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
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