PHILHEALTH SECTION

OBJECTIVE OF THE SECTION

The section focuses on efficient and effective processing of PHIC claims ensuring adequate
benefits and availment in compliance with the policies, guidelines and circulars mandated by
PHILHEALTH

CURRENT MANPOWER:

Regular Employees- 28
Job orders- 47
Total : 75

UNITS:

1. Receiving Unit
2. Availment Uni
3. CF2 Unit
4. CF4 Unit
5. Claims Review Unit
6. Testing Unit
7. Transmittal Unit
8. RTH and Denied Claims Unit

PROCESSING TIME IN THE PROCESSING OF PHIC CLAIMS:

Processing of PHIC Claims shall take 57 days (based on the target) from date of discharge of
patients and upon endorsement of PHIC Claims by Billing Section/ Social Worker to Transmittal of E-
Claims

PROCESS FLOW IN THE PROCESSING OF PHIC CLAIMS

1.) Receiving of PHIC Requirements (mandatory requirements: CSF or Claim Signature Form and PBEF or
Philhealth Benefit Eligibility)

2.) Availment of Proper PHIC Benefit Package- PHIC staff based on its final diagnosis

3.) CF2 Encoding- PHIC staff encodes relevant data of the patient and member in BIZBOX System

4.) CF4 Encoding- PHIC staff encodes pertinent clinical information of a patient/member during their
hospitalization/episode of care in BIZBOX System

5.) Claims Review Unit- PHIC staff reviews the claims with its supporting documents as to completeness
and accuracy prior to signing of HCI

6.) Signing of HCI Representative- HCI representative signs the claim after

7.)Transmittal of E-Claims- uploads claim form and other supporting documents to the Philhealth System
OKR PERFORMANCE TARGETS OF THE SECTION

Financial Perspective (OKR1)

1) 95% timely processing and transmittal of claims to PHIC Regional office within 57 days from
discharge
2) 98% of complete Z-benefits documents received shall be submitted to Philhealth Office within 3
working days
3) 98% of Type Z Benefit Package pre authorizations are signed within 3 working days from date of
receipt of PHIC requirements
4) 95% timely processing and transmittal of RTH claims to PHIC Regional office within 60 days from
date of receipt
5) Reduction of Return To Hospital Claims of less than 4% compared from previous year
6) Reduction of Denied Claims of less than 4% compared from previous year

Customer Perspective(OKR2)

1) 100% of the documented queries and concerns are properly addressed upon receipt

Internal Process Flow (OKR3)

1.) 95% timely processing of all MGH Patient's Charts within 30 minutes from the time the patient is
tagged as MGH in Bizbox System
2.) 100% of PPMP shall be submitted on or before the deadline

Learning and Growth Perspective (OKR4)

1.) 100% of Philhealth Staff are ICD Trained

2.) 100% of qualified employees of certain criteria are awarded

RETURN TO HOSPITAL CLAIMS

These are deficient claims after due adjudication and validation, redirected back to the Health Care
Institution (HCI) with instructions to comply with certain requirements, but from which the action of
returning the complied claim to PhilHealth may result in the reversal of the deficiency into a good claim
or non-compliance that may result into the denial of the claim.

DENIED CLAIMS
Denied claim is a claim that has been determined to be invalid and unworthy of
payment/reimbursement due to an absolute deficiency that cannot be remedied through Return to
Hospital (RTH) or due to a finding of an unmet requirement.

HOW TO REDUCE NO. OF RTH AND DENIED CLAIMS RECEIVED?

1. Strict adherence of all Philhealth circulars, policies and guidelines in the processing of PHIC
Claims
2. Thorough review of all Philhealth claims as to the accuracy and completeness before
transmitting to Philhealth System.
List of Accredited PHIC Z-Packages of Vicente Sotto Memorial Medical Center as of JULY 2022

Z-BENEFIT PACKAGE CONTRACT DATE COVERAGE

1. Coronary Artery Bypass Grafting- December 10, 2014 550,000.00

2. Kidney Transplant- January 1, 2015 600,000.00

3. Tetralogy of Fallot- April 30, 2016 320,000.00

4. Ventricular Septal Defect- April 30, 2016 250,000.00

5. Cervical Cancer- December 10, 2014 175,000.00

6. Breast Cancer- January 12, 2016 100,000.00

7. Orthopedic Implants- January 7, 2015 169,400.00 (Cementless Implant)

103,400.00 (Cemented Implant)

73,180.00 (Bipolar Implant)

8. Peritoneal Dialysis (PD) First- June 23, 2020 270,000.00/YEAR

What is no balance billing policy of PhilHealth?

The No Balance Billing (NBB) policy was among the first policies of PhilHealth that aimed to drastically
reduce patients' out-of-pocket expense to ensure financial risk protection for indigent, sponsored,
domestic worker or kasambahay, senior citizen, and lifetime members.
1. What is the Vision, Mission, Core Values and Quality Policy of VSMMC