Article 76Expenses for Benefits for Medical Treatment
第七十六条（療養の給付に関する費用）
Insurers is to pay expenses related to benefits for medical treatment to medical institutions providing services covered by health insurance and pharmacies providing services covered by health insurance. The amount of expenses which a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance may claim to an insurer in relation to benefits for medical treatment is calculated by deducting the amount of co-payment payable to the medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance by the insured person in relation to the benefits for medical treatment from the amount of expenses incurred in providing the benefits for medical treatment.
The amount of expenses for benefits for medical treatment referred to in the preceding paragraph is to be calculated as specified by the Minister of Health, Labour and Welfare.
前項の療養の給付に要する費用の額は、厚生労働大臣が定めるところにより、算定するものとする。
An insurer may, with the authorization of the Minister of Health, Labour and Welfare, specify otherwise in a contract with a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance with respect to the amount of expenses incurred in providing the benefits for medical treatment referred to in paragraph (1) to be provided at the medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance within the range of the amount calculated pursuant to the provisions of the preceding paragraph.
When receiving a claim for expenses incurred in providing medical services from a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance, the insurer is to make payment after conducting an examination in light of the provisions of Order of the Ministry of Health, Labour and Welfare referred to in Article 70, paragraph (1) and Article 72, paragraph (1) and the provisions of the preceding two paragraphs.
An insurer may delegate affairs concerning the examination and payment pursuant to the provisions of the preceding paragraph to the Medical Information Infrastructure and Medical Fee Examination and Payment Organization (hereinafter referred to as the "Infrastructure Organization") under the Medical Information Infrastructure and Medical Fee Examination and Payment Organization Act (Act No. 129 of 1948) or a federation of National Health Insurance Associations prescribed in Article 45, paragraph (5) of the National Health Insurance Act (hereinafter referred to as the "NHI federation").
保険者は、前項の規定による審査及び支払に関する事務を医療情報基盤・診療報酬審査支払機構法（昭和二十三年法律第百二十九号）による医療情報基盤・診療報酬審査支払機構（以下「基盤機構」という。）又は国民健康保険法第四十五条第五項に規定する国民健康保険団体連合会（以下「国保連合会」という。）に委託することができる。
Beyond what is provided for in the preceding paragraphs, necessary matters concerning claims for expenses incurred in providing medical services at a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance are specified by Order of the Ministry of Health, Labour and Welfare.
第七十七条（療養の給付に要する費用の額の定めに関する厚生労働大臣の調査）
The Minister of Health, Labour and Welfare may conduct a necessary survey to ensure the appropriateness of the provisions for chemicals among the provisions of paragraph (2) of the preceding Article and other provisions specified by the Minister of Health, Labour and Welfare.
厚生労働大臣は、前条第二項の定めのうち薬剤に関する定めその他厚生労働大臣の定めを適正なものとするため、必要な調査を行うことができる。
The Minister of Health, Labour and Welfare is to conduct a necessary survey in order to ensure the appropriateness of the provisions of paragraph (2) of the preceding Article with regard to hospitals, among medical institutions providing services covered by health insurance, that are specified by Order of the Ministry of Health, Labour and Welfare.
A hospital prescribed in the preceding paragraph must, in order to contribute to the survey under that paragraph, report to the Minister of Health, Labour and Welfare information specified by the Minister of Health, Labour and Welfare, such as the content of medical care provided to patients admitted to that hospital (referred to as "medical care-related information" in Article 150-2, paragraph (1) and Article 150-3).
前項に規定する病院は、同項の調査に資するため、当該病院に入院する患者に提供する医療の内容その他の厚生労働大臣が定める情報（第百五十条の二第一項及び第百五十条の三において「診療等関連情報」という。）を厚生労働大臣に報告しなければならない。
第七十八条（保険医療機関又は保険薬局の報告等）
When the Minister of Health, Labour and Welfare finds it necessary in relation to benefits for medical treatment, the minister or governor may order a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance, or a person who was an establisher or manager, physician who provided health insurance treatment, pharmacist who filled health insurance prescriptions, or another employee of a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance (hereinafter referred to as "former establisher, etc." in this paragraph) to make a report or submit or present medical records or other books and other documents, may request an establisher, manager, physician providing health insurance treatment, pharmacist filling health insurance prescriptions or another employee of a medical institution or pharmacy providing services covered by health insurance (including former establishers, etc.) to appear, or may have an official question persons involved or inspect any equipment or medical records, record books and documents or other objects of the medical institution or pharmacy providing services covered by health insurance.
The provisions of Article 7-38, paragraph (2) and Article 73, paragraph (2) apply mutatis mutandis to questions or inspections pursuant to the provisions of the preceding paragraph, and the provisions of Article 7-38, paragraph (3) apply mutatis mutandis to the authority granted pursuant to the provisions of the preceding paragraph.
第七条の三十八第二項及び第七十三条第二項の規定は前項の規定による質問又は検査について、第七条の三十八第三項の規定は前項の規定による権限について準用する。
第七十九条（保険医療機関等の指定の辞退又は保険医等の登録の抹消）
A medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance may decline its designation by giving notice not less than one month in advance.
A physician providing health insurance treatment or pharmacist filling health insurance prescriptions may request deregistration by giving notice not less than one month in advance.
第八十条（保険医療機関又は保険薬局の指定の取消し）
The Minister of Health, Labour and Welfare may rescind the designation referred to in Article 63, paragraph (3), item (i) pertaining to a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance if the medical institution or pharmacy falls under any of the following items:
厚生労働大臣は、次の各号のいずれかに該当する場合においては、当該保険医療機関又は保険薬局に係る第六十三条第三項第一号の指定を取り消すことができる。
a physician providing health insurance treatment at a medical institution providing services covered by health insurance or a pharmacist filling health insurance prescriptions at a pharmacy providing services covered by health insurance has violated the provisions of Article 72, paragraph (1) (including when applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (4), Article 110, paragraph (7), and Article 149; excluding when the medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance had made efforts to provide reasonable care and supervision so as to prevent that violation);
the administrator of a medical institution providing services covered by health insurance has violated the provisions of Article 70-2, paragraph (2) (excluding when the administrator has exercised reasonable care and supervision as the administrator of that medical institution providing services covered by health insurance in order to prevent that violation);
beyond the preceding two items, a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance has violated the provisions of Article 70, paragraph (1) (including when applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (4), Article 110, paragraph (7), and Article 149);
wrongdoing is found with regard to a claim for expenses incurred in providing medical services, or a claim for payment pursuant to the provisions of Article 85, paragraph (5) (including when these provisions are applied mutatis mutandis to Article 85-2, paragraph (5), and Article 86, paragraph (4)) or Article 110, paragraph (4) (including when applied mutatis mutandis to Article 149);
療養の給付に関する費用の請求又は第八十五条第五項（第八十五条の二第五項及び第八十六条第四項において準用する場合を含む。）若しくは第百十条第四項（これらの規定を第百四十九条において準用する場合を含む。）の規定による支払に関する請求について不正があったとき。
the medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance is requested to make a report, or to submit or present medical records, record books and other documents pursuant to the provisions of Article 78, paragraph (1) (including the cases where the same provision is applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (4), Article 110, paragraph (7), and Article 149; the same applies in the following item) but fails to comply with the order or submits a false report;
the establisher or an employee of the medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance has been requested to appear pursuant to the provision of Article 78, paragraph (1) but failed to comply with the order or answer questions pursuant to the provisions of the same paragraph, answered untruthfully, or refused, obstructed, or evaded an inspection pursuant to the same paragraph (except if the medical institution or pharmacy had made efforts to provide reasonable care and supervision so as to prevent that conduct);
there are grounds that correspond to any of the preceding items with respect to benefits for medical treatment pursuant to medical insurance laws other than this act, benefits for medical treatment pursuant to the Act on Assurance of Medical Treatment for Insured Persons or Dependents or Medical Care for Elderly People, or medical treatment pertaining to dietary treatment expenses for inpatients, to living support expenses for inpatients or to medical expenses combined with treatment outside insurance coverage;
この法律以外の医療保険各法による療養の給付若しくは被保険者若しくは被扶養者の療養又は高齢者の医療の確保に関する法律による療養の給付、入院時食事療養費に係る療養、入院時生活療養費に係る療養若しくは保険外併用療養費に係る療養に関し、前各号のいずれかに相当する事由があったとき。
the establisher or administrator of the medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance has been sentenced to a fine pursuant to the provisions of this Act or other laws concerning citizens' health and medical care which are specified by Cabinet Order, and the execution of the sentence has not yet been completed or the execution of the sentence still applies;
the establisher or administrator of a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance has come to fall under the category of a person who has been sentenced to imprisonment or a severer punishment, and the execution of the sentence has not yet been completed or the execution of the sentence still applies; or
beyond what is provided for in the preceding items, the establisher of the medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance has violated the provisions of this Act or other medical insurance laws which are specified by Cabinet Order, or an order or disposition based thereon;
第八十一条（保険医又は保険薬剤師の登録の取消し）
The Minister of Health, Labour and Welfare may cancel the registration under Article 64 pertaining to the physician providing health insurance treatment or pharmacist filling health insurance prescriptions concerned (in the case listed in item (ii), the registration under that Article pertaining to the physician providing health insurance treatment who is the administrator of the medical institution providing services covered by health insurance concerned) in the case where any of the following items applies:
the physician providing health insurance treatment or pharmacist filling health insurance prescriptions has violated the provisions of Article 72, paragraph (1) (including when applied mutatis mutandis to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (4), Article 110, paragraph (7), and Article 149);
the administrator of a medical institution providing services covered by health insurance has violated the provisions of Article 70-2, paragraph (2) (excluding when the administrator has exercised reasonable care and supervision as the administrator of that medical institution providing services covered by health insurance in order to prevent that violation);
the physician providing health insurance treatment or pharmacist filling health insurance prescriptions had been requested to appear pursuant to the provisions of Article 78, paragraph (1) (including when applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (4), Article 110, paragraph (7), and Article 149; the same applies hereinafter in this item) but failed to respond or to reply to questions pursuant to the provisions of Article 78, paragraph (1), or answered untruthfully, or refused, obstructed, or evaded an inspection pursuant to the provisions of the same paragraph;
there are grounds that correspond to any of the preceding three items with respect to medical care or prescription based on medical insurance laws other than this act or the Act on Assurance of Medical Care for Elderly People;
この法律以外の医療保険各法又は高齢者の医療の確保に関する法律による診療又は調剤に関し、前三号のいずれかに相当する事由があったとき。
the physician providing health insurance treatment or pharmacist filling health insurance prescriptions has been sentenced to a fine pursuant to the provisions of this Act and other laws concerning citizens' health and medical care which are specified by Cabinet Order, and the execution of the sentence has not yet been completed or the execution of the sentence still applies;
the physician providing health insurance treatment or pharmacist filling health insurance prescriptions has come to fall under the category of a person who has been sentenced to imprisonment or a severer punishment, and the execution of the sentence has not yet been completed or the execution of the sentence still applies; or
beyond the cases listed in the preceding items, the physician providing health insurance treatment or pharmacist filling health insurance prescriptions violates this Act, medical insurance laws other than this act which are specified by Cabinet Order, or an order or disposition based on these Acts.
Article 82Advisory to Social Insurance Medical Councils
第八十二条（社会保険医療協議会への諮問）
When intending to issue the Order of the Ministry of Health, Labour and Welfare referred to in Article 70, paragraph (1) (including when applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (4), Article 110, paragraph (7), and Article 149) or Article 70, paragraph (3), Article 70-2, or Article 72, paragraph (1) (including when applied mutatis mutandis pursuant to Article 85, paragraph (9), Article 85-2, paragraph (5), Article 86, paragraph (4), Article 110, paragraph (7), and Article 149), or intending to make a determination under Article 63, paragraph (2), item (iii) or (v), or Article 76, paragraph (2) (including when these provisions are applied mutatis mutandis pursuant to Article 149), the Minister of Health, Labour and Welfare is to consult with the Central Social Insurance Medical Council; provided, however, that this does not apply to a determination under Article 63, paragraph (2), item (iii) pertaining to advanced medical care techniques.
厚生労働大臣は、第七十条第一項（第八十五条第九項、第八十五条の二第五項、第八十六条第四項、第百十条第七項及び第百四十九条において準用する場合を含む。）若しくは第三項、第七十条の二若しくは第七十二条第一項（第八十五条第九項、第八十五条の二第五項、第八十六条第四項、第百十条第七項及び第百四十九条において準用する場合を含む。）の厚生労働省令を定めようとするとき、又は第六十三条第二項第三号若しくは第五号若しくは第七十六条第二項（これらの規定を第百四十九条において準用する場合を含む。）の定めをしようとするときは、中央社会保険医療協議会に諮問するものとする。ただし、第六十三条第二項第三号の定めのうち高度の医療技術に係るものについては、この限りでない。
When intending to make or rescind a designation referred to in Article 63, paragraph (3), item (i) pertaining to a medical institution providing services covered by health insurance or pharmacy providing services covered by health insurance, or to rescind a registration referred to in Article 64 pertaining to a physician providing health insurance covered treatment or pharmacist filling health insurance prescriptions, the Minister of Health, Labour and Welfare is to consult with the relevant Local Social Medical Insurance Council as specified by Cabinet Order.