For more detailed information on the guidelines for the assessment and payment of health insurance (BHYT) medical examination and treatment costs, including the applicable regulations, please refer to the following article:
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Procedure for Automated Assessment of Health Insurance (BHYT) Medical Examination and Treatment Costs
Pursuant to Article 10 of Circular No. 12/2026/TT-BTC, the assessment of health insurance (BHYT) medical examination and treatment costs under the automated method is carried out by the Health Insurance Assessment Information System of Vietnam Social Security, which processes dossiers requesting payment based on the contents specified in item (1), and issues warnings on increases in the average number of medical examination and treatment cases as prescribed in Article 13 of Circular No. 12/2026/TT-BTC.
(1) Contents for reviewing dossiers requesting payment include:
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Health insurance card information;
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Benefit levels and entitlements of insured patients;
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Scope of payment for medicines, medical devices, and medical examination and treatment services according to the list applied at healthcare facilities;
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Payment rates for costs of medicines, blood and blood products, medical devices, technical services, medical examination, inpatient bed-days, and patient transportation;
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Costs of medicines, medical devices, and medical examination and treatment services subject to regulated payment rates and conditions;
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Scope of professional activities and operating hours of healthcare facilities;
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Scope of practice and working hours of practitioners;
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Intervals between medical examination and treatment visits of a patient;
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Provision of medical examination and treatment services in a reasonable manner in accordance with standards and criteria issued by the Minister of Health as prescribed in Clause 3, Article 6 of the Law on Health Insurance;
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Consistency of data in the detailed statement/list;
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Quantities of medicines and medical devices used in accordance with procured quantities under the law on bidding or those transferred in accordance with Article 43 of Decree No. 188/2025/NĐ-CP.
Image 1. Procedure for Automated Assessment of Health Insurance (BHYT) Medical Examination and Treatment Costs_Hotline: 0972118764
(2) Within 07 working days from the date of receipt of the payment request dossier, the results of the automated assessment shall be sent to the healthcare facility via the Data Receipt Portal as follows:
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Dossiers requesting payment that comply with legal regulations with respect to the contents specified in item (1);
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Detailed statements listing costs refused for payment due to non-compliance with legal regulations with respect to the contents specified in Clause 1 of this Article;
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Detailed statements containing the contents specified at point đ or point i, Clause 1 of this Article but lacking sufficient information to determine whether the medical examination and treatment costs are eligible for payment.
(3) Within 03 working days from the date of receiving feedback from the Data Receipt Portal, the healthcare facility is responsible for reviewing and providing or supplementing documents and data as follows:
(i) A written explanation accompanied by supporting documents proving eligibility for payment for the contents specified at point b and point c, Clause 2 of this Article; or copies of relevant contents in the medical records where the healthcare facility identifies that the detailed statement does not correspond with the medical records.
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Image 2. Procedure for Automated Assessment of Health Insurance (BHYT) Medical Examination and Treatment Costs_Hotline: 0972118764
(ii) An adjusted detailed statement prepared in accordance with Form No. 09/BH in Appendix I issued together with this Circular, for the contents specified at point b or point c, Clause 2 of this Article.
(4) The Health Insurance Assessment Information System shall process the data specified at item (ii), Clause (3), and shall refuse payment in cases where adjustments have been made but remain non-compliant with legal regulations with respect to the contents specified in Clause (1).
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