BERNADETTE CLEMENTE-LICO MD HEAD PMT for Claims
Philippines Hospital Association
The Challenge of Change: Building Bridges Together
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CLAIMS FOR REIMBURSEMENT and COMPLIANCE
BENEFITS AND CLAIMS (Updates)
Top 10 Paid Medical Claims
Circular 2017-0028 Length of Stay (LOS) removed as basis for payment of claims for:
Pneumonia
AGE
UTI
• All claims require submission of certified true copy of complete clinical chart (including SEPSIS)
– Claims without complete clinical chart will be returned
CLAIM FORM (CF) 4 (PC No.2018 – 0007)
Issues and concerns on patient privacy, administrative cost ,
tedious process etc.
tool containing clinical
(including results of diagnostic tests)
and administrative data
Attached:
laboratory and/or imaging results (scanned or photocopy)
operative room (OR) technique
IMPORTANT POINTS: CF4
Improperly accomplished or illegible CF4
and/or incomplete attachments
shall be RETURNED to Hospital.
IMPORTANT POINTS: CF4
****All claims should be accompanied by CF4
IMPORTANT POINTS: CF4
CF 4 along with attached lab results and OR record shall replace clinical charts
All claims shall still require CF1 and CF2 or CSF and SOA
The Claim Form 4 (CF 4) replaces Part 1 of the Claim Form 3 (CF 3).
Part 2 of the Claim Form 3 (CF 3) is retained for maternity claims reimbursement
What is not covered by this Circular?
Claims directly filed with PhilHealth
Confinements abroad
Specific packages/ benefits (current requirements still apply):
Z-Benefit packages Outpatient
HIV/AIDS Treatment (RVS 99246)
Animal Bite Treatment (RVS
90375)
TB-DOTS (RVS 89221 and 89222)
Normal Spontaneous
Delivery ( NSD01)
Maternity Care Package (MCP01)
Newborn Care Package (RVS
99432)
Resuscitation Package (P00000)
Referral Package (P00001)
Medical Prepayment Review : (initial phase)
Pneumonia
AGE
UTI
Sepsis
IMPORTANT POINTS: CF4
***PhilHealth reserves the right to subject any and/ or all claims
to medical prepayment review.
PhilHealth shall DENY claims:
over-utilization or under- utilization of services; unnecessary diagnostic and therapeutic
procedures and intervention; irrational medication and prescriptions;
PhilHealth shall DENY claims:
fraudulent, false or incorrect information as determined by the appropriate office;
gross deviations from currently accepted
standards of practice; inappropriate referral practices;
PhilHealth shall DENY claims:
use of fake, adulterated or misbranded pharmaceuticals, or unregistered drugs;
use of drugs other than those recognized in the
latest PNF and those for which exemptions were granted by the Board
unethical patient recruitment
Monitoring of HCPs
• PhilHealth Circular No. 54, s-2012 (Provider Engagement through Accreditation and Contacting for Health Sevices (PEACHes)
• PhilHealth Circular No. 2016-0026 re: (Health Care Provider Performance Assessment System (HCP PAS) Revision 1).
Effectivity of CF4
• All admissions starting May 1, 2018 onwards. DEFERRED UNTIL FURTHER NOTICE
as per ADVISORY 0043 2018
May submit any of the Following:
Photocopy of clinical chart
Claim Form 3
Clinical Abstract
Discharge Summary
PhilHealth Advisory 2018 – 0017
Philippine National Formulary (PNF) 8th Edition Essential Medicines List (EML) 2017
posted and can be accessed at:
https//www.philhealth.gov.ph/partners/providers/pdf/PNF8thEd_2017.pdf
The new PNF shall be basis for claims reimbursement and performance
monitoring for all admissions starting March 1, 2018.
Download at:
https://www.philhealth.gov.ph/partners/providers/pdf/
PNF8thEd_2017.pdf
PCB1 Package PCB1 Package
Sponsored Program
Organized Groups
Overseas Workers Program
DepEd Personnel
M E M B E R S a n d D E P E N D E N T S
Expansion of PCB 1
PhilHealth shall expand the Primary Care Benefit to all members and dependents
of the formal sector,
lifetime and senior citizen members
Expansion of PCB 1
private and government health care institutions, including out patient department of hospitals
may proceed to their
respective PhilHealth Regional Offices
for inclusion in their Performance Commitment as an
Accredited Provider for the PCB1 Expansion.
Expansion of PCB 1
coordination with the IT of the
PhilHealth Regional Office
to gain access of the ePCB Module
“PhilHealth ACR Search”
Mobile Application
“PhilHealth ACR Search”
Mobile Application
How to install?
1. Enter the ICD 10 Code/RVS
Code/Description then press
“Search”
2. No. of record/s
will display
then select “Ok”
3. Search results will
display. Select the final
diagnosis you are
looking for.
How to use?
4. Case rate details will display.
There is an option to choose the
type of HCI.
UPDATES ON PHILHEALTH ADVISORIES
PhilHealth Advisory 2017 – 0050
• REGISTRATION OF BANK ACCOUNTS FOR THE MANDATORY IMPLEMENTATION OF AUTO CREDIT PAYMENT SCHEME (ACPS)
all accredited Health Care Institutions (HCIs) are required to be ACPS compliant for purposes of claims reimbursements.
What is ACPS?
a payment mechanism where HCI claims are
reimbursed directly into their bank accounts
shortens the time for processing claims by
eliminating check preparation
mandatory to all HCIs
including PCB and MDGs providers
does not cover member-filed claims
Which HCIs should enroll in ACPS?
What are the requirements to register
the HCI bank account?
HCI shall submit details of its servicing bank with
PhilHealth for ACPS registration:
- Notice of ACPS Compliance
- Bank certificate
HCI servicing bank may be Landbank or any other
bank
format of the bank account name:
- Private HCI -
- Government HCI
Is there a format for the name of the HCI bank
account?
Private HCI – „Name of HCI‟ for HCI Charges
Government HCI – two (2) bank accounts:
1.‘Name of HCI’ for HCI Charges
2.‘Name of HCI’ for Professional fees designated
for Pooling
LGUs have two (2) options in registering its bank
accounts:
one (1) bank account EACH for every HCI and every HCI chief
one (1) bank account that covers all HCI under its jurisdiction
and another one for PFs under pooling
Will there be transaction charges?
PhilHealth shall not charge fees for auto-credit
payment.
Real-Time Gross Settlement Fees (RTGS)
- Since PhilHealth servicing bank is Landbank,
- HCIs may be charged with RTGS fees if their
servicing bank is not Landbank
RTGS fees shall be shouldered by the HCI
What is the schedule for auto-credit payments?
Every Wednesday
- or the next working day in case crediting day falls
on a non-working holiday
Cut-off time: all claims processed up to 1 day prior
to generation of the auto-credit list
What is the implication of ACPS Noncompliance?
PhilHealth Circular No. 2017-0020
All Claims of noncompliant facilities to ACPS
shall be processed by the PROs until check
generation but the printed checks shall not be
released to the HCIs until they have complied
with the requirements of the ACPS policy.
PRO AUTO CREDIT PAYMENT MONITORING REPORT
Accredited HCIs HCIs on ACPS % Compliance to ACPS
CAR 369 206 56%
I 492 449 91%
II 441 261 59%
IIIA 556 346 62%
IIIB 502 284 57%
NCR North 426 311 73%
NCR Central 460 337 73%
NCR South 503 299 59%
IVA 635 461 73%
IVB 388 364 94%
V 445 364 82%
VI 499 261 52%
VII 635 404 64%
VIII 663 552 83%
IX 312 299 96% X 397 188 47%
XI 398 309 78%
XII 372 363 98%
CARAGA 274 269 98%
ARMM 355 308 87%
NATIONAL 9,122 6,635 73%
NON COMPLIANCE TO AUTO CREDIT PAYMENT SCHEME
SIOCON RURAL HEALTH UNIT ANIMAL BITE TREATMENT CENTER ANIMAL BITE PACKAGE PROVIDER
SIMATA BARANGAY HEALTH STATION MCP PROVIDER
RURAL HEALTH UNIT OF SIOCON MCP PROVIDER
BAYOG RHU OUTPATIENT MALARIA PROVIDER
RURAL HEALTH UNIT OF SIOCON OUTPATIENT MALARIA PROVIDER
STA. LUCIA MAIN HEALTH CENTER PRIMARY HEALTH CLINIC
SAN PEDRO MAIN HEALTH CENTER PRIMARY HEALTH CLINIC
RURAL HEALTH UNIT OF SIOCON PRIMARY HEALTH CLINIC
SAN JOSE MAIN HEALTH CENTER PRIMARY HEALTH CLINIC
SAN PEDRO MAIN HEALTH CENTER TB DOTS PACKAGE PROVIDER
STA. LUCIA MAIN HEALTH CENTER TB DOTS PACKAGE PROVIDER
RURAL HEALTH UNIT OF SIOCON TB DOTS PACKAGE PROVIDER
SAN JOSE MAIN HEALTH CENTER TB DOTS PACKAGE PROVIDER
IMPORTANT
• HCIs partnered with HITP --- CONTINUE
• HCIs with existing HIS/EMR – write to PhilHealth for confirmation and validation of software compliance to PhilHealth requirements
OPTION
• NO HIS/EMR can use PhilHealth Hospital Information and Claims System (PHICS) or Softcopy Claims System (Sclaims)
IMPORTANT
• Software is certified by PhilHealth as complying to the technical specifications of claims submission and data validation
What is eClaims?
• modular information system
• consists of:
– a front end application for HCIs to conduct claim transactions
– a back-end application for PhilHealth to process claims
What is eClaims?
What is the purpose of eClaims?
•Contains 3 modules:
• Module 1: checks the eligibility of a patient avail of PhilHealth benefits
• Module 2: submit claims online
• Module 3: track status of claims
What is eClaims?
Electronic Eligibility
Check (Initial)
Electronic Claim
Submission
HCI PHIC
Electronic Payment
Electronic Adjudication
Electronic Eligibility
Check (Final)
Electronic Claim Status Verification
Module 1
Module 2 Module 4
Module 5
Module 3
H I T P
E CLAIMS NON COMPLIANT
ST. PAUL'S HOSPITAL OF ILOILO, INC.
DR. PABLO O. TORRE, SR. MEMORIAL HOSPITAL
SULU PROVINCIAL HOSPITAL
SULU SANITARIUM
DATU HALUN SAKILAN MEMORIAL HOSPITAL
HOLY FAMILY HOSPITAL
SERGIO OSMEÑA SR. MUNICIPAL HOSPITAL
STA. ISABEL GENERAL HOSPITAL, INC.
TRIFON SAILE MEMORIAL HOSPITAL (FORMERLY MEDICARE COMMUNITY HOSPITAL OF MANUKAN)
SINDANGAN DISTRICT HOSPITAL
CRISTINO M. PARAGAS MEMORIAL COMMUNITY HOSPITAL
EDWIN ANDREWS AIR BASE HOSPITAL
DR. SALVADOR A. CABATO MEMORIAL HOSPITAL
WESTERN MINDANAO MEDICAL CENTER
E CLAIMS NON COMPLIANT
REDOBLE MEDICAL CLINIC
LAKEWOOD MUNICIPAL HOSPITAL
REVELO COMMUNITY HOSPITAL
SINGIDAS MEDICAL CLINIC
ST. JUDE MEDICAL CLINIC
GEMARINO HOSPITAL
WESTERN ZAMBOANGA POLYMEDIC HOSPITAL
AURORA GENERAL HOSPITAL
TAGALOGUIN CLINIC
KUTA MAJOR CESAR L. SANG-AN STATION HOSPITAL
MAHAYAG MUNICIPAL HOSPITAL
EUSER MEDICAL CLINIC
SAINT FRANCIS CLINIC
JUAN S. ALANO MEMORIAL HOSPITAL, INC.
BASILAN COMMUNITY HOSPITAL, INC.
E CLAIMS NON COMPLIANT INFANTE HOSPITAL MANAGEMENT CORPORATION
DR. JOSE MA. TORRES MEMORIAL FOUNDATION HOSPITAL, INC.
ZAMBOANGA DEL SUR HEALTH SERVICES COOP. HOSPITAL
TAMBULIG MUNICIPAL HOSPITAL
PAYAO MUNICIPAL HOSPITAL
BASILAN GENERAL HOSPITAL
EASTERN SUN MEDICAL AND DIAGNOSTIC CENTER, INC.
KABASALAN PATHFINDER HOSPITAL
SIBUCO MUNICIPAL HOSPITAL
CORAZON C. AQUINO HOSPITAL
EVANGELISTA MEDICAL CLINIC AND HOSPITAL
MANUEL J. SANTOS HOSPITAL
UPH-DR. JOSE G. TAMAYO MEDICAL UNIVERSITY FOUNDATION, INC.
BATANGAS MEDICAL CENTER
DR. VICTOR R. POTENCIANO MEDICAL CENTER
NATIONAL KIDNEY AND TRANSPLANT INSTITUTE
Summary of Claims Status Report
ADVISORY No. 2018 - 0042
CLAIMS STATUS REPORTS TO BE SENT TO ALL ACCREDITED
INSTITUTIONAL HEALTH CARE PROVIDERS VIA E-MAIL
assist in the reconciliation of provider and insurer records, all accredited HCIs shall be provided with a Summary of Claims Status Report (SCSR) of their claims reimbursements through their official email accounts or addresses. SCSR contains the status of claims Paid pending in process Denied Returned to Hospital
PHILHEALTH ABS CBN HOSPITAL
gross
TOP TEN REASONS FOR RETURN TO HOSPITAL CLAIMS
TOP TEN REASONS FOR DENIED CLAIMS
RECONCILIATION SUMMARY MODULE
HCI PORTAL
JASPERSAM MEDICAL CENTER
JASPERSAM MEDICAL CENTER
HFPS Forum, <date>
JASPERSAM MEDICAL CENTER
JASPERSAM MEDICAL CENTER
HFPS Forum, <date>
JASPERSAM MEDICAL CENTER
Main page ->Reconciliation Summary ->Claims Status Summary Report
JASPERSAM MEDICAL CENTER
HFPS Forum, <date>
JASPERSAM MEDICAL CENTER
HFPS Forum, <date>
JASPERSAM MEDICAL CENTER
For STATUS (required field ADMISSION DATE)
STATUS : PAID
JASPERSAM MEDICAL CENTER
CLICK VALIDATE
JASPERSAM MEDICAL CENTER
CLICK PDF PRINT
HFPS Forum, <date>
JASPERSAM MEDICAL CENTER
HFPS Forum, <date>
HFPS Forum, <date>
HFPS Forum, <date>
HFPS Forum, <date>
HFPS Forum, <date>
HFPS Forum, <date>
SEARCH Series number
JASPERSAM MEDICAL CENTER
Click Validate
JASPERSAM MEDICAL CENTER
Click PRINT PDF JASPERSAM MEDICAL CENTER
STATUS : FOR VOUCHER PREPARATION
JASPERSAM MEDICAL CENTER
CLICK VALIDATE
JASPERSAM MEDICAL CENTER
PRINT PDF
IN PROCESS
JASPERSAM MEDICAL CENTER
VALIDATE
JASPERSAM MEDICAL CENTER
PRINT PDF
FOR DENIED STATUS
JASPERSAM MEDICAL CENTER
VALIDATE
JASPERSAM MEDICAL CENTER
PRINT PDF
RETURN TO HOSPITAL
JASPERSAM MEDICAL CENTER
VALIDATE
JASPERSAM MEDICAL CENTER
PRINT PDF
SEARCH BY NAME (required field ADMISSION DATE)
ADARNA ELLEN CRUZ
JASPERSAM MEDICAL CENTER
VALIDATE
JASPERSAM MEDICAL CENTER
PRINT PDF
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