20131025 ric ore process flow

7/25/2019 20131025 Ric Ore Process Flow

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Process (LEVEL 2)

Member Registration

Document Reference Code

Revision No. E. Date

Sub-Process (LEVEL )Enrolment at the Point of Care

Pa!e "##roved b$%

Procedure Descri#tion%

Pur#ose To ensure PhilHealth coverage of the poor thru enrolment at the point of care Sco#e Admitted patients and their dependents in a DOH Retained hospital

De&nition of 'ermsA. Hospital!ponsored Members "H!M# Patients for admission $ho $ere assessed a

identi%ed as poor b& the hospital Medical !ocial 'or(er $ho are not covered PhilHealth at the time of con%nement

). *o )alance )illing + *o other fees or e,penses shall be charged to or paid for b& tpatientmember above and be&ond the pac(aged rates - hospital bill

C. HCP a s&stem deplo&ed b& PhilHealth in Health Care nstitutions $hich is capableproviding membership and eligibilit& details necessar& for bene%t availment

D. Onsite Rapid Enrollment !&stem "ORE# + an application utili/ed b& hospital person$hich allo$s membership0 eligibilit& validation and enrollment of Hospitalsponsormembers

E. Pa&ment !lip Details + a usergenerated report in ORE $hereb& all patients enrolled particular period is listed. These shall be the basis for premium pa&ments.

"reas of Res#onsibiit$% HospitalAdmitting !ection-Medical !ocial 'or( !ervice-PhilHealthCARE!-Hospital Accounting !ection-1HO Cashier-PRO)ranch Mem!ec-)A!-T2-O3PMM4-D!'D

Procedure Detais%Res#onsib

e

*ce+Person

"ctivit$ ,o "ctivit$ Detais Referens

"dmittin!Section

("S)+Pi/eat

Section(PS)

Pi/eatSection

5. 3eri%cation of PhilHealth

eligibilit&

A. Patient-companion of the

patient coming from the

Emergenc& Room "ER-OPD# for

admission $ill be referred to

the A!

). A!-P! !ta6 $ill verif& if

patient is alread& a member or

dependent using the HCP Portal

- ORE.C. f covered for that

hospitali/ation0 A!-P! provide

Claim 2orms and detailed

instruction on ho$ to %ll up

forms0 documentar&

re7uirements needed and other

pertinent details to facilitate

bene%t availment.

D. f not covered during the time

of hospitali/ation0 i.e. patient is

nonmember or $as once a

A. 8o

Circular

Enrolmen

of Crit

Poor un

the

!ponsore

Program

the *atio

Healthnsurance

Program

PointOf

!ervice

). Manua

Operation

and

Procedure

PO*T O2

CARE

Patient from

ER- OPD

Mem

ber

Eligible:

;sual

Processing of

Claims


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0edicaSocia1or

Service

C"RES

PR+3R"NC/+

L/40E0SEC

0edicaSocia1or

Service

member but does not have a

7ualif&ing contribution0 active

sponsorship0 A!-P! !ta6 refers

the patient-companion to

Medical !ocial !ervices for

assessment if 7uali%ed to be

enrolled as Hospital!ponsored

Member.

=. Medical !ocial 'or(er>s

Assessment

A. The M!' shall assess and

evaluate all admitted service

patients using the M!'!

Assessment Tool based on DOH

Administrative Order no ?5A s.

=@@5 and other issuances

relative to it.

). The M!' shall validate and

verif& identi%ed Class C andClass D patients at Eportal.

5.5 Patients classi%ed as Class

C and Class D shall be enrolled

mandatoril&.

5.=. Patients classi%ed as Class

A0 )0 C5 and C= shall be

referred to PhilHealth CARE! for

EC on membership as part of

the informal sector.

5. CARE! shall issue PMR2 to

the patient and assist them on%lling up the form

5.B CARE! shall refer the

patient to the nearest 1HO for

pa&ment

C. M!' enrolls identi%ed

patients using ORE.

D. ;pon enrollment to ORE0 the

M!' shall stamp Hospital

!ponsored Member at the

Patients Data !heet "PD!#.

. Pin generation and

updating-shifting of member

categor&

;pon receipt of generated P*0

the M!' issues the H!M

Certi%cate signed b& the Chief

Medical !ocial 'or( !ervice and

Chief of the Hospital for

patient>s use in claiming their

MDR - D. The same ma& also

E*RO11M

T PRO4RA

Register through

ORE and tag

Documents $ith

Mem!ec process

registered H!Ms

"Pin 4eneration#and load data in

!end Member>s P*

to Hospital

"!&stem

4enerate P!D

Processing

of premium

pa&ments

A

M!'!Assesses

uali%ed asH!M:

H!FCARE!

conduct EC

for nformal

!ector

Enrollment


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"ccountin!Section

PR +L/4

Pi/eatSection

3"S

',4

VP-005

be used for subse7uent

con%nements in an& accredited

facilit&.

B. 4eneration of Pa&ment

!lip Details

A. The M!' generates P!D on a

$ee(l& basis.

). 4enerated P!Ds shall besubmitted to P! - Accounting

Department

?. Pa&ment of Premium

A. The P! !ta6 shall receive and

process the list submitted b&

M!'. This shall be endorsed to

the accounting department for

voucher preparation and

disbursement of fund.

B. Pa&ment shall be made in

1HOs $ith the batch list asattachment. The POR issued

shall be attached to the claims

transmittal.

G. Claims !ubmission

A. P! !ta6 submits claims of

H!Ms separatel& from regular

claims.

). P! tags the entire batch as

H!M Claims0 attaches the P!D

and OR.

. )ac(room Mem!ec toprocess the data encoded b&the M!'s including P*generation and loading ofdata to MC! on a dail& basise,cept $ee(ends andholida&s.I. Mem!ec to informhospital thru email the P*and status of enrolled H!Ms.J. Col!ec to postpaid H!Msand coordinate $ith Mem!ec

to indicate validit& of H!Msin MDR.

5@. )A! to process claims

reimbursement $ithin @

da&s.

5. E,traction of Data

Tag batch of H!M

Claims and submit it

Prepares Claim

2orms in batches

and attaches P!D

2aster Claims

T2 "Tas( 2orce

nformatics#

generates enrolled

Endorsement of

E,tracted data to

O3PMM4 to formall&endorse data to

*HTO D!'D Central

Remittance of

premium

pa&ment to

1HO issues

OKcial

A

A


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DS1D

DS1D

a. T2 to generate listof enrolled H!Ms ona 7uarterl& basis

b. T2 endorsee,tracted data toO3PMM4

=. Endorsement toD!'D

a. D!'D conducts

3alidation

b. D!'D

incorporates

validated H!M to*HT!PR

D!'D conducts

D!'D incorporates

validated H!Ms to

roster of *HT!PR