Decree of the Ministry of Health No. 457 / 2000 Coll.
Decree of the Ministry of Health issuing framework contracts
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Order
Effective from 01.01.2001
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01.01.2001
29.12.2000
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457
DECLARATION
Ministry of Health
of 13 December 2000
on the issue of framework contracts
According to Article 17 (2) of Act No. 48 / 1997 Coll., on Public Health Insurance and on the amendment and addition of certain related laws, as amended by Act No. 2 / 1998 Coll.:
Framework contracts for health insurances1) and health establishments: 2)
1. providing health care for practitioners and practitioners for children and adolescents,
2. providing outpatient specialised care and care for female doctors (expertise 603 and 6043), with the exception of medical facilities providing physical therapy (expertise 902 and 9183), ergotherapy and clinical speech,
3. providing outpatient care for dental practitioners,
4. providing health care in hospitals, professional medical institutions, professional children's and health and long-term care centres,
5. outpatient diagnostic care (expertise 222, 801 - 805, 807, 812 - 823, 8093),
6. providing domestic health care, physiotherapy (expertise 902 and 9183), ergotherapy and clinical speech,
7. providing medical rescue and transport services,
8. medical care,
9. providing spa care
are listed in Annexes 1 to 9.
Where a healthcare establishment provides healthcare covered by more than one framework contract, the health establishment and the health insurance undertaking shall be governed by all framework contracts concerned when concluding the contract.
This decree shall take effect on 1 January 2001.
Minister:
Prof. MUDr. Fisher, CSc.
Příloha č. 1
Annex No 1 to Decree No 457 / 2000 Coll.
Framework contract for health care institutions providing medical care for practitioners and practitioners for children and adolescents and health insurance companies
General provisions
Contractual relations
(1) The framework agreement sets out the conditions under which contracts between health establishments (1) and health insurers (2) (hereinafter referred to as "insurance undertakings") are concluded in order to ensure that health care covered by public health insurance (hereinafter referred to as "covered healthcare") is carried out in kind.
(2) The legal relationships provided for in the contract for the provision and reimbursement of health care paid (hereinafter referred to as "the contract") between insurance undertakings and medical establishments of practitioners and practitioners for children and young persons must not derogate from the provisions of the framework contract provided for in this decree, unless the framework agreement itself permits it. In order to ensure uniform conditions for identical or comparable transactions, in accordance with specific legislationm3), representatives of insurance undertakings and representatives of health care providers are involved in the drafting of the text of the contract, authorisation to represent them.
Contracts
Conclusion of contracts
(1) The obligations between the insurance undertaking and the health establishment are governed by a written contract concluded under this framework agreement, by legislation governing public health insurance and the provision of healthcare, by a commercial or civil code and by other legislation.
(2) Basic conditions for the conclusion of a contract:
(a) the authorisation of a healthcare establishment to provide healthcare in the relevant field;
(b) acceptance of the agreed procedure for the acquisition, transfer and evaluation of documents in accordance with the Methodology for the acquisition and transmission of documents (hereinafter referred to as "the methodology") and the rules for the evaluation of documents (hereinafter referred to as "the rules") and the single data interface established by the General Health Insurance Corporation in liaison with representatives of insurance undertakings and representatives of professional associations of health care providers and issued by the General Health Insurance Agency.
(3) The Treaty contains:
(a) the rights and obligations of the Contracting Parties;
(b) the conditions for the quality and effectiveness of the provision of health care, in particular the type, category and extent of healthcare provided, specified by the list of points of performance according to the types of care which the healthcare establishment is authorised to provide, including material and technical equipment and personnel security;
(c) the amount of the reimbursement of medical care paid or the method of determining it;
(d) the way in which the reimbursement of healthcare provided is carried out;
(e) the conditions necessary to check the performance of the contract, including the accuracy of the amounts charged;
(f) the extent and manner of communication of the data necessary to check the performance of the contract;
(g) provisions on the agreed methodology, rules and data interface in force at the time of conclusion of the contract;
(h) the way in which the medical institution is to be acquainted with changes in the methodology, rules and data interface, including the way in which those changes are transmitted;
(i) provisions on the resolution of disputes in the conciliation negotiations and, where appropriate, provisions on the application of arbitration in the event of failure of conciliation;
(j) the period of validity of the contract, the manner and reasons for its termination.
(4) The Treaty may include other arrangements necessary for its implementation and control, provided that they comply with this Framework Treaty and legislation.
Rights and obligations of the Contracting Parties
(1) Contracting Parties:
(a) comply with the agreed methodology, rules and data interface when reporting and paying for paid health care;
(b) undertake its staff, with a view to protecting the rights of insured persons and the interests of health care institutions and insurance undertakings, to maintain the confidentiality of the facts which they have learned in the performance of their duties or employment or in the processing of data from the information system under contract or in connection with them, where appropriate.
(2) Medical facilities:
(a) provide paid health care in accordance with the legislation in the fields of expertise and scope agreed and defined in the contract for which it is factually and technically equipped and staffed;
(b) be responsible for ensuring that its staff who will provide the insured with paid health care in a contract comply with the professional competence requirements laid down by the legislation on the provision of such health care;
(c) be responsible for the fulfilment of the substantive and technical conditions laid down for the healthcare provided by him under special legislation4);
(d) provide paid health care without overcost, but always taking into account that the necessary diagnostic or therapeutic effect is achieved with regard to the individual health status of the insured person;
(e) be responsible for the effectiveness of the indication when sending the insured person to complementary and consul examinations and, on the basis of their results, regulates the diagnosis or treatment procedure;
(f) shall, for the purposes of assessing the legitimacy of the health care to be charged in a conclusive form, provide documentation on the treatment of insured persons, in which the medical performance, requested health care, prescribed medicinal products and medical devices will be recorded and stored, as well as the results of the examinations requested and delivered,
(g) provide, in accordance with the legislation, health care institutions to which the insured person is to be given custody or chosen by the insured person with the information necessary to ensure the continuity of healthcare and to avoid duplication of diagnostic and therapeutic performance and, when taking custody of the insured person, will require such information from the relevant establishments;
h) does not refuse the admission of the insured person into their custody except for the reasons set out in § 11 (1) (b) of Act No. 48 / 1997 Coll., on Public Health Insurance and on the amendment and addition of certain related laws, as amended ("Act No. 48 / 1997 Coll."),
(i) shall not make the insured person's right to free choice of doctor, health care establishment or to provide paid health care subject to any registration fees or sponsorship gifts and no financial compensation shall be levied on the insured person for the provided health care provided by the insurance undertaking, unless it results from legislation;
(j) does not make the insured person's right to receive paid health care subject to a change in the insurance undertaking or otherwise;
(k) does not favour the insured persons of one or more insurance undertakings to the detriment of the insured persons of the insurance undertakings of others, and will make the availability of health care paid by the insurance undertaking more favourable by providing care otherwise;
(l) notify the insurance undertaking, in accordance with Article 55 of Law No 48 / 1997 Coll. of accidents or other damage to the health of persons to whom it has provided paid medical care, if it has reasonable grounds to suspect that they have been caused by acts of a legal or natural person,
m) ensure that doctors - graduates, as part of specialist training for first degree specialisation, will provide paid health care only under the guidance of another accredited doctor;
(n) be responsible for the correct and complete completion of the recipe form under special legislature5; is also responsible for the correct and complete completion of the voucher for medical devices or for the examination / treatment or the health transport order. If the prescription restriction resulting from the legislation has not been respected during the prescription, and the insurance company has paid this medicinal product or medical device to the pharmacy, the insurance undertaking shall have the right to require the medical establishment to pay the amount paid. The insurance undertaking shall not be entitled to claim such reimbursement if the medicinal product or medical device has been prescribed for its insured person and the health care establishment has eliminated the deficiencies within one month of transmission of the relevant recipe or voucher by the insurance undertaking. The same procedure will be applied to the health care facility in the event of incorrect completion of the examination / treatment voucher.
(3) Insurance undertaking:
(a) pay to the healthcare establishment paid for by health care, documented and justified to its insured persons in accordance with legislation and contract;
(b) establish, at the request of the medical institution, the insurer's jurisdiction to the insurance undertaking without undue delay in cases where the insurer's ID is not available and his personal data are available;
(c) does not require the benefit of its insured persons at the expense of the insured persons of other insurance undertakings;
(d) be entitled to carry out checks on the performance of the contractually agreed material and technical conditions of the healthcare provided to the healthcare establishment under the contract;
(e) provide health care institutions with an agreed methodology, rules, data interface and the relevant code lists issued by the General Health Insurance Company to report and calculate the reimbursement of the paid health care;
(f) inform the health care institution of the agreed changes to the methodology, rules and code list changes for at least one month and the change to the data interface at least two months before the date of their validity, including the documentation management methodology. In the event of a change in legislation which does not allow that period to be met, that period may be reduced accordingly.
Reimbursement of paid health care
(1) The price of the point and the amount of the reimbursement of the health care paid shall be negotiated in the contract in accordance with the results of the conciliation procedure, where appropriate in accordance with specific legislation.
(2) In particular, the methods of payment shall be:
(a) payment for health performance according to the list of health performance with points;
(b) combined remuneration for registered insured persons and health benefits according to the list of health performance with point values (combined capital charge);
(c) other forms of reimbursement agreed in the conciliation procedure on the price of the point and the amount of medical care paid by public health insurance, or in accordance with specific legislation.
(3) An increase or reduction in the volume of healthcare provided due to a change in the capacity or structure of the healthcare establishment shall always be agreed between the Contracting Parties.
(4) The medical establishment for the application of claims for reimbursement of paid health care shall transmit to the insurance undertaking once a month the accounts of the care provided by the invoice with annexes. The invoice shall contain the particulars of the accounting document6). The elements of the Annex are contained in the methodology or shall be specified in the contract in accordance with the methodology. Where the invoice does not contain the particulars of the accounting document6) and the annex does not contain the particulars of the agreed methodology or contract, the insurance undertaking shall have the right to refuse it and return it without undue delay to the medical institution for replenishment or repair, where appropriate; in such a case, the repayment period shall run only from the date of its readmission by the insurance undertaking.
(5) The medical establishment is responsible for the completeness, formal and factual accuracy of the documents and for their transmission in a manner agreed in the methodology and data interface. Individual documents for paid health care provided to insured persons shall be transmitted by the medical institution to the insurance undertaking, together with the bill by the deadline and in the manner agreed in the contract (on magnetic media or paper documents or by other agreed means).
(6) If the insurance undertaking ascertains in the bill before the payment is made incorrectly or incorrectly accounted for, it shall not pay this part of the account by the due date. The insurance company shall notify the medical institution without undue delay of the extent, reason and amount of the care charged but not paid. In doing so, the insurance company will call on the health care establishment to correct the incorrectly accounted care or to provide evidence of the provision of paid health care. The insurance undertaking shall pay the due and settled care within the next payment deadline.
(7) The insurance company shall pay for its insured person the medical care paid out in accordance with the legislation and contract. If the check reveals errors in the documents, it shall follow the methodology and rules. The refusal of the payment or part of the payment of the insurance undertaking shall be justified in writing without undue delay to the healthcare establishment. The granting of the remuneration shall be without prejudice to the insurance undertaking's right to carry out a follow-up check on the bill paid to the extent and under the conditions laid down in the legislation and the contract.
(8) If the insurance undertaking finds that the misstatement transmitted to the health care establishment has been made retrospectively, i.e. after payment and the health care establishment within 10 working days of receipt of the written request by the insurance undertaking does not cover the amount itself, or does not demonstrate the validity of the contested amount charged or any other payment date agreed between the parties, the insurance undertaking shall reduce the amount of the claim by unilaterally setting aside the medical establishment by the appropriate amount or, where appropriate, the contractual fine agreed in the contract, the payment for the payment of the medical care paid in the following settlement period.
(9) Reimbursement of the covered health care provided, subject to the conditions agreed in the contract, will be made at the time of transmission of the bill to the insurance undertaking on the magnetic media within 20 calendar days and at the time of transmission of the bill to the insurance undertaking on paper documents within 40 calendar days of the date of receipt of the invoice to the insurance undertaking, unless otherwise assessed by the Contracting Parties.
(10) In the event of a malfunctioning of the calculation system, which makes it impossible to carry out the bill or reimbursement of the paid health care in good time, the insurance undertaking shall, within the agreed payment deadline, provide an advance of the average monthly amount of the reported health care, calculated from the last two closed calendar quarters, unless otherwise agreed by the parties in the case in question.
Control
(1) In accordance with Article 42 of Law No 48 / 1997 Coll. and with the contract, the insurance undertaking carries out checks on the use and provision of paid health care in its volume and quality, including compliance with prices, through its information system, review doctors and other health professionals, eligible for review activities (hereinafter referred to as "experts").
(2) In the context of their professional competence, the review practitioners and the professional staff authorised to check whether the chosen method of healthcare paid has been indicated with regard to the health status of the insured person, is in line with current available medical science knowledge and has not been unnecessarily economically demanding.
(3) In cases provided for by legislation, the review physician shall also assess the justification of the treating physician proposed or, where appropriate, the treatment process and shall approve whether the insurance undertaking will pay for the procedure used. The decision to use the treatment procedure, including pharmacotherapy, is the responsibility of the treating physician.
(4) The health care establishment shall provide the insurance undertaking with the necessary synergies in the performance of the check, in particular providing the required documents, communicating the data and providing explanations. It will allow audit doctors and insurance professionals to enter their premises, access to the health records of the insured persons and to the accounting documents directly related to the checks carried out on the health performance, medicines and medical devices, including the medicaments and the material specifically charged.
(5) The review report, containing the conclusions of the check, shall be prepared by the insurance undertaking and transmitted to the healthcare establishment within 15 calendar days of the completion of the check; where it is not possible for objective reasons to meet this deadline, the insurance undertaking shall notify the health care establishment accordingly. The check shall, as a general rule, be terminated within 30 calendar days of its initiation. In the case of an on-the-spot check at the health care establishment, an alert shall be made indicating the most important findings and opinions of the health care establishment.
(6) The medical establishment shall be entitled to submit reasoned objections to the insurance undertaking in writing within 15 calendar days of receipt of the conclusion of the check. The insurance undertaking shall give its opinion on the objections within 30 calendar days of their receipt. If, for objective reasons, these time limits cannot be complied with, the relevant time limit shall be extended up to twice as much at the request of the Contracting Party. Within the prescribed period, the insurance undertaking shall inform the health care institution whether it confirms or changes the findings of the check. The submission of objections shall not have suspensory effect in respect of the insurance undertaking's financial claims towards the medical establishment. This is without prejudice to the right of the healthcare establishment to exercise its opposition to the decision of the insurance undertaking in another proceedings.
(7) If the check proves that the health care covered is not justified or incorrect, or the provision thereof is not justified, the insurance company will not reimburse such care under Article 42 (3) of Act No 48 / 1997 Coll. and is entitled to comply with the penalties provided for in the contract. In the event that the findings of the check prove unjustified, the insurance undertaking shall reimburse the medical establishment for the amount by which the check reduced the reimbursement of the covered healthcare. The medical establishment shall be entitled to comply with the penalties provided for in the contract.
Limitation of remuneration
The principles of the application of the reimbursement restrictions under Section 17 of Act No. 48 / 1997 Coll. are discussed between representatives of insurance companies and representatives of the relevant professional associations of providers as representatives of contractual medical facilities.
Penalties
(1) The Contracting Parties may agree on an obligation to pay the contract fine and its amount for failure to fulfil their obligations under paragraph 2.
(2) Where:
(a) Contracting Party
1. disclose false, incomplete or distortive information at the time of conclusion of the contract or at the time of performance;
2. Failure to comply with the provisions of the contract, with the result that the public health insurance funds are clearly inefficient,
3. does not provide the information agreed in the contract;
(b) medical facilities
1. it has proven to be incorrectly or multiple-checking medical care;
2. does not provide mandatory legal reporting;
3. Unjustifiably late in showing paid health care;
4. has repeatedly infringed the obligation to notify the insurance undertaking in accordance with Article 55 of Act No. 48 / 1997 Coll. of accidents or other damage to the health of the insured person caused by the conduct of a legal or natural person,
(c) insurance undertaking
1. Proporably unjustifiably reduces or rejects the reimbursement of paid health care,
2. to make payment of the healthcare provided with delay, which is legally charged.
(3) The application of the penalty shall be without prejudice to the right of the Contracting Parties to refund for wrongfully or wrongly charged and paid medical care.
Duration, method and reasons for termination
The contract shall be concluded for a period of 5 years, unless the Contracting Parties agree otherwise.
The contract may be terminated by written denunciation, with notice of six months, on 1 January of the following year, if:
(a) medical devices through written notice
1. without prior agreement with the insurance undertaking, it does not provide health care of the agreed scope and quality without justification;
2. without prior agreement with the insurance undertaking, it shall repeatedly charge health care provided beyond the agreed type, expertise and scope of activity;
3. Unjustifiably limits the period of service agreed in the contract for insured persons of insurance undertakings;
(b) the insurance undertaking, through written notice, repeatedly:
1. fails to comply with the repayment deadlines agreed in the contract;
2. provide third parties with information on health facilities in excess of legislation or contract.
The contract may be terminated by written notice of termination before the expiry of the period of three months, starting on the first day of the month following receipt of the notice to the other Contracting Party if, as a result of serious circumstances, no further performance of the contract can reasonably be expected, provided that:
(a) Contracting Party
1. Misled the other Contracting Party when the contract was concluded,
2. in contractual relations it has in a gross manner infringed a serious obligation imposed on it by the relevant legislation or contract;
3. repeatedly infringes the obligation arising out of § 41 of Act No. 48 / 1997 Coll.,
4. enter into liquidation or the court shall declare bankruptcy,
b) Health care facilities through written notice
1. it has proven to be incorrectly charging health care and thereby causing financial damage to the insurance undertaking;
2. does not provide the necessary synergies to carry out the control activities carried out by the insurance undertaking in accordance with Act No. 48 / 1997 Coll.,
3. it does not provide health care to insured persons in good quality and "atviartis" or, if necessary, repeatedly refuse to provide health care for reasons other than those laid down by law,
4. Requires, contrary to legislation, financial compensation from insured persons for the health care paid by the insurance undertaking or for the admission of the insured person to custody;
(c) insurance undertaking through written notice repeatedly
1. it shall not, as evidenced, unduly cover the healthcare provided to the healthcare establishment covered by the covered health care;
2. exceeds the scope of the control activity laid down by Act No. 48 / 1997 Coll.
The contract may be terminated before the end of the agreed period
(a) by written agreement of the Contracting Parties, under the conditions and within the time limit specified therein; or
(b) where the law so provides.
Communication of data and transmission of documents necessary to check the performance of the contract
(1) Contracting Parties:
(a) use the establishment identification number in accordance with the methodology for unambiguous identification of the health establishment;
(b) communicate the information necessary to check the performance of the contract;
(c) ensure continuous and clear information on the existence of the contractual relationship and the rights deriving therefrom for the insured;
(d) they may transmit the data necessary to evaluate the quality and effectiveness of the healthcare provided to the extent and under the conditions agreed in the contract.
(2) Medical facilities:
(a) provide evidence to the insurance undertaking, where there are reasonable grounds for suspecting non-compliance with the procedure, that medical devices have been used in the provision of covered healthcare in accordance with specific legislation7);
(b) notify the other Contracting Party without delay, and within 30 calendar days at the latest, of the facts which could significantly affect the performance of the contract, such as the occurrence of malfunctions in the calculation system, changes in the information contained in the contract, if any
1. to cancel the workplace or part thereof without compensation or to close it for more than 30 calendar days;
2. to leave the staff member named in the contract,
3. the failure of the apparatus necessary for performance without compensation for more than 30 calendar days.
(3) The insurance undertaking may provide a general form of information to the healthcare establishment to economic its activities or to its scientific and research activities and to control the quality of the healthcare provided, to the extent and under the conditions agreed in the contract.
Dispute settlement
(1) The Contracting Parties shall address any disputes concerning the performance of the contract, in particular by mutual action of the representatives of the Contracting Parties, as a rule within 14 calendar days of the request of one of the Contracting Parties. If there is no agreement between them, they may discuss the issues at issue in conciliation. This is without prejudice to the right of the Contracting Parties to exercise their right to settle a dispute in a court or arbitration procedure under a special legislative provision (8).
(2) Conciliation is proposed by one of the Contracting Parties. The proposal shall contain a precise and sufficiently detailed definition of the dispute. A party to the conciliation proceedings shall be a party to the dispute, a party to the dispute addressed by the dispute, a representative of the relevant group contractual health institutions represented by their interest associations (9), pursuant to Article 17 (2) of Law No 48 / 1997 Coll. and a representative of the insurance undertaking. Each Party may invite a maximum of two expert advisers to discuss the dispute. The conciliation negotiations shall be terminated by a record containing a settlement or the conclusion that the contradiction has not been removed, indicating the views of both parties.
The Contracting Parties are obliged to adjust the content of contracts concluded by 31.12.2000 under this Framework Agreement by 30.6.2001 at the latest.
Příloha č. 2
Annex No 2 to Decree No 457 / 2000 Coll.
Framework contract for medical institutions providing outpatient specialised care and care for female doctors (expertise 603, 6041) excluding medical institutions providing physiotherapy (expertise 902 and 9181), ergotherapy and clinical loopedia and health insurance companies
General provisions
Contractual relations
(1) The framework agreement sets out the conditions under which contracts between health establishments (2) and health insurers (3) (hereinafter referred to as "insurance undertakings") are concluded in order to ensure that health care covered by public health insurance (hereinafter referred to as "covered healthcare") is carried out in kind.
(2) The legal relationships provided for in the contract for the provision and reimbursement of covered health care (hereinafter referred to as the "contract") concluded between individual insurance undertakings and medical establishments of outpatient specialised care must not derogate from the provisions of the framework contract provided for in this decree, unless the framework contract itself permits it. In order to ensure uniform conditions for identical or comparable transactions, in accordance with special legislation4), representatives of insurance undertakings and representatives of health care providers are involved in the drafting of the text of the contract, authorisation to represent in this matter.
Contracts
Conclusion of contracts
(1) The obligations between the insurance undertaking and the health establishment are governed by a written contract concluded under this framework agreement, by legislation governing public health insurance and the provision of healthcare, by a commercial or civil code and by other legislation.
(2) Basic conditions for the conclusion of a contract:
(a) the authorisation of a healthcare establishment to provide healthcare in the relevant field;
(b) acceptance of the agreed procedure for the acquisition, transfer and evaluation of documents in accordance with the Methodology for the acquisition and transmission of documents (hereinafter referred to as "the methodology") and the rules for the evaluation of documents (hereinafter referred to as "the rules") and the single data interface established by the General Health Insurance Corporation in liaison with representatives of insurance undertakings and representatives of professional associations of health care providers and issued by the General Health Insurance Agency.
(3) The Treaty contains:
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Regulation Information
| Citation | Decree of the Ministry of Health No. 457 / 2000 Coll., which issues framework contracts |
|---|---|
| Regulation Type | Order |
| Author | - |
| Collection | Code of Laws |
| Date of Promulgation | 29.12.2000 |
|---|---|
| Effective from | 01.01.2001 |
| Effective until | - |
| Status | Valid |
The regulation text is for informational purposes only.
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