Article 43. Personalized accounting in the field of compulsory health insurance

1. Personalized accounting in the field of compulsory health insurance (hereinafter referred to as personalized accounting) - organization and maintenance of records of information about each insured person in order to realize the rights of citizens to free medical care within the framework of compulsory health insurance programs.

2. The goals of personalized accounting are:

3. Personalized accounting, collection, processing, transfer and storage of information are carried out by the Federal Fund and territorial funds, the Pension Fund of the Russian Federation and its territorial bodies, medical insurance organizations, medical organizations and insurers for unemployed citizens in accordance with the powers provided for by this Federal Law.

4. For the purposes of personalized accounting, the Federal Fund and territorial funds carry out information interaction with insurers for non-working citizens, with the Pension Fund of the Russian Federation and its territorial bodies, medical organizations, medical insurance organizations and other organizations in accordance with this Federal Law.

5. The procedure for maintaining personalized records is determined by the authorized federal executive body.

Personalized information recording information about insured persons is maintained in the form of a unified register of insured persons, which is a combination of its central and regional segments, and includes the collection, processing, transfer and storage of certain information about insured persons.

The list of information included in registers is contained in Art. 44 of the Law, and is also duplicated in the order of the Ministry of Health and Social Development of the Russian Federation dated January 25, 2011 No. 29n “On approval of the Procedure for maintaining personalized records in the field of compulsory health insurance.” The established procedure determines the rules for maintaining personalized records of information about each insured person in the field of compulsory health insurance. In particular, the organization of personalized accounting in the field of compulsory health insurance; maintaining a unified register of insured persons; maintaining personalized records of information about medical care provided to insured persons and information exchange technology when maintaining personalized records in the field of compulsory health insurance.

The organization of personalized accounting in relation to pension insurance required the adoption of a special voluminous Federal Law dated April 1, 1996 No. 27-FZ “On individual (personalized) accounting in the compulsory pension insurance system.” In the field of compulsory health insurance, such a law has not been adopted, and the relevant legal relations are regulated by by-laws.

The Federal Compulsory Health Insurance Fund has approved the general principles for the construction and operation of information systems and the procedure for information interaction in the field of compulsory health insurance (Compulsory Medical Insurance Order No. 79 dated 04/07/2011). In order to establish uniform requirements and rules for information interaction applied by participants and subjects of the compulsory health insurance system on the territory of the Russian Federation, the following were approved:

General requirements for the construction and operation of information systems in the field of compulsory health insurance;

Requirements for the regional information system of compulsory health insurance;

General requirements for the information system of the territorial compulsory health insurance fund;

Requirements for the subsystem for maintaining the regional segment of the Unified Register of Insured Persons;

Requirements for the subsystem for maintaining personalized records of medical care provided to insured persons in the field of compulsory health insurance;

Requirements for the citizen information subsystem (the official website of the territorial compulsory health insurance fund on the Internet);

General requirements for the information system of a medical insurance organization;

Requirements for the subsystem for personalized recording of information about insured persons;

Requirements for the subsystem of personalized accounting of medical care provided to insured persons in the field of compulsory health insurance;

Requirements for the citizen information subsystem (the official website of the medical insurance organization on the Internet);

General requirements for the information system of a medical organization; requirements for the subsystem of personalized accounting of medical care provided to insured persons in the field of compulsory health insurance.

In order to ensure information interaction between the Federal Fund and territorial funds, insurers for non-working citizens, with the Pension Fund of the Russian Federation and its territorial bodies, medical organizations, medical insurance organizations and other organizations, the following were concluded:

– Agreement on information exchange between the Pension Fund of the Russian Federation and the Federal Compulsory Medical Insurance Fund dated December 31, 2010, Pension Fund of the Russian Federation No. AD-30-32/09sog, Compulsory Medical Insurance Fund No. 6547/20-1264;

– Agreement on information exchange between the Pension Fund of the Russian Federation and the Federal Compulsory Medical Insurance Fund dated January 31, 2011, Pension Fund of the Russian Federation No. AD-08-33/03sog, Compulsory Medical Insurance Fund No. 558/91-i265.

Thus, a completely legal basis for information interaction between these bodies has not yet been created and is subject to development in the future.

The purposes of personalized accounting according to the law are:

1) creation of conditions to ensure guarantees of the rights of insured persons to free provision of medical care of appropriate quality and in the appropriate volume within the framework of compulsory health insurance programs;

2) creating conditions for monitoring the use of compulsory health insurance funds;

3) determining the need for volumes of medical care in order to develop compulsory health insurance programs.

In fact, personalized accounting data will make it possible to unambiguously identify a citizen, determine the volume and quality of medical care provided to him, but only within the framework of compulsory health insurance, that is, provided to him free of charge within the framework of the basic and territorial program; will allow for more accurate forecasting

assessment of medical care needs, determine the necessary costs.

Analysis of personalized accounting data is one of the conditions for organizing control over the quality of medical care provided and, accordingly, the use of compulsory health insurance funds, which in the case of poor-quality medical care: violation of the volume, timing, quality and conditions of medical care, are subject to deduction from the volume funds provided for payment for medical care provided by medical organizations, or are subject to return to the medical insurance organization in accordance with the contract for the provision and payment of medical care under compulsory health insurance, a list of grounds for refusal to pay for medical care, or payment for medical care is reduced.

Article 44. Personalized recording of information about insured persons and information about medical care provided to insured persons

1. In the field of compulsory health insurance, personalized records of information about insured persons and personalized records of information about medical care provided to insured persons are maintained.

2. When maintaining personalized records of information about insured persons, the following information about insured persons is collected, processed, transferred and stored:

1) last name, first name, patronymic;

3) date of birth;

4) place of birth;

5) citizenship;

6) details of the identity document;

7) place of residence;

8) place of registration;

9) date of registration;

10) insurance number of an individual personal account (SNILS), adopted in accordance with the legislation of the Russian Federation on individual (personalized) accounting in the compulsory pension insurance system;

12) information about the medical insurance organization chosen by the insured person;

13) date of registration as an insured person;

14) status of the insured person (working, non-working).

3. Personalized records of information about insured persons are maintained in the form of a unified register of insured persons, which is a combination of its central and regional segments containing information about insured persons.

4. When maintaining personalized records of information about medical care provided to insured persons, the following information is collected, processed, transferred and stored:

1) number of the compulsory health insurance policy of the insured person;

8) diagnosis;

11) applied medical and economic standards;

5. Information about the insured person and the medical care provided to him may be provided in the form of documents, both in written form and in electronic form, subject to a guarantee of their reliability (authenticity), protection from unauthorized access and distortion. In this case, the legal force of the submitted documents is confirmed by an electronic digital signature in accordance with the legislation of the Russian Federation. The decision on the possibility of providing information in electronic form is made jointly by the participants in the information exchange.

6. Information about the insured person and the medical care provided to him is classified as restricted information and is subject to protection in accordance with the legislation of the Russian Federation.

The regional segment of the unified register of insured persons is maintained by the territorial fund on the basis of information about insured persons provided by the medical insurance organization.

At the stage of automated processing of information about personalized records of medical care provided to insured persons, the following is carried out in the territorial fund:

1) identification of the insured person according to the regional segment of the unified register of insured persons, determination of the medical insurance organization responsible for paying the bill;

2) identification of insured persons who received medical care outside the insurance territory and determination of their insurance territory;

3) sending electronically the results obtained in accordance with paragraphs 1 and 2 above to the medical organization that provided medical care to the insured persons.

Based on the results of automated processing of information about medical care provided to insured persons, a medical organization submits it to medical insurance organizations in the amount and within the time frame established by the contract for the provision and payment of medical care under compulsory health insurance.

The exchange of data between medical organizations, medical insurance organizations, territorial funds and the Federal Fund for the purpose of maintaining personalized records of information about medical care provided to insured persons is carried out electronically via dedicated or open communication channels, including the Internet, using an electronic digital signature in in accordance with the requirements established by the legislation of the Russian Federation for the protection of personal data.

The protection of personal data is ensured by the following mechanism, provided for by the Federal Law of July 27, 2006 No. 152-FZ “On Personal Data” and the Decree of the Government of the Russian Federation of November 17, 2007 No. 781 “On approval of the Regulations on ensuring the security of personal data during their processing in personal data information systems "

The medical insurance organization and the territorial fund, by orders, determine the employees allowed to work with the regional segment of the unified register of insured persons, and comply with the requirements of the legislation of the Russian Federation on the protection of personal data.

When processing personal data, the operator is obliged to take the necessary organizational and technical measures to protect personal data from unauthorized or accidental access, destruction, modification, blocking, copying, distribution of personal data, as well as from other unlawful actions.

The implementation of information security requirements in information security tools rests with their developers.

Article 45. Compulsory health insurance policy

1. The compulsory medical insurance policy is a document certifying the right of the insured person to free medical care throughout the Russian Federation to the extent provided for by the basic compulsory medical insurance program.

2. The compulsory health insurance policy is provided by the federal electronic application contained in the universal electronic card, in accordance with the Federal Law of July 27, 2010 No. 210-FZ “On the organization of the provision of state and municipal services.” Uniform requirements for a compulsory health insurance policy are established by the rules of compulsory health insurance.

In accordance with Part 2 of Art. 50 of the commented Law, from May 1, 2011, policies of a single type are valid for all subjects of the Russian Federation. Their production is organized by the Federal Compulsory Medical Insurance Fund. At the same time, policies issued before the Law came into force are valid until they are replaced with policies of a single standard.

The rules of compulsory health insurance establish the following requirements for the compulsory health insurance policy. The policy can be presented in the form of a paper form or in the form of a plastic card with electronic media. Uniform requirements have been introduced for both forms of policy.

Firstly, the policy is a strict reporting document and, accordingly, accounting is carried out as for a strict reporting form. Secondly, both policies are double-sided (have a front and back side that reflect the relevant information) and have a protective complex.

At the same time, the difference in media causes additional requirements. Thus, a paper policy is an A5 sheet, the front side of which contains information about the policy and personal data of the insured person, certified by his signature. In addition, a barcode containing general information about the policy and the insured person is placed on the front side. The reverse side of the policy contains information about the medical insurance organization chosen by the insured person, certified by the signature of its representative and seal.

A plastic policy with electronic media (electronic policy) has visual (graphic) information about the policy and the insured person. In addition, for insured persons over 14 years of age, it is mandatory to place a photograph on the back of the policy. For electronic policies, it is possible to post (read) insurance and medical applications. Through the first, the insured person’s access to services in the field of compulsory health insurance is realized, and changeable and unchangeable data about the policy and the insured person are built in. The medical application provides information about the insured person necessary to provide him with medical care.

In accordance with paragraph 1 of Art. 940 of the Civil Code of the Russian Federation, an insurance contract must be concluded in writing. However, Federal Law No. 326-FZ does not directly provide for the conclusion of a compulsory medical insurance agreement in this form. Obligatory relations between the policyholder, the insurer and the insured persons are formed directly by force of law.

The Civil Code of the Russian Federation provides that an insurance contract can be concluded by issuing a policy by the insurer, while Federal Law No. 326-FZ establishes that a compulsory medical insurance policy is issued by a medical insurance organization.

Federal Law No. 326-FZ does not explain the legal nature of the compulsory medical insurance policy. The article containing the rules for issuing compulsory medical insurance policies is located in the section on personalized accounting in the field of compulsory medical insurance.

In Art. 45 of Federal Law No. 326-FZ provides that the compulsory medical insurance policy is provided with a federal electronic application contained in a universal electronic card in accordance with Art. 23 of the Federal Law of July 27, 2010 No. 210-FZ “On the organization of the provision of state and municipal services.”

In accordance with Art. 25 of the Federal Law “On the organization of the provision of state and municipal services”, universal electronic cards are issued to citizens on the basis of applications for the issuance of cards from 01/01/2012 to 12/31/2013. However, the law of a subject of the Russian Federation, as well as a decree of the Government of the Russian Federation, may be established an earlier date for issuing such cards. Issuing the card is free.

If citizens do not apply for a universal electronic card within the specified period and do not submit an application for refusal to receive a card, then the right to receive a card is not lost.

Article 26 of the Federal Law “On the organization of the provision of state and municipal services” establishes that citizens who have not submitted applications for the issuance of a universal electronic card before January 1, 2014 and have not applied for refusal to receive this card, will be issued a universal electronic card at on a free basis by an authorized organization of a constituent entity of the Russian Federation from January 1, 2014 (Fig. 1). If a citizen refuses to receive a universal electronic card, he will be able to use a compulsory health insurance policy. Citizens can also refuse the card at any time after receiving it: such a card is canceled in accordance with the established procedure.

Rice. 1. Sample of a universal electronic card.

Article 46. Procedure for issuing a compulsory health insurance policy to the insured person

1. To obtain a compulsory health insurance policy, the insured person personally or through his representative submits, in the manner established by the rules of compulsory health insurance, an application for choosing a medical insurance organization, provided for in paragraph 2 of part 2 of Article 16 of this Federal Law, to the medical insurance organization or at its absence from the territorial fund.

2. On the day of receipt of the application for the choice of an insurance medical organization, the insurance medical organization, or in the absence of one, the territorial fund issues to the insured person or his representative a compulsory health insurance policy or a temporary certificate in cases and in the manner determined by the rules of compulsory health insurance.

An application for choosing a medical insurance organization is submitted to the medical insurance organization. If there is no such organization, then the corresponding application is submitted to the territorial compulsory health insurance fund.

The insured person submits an application to select a medical insurance organization personally or through his representative. In cases established by law, such a legally significant action as filing an application to select a medical insurance organization can be carried out exclusively through a legal representative (for minors, persons declared incompetent by the court).

An application for selection (replacement) of a medical insurance organization is drawn up in writing or typewritten and submitted (sent) to the medical insurance organization or transmitted using public information and communication networks, including the Internet, through the official website of the territorial fund or a single portal government services.

Article 47. Interaction of a medical organization with the territorial fund and medical insurance organization when maintaining personalized records of information on medical care provided to insured persons

1. Medical organizations provide information on medical care provided to insured persons, provided for in paragraphs 1–13 of part 4 of Article 44 of this Federal Law, to the territorial fund and medical insurance organization in accordance with the procedure for maintaining personalized records established by the authorized federal executive body.

2. Personalized records of information about medical care provided to insured persons are provided by medical organizations to medical insurance organizations in the amount and within the time frame established by the contract for the provision and payment of medical care under compulsory health insurance.

3. Insurance medical organizations and medical organizations, in accordance with the rules for organizing state archival affairs, store copies of documents on paper and electronic media containing the information specified in Part 1 of this article and provided to the territorial fund for maintaining personalized records.

4. Medical organizations, medical insurance organizations and territorial funds identify employees authorized to work with personalized records of information about medical care provided to insured persons and ensure their confidentiality in accordance with the requirements established by the legislation of the Russian Federation for the protection of personal data.

5. After the expiration of the period established for storing copies of documents on paper and electronic media in the medical insurance organization specified in Part 3 of this article, these copies are subject to destruction in accordance with the legislation of the Russian Federation on the basis of an act of their destruction, approved by the head of the medical insurance organization .

6. Personalized records of information about medical care provided to insured persons, specified in Part 1 of this article, are subject to storage in accordance with the legislation of the Russian Federation.

Every citizen in accordance with Art. 23 of the Constitution of the Russian Federation has the right to personal privacy, which also includes information about the state of his health, previous or existing diseases. Information about medical care provided to insured persons is classified as confidential information. In this regard, increased requirements are imposed on the relevant information regarding its safety and non-disclosure. Confidential information- this is information that requires protection, access to which is limited within established limits. Therefore, medical organizations, medical insurance organizations and territorial funds provide the necessary protection of relevant information.

For these purposes, they are obliged to identify employees authorized to work with personalized records of information about medical care provided, and charge them with the duties of maintaining the secrecy of the relevant information, as well as responsibility for their disclosure.

Confidentiality of personal data is a mandatory requirement for the operator or other person who has access to personal data to not allow their distribution without the consent of the subject of personal data or the presence of another legal basis.

Specifically, the relevant organizations are entrusted with the obligation to ensure the confidentiality of information within the framework of the requirements established by legislation on the protection of personal data, including by blocking access to it, depersonalizing it, etc.

The law establishes special periods for insurance organizations to store copies of documents on the provision of medical care within the framework of compulsory health insurance. Upon expiration of the established storage periods, copies of documents (on paper and electronic media) about the medical care provided must be destroyed.

An appropriate act must be drawn up regarding the destruction of documents. An act on the allocation for destruction of files that are not subject to storage is drawn up for the affairs of the entire organization. If the act indicates the affairs of several divisions, then the name of each division is indicated before the group of headings of the cases of this division. The headings of similar cases selected for destruction are included in the act under a common heading indicating the number of cases assigned to this group. Cases subject to destruction are transferred for processing (disposal). The transfer of cases is formalized by an acceptance note, which indicates the date of transfer, the number of cases to be handed over and the weight of the waste paper. Loading and removal for disposal are carried out under the control of an employee responsible for ensuring the safety of archive documents (clauses 2.4.5, 2.4.7 of the Basic Rules for the Operation of Organizational Archives).

Based on the informational significance of certain types of archival documents, the Law on Archival Affairs in Art. 22 established the period for temporary storage in the archives of organizations of personnel documents, which include information about personal and family secrets, at 75 years. Consequently, personalized accounting data (information about medical care provided to insured persons) will be subject to mandatory storage for a specified period.

Article 48. Interaction between a medical insurance organization and a territorial fund when maintaining personalized records of information on medical care provided to insured persons

1. Medical insurance organizations provide information about medical care provided to insured persons, received from medical organizations and specified in Part 4 of Article 44 of this Federal Law, to the territorial fund in accordance with the procedure for maintaining personalized records.

2. Data from personalized records of information about medical care provided to insured persons are provided by medical insurance organizations to the territorial fund in the amount and time frame established by the agreement on financial support for compulsory health insurance, but no later than the 20th day of the month following the reporting month.

3. Based on the information specified in Part 1 of Article 47 of this Federal Law and Part 1 of this Article, territorial funds keep personalized records of information about medical care provided to insured persons in accordance with this Federal Law and the procedure for maintaining personalized records.

4. Maintaining personalized records of information about medical care provided to insured persons in territorial funds is carried out on paper and (or) electronic media. If there is a discrepancy between the information on paper and the information on electronic media, the information on paper takes precedence.

5. The information specified in part 4 of this article is subject to storage in accordance with the rules for organizing state archival affairs.

Personalized accounting information about medical care provided to insured persons includes the collection, processing, transfer and storage of the following information:

1) number of the compulsory health insurance policy of the insured person;

2) the medical organization that provided the relevant services;

3) types of medical care provided;

4) conditions for providing medical care;

5) timing of medical care;

6) volumes of medical care provided;

7) the cost of medical care provided;

8) diagnosis;

9) profile of medical care;

10) medical services provided to the insured person and medications used;

11) applied medical and economic standards;

12) specialty of the medical worker who provided medical care;

13) the result of seeking medical help;

14) the results of monitoring of the volumes, timing, quality and conditions of medical care.

Part 2 of Article 48 defines the procedure for providing personalized records of information on medical care provided to insured persons by medical insurance organizations to the territorial fund.

Conditions on the volume and timing of provision are sent by medical insurance organizations within the time limits provided for in the agreement on financial support for compulsory medical insurance. The deadline for providing information to the territorial fund can be set individually for the medical insurance organization, but no later than the 20th day of the month following the reporting month.

Part 4 of Article 48 provides that information about the insured person and the medical care provided to him may be provided to territorial funds both in the form of documents in writing and in electronic form, subject to guarantees of their reliability (authenticity), protection from unauthorized access and distortion in accordance with established requirements for the protection of personal data. In this case, the legal force of the submitted documents is confirmed by an electronic digital signature in accordance with the Federal Law of January 10, 2002 No. 1-FZ “On Electronic Digital Signature”.

The decision on the possibility of presenting information in electronic form is made jointly by the participants in the information exchange.

In cases of discrepancy between the information provided on paper and information on electronic media, the information on paper will take precedence.

Part 5 of Article 48 stipulates that maintaining personalized records of information about medical care provided to insured persons in territorial funds is subject to storage in accordance with the Federal Law of the Russian Federation of October 22, 2004 No. 125-FZ “On Archival Affairs in the Russian Federation.” According to Art. 22 of this Law, the storage period is 75 years.

Article 49. Interaction of the territorial body of the Pension Fund of the Russian Federation, the insurer for non-working citizens and the territorial fund in maintaining personalized records of information about insured persons

1. The territorial body of the Pension Fund of the Russian Federation, quarterly no later than the 15th day of the second month following the reporting period, provides to the relevant territorial fund information about working insured persons specified in paragraphs 1–10 and 14 of part 2 of Article 44 of this Federal Law.

2. On a monthly basis, no later than the 5th day of each month, the insurer for non-working citizens provides to the relevant territorial fund information about non-working insured persons, provided for in paragraphs 1–10 and 14 of part 2 of Article 44 of this Federal Law.

3. Territorial bodies of the Pension Fund of the Russian Federation, insurers for non-working citizens exchange information with territorial funds in electronic form in the manner determined by agreements on information exchange, and in the form approved by the Federal Fund and the Pension Fund of the Russian Federation.

4. Territorial funds, within 15 working days from the date of receipt of information about the insured person provided for in parts 1 and 2 of this article, enter them into the regional segment of the unified register of insured persons.

Article 49 is aimed at ensuring the uninterrupted functioning of the unified register of insured persons and creating a clear system of interaction between subjects of compulsory health insurance at the regional level.

Article 49 establishes the basis for interaction between the territorial body of the Pension Fund of the Russian Federation, the insurer for non-working citizens and the territorial fund when maintaining personalized records of information about insured persons. The interaction of these entities is regulated in more detail by Order of the Ministry of Health and Social Development of the Russian Federation dated January 25, 2011 No. 29n “On approval of the Procedure for maintaining personalized records in the field of compulsory health insurance” and the “Agreement on information exchange between the Pension Fund of the Russian Federation and the Federal Compulsory Health Insurance Fund.”

The territorial body of the Pension Fund of the Russian Federation (hereinafter referred to as OPFR), quarterly no later than the 15th day of the second month following the reporting period, provides information on working insured persons to the corresponding territorial fund for inclusion in the regional segment of the unified register of insured persons. This is ensured by the Agreement on Information Exchange between the Pension Fund of the Russian Federation and the Federal Compulsory Medical Insurance Fund.

The insurer for non-working citizens monthly, no later than the 5th day of each month, provides information about non-working insured persons to the relevant territorial fund. This is carried out in accordance with agreements on information exchange between territorial funds and insurers for non-working citizens in the constituent entities of the Russian Federation, and in a form approved by the Federal Fund and the Pension Fund of the Russian Federation.

In accordance with the Agreement on information exchange between the Pension Fund of the Russian Federation and the Federal Compulsory Medical Insurance Fund, interaction between the OPFR and the TFOMS is carried out daily, monthly, quarterly and annually.

Commentary on Chapter 10

This chapter establishes the basics of personalized accounting in the field of compulsory medical insurance, gives the concept of a compulsory medical insurance policy, and also regulates the procedure for issuing a compulsory medical insurance policy.

Article 43. Personalized accounting in the field of compulsory health insurance

Commentary on Article 43

The commented article gives concept personalized accounting, as well as goals maintaining such records in the field of compulsory medical insurance.

One of the first laws that gave the concept and basic conditions for working with personal data was Federal Law No. 27-FZ of April 1, 1996 “On individual (personalized) accounting in the compulsory pension insurance system.” This Law provided the legal basis and principles for organizing individual (personalized) recording of information about citizens who are subject to the legislation of the Russian Federation on state pension provision (in terms of labor pensions). Among the fundamental principles of organizing personalized accounting were the federal nature of compulsory pension insurance in the Russian Federation, universality and obligatory nature. This Law for the first time clearly defined the rights and obligations of participants in individual (personalized) accounting and regulated issues of liability. Considering that the Pension Fund of the Russian Federation, like the FFOMS, is a state fund, it seems that personalized accounting in compulsory medical insurance should be organized in a similar way.

Personalized accounting is a special type of activity associated with the collection, processing, storage and exchange of information about insured persons in order to optimize and ensure the possibility of providing medical care within the framework of compulsory medical insurance programs to such persons.

Under collection refers to activities aimed at obtaining information about insured persons (receiving documents, requesting information, etc.).

Treatment- activities aimed at analyzing information from different sources, determining its authenticity, synchronicity (coincidence, accuracy of information from different sources), creating forecasts based on the data obtained, using information to control the medical care provided, etc.

Storage- activities to ensure a centralized collection of information in a single source, ensuring conditions for maintaining the relevance of such information and the security (confidentiality) of data.

Personalized accounting is carried out by drawing up a special unified register of insured persons, divided into two segments - regional and central (consolidated register of insured persons throughout the country).

Goals personalized accounting in accordance with Part 2 of the commented article are:

Creating conditions to ensure guarantees of the rights of insured persons to free medical care of appropriate quality and in the appropriate volume within the framework of compulsory medical insurance programs;

Creating conditions for monitoring the use of compulsory medical insurance funds;

Determining the need for volumes of medical care in order to develop compulsory medical insurance programs.

Personalized accounting is carried out to collect not any information about insured persons, but only that which allows one to identify this person and distinguish him from other persons, and contains information related to the receipt of medical care by such a person within the framework of compulsory medical insurance programs (i.e., the legislator establishes limits for collecting such information).

Such information allows, first of all, to determine the need for medical care in a particular region (district) by type of such care and diseases, and to predict the need for medical care in the future (i.e., conduct an morbidity analysis). Based on personalized accounting data, they also calculate the need for volumes of medical care by establishing standards for such assistance in compulsory medical insurance programs per person (per capita standards, the calculation of which is regulated by the Compulsory Medical Insurance Rules, approved by Order of the Ministry of Health and Social Development of the Russian Federation dated February 28, 2011 N 158n) .

Control is also impossible without taking into account the data obtained through personalized accounting. The information contained in the unified register makes it possible to monitor the volume, quality, types and timeliness of medical care that is provided to insured persons on the territory of a particular subject of the Russian Federation and the Russian Federation as a whole, and, therefore, to take appropriate measures. An additional opportunity to work with personalized data in compulsory medical insurance is remote work, which can be carried out continuously during medical and economic control.

Legal basis maintaining personalized records is the commented Law, as well as the system of by-laws, which at the moment has not yet been fully formed in connection with the transition period in the field of compulsory medical insurance. First of all, you need to pay attention to:

- FFOMS Order dated 04/07/2011 N 79 "On approval of the General principles for the construction and operation of information systems and the procedure for information interaction in the field of compulsory health insurance."

This Order establishes electronic file formats for interaction between the regional and central segments of the register of insured persons and the procedure for providing such files, the structure and layout of the compulsory health insurance information system, requirements for such a system and information exchange; as well as Regulations for information interaction when maintaining a unified register of insured persons and other regulations for information interaction; Regulations for information interaction when maintaining personalized records of medical care provided to insured persons in the field of compulsory medical insurance; Regulations for information interaction when maintaining personalized records of medical care provided to insured persons in the field of compulsory medical insurance outside the constituent entity of the Russian Federation on the territory of which the compulsory medical insurance policy was issued, etc.;

Agreement on information exchange between the Pension Fund of the Russian Federation and the Federal Compulsory Medical Insurance Fund dated December 31, 2010 N AD-30-32/09sog; 6547/20-1;

Agreement on information exchange between the Pension Fund of the Russian Federation and the Federal Compulsory Medical Insurance Fund dated January 31, 2011 N AD-08-33/03sog; 558/91-i.

The last agreement was concluded in order to fulfill the provisions of Parts 3 and 4 of Art. 43, parts 1 and 3 art. 49 of the commented Law and defines the rules for the exchange of information in electronic form between branches of the Pension Fund of the Russian Federation and the TFOMS. It is devoted, among other things, to information interaction on the transfer of information about working insured persons available in the registers of insured persons under compulsory medical insurance for each constituent entity of the Russian Federation.

Also according to part 5 of the commented article order of conduct personalized accounting must be determined by the authorized federal executive body. Such a body is the Ministry of Health and Social Development of the Russian Federation (see clause 1 of the Regulations on the Ministry of Health and Social Development of the Russian Federation, approved by Decree of the Government of the Russian Federation of June 30, 2004 N 321). In pursuance of the requirements of the commented article, the Ministry of Health and Social Development of the Russian Federation, by Order dated January 25, 2011 N 29n, approved The procedure for maintaining personalized records in the field of compulsory medical insurance (hereinafter referred to as the Procedure for personalized accounting).

The procedure for personalized accounting as a regulatory legal act consists of five sections:

1. General Provisions;

2) organization of personalized accounting;

3) maintaining the regional segment of the unified register of insured persons;

4) maintaining the central segment of the unified register of insured persons;

5) the procedure for maintaining personalized records of information about medical care provided to insured persons.

According to clause 1 of the Procedure for personalized accounting, it defines the rules for maintaining such accounting, including maintaining a unified register, organizing personalized accounting and technology for exchanging information when maintaining such accounting in the field of compulsory medical insurance.

Register of insured persons is an information database that includes regional and central segments. Responsible for maintaining such a register are the FFOMS (in the central segment) and the TFOMS (in the regional segment). The volume and list of information about insured persons that can and should be contained in such a register are established both by the commented Law (see Article 44) and by the Procedure for personalized accounting (see paragraphs 3 - 4 of the Procedure).

For the purpose of maintaining such a register, it is entrusted duty for medical insurance organizations, medical organizations, the Pension Fund of the Russian Federation, insurers for non-working citizens provide relevant information in the TFOMS and FFOMS within the time frame and manner established by both the commented Law (see, for example, Article 49), and regulations, as well as agreements and treaties in the field of compulsory medical insurance. In order to guarantee the fulfillment of such an obligation, the responsibility of the relevant entities is established for failure to provide such information, usually in the form of a fine (see, for example, Part 10 of Article 38 of the commented Law).

Thus, the Pension Fund of the Russian Federation, represented by its territorial branches, is obliged to provide periodically (daily, monthly, quarterly, annually) information on the registration and deregistration of policyholders for working citizens, as well as policyholders who do not make payments to individuals (i.e. paying insurance premiums for themselves); about accrued and paid insurance premiums for compulsory medical insurance and other information that is or may be provided for in agreements with compulsory medical insurance funds (see commentary to Article 49).

Medical insurance organizations are also obliged to transfer information (information) about insured persons, including when information about these persons changes (for example, a change of last name, first name and patronymic) in accordance with the agreement on financial support for compulsory medical insurance (see for more details the commentary to Art. 38).

Insurers for non-working citizens transfer information about non-working insured citizens to the TFOMS, including when such information changes if there is an entry about the insured person in the register of insured persons (see commentary to Article 49).

Medical organizations transmit information about medical care provided to insured persons, indicating the time, type, volume of medical care, diagnosis, etc. (see commentary to article 47).

In turn, TFOMS and FFOMS are obliged keep up to date register of insured persons, make timely changes upon receipt of information from other participants in the information exchange, as well as notify participants about changes in information in the register of insured persons (for example, send a notification of the death of the insured person received on the basis of death registration from the registry office). In particular, the Federal Compulsory Compulsory Medical Insurance Fund is obliged to maintain the relevance of the register by reconciling the data with information about insured working persons contained in the databases of the Pension Fund of the Russian Federation. Quarterly, the TFOMS also sends information about working insured persons, information about which is not available in the regional segment of the unified register of insured persons, to the FFOMS to update the central segment of the register.

Information interaction (exchange) is carried out mainly electronic through telecommunication networks, including the Internet. In this case, encryption systems (cryptographic complexes) are usually used to ensure the security and confidentiality of transmitted information. The transmitted data must be certified with an electronic digital signature. Transfer can also be carried out in case of technical impossibility of transfer over the network by exchanging electronic media (flash memory cards, optical disks, etc.) with files of a certain format (csv, xml, etc.), certified by a digital electronic signature. Work with electronic digital signatures is regulated by Federal Law dated 04/06/2011 N 63-FZ. The previous Law (No. 1-FZ dated January 10, 2002 “On Electronic Digital Signature”) becomes invalid as of July 1, 2012. The new Law expands the scope of use and acceptable types of electronic signatures. The previous Law allowed the use of only certified means of electronic signature, and the scope of its use was limited to civil law relations. The new Law distinguishes two types of electronic signature: simple and enhanced. An enhanced digital signature can be qualified or unqualified. A simple electronic signature confirms that a given email message was sent by a specific person. A strengthened unqualified electronic signature allows not only to uniquely identify the sender, but also to confirm that no one has changed it since the document was signed. A message with a simple or unqualified electronic signature can be equated to a paper document signed with one’s own hand, if the parties have agreed on this in advance, as well as in cases specifically provided for by law. An enhanced qualified electronic signature is additionally confirmed by a certificate issued by an accredited certification center. A message with such a signature in all cases is equivalent to a paper document with a handwritten signature. Accreditation of certification centers is carried out by the Government of the Russian Federation. The requirements for the certification center have been fixed. Thus, the value of its net assets must be at least 1 million rubles, and the staff must employ qualified employees. The maximum accreditation period for such centers is 5 years.

As a last resort, if this is provided for by agreements, contracts or other legal acts, data can also be transferred on paper (or an electronic copy is duplicated on paper).

Article 44. Personalized recording of information about insured persons and information about medical care provided to insured persons

APPROVED

by order of the Ministry of Health and Social Development of the Russian Federation dated January 25, 2011

Order

maintaining personalized records

in the field of compulsory health insurance

I.General provisions

1. This Procedure defines the rules for maintaining personalized records of information about each insured person in the field of compulsory health insurance, including:

1) organization of personalized accounting in the field of compulsory health insurance;

2) maintaining a unified register of insured persons;

3) maintaining personalized records of information about medical care provided to insured persons;

4) technology for information exchange when maintaining personalized records in the field of compulsory health insurance.

2. The goals of personalized accounting in the field of compulsory health insurance are:

1) creation of conditions to ensure guarantees of the rights of insured persons to free provision of medical care of adequate quality and volume within the framework of basic and territorial compulsory health insurance programs;

2) creating conditions for monitoring the use of compulsory health insurance funds;

3) determining the need for volumes of medical care in order to form basic and territorial compulsory health insurance programs.

II. Organization of personalized accounting

3. Personalized accounting of information about insured persons is maintained in the form of a unified register of insured persons, which is a combination of its central and regional segments, and includes the collection, processing, transfer and storage of the following information about insured persons:

1) last name, first name, patronymic;

3) date of birth;

4) place of birth;

5) citizenship;

6) details of the identity document;

7) place of residence;

8) place of registration;

9) date of registration;

10) insurance number of an individual personal account (SNILS), adopted in accordance with the legislation of the Russian Federation on individual (personalized) accounting in the compulsory pension insurance system;

11) number of the compulsory health insurance policy of the insured person;

12) information about the medical insurance organization chosen by the insured person;

13) date of registration as an insured person;

14) status of the insured person (working, non-working).

4. Personalized recording of information about medical care provided to insured persons includes the collection, processing, transfer and storage of the following information:

1) number of the compulsory health insurance policy of the insured person;

2) the medical organization that provided the relevant services;

3) types of medical care provided;

4) conditions for providing medical care;

5) timing of medical care;

6) volumes of medical care provided;

7) the cost of medical care provided;

8) diagnosis;

9) profile of medical care;

10) medical services provided to the insured person and medications used;

11) applied medical and economic standards;

12) specialty of the medical worker who provided medical care;

13) the result of seeking medical help;

14) the results of monitoring of the volumes, timing, quality and conditions of medical care.

5. Information about the insured person and the medical care provided to him can be provided both in the form of documents in written form and in electronic form, subject to guarantees of their reliability (authenticity), protection from unauthorized access and distortion in accordance with the requirements established by the legislation of the Russian Federation on the protection of personal data. In this case, the legal force of the submitted documents is confirmed by an electronic digital signature in accordance with the legislation of the Russian Federation. The decision on the possibility of presenting information in electronic form is made jointly by the participants in the information exchange.

6. Insurance medical organizations and medical organizations store copies of paper documents and electronic archives containing personalized information about insured persons and the medical care provided to them, submitted to the territorial compulsory health insurance fund (hereinafter referred to as the territorial fund) for personalized accounting, according to the rules of the organization of the state archival affairs.

7. After the expiration of the period established for storing copies of documents on paper and electronic media in a medical insurance organization, they are subject to destruction in accordance with the legislation of the Russian Federation on the basis of an act of their destruction, approved by the head of the medical insurance organization.

8. Information about the insured person and the medical care provided to him is classified as restricted information and is subject to protection in accordance with the legislation of the Russian Federation.

III. Maintaining the regional segment of the unified register of insured persons

9. Information about each insured person specified in paragraph 3 of this Procedure is entered into the unified register of insured persons.

10. The regional segment of the unified register of insured persons is maintained by the territorial fund on the basis of information about insured persons provided by the medical insurance organization.

11. The medical insurance organization and the territorial fund, by orders, determine the employees allowed to work with the regional segment of the unified register of insured persons, and comply with the requirements of the legislation of the Russian Federation on the protection of personal data.

12. When entering information about an insured person into the regional segment of the unified register of insured persons, the insurance medical organization ensures the accuracy and correctness of the entered information and carries out checks to prevent the appearance of duplicate entries in the regional segment of the unified register of insured persons:

1) for the presence of repetitions of last name, first name, patronymic, date and place of birth;

2) for the presence of repetitions according to the data of the identity document;

3) correct indication of the gender of the insured person;

4) for the presence of repetitions by date of birth and address of registration at the place of residence;

5) for the presence of repetitions of last name, first name and patronymic and registration address at the place of residence;

6) for the presence of repetitions according to the insurance number of the individual personal account (SNILS).

13. In order to update the regional segment of the unified register of insured persons and enter information about insured persons into it, the insurance medical organization generates and transmits information files with changes in information about insured persons provided for in paragraph 3 of this Procedure (hereinafter referred to as files with changes) to the territorial fund as necessary, but at least once a day if there are changes in information about the insured persons, in accordance with the agreement on financial support for compulsory health insurance.

14. The territorial fund provides round-the-clock reception and processing of files with changes received from medical insurance organizations.

15. When processing files with changes in the territorial fund, format-logical control of data, identification of records in the regional segment of the unified register of insured persons, and entry of information about insured persons are carried out.

16. After processing files with changes in the territorial fund, files confirming and/or rejecting changes are generated, which are sent to the relevant insurance medical organizations to adjust information about insured persons.

17. The territorial body of the Pension Fund of the Russian Federation, quarterly no later than the 15th day of the second month following the reporting period, provides, in accordance with the Agreement on information exchange between the Pension Fund of the Russian Federation and the Federal Compulsory Medical Insurance Fund, information about working insured persons to the corresponding territorial fund persons for inclusion in the regional segment of the unified register of insured persons.

18. Territorial fund on a monthly basis on the basis of information on state registration of death provided by civil registry authorities in accordance with Article 12 of the Federal Law of 01.01.01. “On acts of civil status” (Collected Legislation of the Russian Federation, 1997, No. 47, Art. 5340; 2001, No. 44, Art. 4149; 2003, No. 17, Art. 1553; No. 50, Art. 4855; 2009, No. 51 , Art. 6154; 2010, No. 15, Art. 1748), updates the regional segment of the unified register of insured persons, notifies insurance medical organizations in the territory of the Russian Federation and sends information files with information on the state registration of death in the territory of the Russian Federation. for persons whose information is not available in the regional segment of the unified register of insured persons, to the Federal Compulsory Medical Insurance Fund (hereinafter referred to as the Federal Fund) to update the central segment of the unified register of insured persons.

19. The territorial fund quarterly updates the regional segment of the unified register of insured persons based on information about working insured persons and sends information files with information about working insured persons, information about which is not in the regional segment of the unified register of insured persons, to the Federal Fund for updating the central segment of the unified register of insured persons.

20. The insurer for non-working citizens monthly, no later than the 5th day of each month, provides to the relevant territorial fund information about non-working insured persons, provided for in subparagraphs 1-10, 14 of paragraph 3 of this Procedure, in accordance with agreements on information exchange between territorial funds and policyholders for unemployed citizens in the constituent entities of the Russian Federation, and in the form approved by the Federal Fund and the Pension Fund of the Russian Federation.

21. The territorial fund updates the regional segment of the unified register of insured persons on the basis of information received from the Federal Fund from the central segment of the unified register of insured persons.

22. If the deadlines for providing data on insured persons, as well as information about changes in this data, established by the agreement on financial support for compulsory health insurance are violated, the insurance medical organization is obliged to pay the territorial fund at its own expense a fine in the amount established by Part 10 of Article 38 of the Federal Law dated 29 November 2010 “On compulsory health insurance in the Russian Federation” (hereinafter referred to as the Federal Law “On compulsory health insurance in the Russian Federation”).

23. The territorial fund exercises general control over the regional segment of the unified register of insured persons. If errors and inconsistencies are detected, the territorial fund sends the relevant information to the medical insurance organization indicating the list of inconsistencies and the time frame for their correction.

IV. Maintaining the central segment of the unified register of insured persons

24. When making changes to the regional segment of the unified register of insured persons, the territorial fund generates files with changes, which it sends to the Federal Fund to update the central segment of the unified register of insured persons as necessary, but at least once a day if there are changes in information about the insured faces.

The files with changes include all newly entered and changed information about insured persons since the last submission.

25. The Federal Fund provides round-the-clock reception and processing of files with changes from territorial funds.

26. When processing files with changes, a check is made to ensure that the insured person has a previously issued valid compulsory medical insurance policy of a single sample in the central segment of the unified register of insured persons.

27. In the central segment of the unified register of insured persons, information files are processed with information on the state registration of death and information on the status of insured persons (working, non-working), sent by territorial funds for persons whose information is not available in their regional segments of the unified register of insured persons, the results of which are sent to the territorial funds at the place of insurance.

28. The Federal Fund maintains the central segment of the unified register of insured persons and provides general control over the updating and use of the unified register of insured persons.

29. Data exchange between medical insurance organizations, territorial funds and the Federal Fund for the purpose of maintaining personalized records of information about insured persons is carried out electronically via dedicated or open communication channels, including the Internet, using an electronic digital signature in accordance with the requirements established by the legislation of the Russian Federation on the protection of personal data.

V. The procedure for maintaining personalized records of information about medical care provided to insured persons

30. Personalized records of information about medical care provided to insured persons are maintained electronically by medical organizations and medical insurance organizations operating in the compulsory health insurance system, and by territorial funds.

31. A medical organization, an insurance medical organization and a territorial fund, by order, determine the employees who are allowed to work with information about personalized records of medical care provided to insured persons, and ensure their confidentiality in accordance with the requirements of the legislation of the Russian Federation on the protection of personal data.

32. Medical organizations provide information on medical care provided to insured persons, provided for in subparagraphs 1 - 13 of paragraph 4 of this Procedure, to the territorial fund.

33. The territorial fund, within two working days, based on the regional segment of the unified register of insured persons, carries out automated processing of information received from medical organizations about medical care provided to insured persons.

34. At the stage of automated processing of information about personalized records of medical care provided to insured persons, the following is carried out in the territorial fund:

1) identification of the insured person according to the regional segment of the unified register of insured persons, determination of the medical insurance organization responsible for paying the bill;

2) identification of insured persons who received medical care outside the insurance territory and determination of their insurance territory;

3) sending electronically the results obtained in accordance with subparagraphs 1 and 2 of this paragraph to the medical organization that provided medical care to the insured persons.

35. Based on the results of automated processing of information about medical care provided to insured persons, carried out in accordance with paragraph 34 of this Procedure, a medical organization submits it to medical insurance organizations in the amount and within the time frame established by the contract for the provision and payment of medical care under compulsory health insurance.

36. After monitoring the volume, timing, quality and conditions of providing medical care in accordance with Article 40 of the Federal Law “On Compulsory Medical Insurance in the Russian Federation”, the information specified in paragraph 4 of this Procedure in the form of information files is transferred by the insurance medical organization to medical organizations and territorial fund within the time limits stipulated by the agreement on financial support for compulsory health insurance.

37. In case of difficulties in determining the insurance territory of a person who received medical care outside the insurance territory, the territorial fund generates an electronic request to the central segment of the unified register of insured persons, where within 5 working days a check is carried out and a response is generated indicating the identified insurance territory and the current policy number of the insured person.

38. Data exchange between medical organizations, medical insurance organizations, territorial funds and the Federal Fund for the purpose of maintaining personalized records of information about medical care provided to insured persons is carried out electronically via dedicated or open communication channels, including the Internet, using electronic digital signatures in accordance with the requirements established by the legislation of the Russian Federation for the protection of personal data.

Chapter 6. PERSONALIZED ACCOUNTING IN THE FIELD OF COMPULSORY HEALTH INSURANCE

One of the innovations introduced by Ch. 10 of Law N 326-FZ, is personalized accounting in the field of compulsory health insurance.

A funny children's cartoon about a kid who could count to 10 comes to mind. A simple plot, accessible to a preschool child. The little goat learned to count to 10 and began to demonstrate his skill to everyone he met. At first everyone was angry with him, but in the end, in a difficult situation, the kid's ability to count came in handy to save the others. Conclusion - how good it is to be able to count.

So, personalized accounting has been introduced to ensure the insured have the right to free medical care of adequate quality and volume within the framework of basic and territorial programs. It is designed to facilitate control over the use of compulsory health insurance funds and help determine the needs for the volume of medical care for the formation of future programs.

• 1. Accounting directions

Personalized accounting is maintained in the form of a single register, which is a combination of its central and regional segments, and includes collection, processing, transfer and storage of a range of information about insured persons.

In addition, a personalized recording information about medical care provided to the insured population.

This area of ​​accounting includes the collection, processing, transfer and storage of information such as the compulsory health insurance policy number, types, conditions, terms of medical care, and which medical organizations provided this assistance. In this direction, accounting will contain information about the volume of medical care provided, its cost, diagnoses given to the insured patient, and the profile of medical care. From the accounting data, it will be possible to clearly know which medical worker of what specialty and using what medical and economic standards provided assistance. Finally, the records will reflect the results of the patient’s request for medical care, as well as the results of monitoring of the volume, timing, quality and conditions of its provision.

The law allows for records to be kept in writing and electronically. The latter option must guarantee the reliability (authenticity) of the data, protection from unauthorized access and possible distortions. Information about the insured person and the medical care provided to him is confidential, refers to restricted access information and is subject to protection in accordance with the law.

• 2. Processing and storage of documents

Information about working insured persons for inclusion in the regional segment of the unified register of insured persons is submitted monthly to the TFOMS by the territorial body of the Pension Fund.

Medical insurance companies, clinics and hospitals must keep copies of paper documents and electronic archives containing personalized information. After the expiration of the established storage period in the medical insurance organization, the documents must be destroyed.

Insurance companies are required to check the information entered into the register for repetitions:

- by last name, first name, patronymic, date and place of birth;

- according to the identity document;

- by date of birth and registered address at the place of residence;

- by last name, first name and patronymic and registered address at the place of residence;

- by insurance number of an individual personal account.

At least once a month, the insurance company must transfer files to the TFOMS with changes in information about the insured. The insurer for non-working citizens also submits information about non-working insured persons to the fund on a monthly basis, no later than the 5th day of each month. This must be done to ensure that the information in the registry is always up to date. TFOMS must receive and process such information around the clock.

Medical organizations provide TFOMS with information about medical care provided to insured persons. Within two working days, based on the regional segment of the unified register of insured persons, it carries out automated processing of the information received.

In this case, persons who received medical care outside the insurance territory are identified, and their insurance territory is determined. In case of difficulties, the TFOMS must prepare a request to the central segment of the unified register, where within five working days a check will be carried out and a response will be generated indicating the identified insurance territory and the current policy number of the insured person.

1) creation of conditions to ensure guarantees of the rights of insured persons to free provision of medical care of adequate quality and volume within the framework of basic and territorial compulsory health insurance programs;

Judicial practice and legislation - Order of the Ministry of Health and Social Development of Russia dated January 25, 2011 N 29n (as amended on January 15, 2019) On approval of the Procedure for maintaining personalized records in the field of compulsory health insurance

Submission of the register of invoices for payment of medical care provided to insured persons outside the constituent entity of the Russian Federation, on the territory of which the compulsory health insurance policy was issued, is carried out electronically in accordance with the order of the Ministry of Health and Social Development of the Russian Federation dated January 25, 2011 N 29n " On approval of the procedure for maintaining personalized records in the field of compulsory health insurance" (registered by the Ministry of Justice of the Russian Federation on February 8, 2011, registration N 19742).