Philippine Health Insurance Corporation Circular No. 20, S 1998

October 19, 1998

OCA CIRCULAR NO. 55-98

 

Quoted hereunder is Philippine Health Insurance Corporation (PHIC) CIRCULAR NO. 20, S 1998, for the information and guidance of all concerned:

"PHIC CIRCULAR NO. 2, S 1998

"TO : ALL ACCREDITED INSTITUTIONAL AND PROFESSIONAL HEALTH CARE PROVIDERS, NATIONAL GOVERNMENT AGENCIES, INSTRUMENTALITIES, GOVERNMENT OWNED AND CONTROLLED CORPORATIONS, SELF GOVERNING BOARDS, STATE COLLEGES AND UNIVERSITIES

"EFFECTIVE April 1, 1998, all claims for the National Health Insurance Program (NHIP) benefits with incomplete documents or insufficient information will automatically be denied payment and returned to hospitals for completion of the documentary requirements.

"All claims requiring submission of additional documents and which are returned to hospitals should be forwarded to PhilHealth within 120 calendar days from the receipt of such claims.

"PhilHealth will return incomplete claim documents to the hospitals only once. If these returned claims are re-submitted without full compliance, this will also be disapproved. Re-submitted claims will be processed according to first in, first out policy.

"This rule applies to all claims filed a behalf of government sector employees, retirees and their dependents.

"PhilHealth will indicate the reasons for the denial or the disapproval of claims. These will be in the form of codes which will be indicated on the PhilHealth benefits voucher, PhilHealth Form No. 2 and the accompanying letter addressed to the hospital where the claims will be returned. Attached is "Annex A" to guide hospitals and NHIP members in evaluating the reasons for claims denial or approval.

"We enjoin all concerned to observe these new policies to help expedite the processing of NHIP claims.

"(SGD) ATTY. JOSE A. FABIA

PRESIDENT and CEO"

Please be guided accordingly.

(SGD.) ALFREDO L. BENIPAYOCourt AdministratorOffice of the Court Administrator

ANNEX A

REASONS FOR DENIAL/DISAPPROVAL OF PAYMENT OF NATIONAL HEALTH INSURANCE PROGRAM (NHIP) CLAIMS FOR GOVERNMENT EMPLOYEES/RETIREES

CODE NO.	DESCRIPTION OF DEFICIENCY/REQUIREMENT	BOX/FORM NO.
1	Incomplete member's name; Please submit birth certificate
	certified by the Local Civil Registry	Box 1, Form 1
2	Without or incomplete member's date of birth; Please submit
	birth certificate certified by the Local Civil Registry	Box 3, Form 1
3	Conflicting or different member's date of birth as verified from
	previous claims; Submit birth certificate certified by the Local
	Civil Registry	Box 3, Form 1
4	Incomplete patient's name; Please submit birth certificate
	certified by the Local Civil Registry	Box 11, Form 1
5	Without or incomplete patient's date of birth; Please submit
	birth certificate certified by Local Civil Registry	Box 13, Form 1
6	Name of spouse not indicated	Box 8, Form 1
7	Spouse's employer and address not indicated	Box 9, Form 1
8	Member's relationship to patient not indicated	Box 15, Form 1
9	Without member's signature	Box 17, Form 1
10	Without printed name, signature and relationship to member
	of witness to thumbmark when member cannot sign	Box 17, Form 1
11	Without registered name and address of employer and
	branch/station	Boxes 18-21, Form 1
12	Without printed name and signature of Employer's Authorized
	Representative (EAR)	Box 22, Form 1
13	Inconsistent signature of Employer's Authorized Representative;
	Submit specimen signature	Box 22, Form 1
14	Official capacity of Employer's Authorized Representative not
	indicated	Box 22, Form 1
15	Date when certification of employee's contribution was signed
	not indicated	Box 22, Form 1
16	Incorrect hospital accreditation number/no hospital accreditation
	number indicated	Box 2, Form 2
17	Address of member not indicated	Box 12, Form 2
18	Confinement period not indicated/inconsistent/tampered date of
	confinement — Please submit PhilHealth Form 3 and Clinical
	Chart	Box 14, Form 2
19	Hospital charges not properly filled up	Box 15, Form 2
20	Claim is without admission or final diagnosis	Box 13, 17, Form 2
21	Printed name and official capacity of Hospital's Authorized
	Representative not indicated (HAR)	Box 16, Form 2
22	Without signature of Hospital's Authorized Representative	Box 16, Form 2
23	Inconsistent signature of Hospital's Authorized
	Representative; Submit specimen signature	Box 16, Form 2
24	Without signature of attending physician/surgeon/anesthesiologist	Boxes 19, 24, 29,
		Form 2
25	Incorrect accreditation number of physician/surgeon/anesthesiologist	Boxes 20, 25, 30,
	or no accreditation number indicated	Form 2
26	Doctors not accredited (NA)/did not renew accreditation (NLA)
27	Doctor's charges not properly filled up	Boxes 23, 28, 33,
		Form 2
28	Part III/IV not properly filled up/not specified/itemized	Form 2
29	Hospital not accredited/did not renew accreditation
30	Hospital's change of name not yet approved by PHIC
31	Without PhilHealth Form 1
32	Regular employees without copy/matured member's GSIS
	Policy Contract; Submit renewed GSIS Policy Contract/Service
	Record
33	GSIS Retirees/Pensioners without copy of Retirement Voucher
	or Latest Retirement Certificate from GSIS or latest Pension
	Check Acknowledgment Receipt or Pension Voucher or Bank
	Account Passbook
34	Other Retirees/Pensioners without copy of Retirement Voucher
	or Certificate/latest Pension Check or Voucher/Bank Account
	Passbook and Service Record or Summary of Services or
	Certification of 120 Monthly NHIP contribution
35	GSIS Retirees under PD 1184, PD 1146 and RA 1616 who are
	less than 60 years old not covered (except under RA 660 and
	Disability Retirement) — DISAPPROVED
36	Retired judges/members of the judiciary who are less than 70
	years old not covered — DISAPPROVED
37	Retired AFP/PNP personnel below 56 years old not covered —
	DISAPPROVED
38	Casual/Temporary employee's Term Insurance (TR) expired; Submit
	renewed TR or certification of monthly premium contribution with
	specific amount, O.R. No. and date of payment by the employer
39	Barangay Officials/CAFGU members not covered —
	DISAPPROVED
40	Claim filed beyond the 60-day statutory period —
	DISAPPROVED
41	Dependent parents below 60 years of age not covered —
	DISAPPROVED
42	Children 21 years and above of age not covered —
	DISAPPROVED
43	Claim should be filed under the membership of the
	father who is employed
44	Claim should be filed under employed patient's own membership
45	Illness not compensable under Medicare — DISAPPROVED
46	The 45 days room and board benefit allowable for the year
	has been exhausted — DISAPPROVED
47	Claim is forwarded to OWWA/SSS
48	Veterans not covered as member — DISAPPROVED
49	Survivorship benefit — Dependents not covered —
	DISAPPROVED
50	Primary Hospital — without PhilHealth Form 3 and
	Clinical Chart
51	Others