Guideline on Reimbursement of Professional Fees and Accomplishment of PhilHealth Claim Form 2 ( PhilHealth Circular No. 14-08 )

October 1, 2008

PHILHEALTH CIRCULAR NO. 14-08

 

PhilHealth reimburses professional fees of physicians based on the information written on Part II of PhilHealth Claim Form 2 and other submitted documents (e.g., official receipts, statement of account, waiver). To ensure appropriate reimbursement of professional fees, accredited health care professionals must be guided by the following in filling up Claim Form 2:

1. It is reiterated that accredited health care professionals should properly fill out Part II of PhilHealth Claim Form 2.

2. Accredited professionals should write the complete final diagnosis in Item No. 14, including the main diagnosis and other co-morbidities to enable the ICD-10 coder to arrive at the correct set of codes.

a. If possible, a doctor should provide the etiologic agent in diagnosing infection.

b. For benign and malignant neoplasm, doctor should indicate the site, morphology and behavior of the tumor.

c. In diagnosing injuries, doctor should provide the nature of injury, and if possible, the place of occurrence and the activity of the injured. cHSTEA

d. When diagnosing poisoning or adverse reaction, specify the offending agent (e.g., drug, chemical)

e. Specify if a condition is a late effect or sequelae of another condition (e.g., pulmonary fibrosis sequelae of PTB)

f. For multiple conditions, the main or primary condition must be the first diagnosis that should be written in Item No. 14 of Part II of the claim form.

3. In Item No. 15, assignment of case type (Case A, B, C or D) is based on PhilHealth Circular No. 32 series of 2006.

4. Correct information on type of service rendered and physician BIR and accreditation details should be written in Item Nos. 16 to 30.

a. On Item Nos. 16 to 18, 21 to 23 and 26 to 28, the correct information on the physician who rendered the service must be complete including: Name and signature of doctor (including date signed), accreditation number, and Bureau of Internal Revenue (BIR) Tax Identification Number. AaITCH

b. Services performed or rendered should be properly indicated in Item Nos. 19, 24 and 29. The appropriate items should be filled out for each of the following services:

	Type of Service	Part II Form 2
Medical management/daily visits/preoperative
	inpatient consultation	Item Nos. 16 to 20
Surgical procedures and other RVU linked
	services	Item Nos. 21 to 25
Anesthesia service	Item Nos. 26 to 30

c. In cases of multiple physicians providing medical management, daily visits or preoperative inpatient consultation (services for Item Nos. 16 to 20); other physicians may fill out Item Nos. 21 to 25 and Item Nos. 26 to 30 if no surgery or RVU-linked service is provided to the patient. EcHIDT

d. For claims with surgical operation or services with relative value units (RVU), the name of the specific procedure or service including the site and date of operation should be indicated in Item No. 24.

e. In cases of multiple surgeries and RVU-linked services, an additional Claim Form 2 may be used. However, only the Part I (except Item Nos. 12 and 13) and Part II of the claim form must be filled out on the additional form.

f. The actual professional fee charges and the amount deducted/claimed from PhilHealth should be specified in Item Nos. 20, 25 and 30.

i. Claims for professional fee without the actual charge or the amount deducted/claimed specified on the appropriate boxes shall be disallowed payment. For example, "AS PHILHEALTH" or "AS MEDICARE" indicated in Item Nos. 20, 25 and 30 for charges for professional fee shall not be considered for reimbursement.

 In such cases, payment shall be deferred pending submission of a written request for adjustment filed either by the doctor or member.

1. For doctor, the request shall be filed together with a properly filled out claim form 2 (indicating actual professional fee charges and exact amount claimed as deducted from the patient's bill in item numbers 20, 25 and 30 using PHIC's Certified True Copy of claim form 2) and copy of Official Receipt of professional fee.

2. For member, the request shall be filed with a copy of official receipt and waiver issued by the physician.

3. Request for adjustment should be filed within 60 days from member's receipt of Benefit Payment Notice. IAETSC

ii. For professional fees equivalent only to PhilHealth benefit, the actual amount of professional fee charges and amount deducted/claimed from PhilHealth should also be indicated in the claim form.

g. The professional who actually rendered the service should be the signatory in Part II of the Claim Form 2. For claims with surgical procedures, the name of the doctor reflected in the Surgical Technique or Operative Record should be the signatory in the Form 2.

h. Claims signed by persons other than the doctor who actually provided the service shall not be compensated. However, claims signed by the Medical Director, Hospital Administrator or Chief of Clinic in behalf of salaried physicians in government or private training hospitals may be compensated. In such cases, the phrase "PAY TO DIRECTOR/ADMINISTRATOR/CHIEF" shall be indicated on Item Nos. 19, 24 and 29.

5. Claims for professional fees with incomplete details shall not be reimbursed. This, however, does not preclude payment of hospital charges if other portions of the Claim Form 2 are properly accomplished. ISDHcT

Illustration 1: Part II of Claim Form 2

6. All reimbursement for professional fees payable to physicians shall be through Auto Credit System. The minimum prescribed balance must be retained in order to prevent closure of respective account. In case of account closure, reimbursement shall be withheld pending re-opening of a new account. Check payment for professional fees shall only be issued to member reimbursement.

7. Accredited doctors are also required to issue PhilHealth invoice or official receipts on professional fees paid by members as prerequisite for processing professional fees.

a. If PhilHealth benefit was deducted from the actual charge, total charges with the exact amount deducted must be specified in the invoice/official receipt.

b. If no PhilHealth deduction was applied, the invoice/official receipt should clearly indicate full payment. Doctors are required to issue Professional Fee waiver to facilitate reimbursement of members. cCSDaI

8. It is recommended that the Official Receipt must be duly signed by the member or his/her representative conforming to the PhilHealth deductions applied.

Illustration 2: Sample

ERIC REJUSO, MD

OFFICIAL RECEIPT

This Circular shall take effect for all claims with admission dates starting October 1, 2008.

For compliance and guidance.

(SGD.) LORNA O. FAJARDO, CESO IIIActing President and CEO

Published in The Philippine Star on July 15, 2008.