Abstract
Special case review is a crucial supplementary mechanism in DRG/DIP payment reforms, designed to provide flexible payment pathways for exceptional cases that cannot be accommodated within standard payment groups due to complex conditions, application of new technologies, or significant individual variations. In practice, special case review process generally faces challenges such as low efficiency, inconsistent standards, and heavy manual review burdens in various regions. As a national pilot city, Shanghai City has innovatively established a "fast-track" mechanism for special case review. By defining eligibility criteria based on historical review experience and big data analysis, it has achieved automatic screening and rapid approval, while retaining a "regular channel" for cases not covered by the fast track. This mechanism has significantly improved review efficiency, standardized payment criteria, and promoted the application of innovative technologies. It is recommended to dynamically adjust the classification criteria for special case review in the future, expand coverage for new technologies and critical illnesses, and establish a "short term-medium term-long term" linkage mechanism to ensure alignment between medical insurance payments and clinical needs.
Key words
DRG/DIP /
special case review /
fast track /
Shanghai City
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Exploration and Reflection on the "Fast-Track" for Special Case Review Under the DRG/DIP Reform——Taking Shanghai City as an Example[J]. China Health Insurance. 2026, 0(3): 12-19 https://doi.org/10.19546/j.issn.1674-3830.2026.3.002
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