第 一 篇 全 民 健 保 組 織 與 制 度
Chapter 1 NHI Administrative Framework
47
The procedural/automated checks focus on the following
criteria:
1.
The eligibility of those treated
2.
The scope of reimbursements
3.
Verification that the medical services or drugs claimed were
appropriate and their respective reimbursement standards
were correct
4.
Whether the submitted forms were properly and fully filled
out
5.
The completeness of appended documents
6.
A preliminary check of the basic treatment services on the
case payment system
7.
Pre-authorization reviewof special surgeries or treatments.
8.
Other procedural items related tomedical expenditures
If any health care providers submit medical services
claims that are found to have violated insurance regulations,
they will not be reimbursed for the claims, with the reason
noted on the file.
程序審查之內容包括：
1.
保險對象資格。
2.
保險給付範圍。
3.
醫療服務給付項目及支付標準、藥物給
付項目及支付標準正確性之核對。
4.
申報資料填載之完整性及正確性。
5.
檢附資料之齊全性。
6.
論病例計酬案件之基本診療項目。
7.
事前審查項目。
8.
其他醫療費用申報程序審查事項。
特約醫療院所申報之醫療服務案件，依
前述程序審查發現有違反全民健保相關法令
規定者，應不予支付該項費用，並註明不予
支付內容及理由。