건강보험 기초이론

제1부 건강보험 이론 ······························································································································ 1

Ⅰ. 건강보험제도 ························································································································ 3
제1장 사회보장과 의료보장 ······································································································· 3
제2장 건강보험 개념과 유형 ···································································································· 7
제3장 국민건강보험법 개요 ···································································································· 12
제4장 건강보험의 적용대상 ···································································································· 15
제5장 건강보험증 ···················································································································· 22

Ⅱ. 국민건강보험공단 ············································································································ 24
제1장 국민건강보험공단 ········································································································ 24

Ⅲ. 건강보험심사평가원 ······································································································· 39
제1장 건강보험심사평가원 ····································································································· 39

Ⅳ. 건강보험 개요 ··················································································································· 55
제1장 건강보험 제도 ············································································································· 55
제2장 건강보험 진료수가 ········································································································ 59
제3장 건강보험 진료비 청구 및 지급관리 ············································································ 67
제4장 건강보험 운영형태와 보수지불방식 ············································································· 69
제5장 질병군별(DRG) 포괄수가제도 ······················································································ 75
제6장 의료수가 비교검토 ········································································································ 78

Ⅴ. 요양급여 규칙 ··················································································································· 79
제1장 요양급여 규칙 및 비급여 대상 ···················································································· 79

Ⅵ. 진료수가 산정 방법 ····································································································· 151
제1장 일반원칙 ···················································································································· 151
제2장 수가, 약가 및 재료대 산정 ······················································································· 158

Ⅶ. 행위급여목록ㆍ상대가치점수표 및 산정지침 ·················································· 161
제1장 기본진료료 ··············································································································· 161
제2장 검사료 ························································································································· 172
제3장 영상진단 및 방사선 치료료 ······················································································· 175
제4장 투약 및 조제료 ··········································································································· 181
제5장 주사료 ························································································································· 196
제6장 마취료 ························································································································· 198
제7장 이학요법료 ·················································································································· 201
제8장 정신요법료 ·················································································································· 211

제9장 처치 및 수술료 등 ····································································································· 212
제10장 치과처치·수술료 ······································································································ 222
제11장 조산료 ························································································································ 223
제12장 보건기관의 진료수가 ································································································ 224
제13장 한방 검사료 ··············································································································· 225
제14장 한방 시술 및 처치료 ································································································ 226
제15장 약국 약제비 ··············································································································· 227
제16장 전혈 및 혈액성분 제제료 ························································································· 228
제17장 입원환자 식대 ··········································································································· 229
제18장 치과의 보철료 ··········································································································· 232
제19장 진료과목별 코드 ······································································································· 233

Ⅷ. 질병군 급여·비급여 목록 및 급여 상대가치점수 ···································· 245
제1장 일반원칙 ······················································································································ 245
제2장 질병군 급여 목록 ? 상대가치점수표 및 적용지침 ···················································· 248

Ⅸ. 요양병원 급여 목록 및 상대가치점수 ······························································ 268
제1장 요양병원 급여 일반원칙 ····························································································· 268
제2장 요양병원 환자군 급여목록ㆍ상대가치점수 및 산정지침 ········································· 269
제3장 요양병원 행위 급여목록ㆍ상대가치점수 및 산정지침 ············································· 270

Ⅹ. 건강보험 요양급여비용 청구방법 ········································································ 276
제1장 건강보험 요양급여비용 청구방법, 심사청구서 명세서 서식 및 작성 요령 ············ 276
제2장 요양급여비용 심사청구서 ··························································································· 297
제3장 요양급여비용 심사조정 ······························································································ 306

XI. 건강보험 요약정리 ······································································································ 313
제1장 요양기관 ······················································································································ 313
제2장 요양급여기준 ··············································································································· 314
제3장 일반원칙 ······················································································································ 315
제4장 기본 진료료 ················································································································ 319
제5장 검사료 ························································································································· 326
제6장 영상진단 및 방사선 치료료 ······················································································· 327
제7장 투약 및 조제료 ··········································································································· 328
제8장 주사료 ························································································································· 329
제9장 마취료 ························································································································· 330
제10장 이학요법료 ················································································································ 332
제11장 정신요법료 ················································································································· 333
제12장 처치 및 수술료 등 ···································································································· 333
제13장 치과처치·수술료 ······································································································ 336
제14장 조산료 ························································································································ 337
제15장 보건기관의 진료수가 ································································································ 337

제16장 한방 검사료 ··············································································································· 338
제17장 한방 시술 및 처치료 ································································································ 339
제18장 약국 약제비 ··············································································································· 340
제19장 전혈 및 혈액성분 제제료 ························································································· 341
제20장 입원환자 식이 ··········································································································· 341
제21장 건강보험 요양급여비용 청구방법 및 처방전 요약정리 ·········································· 346
제22장 심사평가원 요약정리 및 기타 ················································································· 347
제23장 건강보험요양급여비용 및 요양급여 명세서 청구 요약정리 ··································· 351
제24장 건강보험요양급여비용 핵심 요약정리 ····································································· 353
제25장 건강보험 관련 전체 핵심 요약정리 ········································································ 378

제2부 국민건강보험법 관련문제 ································································································ 397

Ⅰ. 국민건강보험법 관련문제 ························································································· 398

Ⅱ. 건강보험 요양급여비용 관련문제 ············································································ 422

Ⅲ. 기타 건강보험 관련문제 (1) ············································································· 448

Ⅳ. 기타 건강보험 관련문제 (2) ············································································· 521

Ⅴ. 기타 건강보험 관련문제 (3) ············································································· 552

정 답 ···································································································································· 566
참 고 문 헌 ··························································································································· 569