目  次

前 言..........................................................................................................................................................1

1 范围.................................................................................................................................................................1

2 规范性引用文件.............................................................................................................................................1

3 术语和定义.....................................................................................................................................................1

4 医疗保障运行模型.........................................................................................................................................1

5 指标体系架构.................................................................................................................................................2

5.1 指标体系构建基本原则.........................................................................................................................2

5.2 总体架构.................................................................................................................................................3

6 指标体系.........................................................................................................................................................5

6.1 参保征缴类.............................................................................................................................................5

6.2 医保扩面类.............................................................................................................................................7

6.3 基金财务类.............................................................................................................................................8

6.4 医疗管理评价类...................................................................................................................................10

6.5 医疗费用支付构成类...........................................................................................................................15

6.6 定点医药机构类...................................................................................................................................18

6.7 稽核监督类...........................................................................................................................................19

6.8 经办机构类...........................................................................................................................................23

6.9 医保智能审核类...................................................................................................................................23

6.10 在线监控类.........................................................................................................................................27

6.11 在线预警类.........................................................................................................................................30

6.12 运行分析类.........................................................................................................................................31

6.13 支持医改类.........................................................................................................................................32

6.14 扩展类.................................................................................................................................................33

7 医保决策辅助...............................................................................................................................................36

7.1 概述.......................................................................................................................................................36

7.2 基本功能要求.......................................................................................................................................36

7.3 主要内容...............................................................................................................................................36

8 指标体系维护...............................................................................................................................................37

8.1 概述.......................................................................................................................................................37

8.2 指标的管理...........................................................................................................................................37

8.3 维护流程...............................................................................................................................................37

附录 A（规范性附录） 代码集......................................................................................................................39

附录 B（规范性附录） 数据项描述方法与规则......................................................................................... 43

参 考 文 献.................................................................................................................................................45

本标准按照GB/T 1.1-2009给出的规则起草。

本标准由成都市医疗保障局提出并归口。