KABACAN MEDICAL SPECIALIST, INC.

Kabacan, Cotabato

POLICY NO. ___________ Date: SUBJECT: PHILHEALTH MANUAL AND PROCEDURES

Philhealth policies: 1. The Record Section In-charge will make daily rounds to all inpatients to identify Philhealth members and beneficiaries; and give instructions on hospital procedures on how to avail PHIC benefits and to include the terms and conditions. SCHEDULE OF DAILY ROUNDS - 8:00am to 9:00am. 2. Philhealth requirements should be submitted within 24hours from the time of admission of patient. 3. If the Philhealth requirements are incomplete upon submission, the lacking requirements should be submitted prior to discharge of patient. “NO / INCOMPLETE PHILHEALTH REQUIREMENTS; NO PHILHEALTH BENEFITS.” 4. If the patient has no Philhealth requirements or the lacking requirements were not submitted on the given time, the patient can file directly to Philhealth Office. 5. Member Data Record is the primary attachment of Philhealth requirements. 6. Less than 24 hours confinement is not covered, but if the patient expired, undergone surgical procedure Philhealth can cover it. 7. Attachment of Statement of Account and Official Receipt of Hospital Bill and Doctors are required in filing our claims. 8. Attachments of Clinical Abstract, Registered Death Certificate of Philhealth Form III are required in expired patient claim. 9. Attachment of Operating Room Technique is required for those patient who undergone surgical procedure. 10. Filings of claims are within 60 days from the date of discharge. 11. Monthly Mandatory Hospital Report shall file every 10th of the month. 12. Philhealth RETURNED TO HOSPITAL (RTH) should comply and file the deficiency within 60 days from the time we received the documents.

Confinement in an accredited hospital for at least 24hour [except when availing of outpatient care and special package] due to an illness or disease requiring hospitalization.The following must first be met to avail of your PHILHEALTH benefits: Payment of at least three monthly premiums within the immediate six months prior to confinement. BENEFIT AVAILMENT PROCEDURES FOR OUTRIGHT / AUTOMATIC DEDUCTION OF BENEFITS: FOR DIRECT FILING / REIMBURSEMENT . Availment is within the 45days allowance for room and board. Attending Physicians must also be PHILHEALTH.accredited.

signed by the authorized signatory of the employer/company Updated Member Data Record Philhealth CF2 signed by Attending Physician OWWA members 1 2 3 Duly accomplish Philhealth CF1 Updated Member Data Record Philhealth CF2 signed by Attending Physician Individually paying members 1 2 3 Duly accomplish Philhealth CF1 Updated Member Data Record ME5 at least 9 months contribution prior to confinement .Philhealth outright filing requirements 1 2 3 4 5 6 7 8 9 Accomplished Philhealth CF1I & CF2I Statement Of Account Official Receipt of Hospital Bill Official Receipt of Doctors Operating Room Technique for surgical procedure Clinical Abstract for patients confined more than 10 days and expired patient Updated Member Data Record Philhealth CF3 for outpatient Copy of Professional Fee form Indigent members 1 2 3 4 Accomplished Philhealth CF1 Copy of Indigent Card or Sponsored Card Member Data Record Philhealth CF2 signed by Attending Physician Employed members (private/government) 1 2 3 Duly accomplish Philhealth CF1.

and Operating Room if there’s an operation done to patient). Inform the Billing . Finalize the Philhealth Benefit deduction of patient. Confinement in an accredited hospital for at least 24hour [except when availing of outpatient care and special package] due to an illness or disease requiring hospitalization. • Receives Philhealth 24 HOURS Requirements. (day 1) Encoding of ICD 10 Code in BizBox to reflect the case type of patient in the system. Availment is within the 45days allowance for room and board. • Validates the compensable items (Pharmacy.PHIC REQUIREMENTS: The following must first be met to avail of your PHILHEALTH benefits: Payment of at least three monthly premiums within the immediate six months prior to confinement. PROCEDURES EXPECTED TIME FRAMED ACTIONS • DESCRIPTTIONS The Record Section staff will scrutinize the Philhealth requirements submitted by patients/members for completeness of the documents. Attending Physicians must also be PHILHEALTH. Identify the ICD 10 Code of patient’s from final diagnosis as basis for case typing deduction of Philhealth benefits availment.accredited. • • Deduct Philhealth Benefits of Discharge patient. Diagnostic & Supplies. The staff will evaluate the documents submitted if the member/patient is qualified to avail the Philhealth benefits. FROM THE DATE OF ADMISSIO N • PATIENT FOR DISCHARGED (MGH) PATIENT’S DISCHARGE DATE Outright processing of `PHIC benefits.

(day 12) • After the 1 WEEK (Day 13) • Prepares Philhealth Transmittal • Segregates the Philhealth Transmittal in their respective Department (SSS. • Attachments of Clinical Abstract. Registered Death Certificate of Philhealth Form III as required in expired patient claim.Officer for final billing. OWWA or Lifetime Members). Signed patient’s Discharge Clearance (Cleared from the Medical Record). Provide explanations on the health actual and PHIC healthcare cost. Identify the RVS code for patient with surgical procedure for our basis in computing Philhealth Benefits of the Surgeon and Anesthesiologist. GSIS. Self Employed. Attachment of Operating Room Technique and anaesthesia record is required for those patient who undergone surgical procedure. . Completion of Deficiency • Completion of Nurses Documentation. Printing of final statement of account. Identify and note deficient data in the patient clinical records. PHIC patient member signed CF2. • The billing officer will do posting of professional fees. The Record Section incharge prints accomplished Philhealth CF2. • Photocopies the accomplish Philhealth CF2 and Transmittal Next day (day 14) MAXIMUM OF • Submission of Philhealth claims to PHIC office • WAITING TIME • Endorse the accomplish Philhealth claims to Liaison Officer for transmittal to Philhealth Office. • • • • Counter checking of After 2 DAYS actual printed Philhealth FROM CF2 against patient data PATIENT recorded in the chart DISCHARG ED (day 3) 1WEEK working days • • Signatures of Attending Physician.

• Complies deficiency of documents / informations of the returned claims.2MONTHS AFTER 2MONTHS • Receives Philhealth checks payment from Liaison Officer • Endorse PHIC Checks payments to cashier. • Posting of PHIC payments in the system. Re-file and noted. . Document and Reports to administrative office. • Check and note Philhealth payments for reconciliation from the actual benefit deducted from patient. • The Accounting Staff encode amount in the PHIC receivables. a letter of adjustment or re-evaluation may be given to Philhealth. Counter check reasons of slashing and returned claims. • If there are underpayments.

submit applicable proof of dependency. the billing section will compute and deduct your benefits from your total hospital bill. • • Agree with your attending physicians on how much is left to be paid for their services over the professional fee (PF) benefit.The following must first be met to avail of your PhilHealth benefits: • • Payment of at least three monthly premiums within the immediate six months prior to confinement.patient is not listed yet in the MDR. Confinement in an accredited hospital for at least 24 hours (except when availing of outpatient care and special packages) due to an illness or disease requiring hospitalization. For direct filing/reimbursement: Submit the following to PhilHealth or through the hospital in addition to the documents mentioned earlier within 60 calendar days after discharge: • • • PhilHealth Claim Form 2 (to be filled up by the hospital and attending physicians) Official receipts or hospital and doctor's waiver Operative record for surgical procedures performed For confinements abroad: . Upon submission of all applicable documents. • Benefit availment procedures For outright/automatic deduction of benefits: • Submit to the billing section the following prior to discharge from the hospital:   Duly accomplished PhilHealth Claim Form 1 (original) Clear copy of Member Data Record (MDR). Attending physicians must also be PhilHealth-accredited. • If dependent . Availment is within the 45 days allowance for room and board.

Prepares Philhealth Transmittal Segregates the Philhealth Transmittal in their respectiveDepartmen(SSS.Encodes member/patient information in Philhealth CF2. .Informs the Biller for final printing of SOA.The Philhealth staff will scrutinize the Philhealth requirements submitted by patients/members for completeness of the documents. • • • • PhilHealth Claim Form 1 MDR or supporting documents Original official receipt or detailed statement of account (written in English) Medical certificate (written in English) indicating the final diagnosis.Diagnostic & Supplies. . Overseas confinements shall be paid based on Level 3 hospital benefit rates. . • • • • • • Encoding of Daily Discharge patients with Philhealth in Excel worksheet.and Operating Room if there’s an operation done to patient). . Prints Summary of Discharge Counter checking of printed daily discharge patient against from the actual printed Philhealth CF2.Finalize the Philhealth Benefit deduction of patient. Manual and procedures Posted by admin on July 3rd.The staff will evaluate the documents submitted if the member/patient is qualified to avail the Philhealth benefits. . Photocopies the accomplish Philhealth CF2 and Transmittal . .Encoding of ICD 10 Code in BizBox to reflect the case type of patient in the system.Prints accomplish Philhealth CF2. .Prints the itemize charges of patient Philhealth Form IV.Identify the ICD 10 Code of patient’s from final diagnosis as basis for case typing deduction of Philhealth benefits availment. 2011 Receives Philhealth Requirements .OWWA or LifetimeMembers).Self Employed. confinement period and services rendered.Identify the RVS code for patient with surgical procedure for our basis in computing Philhealth Benefits of the Surgeon and Anesthesiologist. This policy and procedures will ensure systematic timely reasonable transmittal and submission of claims application to PHILHEALTH office.GSIS. Deduct Philhealth Benefits of Discharge patient . . .Submit the following within 180 days after discharge.Validates the compensable items (Pharmacy.

but if the patient expired. Filing of claims are within 60 days from the date of discharge. • • • • • If the Philhealth requirements is incomplete upon submission.• • • • • • Endorse the accomplish Philhealth claims to Liaison Officer for transmittal to Philhealth Office Receives Philhealth checks payment from Liaison Officer and Post in Philhealth Receivables in Excel Worksheet. Check Philhealth payments for reconciliation from the actual benefit deducted from patient. Processing of Direct Filing is one week upon receiving of the Philhealth requirements. the lacking requirements should be submitted prior to discharge of patient. If there are underpayments. 2011 Philhealth requirements should be submitted within 42 hours from the time of admission of patient. Philhealth RTH ( Returned To Hospital) should comply/file the deficiency within 60 days from the time we received the documents. If the patient has no Philhealth requirements or the lacking requirements were not submitted on the given time. 2011 • Accomplish Philhealth CF1I & CF2I . Monthly Mandatory Hospital Report collection of data from various Department is on every first week of the month. Attachment of Clinical Abstract. Marriage Contract can be attach to the requirements. Philhealth direct filing requirements Posted by admin on July 3rd. Monthly Mandatory Hospital Report shall file every 10th of the month. Member Data Record is the primary attachment of Philhealth requirements.a letter of adjustment or re-evaluation will be given to Philhealth and to HMO (Health Maintenance Organization). Less than 24 hours confinement is not covered. Philhealth policies Posted by admin on July 3rd.the patient can file directly to Philhealth Office. if the MDR is not available the secondary documents like Birth Certificate. Submission of Monthly Mandatory Hospital Report Receives RTH (Returned To Hospital) and complies to the deficiency of documents/information. • • • • • • • • Attachment of Statement of Account and Official Receipt of Hospital Bill and Doctors are required in filing our claims.Registered Death Certificate of Philhealth Form III are required in expired patient claim. Attachment of Operating Room Technique is required for those patient who undergone surgical procedure.undergone surgical procedure it can be covered by Philhealth.

2011 • • • Duly accomplish Philhealth CF1 Updated Member Data Record Philhealth CF2 signed by Attending Physician Individually paying members Posted by admin on July 3rd. 2011 Duly accomplish Philhealth CF1. 2011 • • • • Accomplish Philhealth CF1 Copy of Indigent Card or Sponsored Card Member Data Record Philhealth CF2 signed by Attending Physician employed members (private/government) Posted by admin on July 3rd.• • • • • • • • Statement Of Account Official Receipt of Hospital Bill Official Receipt of Doctors Operating Room Technique for surgical procedure Clinical Abstract for patients confined more than 10 days and expired patient Updated Member Data Record Philhealth CF3 for outpatient Copy of Professional Fee form Indigent members Posted by admin on July 3rd. 2011 • • • • Duly accomplish Philhealth CF1 Updated Member Data Record ME5 atleast 9 months contribution prior to confinement Philhealth CF2 signed by Attending Physician .signed by the authorized signatory of the employer/company • • • Updated Member Data Record Philhealth CF2 signed by Attending Physician OWWA members Posted by admin on July 3rd.

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