CLAIMS FOR REIMBURSEMENT and COMPLIANCE · The Claim Form 4 (CF 4) replaces Part 1 of the Claim...

BERNADETTE CLEMENTE-LICO MD HEAD PMT for Claims

Philippines Hospital Association

The Challenge of Change: Building Bridges Together

1

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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