Federation. Control over compliance with these requirements by medical organizations, regardless of the form of ownership, is carried out by the territorial Department of Health and the Compulsory Medical Insurance Fund.

Medical services provided under the MHI policy

The implementation of medical care within the framework of compulsory medical insurance is carried out by health care facilities and licensed clinics included in a special register. Private clinics that are not included in a special register cannot provide free services under compulsory health insurance. According to compulsory medical insurance, patients can receive medical care under the basic and territorial insurance programs. The list of diseases included in the CHI policy is enshrined in paragraph 6 of Article 35 of the Federal Law on CHI.

The basic program is valid in all regions of the Russian Federation, the patient has the right to free medical care, regardless of the region in which the insured event occurred. As part of the basic CHI program, patients receive:

• Primary care;
• Prevention severe forms diseases;
• Provision of health care at home;
• Ambulance;
• , including ;

In addition, the basic program implies the possibility of conducting,. However, these services will be provided free of charge only on the recommendation and referral of the attending (or duty) doctor, otherwise they will have to be paid for according to the price list established by the medical institution. Rating: 2.6/5 (3 votes)

Citizens of Russia are guaranteed free medical care by the state. A policy is issued to people - a document embodying support state system healthcare in case of illness.

And what does it really mean? What types of services in the clinic are required to provide at no additional charge, and which ones will you have to pay for yourself? Under what circumstances is a free medical examination carried out? Let's look at all the questions in detail.

About free medicine

The 41st article of the Constitution of the Russian Federation lists guarantees to citizens of the country from the state. In particular, it says:

“Everyone has the right to health care and medical care. Medical assistance in state and municipal health care institutions is provided to citizens free of charge at the expense of the relevant budget, insurance premiums, and other revenues.

Thus, the list of free medical services should be determined by the relevant government bodies i.e. the healthcare system. This happens on two levels:

• federal;
• regional.

Important! budget fund on the development of medical institutions is formed by several sources. One of them is tax revenues from citizens.

What types of services are guaranteed by the state

By virtue of the current legislative acts, patients are guaranteed the right to the following types of medical care:

• emergency (ambulance), including special;
• outpatient treatment, including examination;
• hospital services:
  • gynecological, pregnancy and childbirth;
  • with exacerbation of ailments, ordinary and chronic;
  • in cases of acute poisoning, in case of injury, when intensive care is required, associated with round-the-clock supervision;
• planned outpatient care:
  • high-tech, including the use of complex, unique methods;
  • medical care for citizens with incurable ailments.

Important! If the disease does not fall under one of the options, you will have to pay for medical services.

Medicines are issued at the expense of the budget to people suffering from the following types of diseases:

• shortening life;
• rare;
• leading to disability.

Attention! A complete and detailed list of drugs is approved by a government decree.

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New in legislation since 2017

The government decree of December 19, 2016 N 1403 provides a more detailed breakdown of medical services provided free of charge. In particular, primary health care is deciphered. It is divided into subspecies. Namely, the primary

• pre-medical (primary);
• ambulance;
• specialized;
• palliative.

Attention! As part of the program, palliative care has been added to the list of free medical care.

In addition, the text of the document contains a list of medical professionals who are subject to the obligation to treat patients without charging money.

These include:

• paramedics;
• obstetricians;
• other health workers with secondary specialized education;
• general practitioners of all profiles, including doctors of family medicine and pediatricians;
• doctors-specialists of medical organizations providing specialized, including high-tech, medical care.

Attention! The document contains a list of diseases that doctors are required to treat free of charge.

Medical policy

A document guaranteeing the provision of assistance to patients is called a compulsory medical insurance policy (CHI). This paper confirms that the bearer is insured by the state, that is, all the professionals listed above are required to provide services to him.

Important! Not only citizens of the Russian Federation have the right to issue a compulsory medical insurance policy. It is issued (for a small fee) to foreigners permanently residing in the country.

The MHI policy has the following semantic content:

• the citizen is guaranteed medical support;
• medical organizations perceive it as a client identifier (for it, the hospital will transfer funds from the Compulsory Medical Insurance Fund).

Important! The described document is issued only by licensed insurance companies. They are allowed to be changed, but not more than once a year (until November 1 of the current period).

How to get an OMS policy

The document is issued by the relevant companies operating within the framework of the legislation of the Russian Federation. Their rating is regularly published on official websites, allowing citizens to make their choice.

To be issued a CHI policy, you must provide a minimum number of documents.

Namely:

• for children under 14:
  • birth certificate;
  • parent's (guardian's) passport;
  • SNILS (if any);
• for citizens over 14 years old:
  • the passport;
  • SNILS (if available).

Important! For citizens of the Russian Federation, the policy is valid indefinitely. Only foreigners are provided with a temporary document:

• refugees;
• temporarily residing in the country.

Rules for replacing the compulsory medical insurance policy

In some situations, the document is supposed to be changed to a new one. These include the following:

• when moving to a region where the insurer does not work;
• in case of filling out the paper with errors or inaccuracies;
• in case of loss or damage to the document;
• when it fell into disrepair (dilapidated) and it is impossible to make out the text;
• in the event of a change in personal data (marriage, for example);
• in the case of a planned update of the sample form.

Attention! New policy OMS is issued without paying a fee.

What is included in the free service under the MHI policy

Paragraph 6 of Article 35 of Federal Law No. 326-FZ provides complete list free services under a medical policy provided to document holders. They are provided in:

• polyclinic;
• dispensaries;
• hospital;
• Ambulance.

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What can OMS policy holders expect?

In particular, patients are entitled to free medical care and treatment in the following situations:

Dentists, like other professionals, are required to work with patients without pay.

They provide the following types of assistance:

• treatment of caries, pulpitis and other diseases (enamel, inflammation of the body and roots of the tooth, gums, connective tissues);
• surgical intervention;
• dislocations of the jaws;
• preventive actions;
• research and diagnostics.

Important! Services for children are provided free of charge:

• to correct an overbite;
• enamel strengthening;
• treatment of other lesions not related to carious.

How to apply the CHI policy

In order to organize the treatment of patients, they are attached to the clinic. The choice of a medical institution is given to the choice of the client.

It is defined:

• convenience of visiting;
• location (near the house);
• other factors.

Important! It is allowed to change the medical institution no more than once a year. The exception is a change of residence.

How to "attach" to the clinic

You can do this with the help of an insurer (choose an institution when receiving a policy) or on your own.

To attach to the clinic, you should go to the institution and write an application there. Copies of the following documents are attached to the paper:

• identity cards:
  • passports for citizens over 14 years old;
  • birth certificates of a child under 14 years of age and passports of a legal representative;
• compulsory medical insurance policy (original is also required);
• SNILS.

Important! Citizens registered in another region can legally refuse to attach to a polyclinic if the institution is overcrowded (the maximum norm of patients has been exceeded).

In case of refusal, it should be requested in writing. You can complain about a medical institution to the Ministry of Health of the Russian Federation or Roszdravnadzor.

Visit to the doctor

In order to get help from a specialist, you must register with him through the registry. This department issues admission vouchers. Terms and rules of registration, patient care are established at the regional level. They can be found in the same registry.

In addition, the insurer must provide this information to customers (you need to call the number indicated on the policy form).

For example, in the capital there are such rules for providing patients with medical services:

• referral to an initial appointment with a therapist, pediatrician - on the day of treatment;
• coupon to specialist doctors - up to 7 working days;
• carrying out laboratory and other types of examination - also up to 7 days (in some cases up to 20).

Important! If the polyclinic is unable to meet the needs of the patient, he should be referred to the nearest institution where the necessary services are provided under the CHI program.

Ambulance

All people in the country can use emergency medical services (the presence of a CHI policy is optional).

There are regulations governing the activities of ambulance crews. They are:

• the ambulance service responds to emergency calls within 20 minutes in case of a threat to people's lives:
  • accidents;
  • wounds and injuries;
  • exacerbation of the disease;
  • poisoning, burns and so on.
• emergency care arrives within two hours if there is no threat to life.

Important! The dispatcher decides which team will go on the call based on the information of the client.

How to call an ambulance

There are several options for seeking emergency medical care. They are:

1. From a landline, dial 03.
2. By mobile connection:
   • 103;

Important! The last number is universal - 112. This is the coordination center for all emergency services: hide, fire, emergency and others. This number works on all devices if there is a network connection:

• with zero balance;
• with the absence or blocking of the SIM card.

Ambulance Response Rules

The service operator determines if the call is justified. An ambulance will arrive if:

• the patient has signs of an acute illness (regardless of its location);
• there was a catastrophe, a mass disaster;
• received information about the accident: injuries, burns, frostbite, and so on;
• violation of the activity of the main body systems, life-threatening;
• if childbirth or termination of pregnancy has begun;
• the disorder of the neuropsychiatric patient threatens the lives of other people.

Important! For children under the age of one year, the service leaves for any reason.

Calls due to such factors are considered unreasonable:

• the patient's alcoholism;
• non-critical deterioration of the patient's condition of the clinic;
• dental diseases;
• carrying out procedures in the order of planned treatment (dressings, injections, etc.);
• organization of workflow (issuance of sick leave, certificates, drawing up an act of death);
• the need to transport the patient to another place (clinic, home).

Attention! The ambulance only provides emergency care. If necessary, can deliver the patient to a hospital.

Where to file medical complaints

In the event of conflict situations, rude treatment, insufficient level of services provided, you can complain to the doctor:

• chief physician (in writing);
• to the insurance company (by phone and in writing);
• to the Ministry of Health (in writing, via the Internet);
• Prosecutor's office (also).

Attention! The term for consideration of the complaint is 30 working days. Based on the results of the check, the patient is required to send a reasoned response in writing.

If necessary, the attending doctor can be changed to another specialist. To do this, write an application addressed to the head physician of the hospital. However, the change of specialists is allowed to be carried out no more than once a year (except in cases of relocation).

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Last changes

On May 28, 2019, new CHI rules came into force, which provide for the introduction in Russia of policies of a single sample (paper or electronic format). At the same time, there is no need to replace the previously issued policy. In addition, if it is technically possible to unambiguously identify the insured person in the unified register of insured persons, then instead of the CHI policy, a passport can be presented (Order of the Ministry of Health of Russia dated February 28, 2019 No. 108n “On Approval of the Rules for Compulsory Medical Insurance“).

The new Rules provide for stricter control over the observance of the rights of the insured, as well as close electronic interaction between the territorial MHIF, insurance organizations and medical organizations:

• polyclinics every year until January 31 will have to report to the TFOMS (through a single portal) the number of those attached, the number of people under dispensary observation, schedules of professional examinations / medical examinations with a quarterly / monthly breakdown by therapeutic areas; work schedules);
• polyclinics every day on working days before 9 am must report (through the TFOMS portal) on insured persons who have passed a medical examination, as well as on persons undergoing medical examination;
• medical organizations, medical insurance organization (HIO) and TFOMS will exchange information every day in electronic form on the TFOMS portal: hospitals must update data on the implementation of the volume of medical care, free beds, admitted / non-admitted patients by 9 am; polyclinics update information on hospital referrals issued yesterday until 9 am; medical organizations that provide specialized, including high-tech, medical care, post information about patients who have had a telemedicine consultation, and the CMO is obliged to monitor the implementation of the recommendations received from the NMIC doctors, and has the right to conduct an in-person examination within the next 2 working days ;
• regardless of the mentioned interaction, every day no later than 10 am, the CMO informs hospitals about patients referred to such hospitals the day before, and also every day no later than 10 am informs medical organizations about the number of free beds in the context of profiles / departments, about patients whose hospitalization did not take place;
• On the basis of the database from the TFOMS portal, the HMO checks during the working day whether the patients were correctly referred to specialized medical organizations. If hospitalization took place out of time, not according to the profile, the HMO must file a complaint with the head physician of the violating medical organization and the regional Ministry of Health, and, if necessary, take measures and transfer the patient;
• insurance representatives of HIOs received a wide range of responsibilities - working with citizens' complaints, organizing examinations of the quality of medical care, informing and accompanying them when providing them with medical care, inviting them to medical examination, monitoring its passage, forming lists of "persons for medical examination" and lists of citizens who fell under the dispensary observation;
• patients will be able to see when and what medical services were provided to them, and at what cost: in personal account on the portal of public services or through the TFOMS - by means of authorization in the ESIA;
• for oncological patients, the HMO undertakes to create (on the TFOMS portal) an individual history of insurance events (based on registers-accounts) throughout all stages of medical care.

The updated CHI Rules directly impose on the CMO the obligation to carry out pre-trial protection of the rights of insured persons. When they file complaints about poor-quality medical care or charging for services under the compulsory medical insurance program, the CMO registers written appeals, conducts a medical and economic examination and an examination of the quality of medical care.

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In accordance with the Federal Law of November 29, 2010 N 326-FZ "On Compulsory Medical Insurance in the Russian Federation" I order:

1. Approve the attached Procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance (hereinafter referred to as the Procedure).

2. Heads of territorial funds of compulsory medical insurance and insurance medical organizations use the attached Procedure when organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance.

Chairman A. Yurin

The procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care under compulsory medical insurance

I. General provisions

1. Present Order organization and control of the volume, timing, quality and conditions for the provision of medical care under compulsory medical insurance (hereinafter referred to as the Procedure) was developed in accordance with the Federal Law of November 29, 2010 N 326-ФЗ "On Compulsory Medical Insurance in the Russian Federation" of the Russian Federation, 06.12.2010, N 49, Article 6422) and determines the rules and procedure for organizing and conducting by insurance medical organizations and funds of compulsory medical insurance control over the volume, timing, quality and conditions for the provision of medical care by medical organizations in the amount and on conditions that established by the territorial program of compulsory medical insurance and the contract for the provision and payment of medical care under compulsory medical insurance.

2. The purpose of this Procedure is to regulate measures aimed at realizing the rights of insured persons to receive free medical care in the volumes, terms and conditions established by the territorial program of compulsory medical insurance and the contract for the provision and payment of medical care for compulsory medical insurance, of appropriate quality in medical organizations involved in the implementation of compulsory health insurance programs.

II. The goals of controlling the volumes, terms, quality and conditions of provision

medical care under compulsory health insurance

3. The control of the volumes, terms, quality and conditions for the provision of medical care under compulsory health insurance (hereinafter referred to as control) includes measures to verify the compliance of the medical care provided to the insured person with the terms of the contract for the provision and payment of medical care under compulsory health insurance, implemented through medical economic control, medical and economic expertise and expertise of the quality of medical care.

4. The object of control is the organization and provision of medical care under compulsory medical insurance. The subjects of control are territorial compulsory health insurance funds, insurance medical organizations, medical organizations that have the right to carry out medical activities and are included in the register of medical organizations operating in the field of compulsory medical insurance.

5. Goals of control:

5.1. ensuring free provision of medical care to the insured person in the amount and on the terms established by the territorial program of compulsory medical insurance;

5.2. protection of the rights of the insured person to receive free medical care in the amount and on the terms established by the territorial program of compulsory medical insurance, of adequate quality in medical organizations participating in the implementation of compulsory medical insurance programs, in accordance with contracts for the provision and payment of medical care for compulsory medical insurance ;

5.3. prevention of defects in medical care resulting from non-compliance of the medical care provided with the state of health of the insured person; non-compliance and / or incorrect implementation of the procedures for the provision of medical care and / or standards of medical care, medical technologies by analyzing the most common violations based on the results of control and taking measures by authorized bodies;

5.4. verification of the fulfillment by insurance medical organizations and medical organizations of obligations to pay and provide free medical care to insured persons under compulsory medical insurance programs;

5.5. checking the fulfillment by insurance medical organizations of obligations to study the satisfaction of insured persons with the volume, availability and quality of medical care;

5.6. optimization of expenses for paying for medical care in the event of an insured event and reduction of insurance risks in compulsory medical insurance.

6. Control is carried out by conducting medical and economic control, medical and economic examination, examination of the quality of medical care.

III. Medico-economic control

7. Medical and economic control in accordance with Part 3 of Article 40 of the Federal Law of November 29, 2010 N 326-FZ "On Compulsory Medical Insurance in the Russian Federation" (hereinafter referred to as the Federal Law) - establishing the compliance of information on the volume of medical care provided to insured persons on the basis of invoice registers provided for payment by a medical organization to the terms of contracts for the provision and payment of medical care under compulsory medical insurance territorial program compulsory health insurance, methods of payment for medical care and tariffs for payment for medical care.

8. Medical and economic control is carried out by specialists of insurance medical organizations and territorial funds of compulsory medical insurance.

9. During medical and economic control, all cases of medical care provided under compulsory medical insurance are monitored in order to:

1) verification of registers of accounts for compliance with the established procedure for information exchange in the field of compulsory medical insurance;

2) identification of a person insured by a specific insurance medical organization (payer);

3) checking the compliance of the provided medical care:

a) the territorial program of compulsory medical insurance;

b) the terms of the contract for the provision and payment of medical care under compulsory medical insurance;

c) a valid license of a medical organization to carry out medical activities;

4) verifying the validity of the application of tariffs for medical services, calculating their cost in accordance with the methodology for calculating tariffs for paying for medical care approved by the authorized federal executive body, methods of paying for medical care and tariffs for paying for medical care and an agreement for the provision and payment of medical care according to compulsory health insurance;

5) establishing that the medical organization does not exceed the volume of medical care established by the decision of the commission for the development of the territorial program of compulsory medical insurance, payable at the expense of compulsory medical insurance.

10. The violations identified in the registers of accounts are reflected in the act of medical and economic control (Appendix 1 to this Procedure) indicating the amount of account reduction for each register entry containing information about defects in medical care and / or violations in the provision of medical care.

In accordance with Parts 9 and 10 of Article 40 of the Federal Law, the results of medical and economic control, drawn up by the relevant act in the form established by the Federal Compulsory Medical Insurance Fund, are the basis for applying the measures provided for in Article 41 of the Federal Law, the terms of the contract for the provision and payment of medical care on compulsory health insurance and the list of grounds for refusing to pay for medical care (reducing the payment for medical care) (Appendix 8 to this Procedure), and may also be the basis for conducting a medical and economic examination; organizing and conducting an examination of the quality of medical care; conducting repeated medical and economic control, repeated medical and economic examinations and examinations of the quality of medical care by the territorial fund of compulsory medical insurance or an insurance medical organization on the instructions of the territorial fund (except for control when making payments for medical care provided to insured persons outside the subject of the Russian Federation, on territory of which the compulsory health insurance policy was issued).

IV. Medical and economic expertise

11. Medical and economic expertise in accordance with Part 4 of Article 40 of the Federal Law - establishing the compliance of the actual terms of medical care, the volume of medical services presented for payment with records in the primary medical documentation and accounting and reporting documentation of a medical organization.

12. Medical and economic expertise is carried out by a specialist expert (clause 78 of section XIII of this Procedure).

13. Medical and economic expertise is carried out in the form of:

a) targeted medical and economic expertise;

b) planned medical and economic expertise.

14. Targeted medical and economic expertise is carried out in the following cases:

a) repeated visits for the same disease: within 30 days - when providing outpatient care, within 90 days - when re-hospitalization;

b) diseases with an extended or shortened treatment period by more than 50 percent of standard medical care or the average prevailing for all insured persons in reporting period with a disease for which there is no approved standard of care;

c) receiving complaints from the insured person or his representative about the availability of medical care in a medical organization.

15. On the basis of the medical and economic control carried out, the planned medical and economic examination is carried out on invoices submitted for payment within a month after the provision of medical assistance to the insured person under compulsory medical insurance, in other cases it can be carried out within a year after the presentation of invoices for payment.

16. When conducting a planned medical and economic examination, the following are evaluated:

a) the nature, frequency and causes of violations of the rights of insured persons to receive medical care under compulsory health insurance in the amount, terms, quality and conditions established by the contract for the provision and payment of medical care under compulsory health insurance;

b) the volume of medical care provided by the medical organization and its compliance with the volume established by the decision of the commission for the development of the territorial program of compulsory medical insurance, payable at the expense of compulsory medical insurance;

c) the frequency and nature of violations by the medical organization of the procedure for the formation of registers of accounts.

17. The scope of inspections during a planned medical and economic examination from the number of bills accepted for payment in cases of medical care under compulsory health insurance is determined by the contract for the provision and payment of medical care under compulsory health insurance and is not less than:

8% - inpatient care;

8% - medical care provided in a day hospital;

0.8% - outpatient care.

If during the month the number of defects in medical care and / or violations in the provision of medical care exceeds 30 percent of the number of cases of medical care for which a medical and economic examination was carried out, in the next month the volume of checks from the number of invoices accepted for payment by cases provision of medical care should be increased by at least 2 times compared to the previous month.

18. In relation to a certain set of cases of medical care, selected according to thematic criteria (for example, the frequency and types of postoperative complications, duration of treatment, cost of medical services), a planned thematic medical and economic expertise.

19. Based on the results of the medical and economic examination, the specialist expert draws up an act of medical and economic examination (Appendix 2 to this Procedure) in two copies: one is transferred to the medical organization, one copy remains in the medical insurance organization / territorial fund of compulsory medical insurance.

In accordance with Part 9 of Article 40 of the Federal Law, the results of the medical and economic examination, drawn up by the relevant act in the form established by the Federal Compulsory Medical Insurance Fund, are the basis for applying to the medical organization the measures provided for in Article 41 of the Federal Law, the terms of the contract for the provision and payment of medical assistance under compulsory health insurance and a list of grounds for refusing to pay for medical care (reducing the payment for medical care) (Appendix 8 to this Procedure), and may also be the basis for an examination of the quality of medical care.

V. Quality Examination

medical care

20. In accordance with part 6 of Article 40 of the Federal Law, the examination of the quality of medical care is the identification of violations in the provision of medical care, including the assessment of the correctness of the choice of medical technology, the degree of achievement of the planned result and the establishment of causal relationships of identified defects in the provision of medical care.

21. Examination of the quality of medical care is carried out by checking the compliance of the medical care provided to the insured person with the contract for the provision and payment of medical care under compulsory medical insurance, procedures for the provision of medical care and standards of medical care, established clinical practice.

22. Examination of the quality of medical care is carried out by an expert in the quality of medical care included in the territorial register of experts in the quality of medical care (paragraph 81 of section XIII of this Procedure) on behalf of the territorial compulsory medical insurance fund or an insurance medical organization.

23. Examination of the quality of medical care is carried out in the form of:

a) targeted examination of the quality of medical care;

b) scheduled examination of the quality of medical care.

24. A targeted examination of the quality of medical care is carried out within a month after the provision of an insured event (medical services) for payment, except for the cases determined by the current legislation and the cases set forth in subparagraph "e" of paragraph 25 of this section.

25. Targeted examination of the quality of medical care is carried out in the following cases:

a) receiving complaints from the insured person or his representative about the availability and quality of medical care in a medical organization;

b) the need to confirm the volume and quality of medical care in cases selected during medical and economic control and medical and economic examination;

c) deaths in the provision of medical care;

d) nosocomial infection and complications of the disease;

e) primary access to disability of persons of working age and children;

f) repeated justified treatment for the same disease: within 30 days - when providing outpatient care, within 90 days - when re-hospitalization;

g) diseases with an extended or shortened period of treatment by more than 50 percent of the established standard of medical care or the average prevailing for all insured persons in the reporting period with a disease for which there is no approved standard of medical care.

26. When conducting a targeted examination of the quality of medical care in cases selected based on the results of a targeted medical and economic examination, general terms conducting a targeted examination of the quality of medical care may increase up to six months from the date of submission of the invoice for payment.

When conducting a targeted examination of the quality of medical care in cases of repeated treatment (hospitalization) for the same disease deadlines are calculated from the moment of submission for payment of an invoice containing information on repeated treatment (hospitalization).

The terms for conducting a targeted examination of the quality of medical care from the moment the invoice for payment is provided are not limited in cases of complaints from insured persons or their representatives, deaths, nosocomial infections and complications of diseases, primary disability of people of working age and children.

27. Conducting a targeted examination of the quality of medical care in the event of complaints from insured persons or their representatives does not depend on the time elapsed since the provision of medical care and is carried out in accordance with the Federal Law of May 2, 2006 N 59-FZ "On the Procedure for Considering Citizens' Appeals of the Russian Federation" and other regulatory legal acts regulating the work with citizens' appeals.

28. The number of targeted examinations of the quality of medical care is determined by the number of cases requiring it for the reasons specified in this Procedure.

29. A planned examination of the quality of medical care is carried out in order to assess the compliance of the volumes, terms, quality and conditions for the provision of medical care to groups of insured persons, divided by age, disease or group of diseases, stage of medical care and other signs, conditions, stipulated by the contract for the provision and payment of medical care under compulsory medical insurance.

30. The volume of the planned examination of the quality of medical care is determined by the contract for the provision and payment of medical care under compulsory medical insurance and is not less than:

in a hospital - 5% of the number of completed cases of treatment;

in a day hospital - 3% of the number of completed cases of treatment;

when providing outpatient care - 0.5% of the number of completed cases of treatment based on the results of medical and economic control.

31. A planned examination of the quality of medical care is carried out in cases of medical care provided under compulsory medical insurance, selected:

a) by random sampling;

b) according to a thematically homogeneous set of cases.

32. A planned examination of the quality of medical care by random sampling is carried out to assess the nature, frequency and causes of violations of the rights of insured persons to timely receive medical care of the volume and quality established by the territorial program of compulsory medical insurance, including those caused by improper implementation of medical technologies that led to a deterioration in health of the insured person, additional risk of adverse consequences for his health, non-optimal use of the resources of the medical organization, dissatisfaction with the medical care of the insured persons.

33. A planned thematic examination of the quality of medical care is carried out in relation to a certain set of cases of providing medical care under compulsory medical insurance, selected by thematic criteria in each medical organization or group of medical organizations providing medical care under compulsory medical insurance of the same type or under the same conditions.

The choice of topics is carried out on the basis of performance indicators of medical organizations, their structural divisions and specialized areas of activity:

a) hospital mortality, the frequency of postoperative complications, the primary disability of people of working age and children, the frequency of repeated hospitalizations, the average duration of treatment, the cost of medical services and other indicators;

b) the results of internal and departmental quality control of medical care.

34. The planned thematic examination of the quality of medical care is aimed at solving the following tasks:

a) identifying, establishing the nature and causes of typical (repeating, systematic) errors in the treatment and diagnostic process;

b) comparison of the quality of medical care provided to groups of insured persons, divided by age, gender and other characteristics.

35. A scheduled examination of the quality of medical care is carried out in each medical organization providing medical care under compulsory medical insurance at least once during a calendar year within the time limits specified by the inspection plan (paragraph 51 of section VII of this Procedure).

36. Examination of the quality of medical care may be carried out during the period of provision of medical care to the insured person (hereinafter referred to as the face-to-face examination of the quality of medical care), including at the request of the insured person or his representative. The main purpose of the face-to-face examination of the quality of medical care is to prevent and / or minimize the negative impact on the patient's health of defects in medical care.

An expert on the quality of medical care, with notification to the administration of the medical organization, may conduct a tour of the divisions of the medical organization in order to control the conditions for the provision of medical care, prepare materials for an expert opinion, and also consult the insured person.

When consulting, the insured person who applied is informed about the state of his health, the degree of compliance of the medical care provided with the procedures for providing medical care and standards of medical care, the contract for the provision and payment of medical care under compulsory health insurance, with an explanation of his rights in accordance with the legislation of the Russian Federation.

37. The expert of the quality of medical care, who carried out the examination of the quality of medical care, draws up an expert opinion containing a description of the conduct and results of the examination of the quality of medical care, on the basis of which an act of examination of the quality of medical care is drawn up.

In accordance with Parts 9 and 10 of Article 40 of the Federal Law, the results of the examination of the quality of medical care, drawn up by the relevant act in the form established by the Federal Compulsory Medical Insurance Fund (Appendices 5, 6 to this Procedure), are the basis for applying to the medical organization the measures provided for in Article 41 of the Federal Law, the terms of the contract for the provision and payment of medical care under compulsory health insurance and the list of grounds for refusing to pay for medical care (reducing the payment for medical care) (Appendix 8 to this Procedure).

Based on the acts of examination of the quality of medical care, the authorized bodies take measures to improve the quality of medical care.

VI. The procedure for the implementation of the territorial fund

compulsory health insurance activity control

insurance medical organizations

38. The territorial compulsory health insurance fund, on the basis of Part 11 of Article 40 of the Federal Law, exercises control over the activities of insurance medical organizations by organizing control over the volume, timing, quality and conditions for the provision of medical care, conducts medical and economic control, medical and economic examination, examination of the quality of medical assistance, including

39. Repeated medical and economic examination or examination of the quality of medical care (hereinafter referred to as re-examination) - a medical and economic examination conducted by another specialist expert or another expert on the quality of medical care, an examination of the quality of medical care in order to verify the validity and reliability of conclusions on previously adopted conclusions made a specialist expert or an expert on the quality of medical care, who initially conducted a medical and economic examination or an examination of the quality of medical care.

Re-examination of the quality of medical care can be carried out in parallel or sequentially with the first one by the same method, but by another expert of the quality of medical care.

40. The tasks of the re-examination are:

a) verification of the validity and reliability of the conclusion of a specialist expert or an expert on the quality of medical care, who initially conducted a medical and economic examination or examination of the quality of medical care;

b) control over the activities of individual specialists-experts / experts in the quality of medical care.

41. Re-examination is carried out in the following cases:

a) carrying out by the territorial fund of compulsory medical insurance of a documentary check of the organization of compulsory medical insurance by a medical insurance organization;

b) detection of violations in the organization of control by the insurance medical organization;

c) groundlessness and / or unreliability of the conclusion of the expert of the quality of medical care, who conducted the examination of the quality of medical care;

d) receipt of a claim from a medical organization that has not been settled with an insurance medical organization (paragraph 73 of section XI of this Procedure).

42. The Territorial Compulsory Medical Insurance Fund notifies the insurance medical organization and the medical organization of the re-examination no later than 5 working days before the start of work.

To conduct a re-examination to the territorial fund of compulsory health insurance, within 5 working days after receiving the relevant request, the insurance medical organization and the medical organization must provide:

insurance medical organization - copies of acts of medical and economic control, medical and economic examination and examination of the quality of medical care necessary for the re-examination;

medical organization - medical, accounting and reporting and other documentation, if necessary, the results of internal and departmental quality control of medical care, including those carried out by the health management body.

43. The number of cases subject to re-examination is at least 20% of the number of all examinations for the relevant period of time.

44. The Territorial Compulsory Medical Insurance Fund sends the results of the re-examination, drawn up by the act (Appendix 7 to this Procedure), to the medical insurance organization and the medical organization no later than 20 working days after the end of the inspection. The insurance medical organization and the medical organization are obliged to consider these acts within 20 working days from the date of their receipt.

45. In the absence of agreement with the results of the re-examination, the medical insurance organization and the medical organization send a signed act with a protocol of disagreements to the territorial compulsory health insurance fund no later than 10 working days from the date of receipt of the act.

The Territorial Compulsory Medical Insurance Fund, within 30 working days from the date of receipt, considers the act with the protocol of disagreements with the involvement of interested parties.

46. ​​In accordance with Part 14 of Article 38 of the Federal Law, the territorial compulsory health insurance fund, in the event of violations of contractual obligations on the part of the insurance medical organization, when reimbursed to it for the cost of medical care, reduces payments by the amount of detected violations or unfulfilled contractual obligations.

The list of sanctions for violation of contractual obligations is established by the agreement on the financial provision of compulsory medical insurance, concluded between the territorial fund of compulsory medical insurance and the insurance medical organization.

In accordance with the specified agreement, in the event of violations in the activities of the insurance medical organization, the territorial compulsory health insurance fund uses the measures applied to the insurance medical organization in accordance with Part 13 of Article 38 of the Federal Law and the agreement on the financial support of compulsory medical insurance or recognizes those applied by the insurance medical organization to the medical organization measures unreasonable.

47. When detecting violations in the organization and conducting a medical and economic examination and / or examination of the quality of medical care, the Territorial Compulsory Medical Insurance Fund sends a claim to the medical insurance organization, which contains information about the control over the activities of the medical insurance organization:

a) the name of the commission of the territorial fund of compulsory medical insurance;

b) the date (period) of the inspection of the medical insurance organization;

c) composition of the commission of the territorial fund of obligatory medical insurance;

d) regulatory legal acts that are the basis for monitoring the activities of an insurance medical organization for organizing and conducting control and the reasons for conducting control;

e) facts of improper fulfillment by the insurance medical organization of contractual obligations to organize and conduct control, indicating acts of re-examination;

f) the measure of responsibility of the insurance medical organization for the identified violations;

g) applications (copies of acts of re-examination, etc.).

The claim is signed by the director of the territorial fund of obligatory medical insurance.

Execution of the claim is carried out within 30 working days from the date of its receipt by the insurance medical organization, about which the territorial fund of compulsory medical insurance is informed.

48. If the territorial fund of compulsory medical insurance reveals during the re-examination of violations missed by the insurance medical organization during the medical and economic examination or examination of the quality of medical care, the insurance medical organization loses the right to use the measures applied to the medical organization, due to a defect in the medical assistance and / or violation in the provision of medical care.

49. The medical organization returns funds in the amount determined by the act of re-examination to the budget of the territorial fund of compulsory medical insurance.

50. The Territorial Compulsory Medical Insurance Fund analyzes the applications of the insured persons, their representatives and other subjects of compulsory medical insurance based on the results of the control carried out by the insurance medical organization.

VII. Interaction of subjects of control

51. The Territorial Compulsory Medical Insurance Fund coordinates the interaction of subjects of control on the territory of a constituent entity of the Russian Federation, carries out organizational and methodological work that ensures the functioning of control and protection of the rights of insured persons, coordinates the plans for the activities of insurance medical organizations in terms of organizing and conducting control, including plans inspections by insurance medical organizations of medical organizations providing medical care under contracts for the provision and payment of medical care under compulsory medical insurance.

52. When conducting a medical and economic examination and examination of the quality of medical care, a medical organization provides specialist experts and experts in the quality of medical care within 5 working days after receiving a relevant request, medical, accounting, reporting and other documentation, if necessary, the results of internal and departmental quality control medical care.

53. In accordance with Part 8 of Article 40 of the Federal Law, a medical organization is not entitled to prevent specialist experts and experts in the quality of medical care from accessing the materials necessary for conducting a medical and economic examination, an examination of the quality of medical care, and is obliged to provide the requested information.

54. Employees involved in the implementation of control are responsible for the disclosure of confidential information of limited access in accordance with the legislation of the Russian Federation.

55. On the basis of Article 42 of the Federal Law, the resolution of disputes and conflicts arising in the course of control between a medical organization and a medical insurance organization is carried out by the territorial compulsory medical insurance fund.

The commission informs the interested parties and the executive authority of the subject of the Russian Federation in the field of healthcare about the results of resolving controversial and conflict issues, about violations in the organization and conduct of control, in the provision of medical care in a medical organization.

VIII. Accounting and use

control results

56. Reports on the results of the control carried out are provided by insurance medical organizations to the territorial fund of compulsory medical insurance.

The insurance medical organization and the territorial fund of compulsory medical insurance keep records of control acts.

Recording documents may be registers of acts of medical and economic control (Appendix 2 to this Procedure), medical and economic examination and examination of the quality of medical care.

The results of the control in the form of acts are transferred to the medical organization within 5 working days.

Possible to conduct electronic document management between the subjects of control using a digital signature.

57. In the case when the act is delivered to a medical organization personally by a representative of an insurance medical organization / territorial fund of compulsory medical insurance, all copies of the act are marked with the receipt indicating the date and signature of the recipient. When sending an act by mail, specified document sent by registered mail (with an inventory) with notification.

The act can be sent to a medical organization in electronic form if there are guarantees of its reliability (authenticity), protection against unauthorized access and distortion.

58. The head of the medical organization or the person replacing him considers the act within 15 working days from the date of its receipt.

If the medical organization agrees with the act and the measures applied to the medical organization, all copies of the acts are signed by the head of the medical organization, certified by a seal, and one copy is sent to the medical insurance organization / territorial compulsory medical insurance fund.

If the medical organization disagrees with the act, the signed act is returned to the medical insurance organization with a protocol of disagreements.

59. Based on the analysis of the activities of subjects of control, the territorial fund for compulsory medical insurance develops proposals that contribute to improving the quality of medical care and the efficiency of using compulsory medical insurance resources and informs the executive authority of the constituent entity of the Russian Federation in the field of healthcare and the territorial body Federal Service on supervision in the field of health and social development.

60. In accordance with Article 31 of the Federal Law, a claim or lawsuit against a person who has caused harm to the health of the insured person, in order to reimburse the costs of paying for the medical care provided by the medical insurance organization, is carried out on the basis of the results of the examination of the quality of medical care, drawn up by the relevant act.

IX. The procedure for informing the insured persons about the identified violations in the provision of medical care

under the territorial program of compulsory medical insurance

61. In order to ensure the rights to receive affordable and high-quality medical care, insured persons are informed by medical organizations, medical insurance organizations, territorial compulsory medical insurance funds about identified violations in the provision of medical care under the territorial program of compulsory medical insurance, including the results of control.

62. Work with appeals from citizens in the Federal Compulsory Medical Insurance Fund, territorial compulsory medical insurance funds and insurance medical organizations is carried out in accordance with the Federal Law of May 2, 2006 N 59-FZ "On the procedure for considering applications from citizens of the Russian Federation" and other regulatory legal acts regulating the work with citizens' appeals.

63. When a medical insurance organization or a territorial compulsory medical insurance fund receives a complaint from the insured person or his representative about the provision of medical care of inadequate quality, the results of the consideration of the complaint based on the results of the examination of the quality of medical care are sent to his address.

64. In insurance medical organizations that organize the service of representatives of insurance medical organizations for the implementation in medical organizations participating in the implementation of compulsory medical insurance programs, work to protect the rights and legitimate interests of insured persons, representatives of insurance medical organizations take part in the preparation and placement of information materials on protection of the rights of insured persons and the results of control, as well as provide insured persons receiving medical care in medical organizations with information and explanatory materials on their rights.

X. Procedure for the application of sanctions

to a medical organization for violations identified during the control

65. Based on Part 1 of Article 41 of the Federal Law, the amount not payable based on the results of medical and economic control, medical and economic examination, examination of the quality of medical care is withheld from the amount of funds provided for payment for medical care provided by medical organizations, or is subject to return to a medical insurance organization in accordance with the contract for the provision and payment of medical care under compulsory medical insurance, the list of grounds for refusing to pay for medical care or reducing payment for medical care in accordance with this Procedure.

66. The result of control in accordance with the contract for the provision and payment of medical care under compulsory health insurance and the list of grounds for refusing to pay for medical care (reducing the payment for medical care) are:

a) non-payment or reduction of payment for medical care in the form of:

exclusion of a position from the register of accounts subject to payment of volumes of medical care;

reduction of amounts submitted for payment, as a percentage of the cost of medical care provided according to insured event;

return of amounts not payable to the insurance medical organization;

b) payment by a medical organization of fines for failure to provide, untimely provision or provision of medical care of inadequate quality (on an insured event in which defects in medical care and / or violations in the provision of medical care were revealed).

67. Non-payment or reduction of payment for medical care and payment of fines by the medical organization in accordance with subparagraph b) of paragraph 66 of this section, depending on the type of identified defects in medical care and / or violations in the provision of medical care, can be applied separately or simultaneously.

68. If violations of contractual obligations in relation to the volumes, terms, quality and conditions for the provision of medical care are detected, the insurance medical organization does not partially or fully reimburse the expenses of the medical organization for the provision of medical care, reducing subsequent payments on the accounts of the medical organization by the amount of identified defects in medical care and / or violations in the provision of medical care or requires the return of amounts to the medical insurance organization.

The amount that is not payable based on the results of the control is withheld from the amount of funds provided for paying for medical care provided by a medical organization, or is subject to return to the medical insurance organization in accordance with the contract for the provision and payment of medical care under compulsory medical insurance.

69. For failure to provide, untimely provision, or provision of medical care of inadequate quality under a contract for the provision and payment of medical care under compulsory medical insurance, a medical organization pays a fine to an insurance medical organization in the amount established under the specified contract and in accordance with the list of grounds for refusal (reduction ) payment for medical care (Appendix 8 to this Procedure).

70. If there are two or more grounds for refusing to pay for medical care or reducing payment for medical care in the same case of medical care, one - the most significant reason is applied to the medical organization, entailing a larger amount of non-payment, or refusal to pay. The amount of incomplete payment for medical services for one insured event is not summed up.

71. Non-payment or incomplete payment of medical care, as well as the payment of fines by a medical organization for failure to provide, untimely provision or provision of medical care of inadequate quality does not relieve the medical organization from compensating the insured person for harm caused through the fault of the medical organization, in the manner established by law Russian Federation.

72. Funds received as a result of applying sanctions to a medical organization for violations identified during the control are spent in accordance with the Federal Law.

XI. Appeal

medical organization conclusions of an insurance medical organization

according to the results of control

73. In accordance with Article 42 of the Federal Law, a medical organization has the right to appeal against the conclusion of a medical insurance organization based on the results of control within 15 working days from the date of receipt of the certificates of an insurance medical organization by sending a claim to the territorial compulsory medical insurance fund according to the recommended sample (Appendix 9 to this order).

The claim is made in writing and sent along with the necessary materials to the territorial fund of compulsory medical insurance. The medical organization is obliged to provide to the territorial fund of compulsory medical insurance:

a) substantiation of the claim;

b) a list of questions for each disputed case;

c) materials of internal and departmental quality control of medical care in a medical organization.

74. The Territorial Compulsory Medical Insurance Fund, within 30 working days from the date of receipt of the claim, considers the documents received from the medical organization and organizes repeated medical and economic control, medical and economic examination and examination of the quality of medical care, which, in accordance with Part 4 of Article 42 of the Federal laws are formalized by the decision of the territorial fund.

75. The decision of the territorial compulsory health insurance fund, recognizing the correctness of the medical organization, is the basis for the cancellation (change) of the decision on non-payment, incomplete payment for medical care and / or on the payment of a fine by the medical organization for failure to provide, late provision or provision of medical care of inadequate quality based on the results primary medical and economic examination and / or examination of the quality of medical care.

The change in funding based on the results of consideration of disputable cases is carried out by the insurance medical organization no later than 30 working days (during the final settlement with the medical organization for the reporting period).

76. If the medical organization disagrees with the decision of the territorial fund, it has the right to appeal this decision in court.

XII. Organization by the territorial fund of compulsory medical insurance of control in the implementation of settlements

for medical care provided to insured persons outside the subject of the Russian Federation,

on the territory of which the compulsory health insurance policy was issued

77. The organization by the territorial fund of compulsory medical insurance of control when making payments for medical care provided to insured persons outside the subject of the Russian Federation in whose territory the policy of compulsory medical insurance was issued is carried out in accordance with sections III-V of this Order.

XIII. workers,

carrying out medical and economic examination and examination of the quality of medical care

78. In accordance with Part 5 of Article 40 of the Federal Law, a medical and economic examination is carried out by a specialist expert who is a doctor with at least five years of experience in the medical specialty and who has undergone appropriate training in expert activities in the field of compulsory medical insurance.

79. The main tasks of a specialist expert are:

a) monitoring the compliance of the provided medical care with the terms of the contract for the provision and payment of medical care under compulsory health insurance by establishing the correspondence between the actual terms of the provision of medical care, the volume of medical services provided for payment to the records in the primary medical and accounting and reporting documentation of the medical organization;

b) participation in organizing and conducting an examination of the quality of medical care and ensuring guarantees of the rights of insured persons to receive medical care of appropriate quality.

80. The main functions of a specialist expert are:

a) selective control of the volume of medical care for insured events by comparing the actual data on the medical services provided to the insured person with the procedures for providing medical care and standards of medical care;

b) selection of cases for examination of the quality of medical care and substantiation of the need for it, preparation of documentation necessary for an expert on the quality of medical care to conduct an examination of the quality of medical care;

c) preparation of materials used methodological base for the examination of the quality of medical care (procedures for the provision of medical care and standards of medical care, clinical protocols, guidelines, etc.);

d) generalization, analysis of the conclusions prepared by an expert on the quality of medical care, participation in the preparation of an act of the established form or preparation of an act of the established form;

e) preparation of proposals for filing claims or lawsuits against a medical organization for compensation for harm caused to insured persons, and sanctions applied to a medical organization;

f) familiarization of the management of the medical organization with the results of the medical and economic examination and examination of the quality of medical care;

g) generalization and analysis of control results, preparation of proposals for the implementation of targeted and thematic medical and economic examinations and examinations of the quality of medical care;

h) assessment of the satisfaction of the insured persons with the organization, conditions and quality of the medical care provided.

81. Examination of the quality of medical care in accordance with Part 7 of Article 40 of the Federal Law is carried out by an expert on the quality of medical care, who is a medical specialist with a higher professional education, certificate of accreditation of a specialist or certificate of a specialist, work experience in the relevant medical specialty for at least 10 years and trained in expert activities in the field of compulsory health insurance, included in the territorial register of experts in the quality of medical care (paragraph 84 of this section).

An expert on the quality of medical care conducts an examination of the quality of medical care in his main medical specialty, determined by a diploma, a certificate of accreditation of a specialist or a certificate of a specialist.

When conducting an examination of the quality of medical care, the expert on the quality of medical care has the right to remain anonymous / confidential.

82. The main task of an expert in the quality of medical care is to conduct an examination of the quality of medical care in order to identify defects in medical care, including assessing the correctness of the choice of a medical organization, the degree of achievement of the planned result, establishing cause-and-effect relationships of identified defects in medical care, drawing up an expert opinion and recommendations for improvement quality of medical care in compulsory health insurance.

An expert on the quality of medical care is not involved in the examination of the quality of medical care in a medical organization with which he has an employment or other contractual relationship, and is obliged to refuse to conduct an examination of the quality of medical care in cases where the patient is (was) his relative or patient, in the treatment of which the quality of care expert was involved.

83. An expert on the quality of medical care when conducting an examination of the quality of medical care:

a) uses medical documents containing a description of the treatment and diagnostic process, if necessary, performs an examination of patients;

b) provides information about the used normative documents(procedures for the provision of medical care and standards of medical care, clinical protocols, guidelines) on request officials a medical organization in which an examination of the quality of medical care is carried out;

c) comply with the rules of medical ethics and deontology, keep medical secrets and ensure the safety of loans received for temporary use medical documents and their timely return to the organizer of the examination of the quality of medical care or to a medical organization;

d) discusses with the attending physician and the management of the medical organization preliminary results examination of the quality of medical care.

84. The territorial register of medical care quality experts contains information about medical care quality experts who carry out medical care quality examination within the framework of control in the constituent entity of the Russian Federation, and is a segment of the unified register of medical care quality experts.

The maintenance of the territorial register of medical care quality experts is carried out by the territorial compulsory health insurance funds in accordance with paragraph 9 of part 7 of Article 34 of the Federal Law on the basis of uniform organizational, methodological, software and technical principles.

Responsibility for violations in the maintenance of the territorial register of experts in the quality of medical care shall be borne by the director of the territorial fund of compulsory medical insurance.

In accordance with clause 11 of part 8 of Article 33 of the Federal Law federal fund compulsory health insurance single register medical care quality experts, which is a set of electronic databases of territorial registers of medical care quality experts.