Article 45Medical Fees Payable to Health Insurance-Covered Medical Institutions, etc.
第四十五条（保険医療機関等の診療報酬）
Municipalities and Societies must pay to health insurance-covered medical institutions, etc. expenses relating to benefits for medical treatment. The amount of expenses which may be claimed by a health insurance-covered medical institution, etc. from a Municipality or Society in relation to benefits for medical treatment shall be calculated by deducting the amount of any co-payment payable to such health insurance-covered medical institution, etc. by the insured person (or the Householder or Society member of the household to which such insured person belongs in the case set forth in Article 57) in relation to the benefits for medical treatment from the amount of expenses incurred in providing said benefits for medical treatment.
Calculation of the amount of expenses incurred in providing the benefits for medical treatment set forth in the preceding paragraph shall be governed by the same rules as those prescribed by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 76, paragraph (2) of the Health Insurance Act.
前項の療養の給付に要する費用の額の算定については、健康保険法第七十六条第二項の規定による厚生労働大臣の定めの例による。
Municipalities and Societies may, with the authorization of the prefectural governor, specify otherwise in a contract with a health insurance-covered medical institution, etc. with respect to the amount of expenses incurred in providing the benefits for medical treatment set forth in paragraph (1) for the medical treatment to be provided at such health insurance-covered medical institution, etc., within the range of the amount calculated pursuant to the provisions of the preceding paragraph.
Upon receipt of a claim by a health insurance-covered medical institution, etc. for expenses incurred in providing benefits for medical treatment, Municipalities and Societies shall make payment after conducting an examination according to the rules set forth in Article 40, and according to the method for calculating the amount set forth in paragraph (2), and the provisions of the preceding paragraph.
Municipalities and Societies may entrust affairs concerning the examination and payment pursuant to the provisions of the preceding paragraph to a Federation of National Health Insurance Associations whose jurisdiction covers the area of a prefecture (excluding any such Federation the number of whose member prefectures, Municipalities and Societies is less than two-thirds of the total number of prefectures, Municipalities and Societies located within its jurisdiction) or the Medical Information Infrastructure and Medical Fee Examination and Payment Organization (hereinafter referred to as "the organization") under the Act on the Medical Information Infrastructure and Medical Fee Examination and Payment Organization (Act No. 129 of 1948).
Of the affairs concerning the review of medical bills conducted by a Federation of National Health Insurance Associations as entrusted pursuant to the provisions of the preceding paragraph or those of Article 76, paragraph (5) of the Health Insurance Act, those concerned with the review of such medical bills as specified by the Minister of Health, Labour and Welfare may be entrusted by such Federation of National Health Insurance Associations to any of those general incorporated associations or general foundations designated by the Minister of Health, Labour and Welfare as those meeting the requirements specified by Ordinance of the Ministry of Health, Labour and Welfare in terms of the organization involved in such review and other matters, and as capable of conducting such affairs in a proper and reliable manner.
国民健康保険団体連合会は、前項の規定及び健康保険法第七十六条第五項の規定による委託を受けて行う診療報酬請求書の審査に関する事務のうち厚生労働大臣の定める診療報酬請求書の審査に係るものを、一般社団法人又は一般財団法人であつて、審査に関する組織その他の事項につき厚生労働省令で定める要件に該当し、当該事務を適正かつ確実に実施することができると認められるものとして厚生労働大臣が指定するものに委託することができる。
An entity to which affairs concerning the review of medical bills as specified by the Minster of Health, Labour and Welfare pursuant to the provisions of the preceding paragraph have been entrusted must have the review of such medical bills conducted by a person who meets the requirements specified by Ordinance of the Ministry of Health, Labour and Welfare.
前項の規定により厚生労働大臣の定める診療報酬請求書の審査に係る事務の委託を受けた者は、当該診療報酬請求書の審査を厚生労働省令で定める要件に該当する者に行わせなければならない。
In addition to what is provided for in each of the preceding paragraphs, necessary particulars concerning claims for expenses incurred in providing benefits for medical treatment by Health Insurance-Covered Medical Institutions, etc. shall be prescribed by Ordinance of the Ministry of Health, Labour and Welfare.
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