Application
to the order of MGFOMS
Description of the web services of the system of the Regional Segment of the Unified Register of Insured Persons of the Automated Information System of Compulsory Medical Insurance
Version 2. 0 from 01.01.2001
Effective from 08.08.2016
Moscow
1......... GENERAL DESCRIPTION OF THE PRINCIPLES OF OPERATION OF THE WEB SERVICES OF RS ERP AIS OMS 2
1.1 Purpose of the System.. 2
2......... Requirements for data exchange formats .. 2
3......... Order of interaction.. 2
3.1 General information. 2
3.2 Reading data from RS ERZL.. 2
3.3 Recording data in RS ERZL.. 2
3.4 List of data fields of the RS ERZL web service.. 2
3.5 Diagnostic codes and messages. 2
4......... Restrictions on access to certain methods for different categories of users.. 2
4.2 Access Matrix. 2
4.3 Features of access to historical data.. 2
5.1 Searching for an SP and obtaining its identifier current policy OMS.. 2
5.2 Simplified receipt of the ID of a valid CHI policy.. 2
5.3 Transfer of information to RS ERZL about insured persons from other cities. 2
5.4 Transfer of information to RS ERZL about newborns. 2
5.5 Transfer of information to RS ERZL about unidentified persons. 2
5.6 Linking records. 2
APPENDIX 1. STRUCTURE OF DIRECTORIES.. 2
APPENDIX 2. Rules and restrictions when working with attachments 2
APPENDIX 3. Format-logical control.. 2
LIST OF ABBREVIATIONS AND DEFINITIONS
Reduction | Definition |
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AIS OMS MGFOMS | Automated Information System Mandatory health insurance Moscow City Compulsory Medical Insurance Fund |
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Automated workplace |
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Database |
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Provisional certificate |
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Federal State Unitary Enterprise Goznak |
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Voluntary health insurance |
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A document confirming the fact of insurance (compulsory medical insurance policy, temporary certificate) |
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Identity document |
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Unified Medical Information Analytical System of Moscow |
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Unified register of insured persons |
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Office of the Civil Registry of Moscow |
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Insured person |
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Identifier |
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Nonresident insured person |
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An identification number taxpayer |
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Information system |
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counterparty |
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Moscow City Compulsory Medical Insurance Fund |
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Medical organization |
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Multifunctional delivery centers public services Moscow |
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Medical and economic expertise |
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unidentified person |
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Newborn |
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Reference information |
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All-Russian classifier of countries of the world |
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Compulsory health insurance |
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Portal of public services of Moscow |
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Software |
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Compulsory medical insurance policy, a document confirming the fact of insurance of the insured person in the CHI system |
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Regional segment |
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Regional segment of the unified register of insured persons |
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Russian Federation |
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Insurance medical organization |
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Emergency |
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Insurance number of an individual personal account |
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Territorial Compulsory Medical Insurance Fund |
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Unique identity code in AIS OMS MGFOMS |
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Universal electronic card |
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Full Name |
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Format-logical control |
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Federal Compulsory Medical Insurance Fund |
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Central segment |
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Central segment of the unified register of insured persons |
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Quality expertise medical care |
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Hypertext Transfer Transport Protocol Security - a secure protocol for transferring hypertext information |
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Simple Object Access Protocol - a simple protocol for accessing objects - a protocol for exchanging structured messages in a distributed computing environment |
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Unicode Transformation Format, 8-bit - Unicode transformation format, 8-bit |
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Web Services Description Language - Web services description language based on XML |
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eXtensible Markup Language - extensible markup language |
1. GENERAL DESCRIPTION OF THE OPERATING PRINCIPLES OF THE WEB SERVICES OF RS ERP AIS OMS
The work of AS-clients with the System is based on the concept of synchronous "request-response" interaction. The asynchronous request mechanism is not used.
1.1 Purpose of the System
The regional segment of the Unified Register of Insured Persons is designed to collect, store, process and provide data on persons insured in Moscow, as well as on persons who applied for medical assistance to medical organizations in Moscow.
MGFOMS, as part of its activities, maintains RS ERZL, and also ensures, within its competence, the protection of information constituting restricted access information.
Maintenance of RS ERZL includes main and auxiliary processes.
Main processes:
1) receiving from MO/SMO information about APs and entering them into RS ERZL;
2) acceptance, accounting and execution of HMO applications for the issuance of CHI policies; interaction with GOZNAK; accounting of issued CHI policies, including their status;
3) accounting for the attachment of IPs to medical organizations in Moscow, including maintaining a register of scanned documents-applications of IPs for attachment to the Moscow Region;
4) registration of newborns born in Moscow;
5) registration of unidentified persons who received medical care in the Moscow Region;
6) registration of non-resident APs (third-party TFOMS) who received medical care in the Moscow Region;
7) accounting of data on IP, such as:
SP address;
AP contact details;
Citizenship of AP;
Social status, disability, AP benefits;
Information about identity documents of the IP;
To the order of MGFOMS
No. dated "___" _____________ 2016
REGULATIONS
FILE DATA EXCHANGE IN AIS OMC
at information interaction of participants of obligatory medical insurance
Moscow
Version 1.5.3
Moscow City Compulsory Medical Insurance Fund
2016
3.1 MO report files in CMO 27
3.1.1 MoD Handbooks 27
5.1 "Number book" of policies 160
5.2 "Stop-list" of policies 160
5.3 "Start List" of policies 163
Introduction. ten
1. Forms of reporting documentation on paper during file exchange of data between participants in the CHI system when reconciling invoices for medical care provided to patients during the reporting period 11
1.1 Form of the Passport of the MO account for medical care provided to the insured HMO. 13
1.1.1 Instructions for filling out the Passport of account MO 14
1.2 Form of the Protocol of HMOs for accepting the invoice of the MO for medical care provided to the insured HMOs for the reporting period. 16
1.2.1 Instructions for filling out the Protocol for the acceptance of CMO account MO 17
1.3 Form of the Passport of the account of the Moscow Region for medical care provided during the reporting period to patients insured in the territory of another subject of the Russian Federation (nonresident). 21
1.4 Form of the Protocol of acceptance for payment of the invoice of the Ministry of Defense for medical care provided to the insured on the territory of another subject of the Russian Federation for the reporting period. 22
2. Rules for calculating the cost of medical care provided to patients for the reporting period 23
2.1 General provisions according to the calculation of the cost of medical care 23
3. Protocol for the exchange of data between the Ministry of Defense and the HMO when reconciling invoices for medical care provided to insured patients 26
3.1 MO report files in CMO 27
3.1.1 MoD Handbooks 27
3.1.2 MO report files on medical care provided to patients insured by HMOs 30
3.2 Report of the health insurance organization to the MO on the result of automated control / examination of the personalized invoices of the MO for medical care provided to the insured during the reporting period 41
4. Report of the CMO to the MGFOMS on accepted personalized accounts declared by the Ministry of Defense for the reporting period. 46
4.1 Report of the CMO to the MGFOMS on personalized accounts of the Ministry of Defense for the reporting period. 46
4.2. Report of the CMO to the MGFOMS on financial interaction with the Ministry of Defense for the reporting period. 49
4.3. Report of the CMO to the MGFOMS on the defects / violations identified by the CMO in the paid invoices of the Ministry of Defense during the medical and economic examination (scheduled, targeted) and the examination of the quality of medical care (planned, targeted). 51
5. Report of the HMO to the MGFOMS on the volume and cost of medical care accepted by the HMO for payment 52
5.1 Report files of the HMO in the MGFOMS on the volume and cost of medical care accepted by the HMO for payment 52
5.2 HMO report form on the volume and cost of medical care provided to the insured MO during the reporting period and accepted by the HMO for payment 56
6. Protocol for the exchange of data between the Ministry of Defense and MGFOMS when reconciling invoices for medical care provided to patients from other cities during the reporting period. 58
6.1 Report of the Ministry of Defense to the MGFOMS on personalized bills for medical care provided to patients from other cities. 58
6.2 Report of the MGFOMS to the Moscow Region on the result of automated control of personalized invoices of the Moscow Region for medical care provided to patients from other cities during the reporting period 61
7. NSI AIS OMS - list of directories and codifiers AIS OMS 62
8. Description of error codes during format-logical and semantic control of patient registries and registries medical services. 82
8.1 Checking the entries in the Patient Register file. Syntactic control of records and verification of coded information 82
8.2 Identifying duplicate records 84
8.3 Checking the connectivity of the patient registry file with the patient health services registry file 84
8.4 Checking the correctness of the determination of the CMO - payer 84
8.5 Checking the records of the files "Register of medical services for patients". Syntax control 85
8.6 Identification of duplicate entries in the file "Register of medical services for patients". 87
8.7 Checking the compliance of the data given in the records of the invoice file in an encoded form with the codifiers and reference books of the reference data valid in reporting period 87
8.8 Checking the correct organization of the patient account 90
9. Regulations for determining the payer for the medical care provided 107
File interchange rules for applications for the issuance of compulsory medical insurance policies 112
1. General provisions on RS ERZL. 112
2. Structure, format and rules for filling in the CMO report files on applications for the issuance of CHI policies. 115
3. Choosing an algorithm for generating an application 127
3.1 Definitions of the algorithm (scenario) when forming an application for the issuance of a policy 127
3.2 Description of scenarios for the formation of applications for the issuance of policies and features of filling in application files 130
4. Rules for filling type files
depending on scenario (code) 136
5. Reports of the MGFOMS to the SMO according to the RS ERZL database 159
5.1 "Number book" of policies 160
5.2 "Stop-list" of policies 160
5.3 "Start List" of policies 163
6. Additional services of AIS OMC upon request to RS and CA ERZL 165
6.1 Structure of requests to RS ERZL 166
6.2 Structure of requests to CA ERZL 166
7. The procedure for generating a message file about the result of loading 167
Accepted abbreviations and terms
| AIS OMS | Automated information system of compulsory medical insurance |
| APK | Hardware and software complex |
| DB | Database |
| VMP | High-tech medical care |
| sun | Temporary certificate - a document confirming the execution of the policy and certifying the right to free medical care |
| CHI document | Policy CHI of the old sample, CHI policy of a single sample, temporary insurance certificate for CHI |
| DUL | Document proving the identity of the insured person, on the basis of which the CHI policy is issued |
| ERZL | The unified register of insured persons under CHI in the Russian Federation, organized and supported by the FFOMS |
| EPP | The number of the policy of a single sample. Is the identifier of the insured person in ERZL |
| ZL | A person insured under compulsory medical insurance who has received a compulsory medical insurance document |
| Nonresident | A person insured under compulsory health insurance in another constituent entity of the Russian Federation |
| IP | information package |
| KSG | Clinical and statistical group of diseases - specialized medical care in hospitals and day hospitals |
| MGFOMS | Moscow City Compulsory Medical Insurance Fund |
| MO | Medical organization of the CHI system |
| MO with PF | Medical organization financed on a per capita basis |
| MO with GR | A medical organization that makes horizontal payments from per capita funding for medical care provided in the direction of medical organizations to their attached population |
| MS | Medical standard - a set of diagnostic and treatment technologies provided within the framework of a completed case of hospitalization in an inpatient setting |
| MS IS | Medico-sociological integrated system - AIS CHI portal |
| NWO | Emergency medical care |
| NSI | Reference information |
| CHI | Compulsory health insurance |
| Software MO with PF hospital type | Polyclinic department with an attached population, which is a structural unit of a hospital-type medical organization |
| PPO | Application software |
| teaching staff | Application software system |
| PF | Per capita financing is a way of financing medical organizations providing primary health care according to the standard for the attached population |
| Register of patients (accounts) | List of MO patients who received medical care under the compulsory medical insurance program for the reporting period. The register of patients, supplemented by the tariff cost of medical services provided to the patient by the Ministry of Defense during the reporting period and registered in the register of services, determines the register of accounts of the Ministry of Defense |
| Register of services | Consolidated list of medical services provided to patients of the Moscow Region under the CHI program for the reporting period. The connection with the register of patients is carried out according to the CHI document registered in the register of patients and the register of medical services |
| RS ERZL | ERZL regional segment |
| CMO | Insurance medical organization |
| NSR | Emergency |
| joint venture | Insurance affiliation |
| Insurer | HMO that has registered the document of compulsory health insurance of the insured |
| Patient account | The tariff cost of medical services (in accounting units) provided to the patient of the Moscow Region under the CHI program for the reporting period. The number of MO accounts is determined by the number of patients treated in the MO during the reporting period |
| Mon | Attached population - a list of those insured under compulsory medical insurance in Moscow, attached to medical organizations providing primary health care |
| TFOMS | Territorial CHI Fund |
| FLC | Format-logical control |
| ESRD | Territorially attached population |
| FFOMS | Federal CHI Fund |
| CAPC | Central hardware and software complex AIS OMS |
| CVDP | Policy issuance and personalization center |
| COI | Information Processing Center at CAPC |
| CA ERZL | The central segment of the unified register of insured persons. |
| EP | Electronic policy |
Legislative and regulatory documents in the CHI system
1. Federal Law of November 29, 2010 No. 326 - FZ "On Compulsory Medical Insurance in the Russian Federation".
2. The rules of compulsory health insurance approved by the order of the Ministry of Health and social development RF dated February 28, 2011 No. 158n.
3. The procedure for maintaining personalized records in the field of compulsory medical insurance, approved by order of the Ministry of Health and Social Development of the Russian Federation dated January 25, 2011 No. 29n.
4. General principles for the construction and functioning of information systems and the procedure for information interaction in the field of compulsory medical insurance, approved by order of the Federal Compulsory Medical Insurance Fund dated 07.04.2011 No. 79.
5. The procedure for organizing and monitoring the volume, timing, quality and conditions for the provision of medical care under compulsory medical insurance, approved by order of the Federal Compulsory Medical Insurance Fund dated 01.12.2010 No. 230.
6. Accounting for surgical operations within the framework of personalized accounting in the field of CHI (ref. FFOMS dated 05.04.2012 No. 2194 / 21-4 / and)
7. The list of types of high-tech medical care provided at the expense of compulsory medical insurance funds was approved by Decree of the Government of Moscow dated December 24, 2015 No. 949-PP.
Guiding documents on the organization of information exchange in AIS OMS:
8. Automated information system of compulsory medical insurance in Moscow. OMSGW Universal Mail Gateway Interface, 2011.
9. Automated information system of compulsory medical insurance in Moscow. Protocol of information exchange with the regional and central segments of the ERZL, 2011.
10. Automated information system of compulsory medical insurance in Moscow. Information exchange protocol for the transmission of regulatory and reference information in the corporate network, 2011.
11. Instructions for recording medical care provided in a round-the-clock hospital and in day hospitals (outside the per capita financing system) for compulsory medical insurance (Appendix 3 to the Tariff Agreement for 2016 of 12/25/2015).
12. The procedure for information interaction between participants in compulsory medical insurance in the automated information system of compulsory medical insurance in Moscow, approved by order of the Moscow State Compulsory Medical Insurance Fund dated December 1, 2011 No. 192.
13. Regulations for maintaining in the AIS CHI information on the attachment of insured persons to medical organizations in Moscow, version 1.1 dated 11/20/2015.
14. Procedure for calculation and transfer financial resources for per capita financing to medical organizations in Moscow providing primary health care on an outpatient basis to the attached population for 2016 (Appendix 12 to the Tariff Agreement for 2016 of 12/25/2015).
17. Guidelines on registration in the AIS CHI of the first stage of medical examination of the adult population and orphans and children in difficult life situations staying in stationary institutions (version 1.7, 2016).
18. Methodological recommendations for accounting in the AIS CHI of the second stage of medical examination of the adult population and orphans and children in difficult life situations staying in stationary institutions (version 1.7, 2016).
19. Guidelines for recording in the AIS OMS medical examination of orphans and children left without parental care, including adopted (adopted), taken under guardianship (guardianship), in a foster or foster family ( version 1.2, 2016).
20. Regulations for the reception and transmission of data on medical care provided for emergency indications to patients not identified in the CHI system during information interaction in the CHI AIS of participants in the CHI system (version 1.4 from 26.04.16).
7. NSI AIS OMS - a list of directories and codifiers AIS OMS Directory "AIS OMS Subscribers" - "sprabo хх.dbf"
The directory is designed to provide automated exchange of information in the AIS OMS and is used when sending and receiving information packages for various purposes, as well as to control the operation of the corporate network.
Classification objects in the Directory are AIS OMS subscribers.
The sign of the classification is the "Mnemonic name of the subscriber" in conjunction with the "Type of the subscriber".
Directory structure
| Field name | Type of | The size | Purpose |
| Abn_ID | Number | 6 | Subscriber ID |
| Abn_name | Symbol | 27 | Mnemonic name of the subscriber |
| Abn_type | Symbol | 1 | Subscriber type by code "tipaboXX" |
| Object_ID | Number | 6 | Object ID |
| Tip_answer | Symbol | 1 | Type of response to RS ERZL request by code "tipotvXX" |
| Status | Symbol | 1 | Subscriber status |
| Name | Symbol | 40 | Short name of the subscriber |
| Pilot | Symbol | 1 | Reserve |
The Abn_name parameter is used as the primary key when indexing the Directory data file.
“Subscriber type” codifier – “tipabo хх.dbf”
The AIS OMS subscriber type codifier is used as an auxiliary for the AIS OMS subscriber directory in order to determine the subscriber's responsibility as legal entity.
Explanations. A number of AIS OMS subscribers have more than one physically different workstation of a corporate network user. For unambiguity in the provision of reports on the CHI accounts of a legal entity of the CHI system, the subscriber type sets the only address at which data is exchanged between the legal entity, the CMO and the MGFOMS data center when data is exchanged on the CHI account. The rest of the workstations of this legal entity are given the opportunity to access the AIS CHI databases without the right to provide reports on CHI accounts.
The elements of the set of objects included in the Codifier are the possible types of AIS OMS subscribers.
The sign of the classification is the name of the subscriber type.
Codifier Structure
| Field name | Type of | The size | Purpose |
| Tip_ab | Symbol | 1 | Subscriber type code |
| Name_type | Symbol | 40 | Type name |
The Tip_ab parameter is used as the primary key when indexing the Codifier data file.
Codifier "Type of response to the request ERZ" - "tipotv xx.dbf"
The codifier of the type of responses to the request of RS ERZL is used as an auxiliary for the directory of AIS OMS subscribers in order to indicate the amount of data provided to various types of AIS OMS subscribers at the request of RS ERZL.
The elements of the set of objects included in the codifier are the types of responses to the request of RS ERZL ("0" - full, "1" - abbreviated).
A sign of classification is the name of the response type to the request. Establishes MGFOMS
Codifier Structure
| Field name | Type of | The size | Purpose |
| Tip_answer | Symbol | 1 | Response type code (amount of data about the insured person) |
| Name_type | Symbol | 50 | Response Description |
The Tip_answer parameter is used as the primary key when indexing the Codifier data file.
Directory "Streets of Moscow" - "spr_ul xx.dbf"
The directory is designed to generate data on the Moscow address of an object (organization and individual) in the AIS OMS system. It is used in the subsystems of the AIS MHI for maintaining RS ERZL, in the formation of the Moscow address of the patient when registering and maintaining a personalized database on the accounts of patients treated under the Moscow city MHI program, in the NSI subsystems for maintaining databases on the objects of the MHI system (MO, SMO).
The elements of the set of objects included in the Directory are the streets of the city of Moscow according to the "All-Moscow street classifier", which is supported by the Service for Maintaining Citywide Classifiers (hereinafter referred to as SVOK).
A sign of classification is the name of the street.
Directory structure
As a primary key when indexing the data file of the Codifier, the Kod_fo parameter is used in conjunction with the relevance indicator (the Priznak parameter).
Codifier "Administrative-territorial districts of Moscow" - "admokr xx.dbf"
The codifier is intended to determine the administrative-territorial location of the CHI system object in Moscow. It is used in the AIS OMS as auxiliary information on the Moscow address of the object - in the subsystems of maintaining RS ERZL, elements of NSI OMS, in other subsystems of the AIS OMS, etc.
The objects of classification in the Codifier are the administrative-territorial formations (districts) of the city of Moscow. Conducted on the basis of the "All-Moscow classifier of territorial units of Moscow", which is supported by the SVOK.
The sign of classification is the name of the administrative district.
Codifier Structure
| Field name | Type of | The size | Purpose |
| cokr | Symbol | 2 | County code |
| Name_okr | Symbol | 40 | Name |
The parameter Cokr is used as the primary key when indexing the Codifier data file.
Codifier "Territory of the Russian Federation" - "territ xx.dbf"
The codifier is intended to determine the administrative-territorial location of the subject of the CHI system in the Russian Federation. It is used in the RS ERZL subsystem for maintaining a database of insured citizens in calculating the policy number of a single sample, in cooperation with the FFOMS for registering the policy of the insured and with the TsVDP for personalizing and issuing the policy. Also, when creating and maintaining a personalized database of accounts of patients treated in the Moscow Region under the Moscow City Compulsory Medical Insurance Program, registered at the place of insurance and residence in another constituent entity of the Russian Federation.
The object of classification in the codifier is territorial entity RF.
A sign of classification is the name of the administrative-territorial formation of the Russian Federation.
Codifier Structure
| Field name | Type of | The size | Purpose |
| C_t | Number | 3 | Territory code of insurance (residence) |
| Name_t | Symbol | 40 | Territory name |
| C_OKATO | Symbol | 5 | Territory code by All-Russian classifier administrative-territorial formations of the Russian Federation (OKATO) |
The C_t parameter is used as the primary key when indexing the Codifier data file.
Codifier of countries and states - "COUNTRхх.dbf".
The codifier of countries and states is designed to automate the registration of the citizenship of the population insured under compulsory medical insurance. It is used in the AIS OMS subsystem for maintaining RS ERZL. Includes codes of the All-Russian classifier of countries and states: digital and three-letter.
The object of the codifier is a public entity.
A sign of classification is the short name of the country/state.
Codifier Structure
| Field name | Type of | The size | Purpose |
| C_oksm | Number | 3 | Digital code of the country according to the All-Russian classifier of countries and states OKSM |
| Name | Symbol | 35 | Short name of the country/state |
| Code | Symbol | 2 | Country short name code |
| Alfa3 | Symbol | 3 | Letter country code according to OKSM |
Yu.P. BABAK, Head of Information Department of the Fund. THE CONCEPT OF A SINGLE AUTOMATED INFORMATION SYSTEM FOR MANAGING FINANCIAL RESOURCES OF COMPULSORY HEALTH INSURANCE IN MOSCOW
The financial model of compulsory health insurance largely determines the financial support of Moscow's health care. It links the revenue and expenditure parts, ensuring the integrity of the system, its balance.
Improving the financing of the CMI system should be aimed primarily at rational use available financial resources and their compliance with the volume of medical care provided.
Naturally, effective management economic resources Compulsory medical insurance is impossible without taking into account information about the income entering the system, the costs of treatment and its results, the health status of the population served in medical institutions.
To this end, from the first days of the creation of the compulsory medical insurance system in Moscow, a concept was developed for building a unified information management of economic resources based on modern automated technologies. It was based on the scheme for processing information flows necessary for the implementation financial management presented at the end of this article.
When forming the concept of creating an automated information system (AIS), the goal was set - to develop and implement it based on the use of modern software and hardware solutions, integrated information technologies that ensure high-quality and efficient implementation federal law RF "On health insurance of citizens in the Russian Federation".
The main purpose of the AIS CHI is to promptly provide the management of the MGFOMS with reliable comprehensive information about the indicators and characteristics of the functioning of the CHI system in time to ensure the following functions:
- complete (sufficiently) and reliable control of the needs of the city's population in medical services;
- a rational approach to the formation of the city program of compulsory medical insurance of citizens;
- accounting for the receipt and expenditure of financial resources in the CHI system;
- calculation of tariffs for medical services in the CHI system;
- collection, storage, processing and provision of objective information to the management of MGFOMS, necessary for management financial resources systems;
- ensuring control over the volume and quality of treatment and expenditure of funds in the CHI system;
- automation of the processes of activity of the MGFOMS;
- formation of the necessary insurance stock to maintain the life of the CHI system.
At the first stage of the implementation of the concept, the Fund developed and implemented two automated information subsystems for the revenue and expenditure parts of the Moscow Compulsory Medical Insurance.
At the second stage, it was planned, on the basis of the information received and processed in the expenditure and income subsystems, to create in the AS MGFOMS unified registers of taxpayers and insured persons, on the basis of which it was possible to keep personalized records of financial resources, both coming to the MHI in the form of insurance premiums and paid for the rendered in health care facilities.
At the third stage, it was planned to integrate the subsystems implemented at the first and second stages into a single automated information system management of financial resources while creating tools for monitoring financial activities fund in the CHI system.
At the first stage of the implementation of the concept during 1994-1996. The Fund has carried out work during which two automated information subsystems for the revenue and expenditure parts of the OMS of Moscow were developed and implemented.
The first stage of the program
The automated information subsystem of profitable activity is implemented on the basis of the distribution of the database of taxpayers according to the territorial principle of dividing Moscow. It operates on two levels: at the lower level - each accounting and control department (UCD) has a local area network based on the Novell 4.0 operating system. At automated workplaces, the employees of the UCU carry out registration of the taxpayer, obtain a memorial order for the accounting and control department, receive calculations and acts of the payer's inspections, both cameral and documentary, bank statements. Data processing and storage are carried out in the DBMS Clipper.
At the top level, information about the activities of the UCU is transmitted monthly on magnetic media and entered on the workstations of employees of the Insurance Premiums Department for subsequent processing in the Oracle DBMS and the formation of consolidated financial indicators activities of all UCUs. It should be noted that the automation of daily routine procedures has largely freed up the resources of the inspectors, providing additional time for the following functions:
- direct production contact with payers for conducting cameral and documentary checks of the correctness of payment of insurance premiums;
- conducting a more in-depth analysis of the financial performance of payers, using the possibilities of automated sampling and comparison of information from databases;
- control over arrears in the payment of insurance premiums and the application of financial sanctions against payers-debtors.
At the same time, the Fund, together with insurance medical organizations, carried out work on the creation and implementation of an automated information subsystem of the expenditure part, which made it possible to solve the problems of accounting for the insured, forming insurance payments for the medical care provided, funds for the management of medical care, accounting for the medical care provided to patients, and forming personal accounts of patients , formation of invoices for health facilities.
The developed and implemented subsystem consists of three levels. At the top level is the hardware-software complex MGFOMS, implemented according to the client-server scheme. The complex supports automated information technologies that generate insurance payments for HIOs, identify patients when providing them with medical care, mutual settlements between HMOs and other territorial CHI funds.
At the middle level of the subsystem, there are HIO hardware and software systems that automate information technologies developed by insurers to perform the following functions: processing invoices for patients, examination of the medical care provided, generation of accounts for settlements with other HMOs, as well as non-resident and unidentified patients with MGFOMS, support of consolidated registers of insured companies.
The lower level of the subsystem consists of HCI automated workstations that support information technologies created by HMOs according to the methodology and requirements of the Moscow State Commissariat for Health Insurance, allowing you to keep records of medical care provided to patients in HCIs, maintain patient registers, and generate personal invoices for medical care for payment to HMOs. The subsystem has uniform standards for data exchange between the three levels. The Fund has developed and implemented a unified regulatory and reference base. The exchange of information between levels is carried out on magnetic media.
The introduction of an automated information subsystem of the expenditure part made it possible to ensure the transition from payment for medical care based on individual price lists to payment based on uniform tariffs for medical services; creation of medical and economic standards for inpatient care; transition from a costly system of payment by invoices for medical care provided to payment based on per capita standards and personalized bills for patients.
Second stage of the program
At the second stage of the implementation of the concept, a single register of taxpayers and a single register of insured persons were created on the Fund's central server.
At the second stage of the implementation of the concept in 1996-1998. MGFOMS carried out work that made it possible to create a single register of taxpayers and a single register of insured people on the central server of the Fund.
In the automated information subsystem of income, the hardware and software complexes of the UCU were integrated with the hardware and software complex of the executive directorate based on the Faxnet communication network. This made it possible to combine incoming information about taxpayers into a single register of taxpayers. The register contains information on more than 500,000 registered legal entities and individuals who pay insurance premiums, allows you to receive and accumulate statistical data in retrospect for each taxpayer. On the basis of the Oracle-Express software product, an analytical module has been developed and implemented that processes incoming data on the flows of financial resources of the income subsystem, on their basis, models and forecasts about the receipt of financial resources are formed.
Based on the consolidated registers of the insured in the CMO, a unified register of the insured was created and is currently maintained on the central server of the MGFOMS, containing information about 8 million 690 thousand residents of Moscow insured in the compulsory medical insurance system. Its implementation makes it possible to ensure the formation of per capita standards for paying for medical care and funds for the management of HIOs, carrying out work on differentiating tariffs for medical services, calculating insurance payments in HMOs, and making mutual settlements between HMOs.
During the operation of the unified register of the insured, it turned out that information about them has low reliability. Therefore, during the period of work at the second stage, efforts were made to improve the software product that supports its maintenance. In particular, a function was implemented that ensures the inadmissibility of repetition in a single register of series and policy numbers of the insured. In order to increase the reliability of the unified register, a refinement was carried out, allowing to verify the data on the insured with the data coming from the Moscow registry offices on the deceased, who changed their surname, and newborns.
The measures taken made it possible to start work on the introduction of a plastic health insurance card with a new system of identification of the insured. The previously used coding system for compulsory medical insurance policies was limited to the serial number of the issued policy and information about the place of issue and the population group to which the insured belongs.
However, the development of the MHI system has shown the inconsistency of such an approach to the formation of a central database, which is based on both the system for developing the main financial indicators and the medical care accounting system. Therefore, at the second stage, as part of an experiment on pharmaceutical insurance, a new codifier of the insured was developed, which allows, based on his data, to determine the sex and age, the place where the codifier was formed, the category of privilege under which you can receive medicines free of charge or at a discount. On the basis of the unified register, a function has been implemented that allows you to automatically generate a codifier for the insured. On the basis of the codifier, the design of plastic health insurance cards has been developed, and their issuance has begun.
The work carried out made it possible to move on to the implementation of a program to provide the population of Moscow with plastic health insurance cards. Within the framework of this program, at the first stage of the concept, it is planned to replace compulsory medical insurance policies of the 1994 model with compulsory medical insurance policies of the 1998 model for those insured up to working age; on the second - among the insured population of retirement age and on the third - among the able-bodied population.
In 1997, the Fund developed and implemented a program for the modernization of computer equipment and software installed in health care facilities at the first stage of concept implementation. The main goal of the program was to carry out the preparatory work necessary to integrate the created automated information subsystem of the expenditure part financial model CHI in single AIS OMS, the implementation of which was planned to be carried out at the third stage.
In order to transfer health care facilities to a single software, the MGFOMS, as part of the modernization program, held a competition for a single software for accounting for medical care and paying for it within the CHI system. For its implementation, unified technical requirements, the implementation of which ensured the transition of all 598 health care facilities currently operating in the compulsory health insurance system from various HMO software systems to a single basic software.
Based on the software that won the competition, MGFOMS within the framework of the modernization program in 1997-1998. completed work on the creation of a pilot project for a unified automated information system for compulsory medical insurance.
The materials obtained as a result of the work on the pilot project allow us to draw conclusions about the possibility of integrating all software and hardware systems CHI subjects into a single automated information system with its further distribution to health facilities that are not included in the MHI system, in order to build a single information space for healthcare in Moscow.
Third stage of the program
At present, the MGFOMS has begun to implement the third stage of the concept, the main task of which is to create a unified automated information system for managing the financial resources of the Moscow OMS.
To do this, you need to implement the following:
- in all healthcare facilities to combine autonomous workstations into local computer networks with access to a single communication network;
- to create a unified communication network that will ensure the transfer of information in electronic form about the medical care provided to the population of Moscow and payment for medical services from medical facilities to the Moscow State Medical and Social Insurance Fund and SMOs;
- on the basis of AIS MGFOMS to create a hardware and software complex that provides management of the communication network;
- to replace the CHI policies of the 1994 model with the CHI policies of the 1998 model in order to introduce a new individual number of the insured;
- to ensure the introduction in medical facilities of mechanized reading of the individual number of the insured for all types of issued medical documents;
- create and maintain a unified database of personalized data on medical care provided to the population of Moscow and its payment from CHI funds;
- perform work on the interaction of the unified register of taxpayers, the unified register of the insured, the unified database of personalized data;
- monitor the financial activities of CHI and the provision of medical care;
- unite automated technologies processing of information flows of financial resources of compulsory medical insurance, shown in the diagram, into a single data processing system.
The implementation of the programs will make it possible to create a unified automated information system for managing the financial resources of the CHI. The introduction of the system will enable the management of the MGFOMS to conduct operational monitoring of the state financial support CHI systems; raise it economic efficiency; automated collection, storage and processing of data on financial flows; create prerequisites for a comprehensive solution of issues related to the management of financial resources; increase the possibility of making informed objective management decisions.
