第 一 篇 全 民 健 保 組 織 與 制 度
Chapter 1 NHI Administrative Framework
49
The practices and guidelines for these professional
reviews of selected claims are established through consultations
by advisory panels for different medical specialties consisting
of medical experts with clinical or review experience. To
ensure the consistency of the professional reviews, the NHIA
trains and orients panel members on the workings of the
insurance system and related applicable standards, and tries to
develop a consensus of the experts’views on review standards.
In February 2012, the NHIA created a “professional review
databank inquiry system” to give administrative workers in
health-related units and medical experts on the review panels
a convenient way to check or look up related regulations,
improving review efficiency. To follow-up on the initiative
and support the development of a prototype “intelligent
professional review system,” the NHIA took steps from 2011
to 2013 to computerize the order-specific regulations for all
medical services, enabling professional reviewers to call up
every review regulation and standard for any item on the NHI
fee schedule with a click as they conduct their reviews, saving
themconsiderable amounts of time.
有關專業審查的醫療專業審查規範及注
意事項之訂定，均係經具有相關臨床或實際經
驗之醫藥專家組成分科專家諮詢會議討論後訂
立。為有效提升專業審查一致性，健保署對審
查醫師，除辦理業務說明外，亦舉辦各科審查
醫藥專家會議，尋求對醫療專業見解之共識。
此外，於
2012
年
2
月建置「專業審查知識庫
查詢系統」，提供全署各單位行政人員及審查
醫藥專家方便線上查詢審查相關規定，增進審
查效率；後續亦將配合智慧型專業審查雛型系
統之建置，於
2011
年至
2013
年，分年完成
各類審查相關規定醫令別查詢資料之整編建置
及整合運用作業。