Philhealth

I – Duties and Responsibilities

A. Philhealth Claims Officer

•  Final review of claim for completeness and accuracy prior to transmittal.

•  Maintains complete record of PHIC Circulars, rules and regulations governing eligibility and claims of members

•  Leads in implementing circulars

•  Facilitates appeal of denied Claims

•  Submits report that will be required by CEO, Medical Director & CFO

•  Arranges work schedule and rest schedule of Staff

•  Identifies job vacancies

•  Gives job description to newly hired personnel

 B. PHIC Billing Clerk

•  Encodes and prints PBEF result 

•  Deducts Philhealth Benefit 

•  Processes CSF and CF2 

•  Prepares daily monitoring of patients

•  Final review of claim for completeness and accuracy prior to transmittal (DIALYSIS PATIENTS)

•  Reviews philhealth deduction and processing of claim (DIALYSIS PATIENTS)

C. Dialysis Clerk

•  Verifies philhealth eligibility of patient

•  Interviews and review of patient’s previous admission record

•  Screens patient enrollees for dialysis

•  Monitors eligibility of dialysis patients for philhealth deduction (whether exhausted or not)

•  Reviews Philhealth deduction and processing of claim (DIALYSIS PATIENTS)

•  Deducts Philhealth Benefit (dialysis patients)

•  Prepares attachments to claim (Hemodialysis Treatment Sheet, CF4)

D. Scanner

•  Scans all required documents needed to complete the claim for transmittal (these may include Clinical Chart, diagnostic results, Claim forms)

•  Attaches to claim the scanned documents

•  Assists dialysis clerk for Philhealth deduction

•  Performs oth

E. Encoder

•  Encodes the content of CF4 and other details required from Claim Signature Form

•  Assists dialysis clerk for Philhealth deduction

•  Performs other tasks that will be assigned related to claim processing and transmittal

II – DEFINITION OF TERMS

a.  Direct contributors – Refer to those who have the capacity to pay premiums, are gainfully employed and are bound by an employer-employee relationship, or are self-earning, Professional practitioners, migrant workers, including their qualified dependents and lifetime members.

b.  Indirect contributors – Refer to all others not include as direct contributors, as well as their qualified dependents, whose premium shall be subsidized by the national government including those who are subsidized as a result of special laws.

c.  Financially incapable – Refers to a state where a person demonstrates clear inability to pay premium contributions or spend for necessary expenditures for one’s medical treatment as assessed and certified by DSWD, medical social workers, or social worker officers of the LGUs.

d.  Financial capable – Refers to a state where a person demonstrates clear ability to pay premium contributions or spend for necessary expenditures for one’s medical treatment as assessed and certified by DSWD, medical social workers, or social worker officers of the LGUs.

e.  Certificate of Financial Assessment – Refers to a document issued by the Medical Social Workers or Social Worker Officers of the LGUs attending to the level of capacity of the member to pay the prescribed premium contribution based on DOH or DSWD assessment tool. It is valid only within the calendar year and may be re-issued in the subsequent year/s.

f.  Notice of Premium Contributions – Refers to a system-generated document issued during availment of PhilHealth benefits to notify the members of their unpaid premium/s including interest.

g.  Self-Earning Individuals – Refer to those who render services or sell goods as a means of livelihood outside of an employer-employee relationship or enterprises owned and operate by employers which may employ fewer that ten (10) employees or informal sectors such as seasonal employees engaged in the production of goods and services with the primary objective of generating employment and income for the persons concerned including job order contractors and project-based contractors.

h.  Immediate Eligibility – Refers to is the automatic entitlement from selective to full array of PhilHealth benefits in accordance with the criteria and limits set by the Corporation.

III – IMPLEMENTING POLICIES AND PROCEDURES

A.  Type of Membership

Direct Contributors

•  Employees with formal employment

•  Kasambahays

•  Self-earning individuals; Professional practitioners

•  Overseas Filipino Workers

•  Filipinos living abroad and those with dual citizenship

•  Lifetime members

•  All Filipinos aged 21 years and above with capacity to pay

Indirect Contributors

•  Indigents identified by the DSWD

•  Beneficiaries of Pantawid Pamilyang Pilipino Program

•  Senior citizens

•  Persons with disability

•  Sangguniang Kabataan officials

•  Previously identified at point-of-service / sponsored by LGUs

•  Filipinos aged 21 years old and above without capacity to pay premiums

B.  General Guidelines

a.  All Filipinos shall be granted immediate eligibility and access to PhilHealth benefits.

b.  Immediate eligibility shall apply to all services and basic accommodations in HCIs.

•  Provide, Filipinos with full payment of premiums from the reckoning date to the date of admissions shall be eligible to avail their benefits in non-basic accommodations in accredited private hospitals.

•  Provide further, that Filipinos without full payment of premiums must settle the unpaid premiums with interest as provided in PhilHealth Circular No. 2019-0009 in order to avail of the full range of benefits.

c.  All indirect contributors shall be considered to have paid their premiums in full within the prescribed validity period.

d.  To maximize benefit entitlement, Filipinos shall register under the NHIP, update their personal records and regularly pay their premium contributions.

e.  PhilHealth shall provide for an online process to verify members’ records prior to processes.

f.  The online verification system shall generate a Notice of Premium Contribution to be received and acknowledged by the member Registered Filipinos with unpaid contribution.

C.  Availment of Philhealth Benefit

1.  Upon Admission: Forms “CSF & PMRF” are available at the INFORMATION / ADMITTING section.

2.  Fill-out the form and please write in “CAPITAL LETTER” using BLACK PEN only and strictly NO Erasures. For any inquires or additional information needed please look for PHILHEALTH REPRESENTATIVE (PCARES) 8am-2pm from Monday-Friday; this is for updating and other concerns regarding Philhealth records.

3.  Return filled out form at INFORMATION / ADMITTING for the generation of Philhealth Benefits Eligibility Form (PBEF)

Note: Newborns need to be declared as dependent, please coordinate with PCARES.

4.  Bring documents (PBEF, CSF, and PMRF) to PHILHEALTH DEPARTMENT for checking and verification of Philhealth.

5.  Philhealth forms verified from PHIC DEPARTMENT will be forwarded by clerk to billing section for Benefits deduction. Generated PHIC forms must be completely signed by PHIC member/representative prior to release of Statement of Account.