Beijing, China – 11 Sep 2026 – The National Healthcare Security Administration (NHSA) has released the 21st batch of rules and knowledge points under its intelligent supervision “Two Databases” framework — the National Medical Insurance Fund Intelligent Supervision Knowledge Database and Rules Database (2025 Edition) — as part of a broader drive to help designated medical institutions master fund‑supervision rules, achieve proactive and continuous compliance through intelligent means, and shift regulatory oversight upstream.
Regulatory Milestone
| Item | Detail |
|---|---|
| Agency | National Healthcare Security Administration (NHSA), China |
| Action Type | Public release of intelligent supervision rules & knowledge points (Batch 21) |
| Framework | Medical Insurance Fund Intelligent Supervision “Two Databases” – Knowledge Database & Rules Database (2025 Edition), now published and distributed |
| Scope of This Batch | Knowledge‑point details for 9 chapters – including “Certain Infectious and Parasitic Diseases” – corresponding to the “Diagnosis Inconsistent with Patient Gender” rule |
| Mandate to Provincial Authorities | Provincial healthcare security departments must dynamically update the “Two Databases” in provincial intelligent supervision subsystems per the latest knowledge‑point details and codes |
| Feedback Channel | jjjgs522@nhsa.gov.cn |
| Attachments | Batch 21 knowledge‑point details in PDF and XLSX formats |
| Next Steps | Continued batch releases and system integration; further batches’ content and timing Not disclosed |
Policy Profile & Mechanism
- Objective: The 2025 Edition was compiled by the NHSA to familiarize designated medical institutions and their staff with fund‑supervision rules, enabling automated, intelligent compliance rather than retrospective enforcement.
- Rule Logic: The “Diagnosis Inconsistent with Patient Gender” rule flags billing or coding entries where a recorded diagnosis is clinically incompatible with the patient’s sex – a classic marker of miscoding or fraudulent claims.
- Front‑Loading Oversight: The framework is designed to move the regulatory checkpoint upstream (“监管关口前移”), catching non‑compliant behavior at the “budding” stage before fund misuse occurs.
- Batch Cadence: This release is the 21st batch in a systematic, chapter‑by‑chapter rollout of knowledge points – cumulative rule inventory and remaining batches Not disclosed.
Implementation Framework for Designated Institutions
- Institutional Integration: Designated medical institutions may embed the “Two Databases” into their own intelligent reminder and information systems to run automated alerts and self‑inspection/self‑correction at the point of care and billing.
- Direct System Linkage: Alternatively, institutions can connect to the NHSA’s intelligent supervision pre‑reminder function module, aligning internal workflows with the national oversight system.
- Provincial Platform Updates: Provincial‑level intelligent supervision subsystems are required to refresh rules and codes on a dynamic basis, ensuring nationwide consistency of the enforcement logic.
- Fraud Reporting Channels: The NHSA reiterates public reporting lines for suspected fraud against the medical insurance fund (hotlines 010‑89061396 / 010‑89061397; jubao@nhsa.gov.cn), underscoring the fund‑security mandate accompanying the release.
Market Impact & Outlook
- Compliance Landscape: Hospitals, clinics, and pharmacies operating on China’s medical insurance reimbursement rails face increasingly automated, code‑level scrutiny of diagnoses and billing – raising the cost of compliance failures and the value of robust internal audit systems.
- Health‑IT Opportunity: The requirement for institutions to integrate the “Two Databases” into intelligent reminder systems signals sustained demand for medical insurance compliance software and intelligent supervision solutions.
- Enforcement Direction: Front‑loaded, rules‑driven supervision marks a structural shift from ex‑post punishment toward prevention‑first fund governance across the world’s largest basic medical insurance system.
- Institutional Readiness: Providers that adopt pre‑reminder integration early can reduce recoupments and penalties; detailed penalty implications of the new rules – Not disclosed.
Forward‑Looking Statements
This brief contains forward‑looking statements regarding the rollout of additional “Two Databases” batches, provincial system updates, institutional integration timelines, and enforcement outcomes under the NHSA’s intelligent supervision framework. Actual developments may differ due to policy adjustments, implementation variability across provinces, and institutional adoption factors.-China Health Reform Pulse
Policy Source: https://www.nhsa.gov.cn/art/2026/9/8/art_109_22052.html?sessionid=