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Items V, VIII and IX of PhilHealth Circular No. 47, s. 2009 are hereby clarified to respectively read as underscored, to wit:

“V. CONDITIONS FOR A PREVENTIVE SUSPENSION

A preventive suspension may be issued only upon the concurrent presence or existence of the following conditions:

a. There must be a pending administrative case with the Arbitration Department against the health care provider which involves any fraudulent offense as defined under the 2004 Implementing Rules and Regulations (IRR) of Republic Act No. 7875, namely:

1. Padding of Claims (Section 140, Rule XXVIII)
2. Claims for Non-Admitted Patients (Section 141, Rule XXVIII)
3. Extending Period of Confinement (Section 142, Rule XXVIII)
4. Postdating of Claims (Section 143, Rule XXVIII)
5. Misrepresentation by Furnishing False or Incorrect Information (Section 144, Rule XXVIII)
6. Fabrication or Possession of Fabricated Forms and Supporting Documents (Section 148, Rule XXVIII)
7. Other Fraudulent Acts (Section 149, Rule XXVIII)
8. Misrepresentation by False or Incorrect Information (Section 152, Rule XXIX) or
9. Other Violations (Section 154, Rule XXIX)

b. The order of preventive suspension must be recommended by the Arbitration Department, motu propio or upon a motion by the Prosecution Department, and must be approved by the Senior Vice-President or head of the Legal Services Sector;

c. The evidence of guilt is strong against the health care provider in the pending administrative case, as determined by the Arbitration Department; and

d. The health care provider must have been previously adjudged guilty by the Arbitration Department in another administrative case also for a fraudulent offense.

VIII. DENIAL OF CLAIMS FOR CONFINEMENTS DURING THE PREVENTIVE SUSPENSION

All benefit claims filed with PhilHealth for confinements, treatments and professional services during the preventive suspension of the concerned provider shall be denied payment by PhilHealth unless such confinements, treatments and professional services are emergency in nature as contemplated under the existing rules of PhilHealth. However, such denied claims may be granted payment upon a motion for reconsideration with the concerned PhilHealth Regional Office (PhRO) and an appeal with the Protests and Appeals Review Department (PARD) where the concerned provider is subsequently absolved in the subject administrative case.

IX. MOTION TO LIFT THE ORDER OF PREVENTIVE SUSPENSION/RESOLUTION AND EFFECT THEREOF

A “motion to lift the order of preventive suspension” may be filed with the Arbitration Department by the affected health care provider within a non-extendible period of five (5) calendar days from receipt by the latter of an order of preventive suspension. The Arbitration Department shall then resolve such motion within five (5) calendar  days from actual receipt thereof through an order, as approved by the Senior Vice-President of the Legal Sector, either denying or granting the said motion. The filing of such motion shall not affect the execution of an order of preventive suspension unless the said motion is granted. Being summary in nature, a formal hearing on the motion is not required, disposition of the motion shall only be based on the submitted pleadings. No Motion for Reconsideration or Appeal from such order granting or denying the same shall be allowed and entertained.”

This circular shall take effect fifteen (15) days after its publication in a national newspaper of general circulation.

Adopted: 28 Jan. 2010

(SGD.) DR. REY B. AQUINO
President and CEO