KABACAN MEDICAL SPECIALIST, INC. Kabacan, Cotabato
POLICY NO. ___________ Date: SUBJECT:
PHILHEALTH MANUAL AND PROCEDURES
Philhealth policies: 1. The Record Section In-charge will make daily rounds to all inpatients to identify Philhealth members and beneficiaries; and give instructions on hospital procedures on how to avail PHIC benefits and to include the terms and conditions. SCHEDULE OF DAILY ROUNDS - 8:00am to 9:00am. 2. Philhealth requirements should be submitted within 24hours from the time of admission of patient. 3. If the Philhealth requirements are incomplete upon submission, the lacking requirements should be submitted prior to discharge of patient. “NO / INCOMPLETE PHILHEALTH REQUIREMENTS; NO PHILHEALTH BENEFITS.” 4. If the patient has no Philhealth requirements or the lacking requirements were not submitted on the given time, the patient can file directly to Philhealth Office. 5. Member Data Record is the primary attachment of Philhealth requirements. 6. Less than 24 hours confinement is not covered, but if the patient expired, undergone surgical procedure Philhealth can cover it. 7. Attachment of Statement of Account and Official Receipt of Hospital Bill and Doctors are required in filing our claims. 8. Attachments of Clinical Abstract, Registered Death Certificate of Philhealth Form III are required in expired patient claim. 9. Attachment of Operating Room Technique is required for those patient who undergone surgical procedure. 10. Filings of claims are within 60 days from the date of discharge. 11. Monthly Mandatory Hospital Report shall file every 10th of the month. 12. Philhealth RETURNED TO HOSPITAL (RTH) should comply and file the deficiency within 60 days from the time we received the documents.
The following must first be met to avail of your PHILHEALTH benefits: Payment of at least three monthly premiums within the immediate six months prior to confinement. Confinement in an accredited hospital for at least 24hour [except when availing of outpatient care and special package] due to an illness or disease requiring hospitalization. Attending Physicians must also be PHILHEALTH- accredited. Availment is within the 45days allowance for room and board.
BENEFIT AVAILMENT PROCEDURES FOR OUTRIGHT / AUTOMATIC DEDUCTION OF BENEFITS:
FOR DIRECT FILING / REIMBURSEMENT
Philhealth outright filing requirements 1
Accomplished Philhealth CF1I & CF2I
2
Statement Of Account
3
Official Receipt of Hospital Bill
4
Official Receipt of Doctors
5
Operating Room Technique for surgical procedure
6
Clinical Abstract for patients confined more than 10 days and expired patient
7
Updated Member Data Record
8
Philhealth CF3 for outpatient
9
Copy of Professional Fee form Indigent members
1
Accomplished Philhealth CF1
2
Copy of Indigent Card or Sponsored Card
3
Member Data Record
4
Philhealth CF2 signed by Attending Physician Employed members (private/government)
1
Duly accomplish Philhealth CF1, signed by the authorized signatory of the employer/company
2
Updated Member Data Record
3
Philhealth CF2 signed by Attending Physician OWWA members
1
Duly accomplish Philhealth CF1
2
Updated Member Data Record
3
Philhealth CF2 signed by Attending Physician Individually paying members
1
Duly accomplish Philhealth CF1
2
Updated Member Data Record
3
ME5 at least 9 months contribution prior to confinement
PHIC REQUIREMENTS:
The following must first be met to avail of your PHILHEALTH benefits: Payment of at least three monthly premiums within the immediate six months prior to confinement. Confinement in an accredited hospital for at least 24hour [except when availing of outpatient care and special package] due to an illness or disease requiring hospitalization. Attending Physicians must also be PHILHEALTH- accredited. Availment is within the 45days allowance for room and board.
PROCEDURES EXPECTED TIME FRAMED
ACTIONS
• Receives Philhealth 24 HOURS Requirements. FROM THE DATE OF ADMISSIO N
DESCRIPTTIONS •
The Record Section staff will scrutinize the Philhealth requirements submitted by patients/members for completeness of the documents.
•
The staff will evaluate the documents submitted if the member/patient is qualified to avail the Philhealth benefits.
PATIENT FOR DISCHARGED (MGH) PATIENT’S DISCHARGE DATE
(day 1)
Outright processing of `PHIC benefits.
•
Deduct Philhealth Benefits of Discharge patient.
•
Identify the ICD 10 Code of patient’s from final diagnosis as basis for case typing deduction of Philhealth benefits availment.
Encoding of ICD 10 Code in BizBox to reflect the case type of patient in the system. •
Validates the compensable items (Pharmacy, Diagnostic & Supplies, and Operating Room if there’s an operation done to patient).
Finalize the Philhealth Benefit deduction of patient. Inform the Billing
Officer for final billing.
• Counter checking of After 2 DAYS actual printed Philhealth FROM CF2 against patient data PATIENT recorded in the chart DISCHARG ED
•
The billing officer will do posting of professional fees. Identify the RVS code for patient with surgical procedure for our basis in computing Philhealth Benefits of the Surgeon and Anesthesiologist. Printing of final statement of account.
•
The Record Section incharge prints accomplished Philhealth CF2. Provide explanations on the health actual and PHIC healthcare cost.
•
PHIC patient member signed CF2.
•
Signed patient’s Discharge Clearance (Cleared from the Medical Record).
•
Identify and note deficient data in the patient clinical records.
(day 3) 1WEEK working days
• Signatures of Attending Physician. Completion of Deficiency
(day 12)
After the 1 WEEK
• Prepares Philhealth Transmittal
(Day 13)
• Completion of Nurses Documentation. •
Attachments of Clinical Abstract, Registered Death Certificate of Philhealth Form III as required in expired patient claim.
•
Attachment of Operating Room Technique and anaesthesia record is required for those patient who undergone surgical procedure.
• Segregates the Philhealth Transmittal in their respective Department (SSS, GSIS, Self Employed, OWWA or Lifetime Members). • Photocopies the accomplish Philhealth CF2 and Transmittal
Next day (day 14) MAXIMUM OF
• Submission of Philhealth claims to PHIC office •
WAITING TIME
• Endorse the accomplish Philhealth claims to Liaison Officer for transmittal to Philhealth Office.
2MONTHS AFTER 2MONTHS
• Receives Philhealth checks payment from Liaison Officer
• Endorse PHIC Checks payments to cashier. • Check and note Philhealth payments for reconciliation from the actual benefit deducted from patient. Counter check reasons of slashing and returned claims. Document and Reports to administrative office. • If there are underpayments, a letter of adjustment or re-evaluation may be given to Philhealth. • Complies deficiency of documents / informations of the returned claims. Re-file and noted.
• Posting of PHIC payments in the system.
• The Accounting Staff encode amount in the PHIC receivables.
The following must first be met to avail of your PhilHealth benefits: •
Payment of at least three monthly premiums within the immediate six months prior to confinement.
•
Confinement in an accredited hospital for at least 24 hours (except when availing of outpatient care and special packages) due to an illness or disease requiring hospitalization. Attending physicians must also be PhilHealth-accredited.
•
Availment is within the 45 days allowance for room and board.
Benefit availment procedures For outright/automatic deduction of benefits: •
Submit to the billing section the following prior to discharge from the hospital:
Duly accomplished PhilHealth Claim Form 1 (original)
Clear copy of Member Data Record (MDR). •
If dependent - patient is not listed yet in the MDR, submit applicable proof of dependency.
•
Agree with your attending physicians on how much is left to be paid for their services over the professional fee (PF) benefit.
•
Upon submission of all applicable documents, the billing section will compute and deduct your benefits from your total hospital bill.
For direct filing/reimbursement: Submit the following to PhilHealth or through the hospital in addition to the documents mentioned earlier within 60 calendar days after discharge: •
PhilHealth Claim Form 2 (to be filled up by the hospital and attending physicians)
•
Official receipts or hospital and doctor's waiver
•
Operative record for surgical procedures performed
For confinements abroad:
Submit the following within 180 days after discharge. Overseas confinements shall be paid based on Level 3 hospital benefit rates. •
PhilHealth Claim Form 1
•
MDR or supporting documents
•
Original official receipt or detailed statement of account (written in English)
•
Medical certificate (written in English) indicating the final diagnosis, confinement period and services rendered.
This policy and procedures will ensure systematic timely reasonable transmittal and submission of claims application to PHILHEALTH office. Manual and procedures Posted by admin on July 3rd, 2011 Receives Philhealth Requirements - The Philhealth staff will scrutinize the Philhealth requirements submitted by patients/members for completeness of the documents. - The staff will evaluate the documents submitted if the member/patient is qualified to avail the Philhealth benefits. Deduct Philhealth Benefits of Discharge patient - Identify the ICD 10 Code of patient’s from final diagnosis as basis for case typing deduction of Philhealth benefits availment. - Encoding of ICD 10 Code in BizBox to reflect the case type of patient in the system. - Identify the RVS code for patient with surgical procedure for our basis in computing Philhealth Benefits of the Surgeon and Anesthesiologist. - Validates the compensable items (Pharmacy,Diagnostic & Supplies,and Operating Room if there’s an operation done to patient). - Finalize the Philhealth Benefit deduction of patient. - Informs the Biller for final printing of SOA. - Prints the itemize charges of patient Philhealth Form IV. - Encodes member/patient information in Philhealth CF2. - Prints accomplish Philhealth CF2. •
Encoding of Daily Discharge patients with Philhealth in Excel worksheet.
•
Prints Summary of Discharge
Counter checking of printed daily discharge patient against from the actual printed Philhealth CF2. • •
Prepares Philhealth Transmittal
Segregates the Philhealth Transmittal in their respectiveDepartmen(SSS,GSIS,Self Employed,OWWA or LifetimeMembers). • •
Photocopies the accomplish Philhealth CF2 and Transmittal
Endorse the accomplish Philhealth claims to Liaison Officer for transmittal to Philhealth Office
•
Receives Philhealth checks payment from Liaison Officer and Post in Philhealth Receivables in Excel Worksheet. •
Check Philhealth payments for reconciliation from the actual benefit deducted from patient. •
If there are underpayments,a letter of adjustment or re-evaluation will be given to Philhealth and to HMO (Health Maintenance Organization). • •
Submission of Monthly Mandatory Hospital Report
Receives RTH (Returned To Hospital) and complies to the deficiency of documents/information. •
Philhealth policies Posted by admin on July 3rd, 2011 Philhealth requirements should be submitted within 42 hours from the time of admission of patient. •
If the Philhealth requirements is incomplete upon submission, the lacking requirements should be submitted prior to discharge of patient. •
If the patient has no Philhealth requirements or the lacking requirements were not submitted on the given time,the patient can file directly to Philhealth Office. •
Processing of Direct Filing is one week upon receiving of the Philhealth requirements. •
Member Data Record is the primary attachment of Philhealth requirements, if the MDR is not available the secondary documents like Birth Certificate, Marriage Contract can be attach to the requirements. •
Less than 24 hours confinement is not covered, but if the patient expired,undergone surgical procedure it can be covered by Philhealth. •
Attachment of Statement of Account and Official Receipt of Hospital Bill and Doctors are required in filing our claims. •
Attachment of Clinical Abstract,Registered Death Certificate of Philhealth Form III are required in expired patient claim. •
Attachment of Operating Room Technique is required for those patient who undergone surgical procedure. • •
Filing of claims are within 60 days from the date of discharge.
•
Monthly Mandatory Hospital Report shall file every 10th of the month.
Monthly Mandatory Hospital Report collection of data from various Department is on every first week of the month. •
Philhealth RTH ( Returned To Hospital) should comply/file the deficiency within 60 days from the time we received the documents. •
Philhealth direct filing requirements Posted by admin on July 3rd, 2011 •
Accomplish Philhealth CF1I & CF2I
•
Statement Of Account
•
Official Receipt of Hospital Bill
•
Official Receipt of Doctors
•
Operating Room Technique for surgical procedure
•
Clinical Abstract for patients confined more than 10 days and expired patient
•
Updated Member Data Record
•
Philhealth CF3 for outpatient
•
Copy of Professional Fee form
Indigent members Posted by admin on July 3rd, 2011 •
Accomplish Philhealth CF1
•
Copy of Indigent Card or Sponsored Card
•
Member Data Record
•
Philhealth CF2 signed by Attending Physician
employed members (private/government) Posted by admin on July 3rd, 2011 Duly accomplish Philhealth CF1,signed by the authorized signatory of the employer/company • •
Updated Member Data Record
•
Philhealth CF2 signed by Attending Physician
OWWA members Posted by admin on July 3rd, 2011 •
Duly accomplish Philhealth CF1
•
Updated Member Data Record
•
Philhealth CF2 signed by Attending Physician
Individually paying members Posted by admin on July 3rd, 2011 •
Duly accomplish Philhealth CF1
•
Updated Member Data Record
•
ME5 atleast 9 months contribution prior to confinement
•
Philhealth CF2 signed by Attending Physician
