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.
When the Minister of Health, Labour and Welfare or a prefectural governor finds it necessary in relation to benefits for medical treatment, said minister or governor may order a Health Insurance-Covered Medical Institution, etc. or any of the persons who were establishers or administrators, health insurance-covered physicians, health insurance-covered pharmacists or other employees of a Health Insurance-Covered Medical Institution, etc. (hereinafter referred to as "Former Establishers, etc." in this paragraph) to make a report or submit or present medical records or other books and other documents, may request any of the establishers, administrators, health insurance-covered physicians, health insurance-covered pharmacists or other employees of a Health Insurance-Covered Medical Institution, etc. (including Former Establishers, etc.) to appear, or may have personnel question persons involved or inspect any equipment or medical records, the books and other documents or other articles of such Health Insurance-Covered Medical Institution, etc.
In cases where questions are asked or inspections are conducted pursuant to the provisions of the preceding paragraph, the relevant personnel must carry an identification card and present it at the request of any person concerned.
前項の規定による質問又は検査を行う場合においては、当該職員は、その身分を示す証明書を携帯し、かつ、関係人の請求があるときは、これを提示しなければならない。
The authority under paragraph (1) must not be construed as being granted for criminal investigation.
第一項の規定による権限は、犯罪捜査のために認められたものと解釈してはならない。
The provisions of Article 41, paragraph (2) shall apply mutatis mutandis to questions asked or inspections conducted pursuant to the provisions of paragraph (1).
When a prefectural governor finds it necessary that a disposition be made pursuant to the provisions of Article 80 of the Health Insurance Act with respect to a Health Insurance-Covered Medical Institution, etc. in relation to benefits for medical treatment provided under this Act or that a disposition be made pursuant to the provisions of Article 81 of the Health Insurance Act with respect to a health insurance-covered physician or health insurance-covered pharmacist in relation to medical care or prescription service provided under this Act, said governor must notify the Minister of Health, Labour and Welfare thereof, together with the reason therefor.
都道府県知事は、保険医療機関等につきこの法律による療養の給付に関し健康保険法第八十条の規定による処分が行われる必要があると認めるとき、又は保険医若しくは保険薬剤師につきこの法律による診療若しくは調剤に関し健康保険法第八十一条の規定による処分が行われる必要があると認めるときは、理由を付して、その旨を厚生労働大臣に通知しなければならない。
The provisions of Article 64 and Article 82, paragraph (1) of the Health Insurance Act shall apply mutatis mutandis to benefits for medical treatment provided under this Act. In this case, any technical replacement of terms necessary for these provisions shall be specified by Cabinet Order.
健康保険法第六十四条及び第八十二条第一項の規定は、本法による療養の給付について準用する。この場合において、これらの規定に関し必要な技術的読替えは、政令で定める。
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Article 52Dietary Treatment Expenses for Inpatients
第五十二条（入院時食事療養費）
With respect to expenses incurred in Dietary Treatment received by an insured person (excluding a Person Specified as Hospitalized Long-term and Insured) in combination with the medical treatment listed in Article 36, paragraph (1), item (v) at or from the health insurance-covered medical institution of said person's choice, Municipalities and Societies shall pay expenses for Dietary Treatment for inpatients to the Householder or Society member of the household to which said insured person belongs; provided, however, that this shall not apply during any period in which said Householder or Society member is subject to the application of Article 54-3, paragraph (1) or the main clause of paragraph (2) with respect to said insured person.
市町村及び組合は、被保険者（特定長期入院被保険者を除く。）が、自己の選定する保険医療機関について第三十六条第一項第五号に掲げる療養の給付と併せて受けた食事療養に要した費用について、当該被保険者の属する世帯の世帯主又は組合員に対し、入院時食事療養費を支給する。ただし、当該世帯主又は組合員が当該被保険者について第五十四条の三第一項又は第二項本文の規定の適用を受けている間は、この限りでない。
The expenses for Dietary Treatment for inpatients shall be calculated by deducting the amount of standard co-payment for Dietary Treatment set forth in Article 85, paragraph (2) of the Health Insurance Act (hereinafter simply referred to as "Standard Co-payment for Dietary Treatment") from the amount of expenses calculated for said Dietary Treatment in accordance with the standards set by the Minister of Health, Labour and Welfare pursuant to the provisions of the same paragraph (or, when said amount exceeds the amount of expenses actually incurred for said Dietary Treatment, the amount of expenses actually incurred for said Dietary Treatment).
入院時食事療養費の額は、当該食事療養につき健康保険法第八十五条第二項の規定による厚生労働大臣の定める基準の例により算定した費用の額（その額が現に当該食事療養に要した費用の額を超えるときは、当該現に食事療養に要した費用の額とする。）から、同項に規定する食事療養標準負担額（以下単に「食事療養標準負担額」という。）を控除した額とする。
When an insured person has received Dietary Treatment at or from a health insurance-covered medical institution, Municipalities and Societies may, on behalf of the Householder or Society member of the household to which said insured person belongs, pay to said health insurance-covered medical institution expenses incurred for said Dietary Treatment payable by such Householder or Society member to said health insurance-covered medical institution, within the limit of the amount payable to such Householder or Society member as expenses for Dietary Treatment for inpatients.
When a payment has been made pursuant to the provisions of the preceding paragraph, the Householder or Society member shall be deemed to have received expenses for Dietary Treatment for inpatients.
前項の規定による支払があつたときは、世帯主又は組合員に対し入院時食事療養費の支給があつたものとみなす。
Upon acceptance of a payment of expenses incurred for Dietary Treatment, the Health Insurance-Covered Medical Institution must, pursuant to the provisions of Ordinance of the Ministry of Health, Labour and Welfare, issue a receipt therefor to the Householder or Society member who makes such payment.
保険医療機関は、食事療養に要した費用につき、その支払を受ける際、当該支払をした世帯主又は組合員に対し、厚生労働省令の定めるところにより、領収証を交付しなければならない。
The provisions of Article 64 of the Health Insurance Act and paragraph (3) of Article 36, Articles 40 and 41, paragraphs (3) through (8) of Article 45 and Article 45-2 of this Act shall apply mutatis mutandis to Dietary Treatment received at or from an Health Insurance-Covered Medical Institution and to the payment of expenses for Dietary Treatment for inpatients associated with such treatment. In this case, any technical replacement of terms necessary for these provisions shall be specified by Cabinet Order.
健康保険法第六十四条並びに本法第三十六条第三項、第四十条、第四十一条、第四十五条第三項から第八項まで及び第四十五条の二の規定は、保険医療機関について受けた食事療養及びこれに伴う入院時食事療養費の支給について準用する。この場合において、これらの規定に関し必要な技術的読替えは、政令で定める。
Article 52-2Living Expenses for Inpatients
第五十二条の二（入院時生活療養費）
With respect to expenses incurred in Living Support received by a Person Specified as Hospitalized Long-term and Insured in combination with the medical treatment listed in Article 36, paragraph (1), item (v) at or from the health insurance-covered medical institution of said person's choice, Municipalities and Societies shall pay Living Support expenses for inpatients to the Householder or Society member of the household to which such Person Specified as Hospitalized Long-term and Insured belongs; provided, however, that this shall not apply during any period in which said Householder or Society member is subject to the application of Article 54-3, paragraph (1) or the main clause of paragraph (2) with respect to such Person Specified as Hospitalized Long-term and Insured.
市町村及び組合は、特定長期入院被保険者が、自己の選定する保険医療機関について第三十六条第一項第五号に掲げる療養の給付と併せて受けた生活療養に要した費用について、当該特定長期入院被保険者の属する世帯の世帯主又は組合員に対し、入院時生活療養費を支給する。ただし、当該世帯主又は組合員が当該特定長期入院被保険者について第五十四条の三第一項又は第二項本文の規定の適用を受けている間は、この限りでない。
The amount of Living Support expenses for inpatients shall be calculated by deducting the amount of Standard Co-payment for Dietary Treatment set forth in Article 85-2, paragraph (2) of the Health Insurance Act (hereinafter referred to as "Standard Living Expense Co-payment") from the Living Support expenses calculated in accordance with the standards set by the Minister of Health, Labour and Welfare pursuant to the provisions of the same paragraph (or, when said amount exceeds the actual amount of Living Support expenses, such actual amount of Living Support expenses).
入院時生活療養費の額は、当該生活療養につき健康保険法第八十五条の二第二項の規定による厚生労働大臣の定める基準の例により算定した費用の額（その額が現に当該生活療養に要した費用の額を超えるときは、当該現に生活療養に要した費用の額とする。）から、同項に規定する生活療養標準負担額（以下「生活療養標準負担額」という。）を控除した額とする。
The provisions of Article 64 of the Health Insurance Act and paragraph (3) of Article 36, Articles 40 and 41, paragraphs (3) through (8) of Article 45, Article 45-2 and paragraphs (3) through (5) of the preceding Article of this Act shall apply mutatis mutandis to Living Support received at or from a Health Insurance-Covered Medical Institution and to the payment of Living Support expenses for inpatients associated with such treatment. In this case, any technical replacement of terms necessary for these provisions shall be specified by Cabinet Order.
健康保険法第六十四条並びに本法第三十六条第三項、第四十条、第四十一条、第四十五条第三項から第八項まで、第四十五条の二及び前条第三項から第五項までの規定は、保険医療機関について受けた生活療養及びこれに伴う入院時生活療養費の支給について準用する。この場合において、これらの規定に関し必要な技術的読替えは、政令で定める。
When an insured person has received evaluation treatment, patient-requested treatment or selective treatment at or from a health insurance-covered medical institution, etc. of said person's choice, Municipalities and Societies shall pay medical expenses combined with treatment outside insurance coverage to the Householder or Society member of the household to which said insured person belongs with respect to the expenses incurred in that treatment; provided, however, that this shall not apply during any period in which said Householder or Society member is subject to the application of Article 54-3, paragraph (1) or the main clause of paragraph (2) with respect to said insured person.
The amount of medical expenses combined with treatment outside insurance coverage shall be the amount specified in item (i) (or the aggregate of such amount and the amount specified in item (ii) or (iii) when such medical treatment includes Dietary Treatment and Living Support, respectively):
the amount calculated by deducting, from the amount of expenses calculated for such medical treatment (excluding Dietary Treatment and Living Support) in accordance with the rules prescribed by the Minister of Health, Labour and Welfare pursuant to the provisions of Article 86, paragraph (2), item (i) of the Health Insurance Act (or, when said amount exceeds the amount of expenses actually incurred in such medical treatment, such amount of expenses actually incurred in such medical treatment), the amount obtained by multiplying such amount by the applicable ratio listed in the items of paragraph (1) of Article 42, in accordance with the categories listed in the items of the same paragraph (or, where the ratio for co-payment has been reduced pursuant to the provisions of Article 43, paragraph (1), the ratio after such reduction) (or, if any of the measures listed in the items of paragraph (1) of Article 44 needs to be taken with respect to the co-payment set forth in Article 42, paragraph (1) for benefits for medical treatment, the amount calculated as if the relevant measures were taken);
the amount calculated by deducting the amount of Standard Co-payment for Dietary Treatment from the amount calculated for such Dietary Treatment in accordance with the standards set by the Minister of Health, Labour and Welfare pursuant to the provisions of the Article 85, paragraph (2) of the Health Insurance Act (or, when said amount exceeds the amount of expenses actually incurred for such Dietary Treatment, such amount of expenses actually incurred for such Dietary Treatment);
当該食事療養につき健康保険法第八十五条第二項の規定による厚生労働大臣の定める基準の例により算定した費用の額（その額が現に当該食事療養に要した費用の額を超えるときは、当該現に食事療養に要した費用の額とする。）から、食事療養標準負担額を控除した額
the amount calculated by deducting the amount of Standard Co-payment for Living Support from the amount calculated for such Living Support in accordance with the standards set by the Minister of Health, Labour and Welfare pursuant to the provisions of the Article 85-2, paragraph (2) of the Health Insurance Act (or, when said amount exceeds the amount of expenses actually incurred in such Living Support, such amount of expenses actually incurred in such Living Support).
当該生活療養につき健康保険法第八十五条の二第二項の規定による厚生労働大臣の定める基準の例により算定した費用の額（その額が現に当該生活療養に要した費用の額を超えるときは、当該現に生活療養に要した費用の額とする。）から、生活療養標準負担額を控除した額
The provisions of Article 64 of the Health Insurance Act and paragraph (3) of Article 36, Articles 40 and 41, paragraphs (3) through (8) of Article 45, Article 45-2 and paragraphs (3) through (5) of Article 52 of this Act shall apply mutatis mutandis to evaluation treatment, patient-requested treatment and selective treatment received at or from a health insurance-covered medical institution, etc. and to the payment of medical expenses combined with treatment outside insurance coverage associated with such treatment. In this case, any technical replacement of terms necessary for these provisions shall be specified by Cabinet Order.
健康保険法第六十四条並びに本法第三十六条第三項、第四十条、第四十一条、第四十五条第三項から第八項まで、第四十五条の二及び第五十二条第三項から第五項までの規定は、保険医療機関等について受けた評価療養、患者申出療養及び選定療養並びにこれらに伴う保険外併用療養費の支給について準用する。この場合において、これらの規定に関し必要な技術的読替えは、政令で定める。
The provisions of Article 42-2 shall apply mutatis mutandis to the payment of the amount calculated by deducting the amount payable as medical expenses combined with treatment outside insurance coverage with respect to expenses incurred in the relevant medical treatment from the amount of expenses calculated for such medical treatment pursuant to the provisions of paragraph (2) in the case set forth in Article 52, paragraph (3) as applied mutatis mutandis pursuant to the preceding paragraph (or, when said amount exceeds the amount of expenses actually incurred in such medical treatment, said amount of expenses actually incurred in such medical treatment).