(NAR) VOL. 24 NO. 2 / APRIL - JUNE 2013
Republic Act No. 8792, known as the “Electronic Commerce Act of 2000” provides that information in the form of electronic documents or electronic data message “shall have the effect, validity or enforceability as any other document or legal writing" for as long as “said electronic document maintains its integrity and reliability and can be authenticated so as to be usable for subsequent reference”.
In 2011, the Corporation launched the eClaims Project by virtue of PhilHealth Circular No. 014-2011. The project was a strategic approach towards improving operational efficiency in health insurance claim processing by enhancing information technology (IT). It empowered institutional health care providers (IHCP) by providing them with standards for automation of claim transactions to PhilHealth. It consisted of three modules aimed at providing institutional healthcare providers (IHCP) with the online capability to verify a patient's eligibility for health insurance, to submit claims electronically, and to track the status of reimbursement. Implementation was by phase and only the first module was released.
However, two years after initial implementation, only five percent of hospitals nationwide had availed of this amenity. Of these, more than half engaged IT companies to provide the application that would enable them to connect to PhilHealth.
As PhilHealth strives to attain its goal of financial risk protection for all Filipinos under the Universal Health Care(UHC) framework, membership has increased and more health insurance benefit packages have been developed to address the health needs of members. This has resulted in a corollary increase in availment of benefits and in the volume of claims. This marked volume increase, under existing operational systems and workforce, translated to a corresponding lag in claim processing and payment mechanisms, and hence, poorer client satisfaction. This chain reaction has highlighted the need to reform business transactions between PhilHealth and its partners.
The Corporation noted that the involvement of an IT company as a third party in electronic claims transactions is pivotal in expediting the implementation of the project. Through PhilHealth Circular 038 series 2012, otherwise known as the “Accreditation of Health Information Technology Providers,” (HITPs) the policy framework for recognizing information technology companies, as links in providing IHCPs with the means to connect to PhilHealth and transact business electronically, was established.
In view of the foregoing considerations, PhilHealth is scaling up the eClaims project to ensure that core processes for claim transactions are performed with utmost efficiency. The goal of the enhanced Claims system is to establish an effective, standards-based transaction system between IHCPs that would efficiently improve claims processing.
Hence, the full eClaims system is expected to tremendously simplify claim processes thereby drastically reducing turnaround time in processing and hastening payment to IHCPs.
II. DEFINITION OF TERMS
- Certificate authority - a third party that issues digital certificates and is trusted by both the sender and the recipient.
- digital certificate - an electronic document which pairs a digital signature with a public key, which ensures authenticity of the document (that is sent by the person who is supposed to send it and not someone else pretending to be him/her) and that the document is meant to be read by another person who is authorized to do so.
- eClaims tracking dashboard - a monitoring tool to determine eClaims utilization
- eClaims utility - the front-end eClaims application provided by health information technology providers (HITP) that complies with any or all of the standards on eClaims modules 1 to 3.
- eClaims web service - a set of standard application programming interfaces (APIs) provided by PhilHealth for electronic transactions.
- electronic document - in R.A. 8792 (e-Commerce Law) refers to information or the representation of information, data, figures, symbols or other modes of written expression, described or however represented, by which a right is established or an obligation extinguished, or by which a fact may be proved and affirmed, which is received, recorded, transmitted, stored, processed, retrieved or produced electronically.
- health information technology provider - also called HITP; a third party information technology provider accredited by PhilHealth after having met the minimum requirements for managing transactions between IHCPs and the Corporation (PhilHealth Circular No. 038 series 2012).
- provider - when not specified, refers to both IHCP and HITP
- tracking number - the code generated in module 1 as proof that the eligibility of the member has been verified and affirmed. Its absence denotes deficiency thereby requiring submission of documentary evidence.
III. THE PHILHEALTH ELECTRONIC CLAIMS SYSTEM
A. The eClaims System Framework. The eClaims System is an interconnected modular information system for claim reimbursement transactions beginning from the time a patient signifies the intention of using a PhilHealth benefit, and ends when the claim is paid. It possesses the following automated features, to wit: 1) ability for IHCP to determine eligibility of patient to avail of insurance; 2) ability to submit a claim online; 3) ability of IHCP to track and verify the status of its claims; 4) ability for PhilHealth to review and process a submitted claim; and, 5) ability for IHCP to be reimbursed for the claim. The first three are tasks performed at the IHCP side while the other two are performed by PhilHealth.
B. Properties of the eClaims System
- The eClaims System is divided into five modules.
Module 1. Claim Eligibility Web Service (CEWS). Launched in 2011, it allowed an IHCP to determine eligibility of a member to avail of an insurance benefit based on patient type and qualifying contributions. It was enhanced to provide a view into compensability of a claim based on PhilHealth rules on annual maximum 45 days confinement, premium payments per member type, and professional healthcare provider status. It also serves to instruct PhilHealth member with compliance to particular deficiencies. To utilize this feature, IHCP will have to input the following information:
- Member and patient data:
- Member name, PhilHealth identification number, birth date, address, membership type, employer name and PhilHealth employer number
- Patient name, birth date, admission and discharge dates
- Procedure performed (RVS)
- IHCP and professional healthcare provider (PHCP) accreditation number
Module 2. Electronic Claim Submission (ECS). This module consists of attributes specified in PhilHealth Claim Forms as Extensible Markup Language (XML). It also allows documents (i.e. official receipts, laboratory results, operative records, etc) required for arbitration and evaluation to be submitted in a format prescribed by PhilHealth (i.e. portable document format or PDF).
Module 3. Electronic Claim Status Verification (CSV). This module functions as a required add-on feature in the eClaims system. It enables an IHCP to track a submitted claim, map it against its own information system, and verify the adjudication and payment status of a claim.
Module 4. Electronic Claim Review and Processing. A module that simplifies the number of processing steps for a claim and enables medical and non-medical adjudicators to review claims in a systematic manner and support decision-making.
Module 5. Auto-Credit Payment of Claim. PhilHealth Circular No. 043 series 2012, also known as the “Reimbursement of Hospital Claims through Auto-Credit Payment Scheme (ACPS)”, provides the guidelines for settling a provider's claim through direct crediting to an IHCP deposit account. The eClaims system shall adopt this mechanism, and for this purpose, it shall be referred to as “Module 5”.
- Data security, privacy, and confidentiality. The eClaims system ensures that all data collected, including personal information and health records, and transmitted through the use of information and communication systems provided by juridical entities, are in accordance with Republic Act No. 10173, otherwise known as the Data Privacy Act of 2012. As such, all electronic claim transactions will be conducted through dedicated telecommunication lines and secure internet connection. In general, PhilHealth security standards that will govern information exchange among IHCP, HITPs and PhilHealth, as specified under PhilHealth Circular No. 038 series 2012, will cover the following:
• security and privacy policies
• data center
• front end security and authentication
• database security
• semantic security (data dictionary and document type definition)
• transmission security
- The Role of a HITP. After having passed rigorous conformance and compliance tests with PhilHealth standards, HITPs were recognized as being qualified to assist IHCPs. They will provide IHCPs with a set of integrated systems and services and ensure secure connection at points of electronic transmission of claims information. Under PhilHealth Circular No. 038 series 2012 on the accreditation of HITP, the HITP will act as a conduit for electronic transactions on claim reimbursements from the IHCP to PhilHealth and vice versa.
IV. THE PHILHEALTH ECLAIMS IMPLEMENTATION GUIDE (PECIG)
There shall be a manual of procedures called the PhilHealth Electronic Claims Implementation Guide (PeCIG). It contains the PhilHealth standards for developing eClaims Modules 1 to 3. It shall be provided to HITPs. It shall be regularly updated to include new system requirement specifications. Every version shall be properly indexed and covered by an advisory prior to its release to the relevant provider. The edition shall also adequately state the PhilHealth policies it has addressed. The PeCIG shall be posted in the Corporate website.
- The eClaims System shall apply to all case rates and special benefit packages (such as Outpatient malaria Package, Outpatient HIV/AIDS Treatment, Maternity Care Package, Newborn Care Package, TB-DOTS Package, Animal Bite Treatment Package, etc).
- The System shall not cover reimbursement claims filed under the following:
- fee-for-service payment
- directly-filed claims
VI. GENERAL GUIDELINES
- All IHCPs shall be required to be eClaims System compliant by the end of 2015.
- There shall be a signature form prescribed (Annex A) for patient and doctor/s It shall be a mandatory supporting document scanned and uploaded with every claim file. This will be required until a new signature mechanism is implemented.
- The IHCP head (i.e. hospital director, chief of hospital) shall be responsible for ensuring the quality (i.e. validity, accuracy, completeness, etc.) of the data submitted electronically.
- Electronic data received by PhilHealth and stored in its database shall be its property and shall not be accessible to IHCP or HITP.
- Submitted electronic claims shall be deemed final, hence, valid for action by PhilHealth. Only PhilHealth may access, retrieve and open the file.
- Electronic claim review, adjudication and payment by PhilHealth shall be conducted following existing policies.
- All submitted claims, together with its attached documents, must be stored and archived at the provider end, in accordance with Republic Act No. 9470, otherwise known as “National Archives Act of 2007”.
- Security over personal and health information processing and transmission must be ensured by provider, in accordance with the Data Privacy Act of 2012.
- IHCP reserve the right to decide which HITP they shall engage with.
- PhilHealth shall not be party to contractual obligations for services or applications between IHCP and HITP.
- Contractual obligations between IHCPs and HITP should contain relevant provisions of “Obligations and Undertakings of HITP”, provided in the Business Agreement of PhilHealth Circular No. 038, series 2012.
- Provider should be able to comply with future system updates within a prescribed period of time set by PhilHealth.
- Encoding of claims whether by HITP or IHCP shall be done within the premises of IHCP compound.
VII. SPECIFIC GUIDELINES
- HITP shall only charge IHCP client for every successful claim paid by PhilHealth.
- PhilHealth may, at any time, set allowable rates for transaction charges, should the necessity arise after monitoring and evaluating the performance of HITPs.
B. ENGAGEMENT OF IHCP
- All IHCPs shall implement the eClaims System through a HITP.
- IHCP must possess the following minimum requirements for eClaims:
- Desktop computer
- Internet connection or leased line with minimum guaranteed bandwidth of 512kbps
- Document scanner that support at least 2400 dpi and legal size documents
- Landbank account, details of which must be submitted to its respective PhilHealth regional office, in accordance with guidelines provided under PhilHealth Circular No. 043 series 2012 known as the “Auto-Credit Payment Scheme”.
- An IHCP shall have the prerogative to determine which HITP it will engage with, based on a roster of accredited HITPs posted on the PhilHealth website.
- The IHCP shall ensure that all the requirements of PhilHealth for an eClaims utility in their facility are met, including subsequent system requirements provided in future issuances.
- IHCP shall ensure that personnel authorized to handle eClaims utilities and encode claim data are adequately trained by its HITP.
- There shall be contract agreements between IHCP and HITP for the minimum services required for eClaims.
C. ENGAGEMENT OF HITP
- The HITP shall provide the following mandatory services to IHCP:
- Utilities, software, web servers, proxies, URLs or any tools that will enable the IHCPs to access the eClaims web service thru the HITP facilities.
- after sales service (helpdesk);
- capability building of IHCP personnel assigned to the eClaims utility;
- assistance to IHCPs in acquiring and installing digital certificates obtained from duly recognized certificate authorities for authentication, digital signing and encryption. However, it should ensure the following:
- Encryption from point of transmission and decryption to PhilHealth through the leased line;
- Compatibility of client certificate with PhilHealth, for decryption purposes.
- HITP shall register to PhilHealth all of its IHCP clients with the eClaims Web Service. It shall email to PhilHealth at email@example.com a scanned copy (PDF) of the IHCP eClaims Account Registration Form (Annex B) duly signed by the HITP and IHCP authorized representatives.
- Before registration, HITP must ensure that a digital certificate had already been installed in the IHCP. A screenshot of the certificate installed in the IHCP must be attached to the registration form.
- HITP shall ensure that all the requirements of PhilHealth for an eClaims utility in their facility are met, including subsequent system requirements provided in future issuances;
- HITP shall maintain a record of digital certificates installed in corresponding IHCP clients.
- HITP shall ensure secure storage of claim files for its IHCP clients, whether in its data center or at IHCP server.
- HITP shall be required to submit an electronic report regularly to PhilHealth. The format of this will be presented in a subsequent issuance.
E. DOCUMENT ATTACHMENTS
- There shall be a minimum set of mandatory supporting documents to an electronic claim (Annex C) as required under existing policies. This is to enable adequate adjudication and post payment audit of the claim.
- Supporting documents (i.e. diagnostic results, operative records, etc.) shall be scanned and saved in provider server.
- The URL of these scanned files shall be embedded into the respective XML claim, in conformance with the standard prescribed by PhilHealth.
- Scanned files shall be saved as portable document format/archive (PDF/A) version.
- IHCP must require Claim Form 1 (CF1) or its electronic form (e-CF1), from member, if, under Module 1 query:
- Member type is categorized as “employed” but PhilHealth response displays “submit proof of contribution”;
- Member type is categorized as “sponsored”, “individual-paying” member, or “lifetime” member, but member declares to be “employed” at the time of benefit availment. If the e-CF1 is not available, then proof of contributions must accompany the scanned CF1.
- Member categorized as “individual-paying” member but declares to be “sponsored” or enrolled under the NHTS or PPPP or CCT or by the LGU.
- Providers shall ensure that scanned documents are stored encrypted in its resting state on a secure file repository accessible only to PhilHealth.
- Provider shall make accessible and readable to PhilHealth, electronic supporting documents stored at the IHCP or HITP level that may be necessary during adjudication and post-payment audit.
F. RE-FILING CLAIMS THROUGH ELECTRONIC SUBMISSION
- Under Module 2, each claim submitted shall be assigned a claim series number (CSN).
- The same CSN of a previously submitted claim shall be utilized when re-filing a claim tagged as "return" to hospital for compliance of document deficiencies. The same claim shall be uploaded again together with the required document attachment.
- Request for adjustment and motion for reconsideration for the denied claim shall still undergo the usual filing procedure.
G. MEMBERSHIP AND CONTRIBUTIONS
- Module 1 (CEWS) provides a tracking number if there is no supporting document required from the member. Such number only means that the member is eligible to avail of an insurance benefit. It shall not be construed to mean that such claim is automatically compensable.
- IHCP shall ensure that contact number/s and/or email address of member is encoded in the XML claim.
- All electronic claims payable to IHCP, hospital chiefs/directors and professional healthcare providers shall be paid through the auto-debit payment scheme, or post-dated check issuance.
- Claims payable to member may be paid through post-dated checks.
VIII. INFORMATION SECURITY
- Providers shall ensure that only duly authorized personnel have access to eClaims utilities. Additionally, providers should have appropriate means to secure personal health information (PHI) and its use within its operations including exchanges of confidential health information with other partners. Each must provide a means to authenticate authorized users.
- PhilHealth must be promptly notified as soon as unauthorized access is detected.
- Providers are required to develop, maintain and implement policies and procedures for protecting PHI stored electronically which includes backups, archives and live electronic records.
IX. ECLAIMS PROCESS FLOW
1. The eClaims process flow shall be as presented in Annex D (ECLAIMS USER GUIDE):
- Eligibility checking
- Initial Call
- Final Call
- Claim Submission
- Claims Status Verification
X. TESTING/DEMONSTRATION OF ECLAIMS UTILITY
1. Demonstrations of eClaims modules by the HITP to IHCP will be done in a test environment prescribe by PhilHealth.
XI. MONITORING AND EVALUATION
- The eClaims system in every provider shall be monitored regularly. PhilHealth shall provide a tracking scheme to ensure security and proper usage of such applications.
- There shall be a prescribed on line community forum where IHCP, HITP, and PhilHealth may interact and discuss concerns.
- Electronic claims will be subjected to post-audit systems. Hence, providers must ensure that XML files and their soft and hard copies of attachments are duly stored and retrievable when necessary. Providers must also ensure that hard copies of the attachments are readily available upon request.
- Transactions using the eClaims system are covered by relevant provisions of the Anti-cybercrime Act (RA 10175), Data Privacy Act (RA 10173), eCommerce Act (RA 8792), National Health Insurance Act (RA 7875), as amended under RA 9241, and relevant PhilHealth policies.
- Provider shall extend assistance to all PhilHealth personnel during monitoring and evaluation.
XII. PENALTY CLAUSE
Failure for HITP and IHCP to comply with PhilHealth issuances shall be subject to sanctions, based on applicable laws.
XIII. REPEALING CLAUSE
This Circular shall hereby repeal previous issuances that are inconsistent with any of these provisions, but only in the instance of eClaims transactions.
XIV. SEPARABILITY CLAUSE
Should parts herein be deemed unconstitutional, all other provisions shall remain in full force and effect.
This circular shall take effect fifteen days after its publication in the Official Gazette or in a newspaper of general circulation and deposited thereafter with the National Administrative Register at the University of the Philippines Law Center.
(SGD.) ENRIQUE T. ONA, MD
Secretary of Health/Chairman of the Board
OIC - President and CEO