Guidelines on processing of claims
To avoid confusion and to put a system on the processing of claims, PhilHealth has issued the OMNIBUS GUIDELINES ON CLAIMS PROCESSING. The following are the general policy on claims application:
The health care provider shall determine in good faith the member's eligibility and substantial compliance with the requirements for
availment set forth by the Corporation. It shall deduct from the total charges all expenses reimbursable by the Corporation upon discharge of the patient. The payment of NHIP benefits shall be made directly to the health care provider.
In exceptional cases, if the member fails to submit the requirements which only he/she can provide within the prescribed period, the Corporation may deny payment of the claim of the member but not the claim of the health care provider who acted in good faith, as may be determined by the Corporation.
Health care institutions are not allowed to charge for PhilHealth forms and processing fees from the member when claiming reimbursement from the Corporation.
All claims except those under investigation shall be acted upon by the Corporation within sixty (60) calendar days from receipt.
When the claim filed by a health care institution indicate that its bed occupancy rate exceeds its accredited bed capacity, such claims should be accompanied by a justification in writing. Otherwise, the same shall not be processed.
All claims for services filed by a health care institution after its category is downgraded/upgraded pursuant to this Rule shall be paid based on rates for such downgraded/upgraded category, as determined by the Corporation. In cases wherein the effectivity of change in category of the provider falls during the confinement period of member, the payment of claims shall be computed based on the higher category.
Public health care institutions shall retain charges paid for use of facilities. Such revenues shall be kept in a trust fund and shall be used to defray operating costs to maintain or upgrade equipment, plant or facility and to maintain or improve the quality of service in the public sector except for remuneration of personnel services.
In any instances when a member can show proof of under deduction while complete payment is reimbursed by PhilHealth to provider, the latter is bound to refund the balance to the member within thirty (30) calendar days from receipt of reimbursement check.