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Chapter I General Principles
Article 1
The Regulations is enacted pursuant to Paragraph 3, Article 6 of National Health Insurance Acts (hereinafter referred to as "the Act").
Article 2
If beneficiary, insured units, premium withholder and insurance contracted medical care institutions dispute against insurer over the following National Health Insurance benefit case evaluated by the insurer, they shall apply for mediation first in accordance with the Regulations:
I. The matters concerning the insured's qualification and the insurance procedures.
II. The matters concerning the insured amount.
III. The matters concerning the insurance premium, the late fee and the pecuniary fine.
IV. The matters concerning the insurance payment.
V. Other matters concerning the insurance benefits.
If insurance contracted medical care institutions dispute against insurer over the National Health Insurance medical expenditure case evaluated by the insurer, shall apply for mediation in accordance with the Regulation.
If insurance contracted medical care institutions dispute against insurer over the insurance contracted medical care institutions exclusive management case evaluated by the insurer, shall apply for mediation in accordance with the Regulation.
Chapter II The Mediation Procedure
Section I Mediation Presentation and Mediation Approval
Article 3
The beneficiary, insured units, premium withholder and insurance contracted medical care institution shall be the applicants of the applications for mediation.
The insured unit shall put forward the applications referred to in the preceding paragraph at the request of the subordinate beneficiary.
Article 4
When the applicant applies for mediation, he or she shall fill out the National Health Insurance dispute mediation petition (hereinafter referred to as "petition"), and submit it to The National Health Insurance Dispute Mediation Committee (hereinafter referred to as "NHI Dispute Mediation Committee ") within sixty days from the next day of the arrival of the insurer's evaluation notification document.
Article 5
The application for mediation shall be based on the date of the NHI Dispute Mediation Committee receiving the petition; if the petition is sent to the NHI Dispute Mediation Committee by mail, the postmark date stamped by the original post office shall be referred.
Those who have missed the application for mediation due to natural disaster or any reasons not attributable to the applicant shall state the reasons in writing and apply for restoration within the ten days after the reasons fade away.
However, if it has been over one year since the deadline of the application for mediation, the applicant is not allowed to apply for restoration.
Those who apply for restoration shall carry out all the necessary mediation application procedures during the remedy period.
Article 6
After the applicant applies for mediation, he or she may withdraw his or her application prior to the mediation approval (hereinafter referred to as "approval"); the applicant who withdraws his or her application is not allowed to apply for mediation for the same dispute again.
Article 7
Those who apply for mediation without petitions or with petitions unconformable with the legal procedure and have abilities to correct this fault shall be informed to correct it within 20 days.
Those who have good reasons for postponement of the correction referred to in the preceding paragraph shall apply for postponement within 20 days.
Article 8
For the benefit or exclusive management case conformable with the legal procedure, the NHI Dispute Mediation Committee shall send the copy of petitions to the insurer to get his position paper; the same processes shall be applied to, the medical expenditure case conformable with the legal procedure as necessary.
The insurer shall present the position paper within one month from the next day of the arrival of the letter, and submit it together with necessary materials to the NHI Dispute Mediation Committee. If the insurer deems the application for mediation reasonable, he shall re-evaluate the matter concerned and notify the applicant directly and report it to the NHI Dispute Mediation Committee.
Article 9
The designated members shall make the preliminary assessment for the dispute mediation first and submit the comments on the preliminary assessment to the NHI Dispute Mediation Committee for resolution; and the doctors or experts of the related fields shall be invited to assist in making preliminary assessments for the cases involving special technology or mass occurrence.
Article 10
The dispute case shall adopt the written mediation. If necessary, the relevant institutions or academic institution shall be commissioned to make appraisals and sit in on the mediation to account for the dispute.
Article 11
The NHI Dispute Mediation Committee Chairperson or member who has a concern in the dispute mediation shall be recused and not participate in the mediation.
Article 12
The NHI Dispute Mediation Committee shall approve the dispute case within three months from the next day of receiving the petition; if it is necessary to postpone the approval of the dispute case, the NHI Dispute Mediation Committee shall notify the applicant, except that there is consent of applicant. The approval is allowed to be postponed for only one time and for less than three months.
The period referred to in the preceding Paragraph shall start from the next day of the correction for those who get notified of correction in accordance with the Article 7; from the next day of the end of the correction period for those who fail to make correction; and from the next day of the arrival of the represented reasons for those who represent reasons during the mediation.
If the case fails to be approved within the period referred to in Paragraph 1, the applicant shall start lawsuit over the dispute within the law.
Article 13
Approval shall take the conformation of other legal relations as the criterion. Before confirming the legal relations, the NHI Dispute Mediation Committee shall suspend the mediation procedures in conformity to the legal procedures and notify the applicant.
Section II The Benefit Case
Article 14
The application for mediation of the benefit case requires the applicant to fill out the petition stating the following matters with his attorney's or his own signature or seal:
I. The applicant's name, date of birth, dwelling place, temporary living place and ID No. If the applicant is a corporation or an organization with managers or representatives, the corporation or organization's name, office or business address and the manager or representative's name, date of birth, dwelling place and temporary living place.
II. If the applicant has an attorney, he or she shall present a written form of authorization at the first place of application for mediation conduct. The authorization paper shall include the attorney's name, date of birth, dwelling place, temporary living place and ID No.
III. Claims
IV. Facts and reasons for mediation application
V. The date of receiving or knowing the insurer's original evaluation notification (MM/DD/YY)
VI. The evidence. If the evidence is a written document, the transcript or copy is required.
VII. Transcripts or copies of the insurer's original evaluation notification document and the related documents or materials
VIII. MM/DD/YY
The Subparagraph 4 of the preceding paragraph, facts & reasons shall be stated respectively and the related arguments shall be stated one by one; if the applicant is a foreigner, a Chinese version is required.
Article 15
The insurer shall present the position paper stating the following matters in accordance with Paragraph 2, Article 8
I. The reasons not stated in the original evaluation notification documents.
II. The facts or legal arguments of the mediation application and the insurer's opinions.
III. Comments on all the arguments put forward by the applicant; those who hold the converse opinion shall attach the reasons to the position paper.
IV. The evidence available for the original evaluation notification.
Article 16
The applicant shall apply to the NHI Dispute Mediation Committee in written form for reading, transcribing, copying or shooting the related documents with the exception of the following documents:
I. Draft documents for approval
II. Preparation or mediation documents for approval
III. Documents kept secret to protect the third party's legal rights and interests.
IV. Other documents kept secret based on laws or public benefits.
Article 17
If necessary, the NHI Dispute Mediation Committee shall inform the applicant to express his or her opinions at the given place on the given day in conformity to the legal procedures and the application of the applicant.
Article 18
One of the following cases will invalidate the mediation approval of the benefit case:
I. The petition unconformable with the legal procedure is unable to be corrected or fails to be corrected within the given period.
II. Overdue applications for mediation
III. Those who are not set forth in Paragraph 1, Article 3 put forward the application.
IV. Nonexistence of the original evaluation notification
V. Reapplications of mediation of an approved or withdrawn case.
VI. Disputes not concerning the matters referred to in Article 2.
If the invalid mediation approval referred to in Subparagraph 1 or 2 of the preceding Paragraph can prove that the original evaluation is illegal, the insurer or his higher authorities shall withdraw or modify the original evaluation in conformity to the legal procedures.
Article 19
The NHI Dispute Mediation Committee shall disallow the mediation approval for those who put forward applications without reasons.
The NHI Dispute Mediation Committee shall withdraw all or one part of the original evaluation for those who put forward applications with reasons; and shall approve the evaluation modification directly or return it back to the insurer for re-evaluation within the given days according to the status.
If the insurer presents a position paper not in detail or fails to presents a position paper within the given days, the NHI Dispute Mediation Committee shall carry out the mediation approval directly in conformity to the legal procedures.
Article 20
The approved benefit case requires the approval paper stating the following matters:
I. The matters referred to in Subparagraph 1, Paragraph 1, Article 14.
II. Texts, facts and reasons, among which the facts shall only cover the arguments, the invalid mediation approval referred to in Paragraph 1, Article 18 may not state facts with this Subparagraph as a proof.
III. The agency and its leading officer.
IV. MM/DD/YY
The approval paper shall state remedies, time limit and competent authorities for noncompliance.
Section III The Medical Expenditure Case
Article 21
The application for mediation of the medical expenditure case requires the applicant to fill out the petition and the detailed list (see the attached list I and II) stating the following matters with his seal:
I. The name and code of the insurance contracted medical care institution and the person who is in charge of the institution.
II. Claims
III. Facts and reasons for mediation application
IV. The date of receiving or knowing the insurer's recheck notification (MM/DD/YY)
V. The medical record and other related certifications. The transcripts or copies of materials in written form are required.
VI. Transcripts or copies of the insurer's recheck notification document and the related documents or materials
VII. MM/DD/YY
The facts and reasons referred to in Subparagraph 3 of the preceding Paragraph shall be written to the columns specified by the format.
An applicant submitting an Attachment 2 (details of dispute mediation case) together with relevant documents and materials as prescribed in Paragraph 1 of this Article in electronic form through the system designated by the NHI Dispute Mediation Committee is exempted from providing those documents and materials in paper and physical form. However, the NHI Dispute Mediation Committee may, as it deems necessary, request the applicant to submit those documents and materials in paper and physical form.
Article 22
The insurer shall present the position paper stating the following matters in accordance with Paragraph 2, Article 8:
I. The reasons not stated in the recheck notification documents.
II. Comments on all the arguments put forward by the applicant.
III. The evidence available for the recheck notification.
The evidence available for the recheck notification referred to preceding paragraph shall state the methods of review, analysis and sampling with related information enclosed in case of field audit, file analysis, purposive and random sampling examination.
Article 23
The mediation approval of the medical expenditure case shall be carried out in accordance with Article 18 and 19 (excluding Subparagraph 4, Paragraph 1, Article 18).
Article 24
The approved medical expenditure case requires the approval paper stating the following matters:
I. The name and code of the insurance contracted medical care institution.
II. Texts, facts and reasons, among which the facts and reasons not concerning the arguments may not be stated.
III. The agency and its leading officer.
IV. MM/DD/YY
If the same applicant applies for over two dispute mediations on the same agreement within the given time, only the disputed matters need to be stated as stipulated by Subparagraph 2 of the preceding Paragraph. The same process is also applied to case of the same type and same mediation result.
If the insurer re-evaluates the medical expenditure case in accordance with Paragraph 2, Article 8, the NHI Dispute Mediation Committee is allowed to close the case directly without the approval paper of Paragraph 1.
The approval paper shall have note specifying the relief measures for objection to items approved and the juridical court accepting the case.
Section IV The Exclusive Management Case
Article 25
The mediation procedures for the exclusive management case shall be carried out in accordance with the regulations concerning the benefit case referred to in Section II.
Chapter III Supplementary Provisions
Article 26
The approval paper shall be sent to the applicant and the insurer respectively; if necessary, shall be reported to relevant institutions or units.
The insurer shall enforce the mediation approval made by the NHI Dispute Mediation Committee within 15 days from the arrival of the approval paper.
For the withdrawn case approved by the NHI Dispute Mediation Committee, the enforcement period mentioned in the preceding Paragraph does not include the period from the date of notification of correction to the correction completion date if the insurer shall make corrections due to the incomplete documents submitted by the applicant.
Article 27
The Regulations, with the exception of Articles amended and announced on November 6, 2012, which become effective on January 1, 2013, shall come into force as of the date of promulgation.
Web site:Laws & Regulations Database of The Republic of China