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(NAR) VOL. 14 NOS. 3-4 / OCTOBER - DECEMBER 2003
[ PHILHEALTH CIRCULAR NO. 68, S. 1999, August 05, 1999 ]
MEASURES TO FACILITATE PROCESSING OF MEDICARE CLAIMS
1. Claims for multiple outpatient procedures:
One claim maybe filed for multiple outpatient procedures indicating multiple dates in Form 2. This shall include hemodialysis, chemotherapy, and radiotherapy.
2. On professional fees:
A. Claims without signatures of attending physician, surgeon and/or anesthesiologist shall be processed but only hospital charges will be correspondingly paid. Professional fees will not be paid.
B. Claims without actual charges for professional fees shall be returned to the hospital for completion. The same will actually apply to claims with concomittant HMO benefits.
C. In case the signature is not affixed, the physician may request for payment of professional fees provided the following are submitted to RHIO/Central Office within 60 days upon receipt of refund from PhilHealth: a) letter requesting for adjustment of claim/s concerned, b) photocopy of PhilHealth Form 2 bearing original signature of attending physician and c) photocopy of paid claim voucher.
3. Adjustment of Payment Claims:
Re-evaluation of previously paid claims with a corresponding request for possible adjustment of payment shall be accorded 60 days from receipt of PhilHealth Check and Voucher by the hospital and member. This request may include those adjustment of claims where the members failed to attach original receipts for medicines bought outside the hospital but within the confinement period, underpaid claims for room and board, laboratory procedures, O.R. fees or doctor's professional fees, but excluding adjustment relative to PhilHealth Circular No. 52, s. 1999 regarding increase in NHIP benefits.
4. On female claims:
A female member may declare her children as her dependents even if her husband is employed and also covered by the National Health Insurance Program, provided that the dependent/s declared by one parent shall no longer qualify as dependent/s of other parent (reiterating Rule 1 Sec. 6 of IRR, R.A. 7875).
5. For retiree pensioners:
Bank Account Passbook shall be honored, regardless of the number and consistency of the entries.
6. For dependents of employed members there is no need for any proof of dependency as long as his/her employer signs Philhealth Form 1, certifying the data supplied by him/her on Part 1 are true and conform with their available records.
7. If the dependent child reaches the age of 21 years old during confinement period the whole claim shall be considered for processing.
8. Submission of original official receipts:
In case where the member and/or patient had paid the hospital bill/s, the claim should be supported by official receipt/s OR duly issued by the hospital/pharmacy/attending physician. Tape receipt shall not be considered for purposes of payment.
Please be guided accordingly.
Adopted: 05 Aug. 1999
(SGD.) ENRIQUE M. ZALAMEA
President and CEO