全民健康保險轉診實施辦法

The Regulations Governing the National Health Insurance Referral (hereinafter referred to as the “Regulations”) are enacted according to Paragraph 4 of Article 43 of the National Health Insurance Act (hereinafter referred to as the “Act”).

Referrals of beneficiaries by the contracted hospitals and clinics of the National Health Insurance (hereinafter referred to as the “Insurance”) shall be governed by the Regulations.

1Where a contracted hospital or clinic provides referral service for a beneficiary, the referral shall be made based on medical necessity and conform to the Medical Care Act.

2Referral in the preceding paragraph shall mean that a beneficiary who agrees to the arrangement made by a contracted hospital or clinic to be sent to another suitable level contracted hospital or clinic to continue to receive treatment. This includes the arrangement of sending a beneficiary receiving point of care or mobile medical services under an Insurance plan or project at a correctional institution or any mountain regions, outlying islands, or areas with inadequate medical resources under the Insurance to the contracted hospital or clinic providing the aforementioned medical care services to continue receiving medical treatment.

3Referral in the preceding paragraph shall not be restricted by the category or level of the medical care institution.

4In the event that a beneficiary is referred to a contracted hospital or clinic and no longer requires care there due to his or her medical condition and none of the circumstances in Article 11 apply, the contracted hospital or clinic shall recommend the beneficiary return to the original referring hospital or clinic, or to another suitable contracted hospital or clinic, for continued treatment if follow-up care is still required.

1A contracted hospital or clinic may, based on clinical needs, issue a referral form (refer to Appendix 1) to a beneficiary in order for him or her to receive a medical examination (test) in a designated contracted hospital, clinic, medical examination, or medical radiology institution.

2The items of medical examination (test) in the preceding paragraph shall be limited to those items that the referring hospital or clinic is authorized to conduct according to its level.

1A contracted hospital and clinic shall establish a two-way referral system with other contracted hospitals and clinics.

2A contracted hospital or clinic shall set up proper facilities and hire qualified personnel to provide suitable arrangements for beneficiaries who need referral services. It shall also preserve the priority quota for patients of referral, as the case may be.

1A contracted hospital or clinic shall issue a referral form to a beneficiary who meets the requirements for referral. Prior to issuing the referral form, it may contact the receiving contracted hospital or clinic to arrange appointment scheduling, including the date of service, appropriate medical specialty department, and registration procedures.

2The preceding referral form is valid for 90 days as of the issuance day.

3Where a beneficiary agrees to be referred to another hospital or clinic, the referral shall only be made to the contracted hospital or clinic specified in the referral form.

4Where a beneficiary, without his or her fault, fails to visit the contracted hospital or clinic that accepts the referral on the date of the medical visit specified in the referral form, the beneficiary may directly contact the contracted hospital or clinic that accepts the referral to arrange a substitute date of the medical visit.

1The referral form referred to in the preceding article shall contain the following items and be duly signed by the issuing physician (refer to Appendix 2),

21. The basic information of the beneficiary;

32. Abstract of medical records and medical treatment status;

43. The purpose of referral;

54. The date of issuance and valid period;

65. The name, address, phone number, and diagnostic department of the contract hospital or clinic recommended for referral.

7Where an electronic referral form is adopted, the referring contracted hospital or clinic shall transmit the electronic referral form to the contracted hospital or clinic that accepts the referral and, if required by the beneficiary, print and give a copy of the referral form to the beneficiary who should in turn hand it over to the contracted hospital or clinic which accepts the referral as his or her medical records for future reference.

8A contracted hospital or clinic is recommended to transmit the referral form referred to in the first paragraph through the electronic referral platform set up by the Insurer.

When providing referral service for a beneficiary, a contracted hospital or clinic shall record the category of medical visit of the referral to the beneficiary’s NHI card and transmit the same to the Insurer.

A contracted hospital or clinic shall verify the identity of the beneficiary and the referral form pursuant to the requirements set forth in the Regulations Governing the National Health Insurance Medical Care.

1A contracted hospital or clinic that accepts the referral shall provide feedback on the condition of its primary treatment and subsequent checks as well as medical treatment results for the diagnosed disease on the beneficiary to the referring hospital or clinic

2pursuant to rules governing referral under the Enforcement Rules of the Medical Care Act.

3Where a beneficiary is referred to another hospital or clinic to receive inpatient care, the contracted hospital that accepts the referral shall provide feedback on the post-discharge medical record abstract to the referring contracted hospital or clinic after the beneficiary is discharged from the hospital. The contracted hospital or clinic that accepts the referral shall also inform the referring contracted hospital or clinic if the beneficiary requires continuous treatment or follow-up treatment due to his or her medical condition.

4The preceding two paragraphs shall not apply to the referral where a contracted hospital or clinic accepts a beneficiary returning to continue receiving medical treatment as arranged by the same institution.

1If a beneficiary has any one of the following circumstances, the beneficiary shall be deemed as being referred without the need to hold a referral form:

21. The first re-visit made after outpatient or emergency surgery;

32. Other than the re-visit referred to in the preceding subparagraph, re-visits made with a referral form where the physician considers it necessary for the beneficiary to continue receiving outpatient treatment for the referring illness and all re-visits made within one month from the date of the medical visit of referral do not go beyond four times;

43. The first re-visit made within six weeks of being discharged from the hospital following the delivery of a newborn;

54. The first re-visit made within one month after being discharged from the hospital for a reason other than those set forth in the preceding subparagraph;

65. Where a beneficiary undertakes a medical visit directly to a contracted hospital of his or her township (town, city, district) in the absence of a contracted clinic in the same township (town, city, district).

7The re-visit referred to in the preceding subparagraphs 1 to 4 is only limited to a visit made to the contracted hospital or clinic that accepts the referral, and such hospital or clinic shall issue a certificate by itself to the beneficiary or directly determine it a re-visit as a matter of fact based on the beneficiary’s medical records, as reference for being deemed as a referral.

A contracted hospital or clinic which arranges referral service according to the Regulations shall collect the outpatient medical expense co-payment from the beneficiary pursuant to Paragraphs 1 to 3 of Article 43 of the Act.

The Regulations shall not apply to a referral form issued by a non-contracted hospital or clinic.

In the event that there is any improvement with respect to referrals set forth in the Regulations that need to be made on the part of a contracted hospital or clinic, the Insurer shall mandate such contracted hospital or clinic to improve within the stipulated time. If the contracted hospital or clinic fails to make the mandated improvement within the stipulated time, points shall be recorded for its breach of contract according to the Regulations Governing Contracting and Management of the National Health Insurance Contracted Medical Care Institutions.

1The Regulations shall enter into force on January 1, 2013.

2The amendment to the Regulations shall enter into force on the date of its promulgation.