 BENEFIT SECTION

 VALIDATION OF CHART AND FINAL DIAGNOSIS – Assessment of most resources

used for PhilHealth benefit availment and supporting documents such as Surgical
Memo, Filter Card Sticker, and Others.
 ASSIGNMENT OF ICD-10/RVS CODE FOR DIAGNOSIS AND PROCEDURES –
Identification of proper ICD-10/RVS Code based on the discharged diagnosis and most
resources used for PhilHealth benefit availment of patients.
 UPDATING OF PHILHEALTH MEMBER’S DATA RECORD – Update the PhilHealth
record of members and dependents which also includes the correctness of the
discrepancies from previous PhilHealth record.
 REGISTRATION OF SENIOR CITIZEN AND 4Ps -Enrollment of senior citizens and 4Ps
as PhilHealth members.
 EVALUATION OF PHILHEALTH DOCUMENTARY REQUIREMENTS AND
ATTACHMENTS – Evaluates the accuracy of the member/patient data information.

 CLAIMS SECTION

1. VALIDATION OF CLAIMS – Checks the completeness and accuracy of the claims

which includes attachments and the complete signature of a physician in the Claim
Signature Form.
2. REVIEW OF CLAIMS – Validates the completeness and accuracy of claims prior to
submission to PhilHealth.
3. PROCESSING OF E-CLAIMS – Processing of inpatient and outpatient claims and
submit to the PhilHealth office via E-claims.
4. RTH AND DENIED CLAIMS MONITORING – Monitoring of the PhilHealth Return to
Hospital (RTH) and Denied claims which includes the status of RTH and Denied
claims including re-filed and appealed claims.
5. CLAIMS STATUS REPORTING – Prepares report regarding the status of the
PhilHealth claims which includes, transmitted, untransmitted, paid, and unpaid
claims.