I.     RATIONALE

Electronic Claims System or eClaims is an interconnected modular information system for claim reimbursement transaction beginning from the time a patient signified the intention of using a PhilHealth benefit, and ends when the claim is paid. It enables a Health Care Institution (HCI) to determine eligibility of patient to avail of insurance,  submit  a claim  electronically  or online,  track and verify the status  of claims,  and  be  reimbursed.  The  Electronic  Claims  System  removes

duplication  of  effort  in  entering  claims  data  especially  if  HCIs  have  existing Hospital  Information  System  (HIS)  or  Electronic  Medical  Record  (EMR).  Data quality is a perennial issue with data entry and associated quota requirements among other factors in PhilHealth. Efficiency issues which are manifested in turn- around-time (TAT) indicator is PhilHealth’s challenge as claim forms have to be physically  submitted  to PhilHealth  and  entered  by the Local  Health  Insurance Offices  (LHIOs)  or PhilHealth  Regional  Offices  (PROs);  or printing  of required claim forms and transmittal  list, saving  of claims  data to a storage  device  like flash  drives,  and being  physically  submitted  to the PROs  where  reconciliation and  validation  of claim  forms  and  electronic  copies  have  to be  done  prior  to uploading to PhilHealth .

The  benefits  of  eClaims  to  PhilHealth   are  enhanced   opportunity   for  fraud detection,  monitoring,  and  prevention;  improved  efficiencies  with  minimization and/or  elimination  of  encoding;  improved  data  quality  through  elimination  of manual encoding and prevention of duplicated encoding; minimal warehousing of claims forms and supporting documentation;  realignment of encoders, document administrators, and other support personnel of legacy manual processes to high- value tasks such as auditing; improved sources for adjudication as all documents are either electronic or imaged; and improved turnaround time in the processing claims.   HCIs   will  also   benefit   from   eClaims   implementation   by  improving processes through automated workflows; improved data integrity through the use of data systems contained in HIS’ or EMRs; minimal warehousing of claims forms and supporting documentation; timelier receipt of payments through shortened processes; and reduction of ‘Return-to-Hospital’  claims with automated validation prior  to  submission.  PhilHealth  members  will  also  benefit  through  improved quality of services from HCIs with the availability of historical medical information from HIS’ or EMRs; improved verification of eligibility leading to timely services; and improved understanding of member costs.

To realize the benefits of eClaims and be able to support its implementation, PhilHealth   opened   the  accreditation   of  service   providers   called  as  Health Information Technology Providers (HITPs) in 2012 to provide software solutions like HIS, EMR, or eClaims Transporter that complied with the requirements of PhilHealth on claims submission for processing and payment. The current implementation  of  eClaims  via  HITPs  provides  one  or  a  combination  of  the following solutions and services: (1) Hospital Information System - a software solution where the business/ operational  processes of the hospital are included and integrated, i.e. Admission, Billing, Medical Record, Cashiering, Laboratory, Radiology, Dietary, among others; (2) Infrastructure and data center support - secured  storage  of data  and  physical  infrastructure  containing  the server  and other  required  equipment/  devices;  (3)  electronic  transmission  of  claims  from HCIs to PhilHealth; ( 4) a software solution where data from existing HIS in the format of XML can be transmitted to PhilHealth; (5) secured connection between HCI  and  PhilHealth  like  dedicated  leased  line  or  secured  tunnel  connection; and/or  (6)  help  desk  support-assistance   or  support  to  answer/troubleshoot queries, questions, and/or technical problems relative to PhilHealth eClaims implementation.

PhilHealth Circular No. 2016-0016 set the implementation guidelines on full implementation  of eClaims. It has focused on HITP engagement  to provide the front  end  interface  for  eClaims  modules,  ensuring  connection  of  an  HCI  to PhilHealth, and facilitating electronic transactions. Under PhilHealth Circular No.

038 series 2012 on the accreditation of HITP, the HITP acts as a conduit for electronic transactions on claim reimbursements  from the HCI to PhilHealth and vice versa.

There are HCIs with existing in-house or outsourced software solutions/products that  may  have  capabilities  to  do  direct  transmission  to  PhilHealth.  Thus,  this Circular  opens  up  the  hybrid  approach  in  implementing  eClaims  for  HCIs  to select the best option appropriate to their needs, environment, capacity, and cost benefits. The opening of the hybrid approach supports the Philippine Health Agenda's mandate on the use of EMR in all health facilities; prepares the HCIs in data harmonization between the Department of Health and PhilHealth; and aligns with the strategic  thrust  of the Philippine  Health  Agenda  (PHA)  in investing  in eHealth and data for decision making.

II.    DEFINITION OF TERMS

1. Direct  Data  Transmission  (DDT)  - transfer  of  data  from  existing  software solution or product of HCI to PhilHealth.
   
   
2. eClaims  Eligibility  Web  Service  (eCEWS)  -  set  of  standard  Application Programming Interfaces (APIs) provided by PhilHealth for electronic claim transactions.
   
   
3. Electronic  Claims  Transporter  (EC1)  -  Software  solution  or  product  that allows extracted data from an HCI existing software solution/product to be electronically transmitted to PhilHealth.
   
   
4. Electronic Document (ED) - 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.
   
   
5. Electronic  Medical  Record  (EMR)  -  A  software  solution  or  product  that enables entry of patient's health-related data or information.
   
   
6. Hospital  Information  System  (HIS)  - A software  solution  or product  that is designed to manage all aspects of hospital’s operations such as Outpatient Department,   Emergency   Room,   Admission,   Billing,   Cashiering,   Medical Record, Laboratory and other Revenue Centers, among others.
   
   
7. Service Provider (SP) - Company, firm, organization, institution, or individual that provides or offers software solutions or products, and other information technology   services.   Health  Information   Technology   Provider   is  also  a service provider.
   
   
8. Software  Solution/Product   (SSP)  -  Set  of  related  software  programs  or services  that  are  developed  or  sold  as  single  package.  Examples  are hospital information system, electronic medical record, electronic claims transporter, and others.

III.   SCOPE OF IMPLEMENTATION

1. This Circular  applies  to all HCIs,  health  care  providers,  service  providers, PhilHealth  national and regional offices, local health insurance  offices, and other concerned.
   
   
2. The  eClaims  applies  to  reimbursement  claims  on  all  case  rates  (ACRs); special benefit packages  (Z Benefits);  outpatient  benefit packages  such as but not limited  to Maternal  Care Package  (MCP),  Newborn  Care Package (NCP), TB-DOTS  Package,  Outpatient  Malaria Package,  Animal Bite Treatment Package; Dialysis and Outpatient HIV /AIDS Treatment Package; and others as shall be defined by PhilHealth.
   
   
3. The  eClaims   does   not  cover   reimbursement   claims   on  Primary   Care Benefit/Tsekap Scheme, readjustment of amount claimed, and directly-filed claims.

IV.  GENERAL GUIDELINES

A.   Compliance to eClaims by HCIs is extended to December 31, 2017 to allow sufficient time to prepare and move to eClaims implementation by January 1,
2018. As such, HCIs shall maintain the status quo of claims submission, i.e. Manual  using  NClaims,  eClaims  using  HITP,  and  PHICS/SCLAIMS.   By January 1, 2018, eClaims shall be mandatory  to all HCIs and all submitted new claims shall be in electronic form.

B.   PhilHealth   shall  require  all  HCIs  to  use  HIS/EMR   to  improve   internal workflows or processes, data quality, efficiency, and client satisfaction.

C.   Only HCIs using software solutions/products  that are certified by PhilHealth shall be allowed to implement eClaims. Multiple certifications  shall be given to specific version of the benefit packages.

D.   Certified in-house or outsourced software solution/product that was endorsed by  one  (1)  HCI  can  be  used  by  other  HCIs.  Agreements,  terms,  and/or conditions on the use of the certified software solution/product shall be made between the service provider and the HCI. PhilHealth shall not be held liable for any action of the service provider with regards to its engagement with the HCI,  or  vice-versa  that  may  result  to  damage  or  injury  to  the  HCI  or  its clientele.

E.   The eClaims implementation shall no longer be exclusive to HITPs. HCIs that partnered with HITPs shall opt to continue the upload of data through the use of software solution/product  (i.e. HIS/EMR, or electronic claims transporter); or consider direct transmission from their existing software solution/product. HCIs shall communicate in writing to PhilHealth to confirm or validate compliance to PhilHealth requirements.

F.   HCIs shall choose from various options to implement eClaims.

G.   PhilHealth  shall  not  charge  any  cost  for  the  use  of  eClaims  services.
Investments on software solutions/products  whether in-house or outsourced shall be borne by the HCIs.

H.   Procedures   and   guidelines   on   direct   transmission   and   certification   of software  solution/product  as  compliant  to  the  requirements  of  PhilHealth claims submission shall be covered in a separate issuance.

I.     HCIs and/ or service providers shall develop and maintain their policies and procedures in compliance to existing and applicable statutory laws, rules and regulations   such  as  but  not  limited  to  Republic  Act  8792  -  Electronic Commerce Act of 2000, Republic Act 10173 - Data Privacy Act of 2012 and Republic Act 9470 - National Archives of the Philippines Act 2007.

J.     The   HCI   head   (i.e.   Hospital    Director,    Chief   of   Hospital,    Hospital Administrator, and the like) shall be accountable for data quality (i.e. validity, accuracy, completeness), security, storage, transmission, among others from their end.

K.   The PhilHealth Electronic Claims Implementation  Guide (PeCIG) shall serve as  the  technical  reference  manual  on  eClaims  compliance.  The  PeCIG defines  the standards  on semantic  security  (data  definition  and document type definition), data security compliance  like data encryption at rest and in transit,  transmission  protocol,  format  of  scanned  files  or  documents  like portable document format for archive, files to be scanned and uploaded like Claim Signature Form and Statement of Account, and/or other technical specifications. Any updates shall be posted or published accordingly.

L.     HCIs   and/   or   service   providers   shall   be   accountable    for   ensuring conformance to updated specifications.

M.   Transmitted claims shall be stored in PhilHealth’s data center and/or service provider  (e.g. Cloud Provider)  which shall comply with the requirements  of the National Privacy Commission, Department of Information and Communication Technology, Department of Health, and other national regulatory agencies or offices. The transmitted claims shall be owned by PhilHealth.

N.  Electronic claims review, adjudication and payment shall be conducted in compliance  with  existing  policies.  Electronic  supporting  documents  at  the HCIs and/ or service  providers  that may be necessary  during  adjudication shall be made available and readable to PhilHealth.

O.   Any use of information/ data exchanged between systems and accessed by the HCIs shall not be used outside of its intended use as stipulated herein.

P.  PhilHealth regional systems like PhilHealth Information and Claims System (PHICS) and Softcopy Claims (SCLAIMS)  shall be used as interim solution up to December 31, 2017 to allow HCIs to transition into a certified HIS/EMR. Implementation of PHICS/SCLAIMS shall cease thereafter.

V.   SPECIFIC GUIDELINES

A.   Transition to eClaims

1. HCIs  shall  be  given  up  to  December  31,  2017  to  plan  and  perform activities  to comply  with  the mandatory  use of eClaims  by January  1, 2018. The existing systems including eClaims with HITPs that HCIs are currently using to transmit claims to PhilHealth  shall remain as is while preparing to move to eClaims.
   
   
2. HCIs shall make a Transition Plan (TP) to layout the tasks and activities that need to be undertaken to efficiently comply with the requirements of eClaims and implement EMR systems. An EMR is an electronic record of health-related information of a person or individual that can be created, gathered, managed, and consulted by authorized health care providers within an organization.  The use of EMR systems can facilitate workflow and improve the quality of patient care and safety; and prepare the HCis to comply with other PhilHealth’s requirements  on submission of clinical data.
   
   
3. HCIs shall submit the TP to their respective PhilHealth Regional Offices for information and monitoring.

B.   eClaims Implementation Model (See Annex A")

HCI has the prerogative to select the appropriate eClaims implementation option.  It  shall  be  the  responsibility   of  the  HCI  to  perform  cost-benefit analysis to determine the strengths and weaknesses  of the modes, and the one that provides greater benefits. Models are as follows:

1.   Outsourced to Service Providers

a.     HCI with existing outsourced  HIS/EMR  that is not yet compliant  to PhilHealth claims requirements,  shall require its service provider to seek compliance to the technical specifications of PhilHealth, and eventually get software certification for compliance.

b.     HCI with existing outsourced HIS/EMR may still get another service provider  whose software  is certified  by PhilHealth  as complying  to the technical specifications of claims submission and data validation.

2.   In-House Developed

a.     HCI  with  existing  in-house  HIS/EMR  can  directly  transmit  claims data to PhilHealth. The HCI shall coordinate with PhilHealth for the technical specifications to comply with the requirements and seek software certification for compliance.

b.     HCI with existing in-house HIS/EMR may still get a service provider
whose  software   is  certified  by  PhilHealth   as  complying   to  the technical specifications of claims submission and data validation.

C.   Agreement Between HCI and Service Provider

1.  HCIs  shall  ensure  that  there  are  appropriate  Memorandum  of Agreements (MOAs) or Contracts, and Service Level Agreements (SLAs) made between their Management and the Service Provider.

2.   The MOA/Contract is a document in which the HCI and Service Provider shall  agree  to  work  together  for  a  common  objective.  It  shall  include working relationships, services covered, compliance with PhilHealth standards, data integrity, data privacy and confidentiality, non-disclosure agreement, data management, reporting, maintenance of secured data center if applicable, data security like data encryption, data storage, data backup, data/ database portability, data ownership, connectivity, data sovereignty in case of cloud environment, data audit, data breach, termination of agreement, transfer to other service provider, problem management,  duties/responsibilities  of parties,  related  fees/costs,  term and effectivity, and other vital requirements between the HCI and Service Provider.

a.     The MOA/Contract  is based on a proposal which is to be accepted by the HCI (to whom  the proposal  is made)  and Service  Provider who makes the proposal.

b.     When   the  Service   Provider's   proposal   is  accepted,   the  MOA/ Contract serves as a promise of parties to each other, and to the provisions therein to which they have agreed upon.

c.     Both  parties  have  the  right  to  go  to  court  in  the  event  of  non- performance of any provision of their agreements.

3.  The SLA shall be part of the MOA/Contract where a service is formally defined such as the scope, quality, and responsibilities of the Service Provider. Common features of the SLA are the contracted delivery time of  the  service  or  performance   system  uptime,  mean  time  between failures,   mean   time   to   repair   or   recovery,   defining   party   that   is responsible  for reporting  faults  or paying  fees,  data  rates,  throughput, and other measurable details as shall be agreed upon.

4.   The MOA/Contract  and SLA between HCIs and Service Providers shall be legal and binding  only to the contracting  parties  therein.  PhilHealth shall not be held liable for any action of the Service Provider with regards to its engagement with the HCI, or vice-versa that may result to damage or injury to the HCI or its clientele.

5.  The HCI and Service Provider shall hold PhilHealth, its personnel and instrumentalities, free from any liability with regards to their engagement.

D.   Software Certification Process

All software solutions/products  submitting eClaims whether outsourced or in- house shall be required to undergo PhilHealth Software Certification. Procedures of which shall be covered by a separate issuance.

E.   Registration Process

HCI shall submit an engagement form and photocopy of the software certification as supporting documents to the nearest PhilHealth Office. HCIs already engaged with HITPs and submitted their engagement forms shall be deemed registered. (See Annex B -Engagement Form)

F.   Data Collection Process

1.   All data required for claims shall be entered and done within the HCIs.

2.  HCIs shall call the eClaims Eligibility Web Service (eCEWS). HCIs shall cease  to use the PhilHealth  Benefit  Eligibility  Form  (PBEF)  generated from  the  PhilHealth  HCI  Portal.  Those  with  “YES”  response  and  has been issued a tracking reference number in the eCEWS shall no longer attach the PBEF as proof of eligibility. For those with “NO” response, the appropriate document listed by the system shall be attached to the claim.

3.  The Claim Signature Form shall be duly accomplished and signed by appropriate   signatories   prior  to  scanning.   (See  Annex   C*  -  Claim Signature Form) It shall be mandatory to all claims.

4.   Other  prescribed  documents   like  official  receipts,  diagnostic  results, operative records, PhilHealth Membership Registration Form, PhilHealth Official Receipt, Statement of Accounts, and others that are necessary to adjudicate and audit the claim shall be scanned and saved in the HCIs and/ or service providers facilities. This may be uploaded as necessary based on existing policies.

G.   Data Transmission Process

1.   Submission  of  electronic  claims  shall  be  allowed  anytime  in  real-time whether singly or in batch.

2.   HCI shall  be notified  of successful  transmission  via system  generated receipt ticket number.

3.   Received claims shall be deemed final and actionable by PhilHealth.

H.   Claims Status Verification

HCIs shall be able to verify the status of transmitted  claims as to returns, reasons, needed documents, and other requirements. As such:

1.   Return  To  Hospital  (RTH)  Claims  -  the  reasons  for  return  and  the required missing documents shall be provided.

2.   Denied Claims - the reasons for denying shall be provided.

3.   Good Claims - the current processing stage shall be provided.

4.   Paid  Claims  -  the  payment  details  like  amount  and  dates  shall  be provided. These shall be used by the facility to reconcile claims records.

I.     Claims Payment

Checks  shall  be  released  to  the  HCIs.  Future  enhancement  to  mode  of payment shall be covered by a separate issuance.

VI.  MONITORING AND EVALUATION

1.     HCIs’ compliance  to eClaims  shall be monitored  by the PhilHealth  Central and/or   Regional   Offices   (PROs).   PhilHealth   Central   Office/PROs   shall conduct random or unscheduled visits to the HCIs to check or verify the use of  the  certified  HIS/EMR  software,  compliance  to  standards,  and  other defined criteria or indicators.

2.     Reports   on  abuse   and  misuse   of  eClaims   shall   be  investigated   and evaluated by PhilHealth and appropriate actions/ sanctions shall be imposed.

VII. PENALTY CLAUSE

A.   Any participating HCI and/or service provider who shall fail to comply with the provisions  of  this  Circular  or  who  shall  commit  any  acts  that  violate  the Electronic Commerce Act of 2000, Cybercrime Prevention Act of 2012, and the Data Privacy Act of 2012, in so far as they relate to the operations of the eClaims, shall be penalized with termination of the right to participate in this undertaking, and revocation of all privileges enjoyed pursuant to said participation  without prejudice to administrative,  civil and criminal liability of its owners, directors or responsible officers under pertinent laws and rules.

B.   Any  individual  involved  in  the  processing  of  health  information  who  shall commit any violation of the policies stipulated in this Circular, or who shall fail to observe internal policies or regulations implemented pursuant to the provisions of this Circular shall have his or her authorization to access the eClaims, without prejudice to administrative, civil and criminal liability under pertinent laws and rules.

C.   The  finding  of guilt  for violation  of this  Circular  shall  not  be  a bar  to the criminal  prosecution  for violation  of the Electronic  Commerce  Act of 2000 (R.A. No. 8792), Cybercrime Prevention Act of 2012 (R.A. No. 10175), Data Privacy  Act  of 2012  (R.A.  No.  10173),  the  Revised  Penal  Code  or  other special laws, whenever applicable.

VIII. SEPARABILITY CLAUSE

Provisions  of  previous  issuances  inconsistent   with  this  Circular  are  hereby repealed accordingly.

IX.  EFFECTIVITY

This Circular shall take effect fifteen (15) 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.