全民健康保險爭議事項審議辦法

The National Health Insurance Dispute Mediation Regulations (hereinafter referred to as “the Regulations”) are enacted pursuant to Paragraph 3, Article 6 of the National Health Insurance Act (hereinafter referred to as “the Act”).

1If the beneficiary, the group insurance applicant, the premium withholder, and the contracted medical care institutions dispute against the Insurer over the following National Health Insurance benefit case evaluated by the Insurer, they shall apply for mediation first in accordance with the Regulations:

21. The matters concerning the beneficiary’s qualification and the insurance procedures.

32. The matters concerning the insured payroll-related amount.

43. The matters concerning the insurance premium, the belated surcharge, and the fine.

54. The matters concerning the insurance benefits.

65. Other matters concerning the insurance rights and interests.

7If the contracted medical care institution disputes against the Insurer over the National Health Insurance medical expenses case evaluated by the Insurer, it shall apply for mediation in accordance with the Regulations.

8If the contracted medical care institution disputes against the Insurer over the contracted medical care institution’s exclusive management case evaluated by the Insurer, it shall apply for mediation in accordance with the Regulations.

1The beneficiary, the group insurance applicant, the premium withholder, and the contracted medical care institution shall be the applicants of the applications for mediation.

2The group insurance applicant shall put forward the applications referred to in the preceding paragraph at the request of the subordinate beneficiary.

When the applicant applies for mediation, he or she shall fill out the National Health Insurance dispute mediation petition (hereinafter referred to as “petition”) and submit it to The National Health Insurance Dispute Mediation Committee (hereinafter referred to as “NHI Dispute Mediation Committee “) within sixty days from the next day of the arrival of the Insurer’s Notice of Assessment document.

1The application for mediation shall be based on the date the NHI Dispute Mediation Committee receives the petition. If the petition is sent to the NHI Dispute Mediation Committee by mail, the postmark date stamped by the original post office shall be used for reference.

2Those who have missed the application for mediation due to a natural disaster or any reasons not attributable to the applicant shall state the reasons in writing and apply for restoration to the status quo ante within ten days after the cause ceases to exist. However, if it has been over one year since the application deadline for mediation, the applicant is not eligible to apply for restoration.

3Those who apply for restoration to the status quo ante shall complete all necessary mediation application procedures during the remedy period.

After the applicant applies for mediation, he or she may withdraw his or her application prior to the mediation disposition (hereinafter referred to as “disposition”); the applicant who withdraws his or her application is not allowed to apply for mediation for the same dispute again.

1Those who apply for mediation without petitions or with petitions unconformable with the legal procedure and have abilities to correct this fault shall be informed to correct it within 20 days.

2Those who have a good cause for postponement of the correction referred to in the preceding paragraph shall apply for postponement within 20 days.

1For the benefit or exclusive management case conformable with the legal procedure, the NHI Dispute Mediation Committee shall send a copy of the petitions to the Insurer to get his position paper; the same processes shall be applied to the medical expenses case conformable with the legal procedure as necessary.

2The Insurer shall present the position paper within one month from the next day of the arrival of the letter and submit it together with necessary materials to the NHI Dispute Mediation Committee. If the Insurer deems the application for mediation reasonable, he shall re-evaluate the matter concerned and, notify the applicant directly and report it to the NHI Dispute Mediation Committee.

The designated members shall make the preliminary assessment for the dispute mediation first and submit the comments on the preliminary assessment to the NHI Dispute Mediation Committee for resolution. Physicians or experts in related fields shall be invited to assist in making preliminary assessments for cases involving specialized technology or mass occurrences.

The dispute case shall be subject to written mediation. If necessary, the relevant institutions or academic institutions shall be commissioned to expert examination and sit in on the mediation to account for the dispute.

The NHI Dispute Mediation Committee Chairperson or member who has a concern in the dispute mediation shall be recused and not participate in the mediation.

1The NHI Dispute Mediation Committee shall dispose the dispute case within three months from the next day of receiving the petition; if it is necessary to postpone the approval of the dispute case, the NHI Dispute Mediation Committee shall notify the applicant, except that there is the consent of the applicant. Disposition can be postponed only once and for less than three months.

2The period referred to in the preceding paragraph shall start from the next day of the correction for those who get notified of correction in accordance with Article 7, from the next day of the end of the correction period for those who fail to correct, and from the next day of the arrival of the represented reasons for those who represent reasons during the mediation.

3If the case fails to be disposed within the period referred to in Paragraph 1, the applicant shall start a lawsuit over the dispute within the law.

Disposition shall conform to other legal relations as the criterion. Before confirming the legal relations, the NHI Dispute Mediation Committee shall suspend the mediation procedures in conformity with the legal procedures and notify the applicant.

1The application for mediation of the benefit case requires the applicant to fill out the petition stating the following matters with his agent’s or his own signature or seal:

21. The applicant’s name, date of birth, domicile, or place of residence, and ID No. If the applicant is a juridical person or an organization with managers or representatives, the juridical person or organization’s name, office or business address, and the manager or representative’s name, date of birth, domicile, or place of residence.

32. If the applicant has an agent, he or she shall present a written form of power of attorney at the first place of the administrative appeal conduct. A power of attorney shall include the agent’s name, date of birth, domicile, or place of residence, and ID No.

43. Claims

54. Facts and reasons for mediation application

65. The date of receiving or knowing the Insurer’s original Notice of Assessment (MM/DD/YYYY)

76. The evidence. If the evidence is a written document, a transcript or copy is required.

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1The Insurer shall present the position paper stating the following matters in accordance with Paragraph 2, Article 8

21. The reasons not stated in the original Notice of Assessment documents.

32. The facts or legal arguments of the mediation application and the Insurer’s opinions.

43. Comments on all the arguments put forward by the applicant; those who hold the converse opinion shall attach the reasons to the position paper.

54. The evidence available for the original Notice of Assessment.

1The applicant shall apply to the NHI Dispute Mediation Committee in written form for viewing, transcribing, copying, or shooting the related documents with the exception of the following documents:

21. Draft documents for disposition

32. Preparation or mediation documents for disposition

43. Documents kept confidential to protect the third party’s legal rights and interests.

54. Other documents kept confidential based on laws or public benefits.

If necessary, the NHI Dispute Mediation Committee shall inform the applicant to state his or her opinions at the designate place on the designate day in conformity with the legal procedures and the application of the applicant.

1One of the following cases will invalidate the mediation disposition of the benefit case:

21. The petition unconformable with the legal procedure is unable to be corrected or fails to be corrected within the designate period.

32. Overdue applications for mediation

43. Those who are not set forth in Paragraph 1, Article 3 put forward the application.

54. The nonexistence of the original Notice of Assessment

65. Reapplications of mediation of a dispositional or withdrawn case.

76. Disputes not concerning the matters referred to in Article 2.

8If the invalid mediation disposition referred to in Subparagraph 1 or 2 of the preceding paragraph can prove that the original evaluation is illegal, the Insurer or his higher authorities shall revoke or modify the original evaluation in conformity with the legal procedures.

1The NHI Dispute Mediation Committee shall dismiss the mediation disposition for those who put forward applications without reason.

2The NHI Dispute Mediation Committee shall revoke all or one part of the original evaluation for those who put forward applications with reasons and shall approve the evaluation modification directly or remand it back to the Insurer for re-evaluation within the designate days according to the status.

3If the Insurer presents a position paper not in detail or fails to present a position paper within the designate days, the NHI Dispute Mediation Committee shall carry out the mediation disposition directly in conformity with the legal procedures.

1The disposed benefit case requires the disposition paper stating the following matters:

21. The matters referred to in Subparagraph 1, Paragraph 1, Article 14.

32. Texts, facts, and reasons, among which the facts shall only cover the arguments, the invalid mediation approval referred to in Paragraph 1, Article 18 may not state facts with this subparagraph as proof.

43. The organization and its leading officer.

54. MM/DD/YYYY

6The disposition paper shall include a notation of the remedial measures available for those who disagree with the decision, the periods for such remedies, and the organizations that handle such matters.

1The application for mediation of the medical expenses case requires the applicant to fill out the petition and the detailed list (see Appendix 1 and 2) stating the following matters with his seal:

21. The name and code of the contracted medical care institution and the medical personnel who is in charge of the institution.

32. Claims

43. Facts and reasons for mediation application

54. The date of receiving or knowing the Insurer’s recheck notification (MM/DD/YYYY)

65. The medical record and other related certifications. The transcripts or copies of materials in written form are required.

76. Transcripts or copies of the Insurer’s recheck notification document and the related documents or materials

87. MM/DD/YYYY

9The facts and reasons referred to in Subparagraph 3 of the preceding paragraph shall be written in the columns specified by the format.

1The Insurer shall present the position paper stating the following matters in accordance with Paragraph 2, Article 8:

21. The reasons not stated in the recheck notification documents.

32. Comments on all the arguments put forward by the applicant.

43. The evidence available for the recheck notification.

5The evidence available for the Insurer’s recheck notification referred to in the preceding paragraph shall state the methods of review, analysis, and sampling with related information enclosed in case of field audit, file analysis, purposive, and random sampling examination.

The mediation disposition of medical expense cases shall apply mutatis mutandis the provisions of Articles 18 and 19, except for the provisions of Article 18, Paragraph 1, Subparagraph 4.

1The dispositional medical expenses case requires the disposition paper stating the following matters:

21. The name and code of the contracted medical care institution.

32. Texts, facts, and reasons, among which the facts and reasons not concerning the arguments may not be stated.

43. The organization and its leading officer.

54. MM/DD/YYYY

6If the same applicant applies for over two dispute mediations on the same agreement within the given time, only the disputed matters need to be stated as stipulated by Subparagraph 2 of the preceding paragraph. The same process is also applied in the case of the same type and the same mediation result.

7If the Insurer re-evaluates the medical expenses case in accordance with Paragraph 2, Article 8, the NHI Dispute Mediation Committee is allowed to close the case directly without the disposition paper of Paragraph 1.

8The disposition paper shall include a notation of the remedial measures available for those who disagree with the decision, as well as the administrative court having jurisdiction to hear such litigation.

The mediation procedures for special contract management cases shall apply mutatis mutandis, the provisions of Section II concerning rights and interests cases.

1The disposition paper shall be delivered to both the applicant and the Insurer. If necessary, it shall be reported to the relevant institutions or units.

2The Insurer shall enforce the mediation disposition made by the NHI Dispute Mediation Committee within 15 days from the arrival of the disposition paper.

3For the revocation case disposed by the NHI Dispute Mediation Committee, the enforcement period mentioned in the preceding paragraph does not include the period from the date of notification of correction to the correction completion date if the Insurer shall make corrections due to the incomplete documents submitted by the applicant.

The Regulations shall enter into force as of the date of promulgation, except for the Articles amended and announced on November 6, 2012, which shall become effective on January 1, 2013.