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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(Expenses for 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。
Open this provision(Expenses for Benefits for Medical Treatment)
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…
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。
Open this provision(Responsibilities of Health Insurance-Covered Medical Institutions, etc.)
The rules applicable in cases where a health insurance-covered medical institution, etc. or a health insurance-covered physician or health insurance-covered pharmacist…
保険医療機関等又は保険医若しくは保険薬剤師（健康保険法第六十四条に規定する保険医又は保険薬剤師をいう。以下同じ。）が、国民健康保険の療養の給付を担当し、又は国民健康保険の診療若しくは調剤に当たる場合の準則については、同法第七十条第一項及び第七十二条第一項の規定による厚生労働省令の例による。
Open this provision(Medical Fees Payable to Health Insurance-Covered Medical Institutions, etc.)
Municipalities and Societies must pay to health insurance-covered medical institutions, etc. expenses relating to benefits for medical treatment.
市町村及び組合は、療養の給付に関する費用を保険医療機関等に支払うものとし、保険医療機関等が療養の給付に関し市町村又は組合に請求することができる費用の額は、療養の給付に要する費用の額から…
Open this provision(Medical Fees Payable to Health Insurance-Covered Medical Institutions, etc.)
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…
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。
Open this provision(Medical Fees Payable to Health Insurance-Covered Medical Institutions, etc.)
Municipalities and Societies may, with the authorization of the prefectural governor, specify otherwise in a contract with a health insurance-covered medical institution…
市町村及び組合は、都道府県知事の認可を受け、保険医療機関等との契約により、当該保険医療機関等において行われる療養の給付に関する第一項の療養の給付に要する費用の額につき、前項の規定により算定される額の範囲内において、別段の定めをすることができる。
Open this provision(Medical Fees Payable to Health Insurance-Covered Medical Institutions, etc.)
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…
市町村及び組合は、保険医療機関等から療養の給付に関する費用の請求があつたときは、第四十条に規定する準則並びに第二項に規定する額の算定方法及び前項の定めに照らして審査した上、支払うものとする。
Open this provision(Medical Fees Payable to Health Insurance-Covered Medical Institutions, etc.)
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…
市町村及び組合は、前項の規定による審査及び支払に関する事務を都道府県の区域を区域とする国民健康保険団体連合会（加入している都道府県、市町村及び組合の数がその区域内の都道府県、市町村及び組合の総数の三分の二に達しないものを除く。）又は医療情報基盤・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…
Open this provision(Medical Fees Payable to Health Insurance-Covered Medical Institutions, etc.)
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…
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…
Open this provision(Medical Fees Payable to Health Insurance-Covered Medical Institutions, etc.)
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…
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。
Open this provision(Co-payment Relating to an Insured Person Who is Not the Householder or Society Member)
In making any co-payment or in paying any difference or medical expenses pursuant to the provisions of paragraph (3) of Article 43 or paragraph (2) of the preceding Article…
一部負担金の支払又は納付、第四十三条第三項又は前条第二項の規定による差額の支給及び療養費の支給に関しては、当該疾病又は負傷が世帯主又は組合員でない被保険者に係るものであるときは、これらの事項に関する各本条の規定にかかわらず、当該被保険者の属する世帯の世帯主又は組合員が一部負担金を支払い、又は納付すべき義務を負い…
Open this provisionSociety
「組合」
A National Health Insurance Society (国民健康保険組合): a body made up, as its members (組合員), of people engaged in the same kind of business or occupation who live in its district, which may provide national health insurance to its members and the people in their households (Articles 3, 13 and 19).
Short name set inArticle 13, paragraph (1)
health insurance-covered medical institution, etc.machine translation
「保険医療機関等」
A hospital, clinic or pharmacy designated by the Minister of Health, Labour and Welfare under Article 63, paragraph (3), item (i) of the Health Insurance Act (a health insurance-covered medical institution (保険医療機関) or pharmacy (保険薬局)), from which an insured person of national health insurance chooses where to receive the benefits for medical treatment (療養の給付).
Defined inArticle 36, paragraph (3)
the organizationmachine translation
「機構」
The organization for medical information infrastructure and the review and payment of medical fees (医療情報基盤・診療報酬審査支払機構), set up under the Act that bears its name (Act No. 129 of 1948), to which municipalities and National Health Insurance Societies (国民健康保険組合) may entrust the review and payment of the claims for medical fees made by health insurance-covered medical institutions and pharmacies (保険医療機関等).
Short name set inArticle 45, paragraph (5)