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questionWhat is HIRA's benefit claims review?
answer

HIRA's claims review process examines the appropriateness of the provided medical service and determines the amount of benefit that will be reimbursed to the provider. The review process consists of basic check, electronic check, AI review standard check, and close review performed by HIRA staff and expert committee.

questionWhat is HIRA's assessment?
answer

HIRA's quality assessment service evaluates clinical validity and cost-effectiveness of medical and pharmaceutical services and releases the results by institution to promote quality improvement. Other purposes include reducing quality gap between institutions by providing financial incentive and disincentive, and supporting voluntary quality improvement by utilizing assessment results.

questionWhat is HIRA's role in resource management and benefit decision making of pharmaceuticals and new medical technology?
answer

Providers report to HIRA about their facility, equipments, and workforce status, and HIRA collects and manages the information. As to new medical technology, HIRA reviews the economic evaluation and cost-effectiveness of technology that passed safety and efficacy test from the Ministry of Health and Welfare. The result is sent to the Ministry, and the Minister makes decision on benefit coverage. For new drugs, HIRA reviews the coverage decision, NHIS negotiates the price with pharmaceuticals for covered drugs, and the Minister confirms those decisions. For generic drugs, the price will be determined by HIRA according to the pre-determined formula.

questionHow does HIRA respond to overclaims?
answer

Overclaims are the cases where the medical service is provided but the full benefit should not be reimbursed due to protocol violations or inaccurate charge of co-payment. HIRA conducts on-site investigation to identify those cases in suspicious institutions. When overclaim or false claim cases are found, the institution will receive administrative measures such as fine, suspension or operation of license, and restitution of illicit profits.

questionHow does HIRA utilize its data?
answer

The data sent from providers to HIRA are used primarily for review and assessment services. The DW is where the data are stored, and it is used for government's policy decision making and statistical purposes.

questionWhat are the difference between KPIS and DUR?
answer

The KPIS assigns KD code to all drugs in Korea's pharmaceutical market to track production, import, and supply of drugs. In sync with HIRA's claims data, the KPIS can fully understand the drug consumption pattern in Korea. The DUR system provides real-time information on drug safety, such as screening for therapeutic duplication, contraindication, and the use of prohibited drugs, at the point of prescribing and dispensing.

questionWhat are the IT services for the public and providers?
answer

HIRA website provides various services including medical fee verification and assessment result release. HIRA's mobile application, free of charge, provides health information and medical institution information to help patients find hospitals and pharmacies. For providers, HIRA built providers portal and claim submission portal, so claims can be submitted electronically and results can be checked more conveniently.

questionWhat is HIRA?
answer

In Korea's National Health Insurance system, there are 3 major acting bodies, which are the Ministry of Health and Welfare (MoHW), the National Health Insurance Service (NHIS), and the Health Insurance Review and Assessment Service (HIRA). The Ministry oversees the system and supervises NHIS and HIRA. The NHIS is in charge of subscriber management, premium collection, and benefit provision. The HIRA is in charge of claims review, benefit adequacy assessment, benefit standards and resource management, and on-site investigation. The two agencies were separated to ensure independency, fairness, and objectivity in the process of benefit claims review, assessment and benefit standard development.