Appendix No. 1

To the order of MGFFOMS

No. dated "___"____________2016

RULES

FILE DATA EXCHANGE IN AIS CHI

during information interaction between participants of compulsory health insurance

Moscow

Version 1.5.3

Moscow City Compulsory Medical Insurance Fund
2016

3.1 MO report files in SMO 27

3.1.1 Directories MO 27

5.1 “Number” of policies 160

5.2 “Stop List” of policies 160

5.3 "Start List" of policies 163

Introduction. 10

1. Forms of reporting documentation on paper for file data exchange between participants in the compulsory medical insurance system when reconciling bills for medical care provided to patients during the reporting period 11

1.1 Form of the Passport of the MO invoice for medical care provided by the insured HMO. 13

1.1.1 Instructions for filling out the Account Passport MO 14

1.2 Form of the CMO Protocol for accepting the MO invoice for medical care provided to the insured CMO for the reporting period. 16

1.2.1 Instructions for filling out the Protocol of acceptance of the QS account MO 17

1.3 Form of the Passport of the MO invoice for medical care provided during the reporting period to patients insured in the territory of another constituent entity of the Russian Federation (non-resident). 21

1.4 Form of the Protocol of acceptance for payment of the MO invoice for medical care provided to the insured in the territory of another constituent entity of the Russian Federation for the reporting period. 22

2. Rules for calculating the cost of medical care provided to patients during the reporting period 23

2.1 General provisions for calculating the cost of medical care 23

3. Data exchange protocol between MO and CMO when agreeing on bills for medical care provided to insured patients 26

3.1 MO report files in SMO 27

3.1.1 Directories MO 27

3.1.2 Files of MO reports on medical care provided to patients insured by CMO 30

3.2 Report of the Medical Inspectorate to the Ministry of Defense on the results of automated control / examination of personalized invoices of the Ministry of Defense for medical care provided to the insured during the reporting period 41

4. Report of the health insurance organization to the Moscow State Compulsory Compulsory Medical Insurance Fund on accepted personalized accounts declared by the Moscow Region for the reporting period. 46

4.1 Report of the CMO to the MGFIF on personalized accounts of the Moscow Region for the reporting period. 46

4.2. Report of the self-government organization to the Moscow State Compulsory Medical Insurance Fund on financial interaction with the Moscow Region for the reporting period. 49

4.3. A report from the health insurance organization to the Moscow State Compulsory Medical Insurance Fund on defects/violations identified by the health insurance organization in paid invoices of the Ministry of Defense during the medical and economic examination (planned, targeted) and examination of the quality of medical care (planned, targeted). 51

5. Report of the health insurance organization to the Moscow State Compulsory Medical Insurance Fund on the volume and cost of medical care accepted by the health insurance organization for payment 52

5.1 Files of the CMO report to MGFIF on the volume and cost of medical care accepted by the CMO for payment 52

5.2 Form of the report of the health insurance organization on the volume and cost of medical care provided to the insured medical organization for the reporting period, and accepted by the health insurance organization for payment 56

6. Protocol for the exchange of data between the Ministry of Defense and the Moscow State Compulsory Medical Insurance Fund when reconciling bills for medical care provided to nonresident patients for the reporting period. 58

6.1 Report from the Ministry of Defense to the MGFIF on personalized invoices for medical care provided to nonresident patients. 58

6.2 Report from the Federal Compulsory Compulsory Medical Insurance Fund to the Ministry of Defense on the results of automated control of personalized invoices of the Ministry of Defense for medical care provided to nonresident patients during the reporting period 61

7. NSI AIS Compulsory Medical Insurance – list of reference books and codifiers of AIS Compulsory Medical Insurance 62

8. Description of error codes when conducting format-logical and semantic control of patient registries and medical services registries. 82

8.1 Checking the entries in the Patient Register file. Syntactic control of records and verification of encoded information 82

8.2 Identifying duplicate entries 84

8.3 Checking the connection between the patient registry file and the medical services registry file for patients 84

8.4 Checking the correctness of determining the CMO - payer 84

8.5 Checking the records of the “Register of Medical Services for Patients” files. Syntax control 85

8.6 Identification of duplicate entries in the “Register of Medical Services for Patients” file. 87

8.7 Checking the compliance of the data given in the invoice file records in coded form with the codifiers and reference data reference books in force during the reporting period 87

8.8 Checking the correctness of the patient account organization 90

9. Regulations for determining the payer for medical care provided 107

Rules for file interchange for applications for the production of compulsory medical insurance policies 112

1. General provisions on RS ERZL. 112

2. Structure, format and rules for filling out CMO report files on applications for the production of compulsory medical insurance policies. 115

3. Selecting an order generation algorithm 127

3.1 Definitions of the algorithm (scenario) when generating an application for the production of a policy 127

3.2 Description of scenarios for generating applications for the production of policies and features of filling out application files 130

4. Rules for filling out type files
depending on the scenario (code) 136

5. Reports from the Federal Compulsory Compulsory Medical Insurance Fund to the self-government organization based on the RS ERZL 159 database

5.1 “Number” of policies 160

5.2 “Stop List” of policies 160

5.3 "Start List" of policies 163

6. Additional services of AIS compulsory medical insurance upon requests 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 download result 167

Accepted abbreviations and terms

AIS compulsory medical insurance	Automated information system for compulsory health insurance
agro-industrial complex	Hardware and software complex
DB	Database
VMP	High-tech medical care
Sun	Temporary certificate - a document confirming the issuance of a policy and certifying the right to free medical care
Compulsory medical insurance document	Old-style compulsory medical insurance policy, unified compulsory medical insurance policy, temporary compulsory medical insurance certificate
DUL	Identification document of the insured person, on the basis of which the compulsory medical insurance policy is issued
ERZL	A unified register of insured persons under compulsory medical insurance in the Russian Federation, organized and supported by the FFOMS
EPP	Uniform policy number. Is the identifier of the insured person in the 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 inpatient settings and in day hospitals
MGFOMS	Moscow City Compulsory Medical Insurance Fund
MO	Medical organization of the compulsory medical insurance system
MO with PF	Medical organization financed on a per capita basis
MO with GR	A medical organization that carries out horizontal payments from per capita financing for medical care provided by medical organizations to their assigned population
MS	Medical standard is a set of diagnostic and treatment technologies provided as part of a completed case of hospitalization in an inpatient setting
MS IS	Medical and sociological integrated system - AIS Compulsory Medical Insurance portal
NMP	Emergency medical care
NSI	Regulatory and reference information
Compulsory medical insurance	Compulsory health insurance
MO software with hospital-type PF	Outpatient 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 method of financing medical organizations providing primary health care according to the standard for the assigned population
Patient Registry (Accounts)	List of Moscow Region patients who received medical care under the compulsory medical insurance program during the reporting period. The register of patients, supplemented by the tariff cost of medical services provided to the patient by the Moscow Region during the reporting period and registered in the register of services, determines the register of accounts of the Moscow Region
Register of services	A consolidated list of medical services provided to patients of the Moscow Region under the compulsory medical insurance program for the reporting period. Linking with the patient registry is carried out according to the compulsory medical insurance document registered in the patient registry and the medical services registry
RS ERZL	Regional segment of ERZL
SMO	Medical insurance organization
SMP	Emergency
JV	Insurance affiliation
Insurer	The health insurance company that registered the compulsory medical insurance document of the insured
Patient account	Tariff cost of medical services (in accounting units) provided to a MO patient under the compulsory medical insurance 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 Compulsory Medical Insurance Fund
FLC	Format-logical control
TPN	Territorially attached population
FFOMS	Federal Compulsory Medical Insurance Fund
TsAPK	Central hardware and software complex AIS compulsory medical insurance
CVDP	Policy Issue and Personalization Center
COI	Information Processing Center at CAPC
CS ERZL	Central segment of the unified register of insured persons.
EP	Electronic policy

Legislative and regulatory documents in the compulsory medical insurance system

1. Federal Law of November 29, 2010 No. 326 - Federal Law “On Compulsory Health Insurance in the Russian Federation”.

2. Rules of compulsory health insurance, approved by order of the Ministry of Health and Social Development of the Russian Federation dated February 28, 2011 No. 158n.

3. The procedure for maintaining personalized records in the field of compulsory health 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 operation of information systems and the procedure for information interaction in the field of compulsory health insurance, approved by order of the Federal Compulsory Medical Insurance Fund dated 04/07/2011 No. 79.

5. The procedure for organizing and monitoring the volumes, timing, quality and conditions of providing medical care under compulsory medical insurance, approved by order of the Federal Compulsory Medical Insurance Fund dated December 1, 2010 No. 230.

6. Accounting for surgical operations within the framework of personalized accounting in the field of compulsory medical insurance (ref. FFOMS dated 04/05/2012 No. 2194/21-4/i)

7. The list of types of high-tech medical care provided at the expense of compulsory health insurance was approved by Decree of the Moscow Government dated December 24, 2015 No. 949-PP.

Guiding documents on the organization of information interaction in the AIS compulsory medical insurance:

8. Automated information system for compulsory medical insurance in Moscow. Interface of the universal mail gateway OMSGW, 2011.

9. Automated information system for compulsory medical insurance in Moscow. Protocol of information exchange with the regional and central segments of the ERZL, 2011.

10. Automated information system for compulsory medical insurance in Moscow. Information exchange protocol for transmitting regulatory and reference information in a corporate network, 2011.

11. Instructions for recording medical care provided in a 24-hour hospital and in day hospitals (outside the capitation financing system) under compulsory health insurance (Appendix 3 to the Tariff Agreement for 2016 dated December 25, 2015).

12. The procedure for information interaction between participants of compulsory health insurance in the automated information system of compulsory health 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 Compulsory Medical Insurance information on the attachment of insured persons to medical organizations in Moscow, version 1.1 dated November 20, 2015.

14. The procedure for calculating and transferring financial resources for per capita financing to medical organizations in Moscow providing primary health care on an outpatient basis to the assigned population for 2016 (Appendix 12 to the Tariff Agreement for 2016 dated December 25, 2015).

17. Methodological recommendations for recording in the AIS compulsory medical insurance the first stage of medical examination of the adult population and orphans and children in difficult life situations staying in inpatient institutions (version 1.7, 2016).

18. Methodological recommendations for recording in the AIS compulsory medical insurance the second stage of medical examination of the adult population and orphans and children in difficult life situations staying in inpatient institutions (version 1.7, 2016).

19. Methodological recommendations for taking into account in the AIS Compulsory Medical Insurance the medical examination of orphans and children left without parental care, including those adopted, taken under guardianship (trusteeship), into 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 compulsory medical insurance system, during information interaction in the Compulsory Medical Insurance AIS of participants in the compulsory medical insurance system (version 1.4 from 26.04.16).

Application

to the order of MGFFOMS

Description of 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 WEB SERVICES RS ERZL AIS Compulsory Medical Insurance 2

1.1 Purpose of the System.. 2

2......... Requirements for data exchange formats.. 2

3......... Interaction order.. 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 individual methods for different categories of users.. 2

4.2 Access Matrix. 2

4.3 Features of access to historical data.. 2

5.1 Search for an individual and obtain the identifier of his current compulsory medical insurance policy.. 2

5.2 Simplified receipt of the identifier of a valid compulsory medical insurance policy.. 2

5.3 Transfer of information to RS ERZL about non-resident insured persons. 2

5.4 Transfer of information to the 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
AIS Compulsory Medical Insurance MGFFOMS		Automated information system for compulsory medical insurance of the Moscow City Compulsory Medical Insurance Fund
		Automated workstation
		Automated system
		Database
		Temporary certificate
		Federal State Unitary Enterprise "Goznak"
		Voluntary health insurance
		Document confirming the fact of insurance (compulsory medical insurance policy, temporary certificate)
		Identity document
		Unified medical information analytical system of Moscow
		Unified register of insured persons
		Department of Civil Registration of Moscow
		Insured person
		Identifier
		Nonresident insured person
		Taxpayer identification number
		Information system
		Counterparty
		Moscow City Compulsory Medical Insurance Fund
		Medical organization
		Multifunctional centers for the provision of public services in Moscow
		Medical and economic examination
		Unidentified person
		Newborn
		Regulatory and reference information
		All-Russian classifier of countries of the world
		Compulsory health insurance
		Portal of public services of Moscow
		Software
		Compulsory health insurance policy, a document confirming the fact of insurance of the insured person in the compulsory medical insurance system
		Pension Fund of the Russian Federation
		Regional segment
		Regional segment of the unified register of insured persons
		Russian Federation
		Medical insurance organization
		Emergency
		Insurance number of an individual personal account
		Territorial Compulsory Health Insurance Fund
		Unique identity code in the AIS Compulsory Medical Insurance MGFFOMS
		Universal electronic card
		Full Name
		Format-logical control
		Federal Compulsory Medical Insurance Fund
		Central segment
		Central segment of the unified register of insured persons
		Examination of the quality of medical care
		Hypertext Transfer Transport Protocol Security - secure protocol for transferring hypertext information
		Simple Object Access Protocol - a simple protocol for accessing objects - a protocol for exchanging structured messages in a distributed computing environment
		Unicode Transformation Format, 8-bit - Unicode transformation format, 8-bit
		Web Services Description Language – a language for describing web services based on XML
		eXtensible Markup Language - extensible markup language

1. GENERAL DESCRIPTION OF THE PRINCIPLES OF OPERATION OF WEB SERVICES RS ERZL AIS Compulsory Medical Insurance

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 intended to collect, store, process and provide data on persons insured in Moscow, as well as on persons who sought medical care in medical organizations in Moscow.

MGFOMS, as part of its activities, conducts the RS ERZL, and also ensures, within its competence, the protection of information that constitutes restricted access information.

Maintaining RS ERZL includes main and auxiliary processes.

Main processes:

1) receiving information about APs from the MO/SMO and entering them into the ERZL RS;

2) receiving, recording and executing applications from health insurance companies for the production of compulsory medical insurance policies; interaction with GOZNAK; accounting of manufactured compulsory medical insurance policies, including their status;

3) accounting for the attachment of APs to medical organizations in Moscow, including maintaining a register of scanned documents of APs’ applications 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 Municipal District;

6) accounting of non-resident APs (third-party TFOMS) who received medical care in the Moscow Municipality;

7) recording data on APs, such as:

ZL address;

AP contact details;

Citizenship of the AP;

Social status, disability, benefits for APs;

Information about the AP’s identity documents;

7. NSI AIS Compulsory Medical Insurance – list of reference books and codifiers of AIS Compulsory Medical Insurance Directory “AIS CHI Subscribers” – “sprabo xx.dbf”

The directory is intended to ensure automated exchange of information in the AIS CHI and is used when sending and receiving information parcels for various purposes, as well as to monitor the operation of the corporate network.

The objects of classification in the Directory are subscribers of AIS compulsory medical insurance.

The classification sign is the “Mnemonic name of the subscriber” in combination with the “Type of subscriber”.

Directory structure

Field name	Type	Size	Purpose
Abn_ID	Number	6	Subscriber ID
Abn_name	Symbol	27	Caller mnemonic name
Abn_type	Symbol	1	Subscriber type according to the codifier “tipaboXX”
Object_ID	Number	6	Object ID
Tip_otveta	Symbol	1	Type of response to the RS ERZL request using the codifier “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.
Codifier “Subscriber type” – “tipabo xx.dbf”

The AIS CHI subscriber type codifier is used as an auxiliary for the directory of AIS CHI subscribers in order to determine the responsibility of the subscriber as a legal entity.

Explanations. A number of AIS OMS subscribers have more than one physically different workstation of a corporate network user. For clarity in the provision of reports on compulsory medical insurance accounts of a legal entity of the compulsory medical insurance system, the subscriber type establishes a single address at which data is exchanged between the legal entity, the self-service organization and the MGFIF data center when exchanging data on the compulsory medical insurance account. The remaining workstations of this legal entity are given the opportunity to access the AIS CHI databases without the right to provide reporting on compulsory medical insurance accounts.

The elements of the set of objects included in the Codifier are the possible types of AIS CHI subscribers.

The classification sign is the name of the subscriber type.

Codifier structure

Field name	Type	Size	Purpose
Tip_ab	Symbol	1	Subscriber type code
Name_tip	Symbol	40	Type name

The Tip_ab parameter is used as the primary key when indexing the Codifier data file.
Codifier “Response type to ERP request” – “tipotv xx.dbf”

The type codifier for responses to the RS ERZL request is used as an auxiliary one 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 the RS ERZL.

The elements of the set of objects included in the codifier are the types of responses to the RS ERZL request (“0” - full, “1” - abbreviated).

A sign of classification is the name of the type of response to the request. Establishes MGFOMS

Codifier structure

Field name	Type	Size	Purpose
Tip_otveta	Symbol	1	Response type code (volume of data about the insured)
Name_tip	Symbol	50	Response Description

The Tip_otveta parameter is used as the primary key when indexing the Codifier data file.
Directory “Streets of Moscow” – “spr_ul xx.dbf”

The directory is intended for generating data at the Moscow address of an object (organization and individual) in the AIS compulsory medical insurance system. It is used in the AIS CHI subsystems for managing RS ERZL, in the formation of a patient’s Moscow address when registering and maintaining a personalized database on the accounts of patients treated under the Moscow City CHI program, in the NSI subsystems for maintaining databases about objects of the CHI system (MO, SMO).

The elements of many 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 All-City Classifiers (hereinafter referred to as SVOC).

The classification sign is the name of the street.

Directory structure

When indexing the Codifier data file, the Kod_fo parameter is used as a primary key in conjunction with the relevance indicator (Priznak parameter).
Codifier “Administrative-territorial districts of Moscow” – “admokr xx.dbf”

The codifier is intended to determine the administrative-territorial location of an object of the compulsory medical insurance system in Moscow. It is used in the AIS CHI as auxiliary information at the Moscow address of the facility - in the subsystems of maintaining the RS ERZL, elements of the compulsory medical insurance reference data, in other subsystems of the AIS CHI, etc.

The objects of classification in the Codifier are administrative-territorial entities (districts) of the city of Moscow. It is conducted on the basis of the All-Moscow Classifier of Territorial Units of Moscow, which is supported by SVOC.

The classification sign is the name of the administrative district.

Codifier structure

Field name	Type	Size	Purpose
Cokr	Symbol	2	County code
Name_okr	Symbol	40	Name

The Cokr parameter 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 compulsory medical insurance 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 interaction with the FFOMS for registering the policy of the insured and with the TsVDP for personalizing and issuing the policy. Also in the formation and maintenance of 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 the territorial entity of the Russian Federation.

The classification sign is the name of the administrative-territorial entity of the Russian Federation.

Codifier structure

Field name	Type	Size	Purpose
C_t	Number	3	Insurance territory code (residence)
Name_t	Symbol	40	Name of territory
C_OKATO	Symbol	5	Territory code according to the All-Russian Classifier of Administrative-Territorial Entities of the Russian Federation (OKATO)

The C_t parameter is used as the primary key when indexing the Codifier data file.
The codifier of countries and states is “COUNTRхх.dbf”.

The codifier of countries and states is intended to automate the registration of citizenship of the population insured under compulsory medical insurance. It is used in the AIS subsystem of compulsory medical insurance 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 public education.

The classification sign is the short name of the country/state.

Codifier structure

Field name	Type	Size	Purpose
C_oksm	Number	3	Digital country code according to the All-Russian Classifier of Countries and States OKSM
Name	Symbol	35	Brief name of the country/state
Code	Symbol	2	Country short name code
Alfa3	Symbol	3	Letter code of the country according to OKSM

No. 4 (15), 1999 - »» COMPULSORY HEALTH INSURANCE FUND in Moscow.

Yu.P. BABAK, head of the Foundation's information department. CONCEPT OF A UNIFIED AUTOMATED INFORMATION SYSTEM FOR FINANCIAL RESOURCE MANAGEMENT OF COMPULSORY MEDICAL INSURANCE OF MOSCOW

The financial model of compulsory medical insurance largely determines the financial support of Moscow healthcare. It links revenue and expenditure parts, ensuring the integrity of the system and its balance.

Improving the financing of the compulsory medical insurance system should be aimed primarily at the rational use of available financial resources and their compliance with the volume of medical care provided.

Naturally, effective management of the economic resources of compulsory health insurance is impossible without taking into account information about the income coming into the system, the costs of treatment and its results, and the health status of the population served in medical institutions.

For these purposes, from the first days of the creation of the compulsory health insurance system in Moscow, the concept of building a unified information management of economic resources based on modern automated technologies was developed. It was based on the scheme for processing information flows necessary for financial management, presented at the end of this material.

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 effective implementation of the Federal Law of the Russian Federation “On Health Insurance of Citizens in the Russian Federation.”

The main purpose of the AIS compulsory medical insurance is to promptly provide the management of the Moscow State Compulsory Medical Insurance Fund with reliable comprehensive information on the indicators and characteristics of the functioning of the compulsory medical insurance system in a time-based manner to ensure the following functions:

• complete (to a sufficient extent) and reliable control of the city population’s need for medical services;
• a rational approach to the formation of a city program of compulsory health insurance for citizens;
• accounting for receipts and expenditures of financial resources in the compulsory medical insurance system;
• calculation of tariffs for medical services in the compulsory medical insurance system;
• collection, storage, processing and provision to the management of MGFIF of objective information necessary for managing the financial resources of the system;
• ensuring control over the volume and quality of treatment and expenditure of funds in the compulsory medical insurance system;
• automation of the activities of MGFIF;
• formation of the necessary safety stock to support the functioning of the compulsory medical insurance system.

The construction of such a system required the development of a program for its implementation in three stages. At the first stage, it was planned to introduce automated information technologies into the income and expenditure systems of compulsory medical insurance in order to automate the collection, processing and analysis of information about their functioning, as well as to ensure the automation of the activities of the executive directorate of the MGFIF.

At the first stage of implementation of the concept, the Fund developed and implemented two automated information subsystems for the revenue and expenditure parts of the compulsory medical insurance in Moscow.

At the second stage, on the basis of the information received and processed in the expenditure and revenue subsystems, it was planned to create unified registers of taxpayers and insured persons in the AS MGFFOMS, on the basis of which it would be possible to keep personalized records of financial resources, both received by compulsory medical insurance in the form of insurance premiums, and paid for services rendered. medical care in health care facilities.

At the third stage, it was planned to integrate the subsystems implemented in the first and second stages into a single automated information system for managing financial resources with the simultaneous creation of tools for monitoring the financial activities of the fund in the compulsory medical insurance system.

At the first stage of implementation of the concept during 1994-1996. The Foundation carried out work during which two automated information subsystems for the revenue and expenditure parts of the Moscow Compulsory Health Insurance were developed and implemented.

First stage of the program

The automated information subsystem for revenue activities is implemented based on the distribution of the taxpayer database according to the territorial principle of dividing Moscow. It operates at two levels: at the lower level - in each accounting and control department (ACD) a local computer network has been created on the Novell 4.0 operating system. At automated workstations, UCU employees register a taxpayer, receive a memorial order for the accounting and control department, receive calculations and inspection reports of the payer, both desk and documentary, and post bank statements. Data processing and storage are carried out in the Clipper DBMS.

At the top level, information on the activities of UCUs is transmitted monthly on magnetic media and entered into the workstations of employees of the Insurance Contributions Department for subsequent processing in the Oracle DBMS and the formation of summary financial indicators of the activities of all UCUs. It should be noted that automation of daily routine procedures has significantly freed up inspectors' resources, providing additional time to perform the following functions:

• direct production contact with payers to conduct desk and documentary checks of the correctness of payment of insurance premiums;
• conducting a more in-depth analysis of the financial indicators of payers, using the capabilities of automated sampling and comparison of information from databases;
• monitoring overdue debt for payment of insurance premiums and applying financial sanctions to debtor payers.

It became possible to reorient department specialists to more important areas of work through partial redistribution of their production responsibilities. For example, the formation of unified banking groups in a number of UCUs made it possible to generally reduce the number of this category of specialists by sending released employees to conduct documentary checks of payers.

In parallel, the Foundation, together with medical insurance organizations, carried out work on the creation and implementation of an automated information subsystem for the expenditure part, which made it possible to solve the problems of accounting for the insured, generating insurance payments for medical care provided, funds for managing the affairs of health insurance, recording medical care provided to patients, and generating personal accounts for patients , generation of invoices for health care facilities.

The developed and implemented subsystem consists of three levels. At the top level there is the MGFFOMS hardware and software complex, implemented according to the client-server scheme. The complex supports automated information technologies that generate insurance payments for health insurance providers, identify patients when providing medical care, and make mutual settlements between health insurance organizations and other territorial compulsory medical insurance funds.

At the middle level of the subsystem there are hardware and software complexes of health insurance companies that automate information technologies developed by insurers to perform the following functions: processing patient bills, examination of medical care provided, generation of invoices for settlements with other health insurance companies, as well as non-resident and unidentified patients with MGFIF, support of consolidated registers of insured companies.

The lower level of the subsystem consists of automated workstations of health care facilities that support information technologies created by the health care organization according to the methodology and requirements of the Moscow State Compulsory Medical Insurance Fund, which allows keeping records of medical care provided to patients in health care institutions, maintaining patient registers, and generating personal invoices for medical care provided for payment to the health care organization. The subsystem has uniform standards for data exchange between three levels. The Foundation has developed and implemented a unified regulatory and reference base. Information exchange between levels is carried out on magnetic media.

The introduction of an automated information subsystem for expenditures made it possible to ensure a transition from payment for medical care provided 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 based on invoices for medical care provided to payment based on capitation standards and personalized patient bills.

Second stage of the program

At the second stage of implementation of the concept, a unified register of taxpayers and a unified register of insured persons was created on the central server of the Fund.

At the second stage of implementation of the concept in 1996-1998. MGFIF carried out work that made it possible to create a unified register of taxpayers and a unified register of insured persons on the Fund’s central server.

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 about more than 500 thousand registered legal entities and individuals making payments of insurance premiums, and allows you to obtain and accumulate retrospective statistical data for each taxpayer. Based on the Oracle-Express software product, an analytical module has been developed and implemented that processes incoming data on financial flows of the income subsystem; on their basis, models and forecasts about the receipt of financial resources are generated.

Based on the consolidated registers of those insured in the CMO, a unified register of the insured was created and is currently maintained on the central server of the MGFFOMS, 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 managing the affairs of health insurance organizations, carrying out work to differentiate tariffs for medical services, making calculations of insurance payments in health insurance organizations, and conducting mutual settlements between health insurance organizations.

During the operation of the unified register of insured persons, it was revealed that information about them is of low reliability. Therefore, during the work at the second stage, efforts were made to improve the software product that supports its maintenance. In particular, a function was implemented to ensure that series and policy numbers of the insured are not repeated in the unified register. In order to increase the reliability of the unified register, improvements have been made to allow data on the insured to be verified with data received from the Moscow registry office on the deceased, those who changed their last name, and newborns.

The measures taken made it possible to begin work on the introduction of a plastic health insurance card with a new system for identifying the insured. The previously used coding system for compulsory medical insurance policies was limited to the serial number of the policy issued and information about the place of issue and the population group to which the insured belongs.

However, the development of the compulsory medical insurance system has shown the inconsistency of this approach to the formation of a central database, on which both systems for developing basic financial indicators and systems for recording medical care rely. Therefore, at the second stage, as part of the experiment on pharmaceutical insurance, a new codifier of the insured was developed, which makes it possible to determine, based on his data, the gender and age, the place of formation of the codifier, and the benefit category under which one can receive medications for free or at a discount. A function has been implemented on the basis of a single register that allows the automatic generation of a codifier for the insured. Based on the codifier, the design of plastic health insurance cards was developed and their production began.

The work carried out made it possible to move on to the implementation of a program to provide the Moscow population with plastic health insurance cards. As part 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 - for the insured population of retirement age and on the third - among the working population.

In 1997, the Foundation developed and implemented a program for modernizing computer equipment and software installed in health care facilities at the first stage of implementation of the concept. 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 of the compulsory medical insurance financial model into a unified AIS compulsory medical insurance, the implementation of which was planned to be carried out at the third stage.

In order to transition healthcare facilities to a unified software, MGFIF, as part of the modernization program, held a competition for a unified software for recording medical care and paying for it within the compulsory medical insurance system. To carry it out, unified technical requirements were formed, the implementation of which ensured the transition of all 598 health care facilities currently operating in the compulsory medical insurance system from various software systems of health insurance to a single basic software.

Based on the software that won the competition, MGFIF as part of the modernization program in 1997-1998. performed 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 of compulsory medical insurance subjects into a single automated information system with its further distribution to health care facilities that are not included in the compulsory medical insurance system, in order to build a unified health care information space in Moscow .

Third stage of the program

Currently, MGFIF 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 compulsory health insurance system.

To do this you need to implement the following:

• in all health care facilities, combine autonomous automated workstations into local computer networks with access to a single communication network;
• create a unified communication network that ensures the transfer of information in electronic form about the medical care provided to the population of Moscow and payment for medical services from medical institutions to the Moscow State Compulsory Medical Insurance Fund and the Health Insurance Fund;
• on the basis of the AIS MGFOMS, create a hardware and software complex that ensures management of the communication network;
• to replace compulsory medical insurance policies of the 1994 model with compulsory medical insurance policies of the 1998 model in order to introduce a new individual number for the insured;
• ensure the introduction in health care facilities of a mechanized reading of the individual number of the insured person 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 compulsory health insurance funds;
• carry out work on the interaction of the unified register of taxpayers, the unified register of the insured, and the unified database of personalized data;
• monitor the financial activities of compulsory health insurance and the provision of medical care;
• combine automated technologies for processing information flows of compulsory medical insurance funds, shown in the diagram, into a unified data processing system.

The listed tasks formed the basis of documents developed by the Foundation and approved by the Moscow government and the City Duma - a program to provide the Moscow population with plastic health insurance cards, a program for the development of an automated compulsory health insurance information system, and a program for creating a unified healthcare information space.

The implementation of the programs will make it possible to create a unified automated information system for managing the financial resources of compulsory medical insurance. The introduction of the system will enable the management of MGFIF to carry out operational control over the state of financial support of the compulsory medical insurance system; increase its economic efficiency; automated collection, storage and processing of data on financial flows; create the prerequisites for a comprehensive solution to issues related to the management of financial resources; increase the ability to make informed, objective management decisions.