Requirements for PhilHealth claims
Review is one of the units under the Claim Processing Division that scrutinizes everything, from every documents submitted to support a claim. So, reviewers may ask for additional documents in order to prove age and relationship, the reason claims are returned to hospital or member for compliance.
To lessen this Return to Hospital (RTH) and denial of claims, let us cite some common errors made by members and/or by hospital medicare-clerks in preparing the claims.
The PhilHealth Claim Form II is a hospital certification form accomplished by medicare-clerks based on the information furnished by members, attending physicians and hospital billing section. Most common errors are found in Part I-Hospital Data & Charges, thereof such as on item # 12-Charges - Be very careful in computations especially when writing numbers in the corresponding column. Our policy is that we pay whichever is lower as indicated in the actual charges and Medicare benefits. For instance, a member is claiming the amount of P3,000 but the clerk had written it as only P300, then of course PhilHealth will be paying the P300 as indicated in the form. If the member will file for an adjustment for the underpayment, it will be denied. Then, on item # 13-Certification of Hospital - This is a waste of time if the reason of RTH is "no signature of the hospital representative, no date signed, and no official capacity". The clerk should check it twice. In case the authorized representative cannot sign for whatever reason, let the authorized next in line sign. Be sure to indicate his name and official capacity.
On Part III & IV for Drugs, Medicines & X-ray and Laboratories, do not think that this part only enumerate the drugs and medicines and laboratories used during confinement. Always complete the data and put these in their proper column. If there is no amount on the item, this will not be paid. If there are two many items to write, you may add another sheet of paper. Do not rumble the item and the amount for it is very confusing in the computation. Sometimes PhilHealth pays it as overpayment or underpayment.
PhilHealth Claim Form III is filled out for direct filers and claims of primary hospitals. Secondary and Tertiary hospitals may be required on a case-to-case basis as it deemed necessary.
The item # 14-Final Diagnosis--The most common error is on the International Coding of Diseases (ICD 10) coding so physicians must provide information as to the final diagnosis so that coders would construe the right ICD coding. Basically, the claim is returned if the code is wrong until it is corrected. Item # 16-30-Attending Physicians, Surgeons & Anesthesiologist that without accreditation and TIN number, the doctor would not be paid including those incorrectly written and non-updated accreditation.
Finally, other valid proofs as to filiation or relationship are required in cases where the dependents are the one confined. For this, Member Data Record is required as proof for dependency but in its absence, the Birth Certificate (BC) is asked where it can also prove the names, acknowledgement of the father on his child in case of illegitimate children, to prove the relationship and the age of the child. Marriage Contract is a proof of marriage and required if the dependent is the member's legitimate spouse. Affidavit of Two Disinterested Person can be submitted in the absence of Birth Certificate, and also for parents who are qualified as dependents, 60 years old and above, whose document of birth is no longer available. However, if there are discrepancies in names as indicated in PhilHealth Claim forms and the supporting documents submitted, PhilHealth may further require additional documents such as an Affidavit of Discrepancy on Name/Manifestation, in order to facilitate processing of claims.