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1.0 ADMISSION AND PHILHEALTH ELIGIBILITY VERIFICATION

ADMISSION:

  • Patient admitted to the hospital.

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DOCUMENTATION:

  • Hospital staff collect patient information and medical records.

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VERIFICATION:

  • Verify the patient’s PhilHealth Membership status.

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If the status is YES:

  • Ask relatives/patient about previous hospitalizations and whether there has been any confinement in other hospitals.

    • If Yes, inform the relatives/patient that they need to request a Certificate of PhilHealth Availment from the previous hospital and submit it to the hospital's PhilHealth staff before the issuance of PhilHealth approval.

    • If they fail to submit the required document, PhilHealth availment shall be disapproved.

  • If No, the hospital's PhilHealth staff will proceed with the issuance of PhilHealth approval.

 

If the status is NO:

  • Determine the documents that relatives/patient need to submit:

    • If NO due to undeclared dependent child/spouse:

      • Relatives/patient must submit documents such as PMRF, birth certificate, marriage certificate, and valid IDs.

  • If NO due to updated status (e.g., Single to Married):

    • Relatives/patient must submit documents such as PMRF, marriage certificate, and valid IDs.

  • If NO due to discrepancies in first name, middle name, surname, suffix, or birthday:

    • Relatives/patient must submit documents such as PMRF, birth certificate, and valid IDs.

  • If NO due to the allowable limit being exhausted (45 days or 156 days for Hemodialysis):

    • PhilHealth availment shall be disapproved.

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Failure to submit required documents shall result in the disapproval of PhilHealth availment.

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1.1 PHILHEALTH DEDUCTIONS

DISCHARGED:

  • The patient must be marked as "Discharged" by billing staff before proceeding with PhilHealth deductions.

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REVIEW PATIENT HISTORY:

  • The hospital's PhilHealth staff must review the patient's history to ensure all information declared by the relative/patient matches and is correct.

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PATIENT DISPOSITION:

  • The nurse station must first set the patient's disposition as Improved, Recovered, HAMA, Transfer, or Deceased.

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PATIENT FINAL DIAGNOSIS/PROCEDURES:

  • The nurse on duty must encode all diagnoses provided by the attending physician completely, including procedures with RVS codes, before review by the hospital's PhilHealth staff.

  • If the diagnosis is NOT COVERED by PhilHealth:

    • The hospital's PhilHealth staff must contact the attending physician to inform them of the situation and request a possible secondary diagnosis that may match the patient's illness and be covered according to PhilHealth ACR.

  • If procedures lack RVS codes in the system:

    • The hospital's PhilHealth staff must contact the attending physician to request appropriate codes for the rendered procedures.

 

PREVIOUS HOSPITALIZATIONS:

  • The hospital's PhilHealth staff must verify the patient's previous hospitalizations to ensure no conflict, particularly concerning the same illness within 90 days (Single Period of Confinement - SPC).

 

CODING:

  • The hospital's PhilHealth staff must analyze and apply the appropriate ICD/RVS code and deduct the amount for healthcare facilities and professionals according to PhilHealth's All Case Rates.

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Notes:

  • If the patient is tagged as "Transferred," PhilHealth availment shall be disapproved.

  • If the current illness matches the previous hospitalization within 90 days, SPC shall be applied, and PhilHealth availment will automatically be disapproved.

  • If patient history and diagnosis match, PhilHealth deductions will be completed within 3–5 minutes. If a revision of the diagnosis is needed, it will depend on the attending physician's response.

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1.2 CLAIMS PROCESSING

CLAIMS PREPARATION:

  • All received claims and the SOA must be submitted daily to the claims processing section.

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CLAIMS PROCESSING:

  • The claims processor is responsible for encoding Claim Form 2 (CF2) and Claim Form 4 (CF4).

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In CF2:

  • Encode claims information such as member/patient information, confinement information, final diagnosis, procedures, ICD/RVS code, doctor’s information, PhilHealth package, and hospital charges.

  • Print CF2.

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In CF4:

  • Encode the patient’s data, reason for admission, physical examination findings, ward course, and drugs/medications written on the patient chart.

  • Download and print CF4.

  • Review claims thoroughly to avoid returns or denied claims.

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CLAIMS CHECKING:

  • Claims checkers must ensure there are no missing attachments, incomplete forms, or missing signatures of the patient/member, healthcare professionals, and provider information.

  • If attachments such as operative techniques are missing, notify and forward the request to the attending physician for immediate completion.

  • If Claim Form 3 (CF3) is incomplete, notify and forward the request to the attending physician.

  • If the ward course for pediatric, surgery, or OB-Gyne cases is incomplete, notify and forward the request to the attending physician.

  • If healthcare professional signatures are missing, notify and forward the request to the attending physician for completion.

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1.3 SCANNING AND CLAIMS SUBMISSION

SCANNING OF CLAIMS:

  • Required documents include:

    • Claim Signature Form (CSF)

    • Statement of Account (SOA)

    • PhilHealth Benefits Eligibility Form (PBEF)

    • Claim Form 2 (CF2)

    • Claim Form 4 (CF4)

    • Claim Form 3 (CF3)

    • Operative Technique (OR)

    • Laboratory results

    • Other required documents

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SUBMISSION OF CLAIMS:

  • Attach all scanned documents before submission, including:

    • Claim Signature Form (CSF)

    • Statement of Account (SOA)

    • PhilHealth Benefits Eligibility Form (PBEF)

    • Claim Form 2 (CF2)

    • Claim Form 4 (CF4)

    • Claim Form 3 (CF3)

    • Operative Technique (OR)

    • Laboratory results

    • Other required documents

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