Build Electronic Medical Claim (レセプト / RECEIPT .UKE)
Skill: Convert clinical encounters into an electronic レセプト (receipt) UKE file
Region: Japan (日本)
Category: Health care — online claims (オンライン請求)
Does: Takes a month's clinical encounters and maps them onto the electronic レセプト (診療報酬明細書) in the CSV .UKE record format for online billing submission to the 支払基金 (Social Insurance Medical Fee Payment Fund) and 国保連 (National Health Insurance Federations).
Spec: MHLW 記録条件仕様 (recording-condition spec) — RECEIPTC.UKE (医科 / medical), RECEIPTD.UKE (歯科 / dental), RECEIPTS.UKE (調剤 / pharmacy)
Claims are billed in 点数 (points) at ¥10 per point; the insurer pays its share and the patient the co-payment (一部負担金). Files are submitted monthly (for the prior month's care) by the 10th, online or by media.
When this applies
- A medical institution / pharmacy bills the month's covered care to the payer organisation through online請求 (online claims), one レセプト per patient per month per insurance.
- Separate file types apply to 医科 (RECEIPTC), 歯科 (RECEIPTD) and 調剤 (RECEIPTS) billing.
Structure (UKE → record types)
IR 医療機関情報 institution code (点数表/都道府県/医療機関コード), billing month, payer org
RE レセプト共通 patient name, sex, DOB, 給付割合, 入院/外来 class, 診療科
HO 保険者 保険者番号, 記号・番号, 本人/家族区分, 給付割合, points & co-pay
KO 公費 公費負担者番号 + 受給者番号 (public-assistance schemes), points
SI 診療行為 procedure code, 点数, 回数 (×count), date(s)
IY 医薬品 drug code (YJ/レセ電コード), amount, 点数, count
TO 特定器材 device/material code, quantity, 点数
CO コメント comment code + free text (justification, conditions)
SY 傷病名 diagnosis (傷病名コード / ICD-aligned), 開始日, 転帰, 主病フラグ
Mapping & rules
- One レセプト per patient, per month, per insurance; combine insurer (HO) and any public schemes (KO) coverage with the correct 給付割合 (benefit ratio) and resulting 一部負担金 (co-payment).
- Points — every billable item (診療行為 SI, 医薬品 IY, 特定器材 TO) carries 点数 × 回数; the receipt total in points × ¥10 splits into the payer share and the patient co-payment per the benefit ratio and any monthly ceiling (高額療養費).
- Codes — use current MHLW 診療行為/医薬品/特定器材 master codes (マスター) and 傷病名コード; diagnoses (SY) must justify the billed acts.
- Comments (CO) — attach required comment codes where the spec mandates justification for an act, quantity, or exception.
- Identifiers — 保険者番号 and 記号・番号 must match the insurance card; institution code and billing month identify the file.
Worked example (outline)
IR 点数表=1(医科), 医療機関コード=…, 請求年月=2026-01, 提出先=社会保険診療報酬支払基金
RE 患者 外来, 給付割合=70/30
HO 保険者番号=06123456, 記号・番号=…, 一部負担金=…
SY 傷病名=急性上気道炎, 開始日=2026-01-08, 主病
SI 初診料 …点 ×1 (2026-01-08)
IY 内服薬 … 点 ×処方
→ レセプト合計点数 × ¥10 → 保険者負担 + 患者一部負担金
Emitted as RECEIPTC.UKE and submitted via online請求 to 支払基金 / 国保連.
Validation checklist
- Correct file type/version: RECEIPTC/D/S.UKE per 医科/歯科/調剤 and current 記録条件仕様
- One レセプト per patient/month/insurance; HO/KO coverage and 給付割合 correct
- All items in 点数 × 回数; total points × ¥10 split into payer share and 一部負担金
- Current 診療行為 / 医薬品 / 特定器材 / 傷病名 master codes used
- Required コメント (CO) codes attached where the spec mandates justification
- 保険者番号・記号・番号 match the card; 医療機関コード and 請求年月 correct
- Submitted online (or by media) by the 10th to 支払基金 / 国保連
Last updated: 2026-06-02 — the MHLW 記録条件仕様, point tariffs (診療報酬改定), and master code tables change on a fixed revision cycle; confirm the current UKE record spec, masters, and submission rules against current 支払基金 (ssk.or.jp) / 国保中央会 guidance before use.