(NAR) VOL. 29 NO. 2/ APRIL - JUNE 18
A. Medical Prepayment Review - The process of reviewing and evaluating clinical data before claims payment to determine compliance to Corporate policies and widely accepted medical practice.V. GENERAL GUIDELINES
B. Claim Form 4 (CF4) - Summary of pertinent clinical information of a patient/member during their hospitalization/episode of care that shall be utilized by PhilHealth to conduct evaluation and review of claims.
A. All claims for reimbursement should be accompanied by the CF4 following the prescribed format (Annex “A”) and photocopies of the corresponding laboratory and imaging results. The Statement of Account shall still be submitted along with the said documents;
B. The CF4 shall replace the requirement for CTC of the complete clinical charts for four (4) conditions (pneumonia, urinary tract infection, acute gastroenteritis and sepsis) which was previously required under PhilHealth Circular No. 2017-0028;
C. eClaims compliant HCls shall scan the above required documents and attach them during claim application transmission;
D. This policy shall not cover claims directly filed with PhilHealth and those involving confinements abroad. Likewise, this Circular shall not apply to the following packages/benefits as their current required documentary requirements shall still apply:
1. Z-Benefit packages;
2. Outpatient HIV/AIDS Treatment (RVS 99246);
3. Outpatient Malaria Package (RVS 87207)
4. Animal Bite Treatment (RVS 90375);
5. TB-DOTS (RVS 89221 and 89222);
6. Antenatal Care Package (ANC01);
7. Normal Spontaneous Delivery (NSD01);
8. Maternity Care Package (MCP01);
9. Newborn Care Package (RVS 99432);
10. Subdermal Contraceptive Implant Package (FP01);
11. Intrauterine Device Insertion Package (RVS 58300);
12. No-scalpel Vasectomy (RVS 55250)
13. Resuscitation Package (P00000); and
14. Referral Package (P00001)
E. Improperly accomplished or illegible CF4 and/or incomplete attachments shall be returned to the HCP. To process the claim, the properly accomplished CF4 and its relevant supporting documents shall be re-filed to PhilHealth within 60 days from receipt of HCI. (Refer to Annex B);
F. The Corporation reserves the right to subject any and/or all claims application to medical prepayment review;
G. The Corporation shall deny claims attended by any, but not limited to the following circumstances:
1. Over-utilization or under-utilization of services;
2. Unnecessary diagnostic and therapeutic procedures and intervention;
3. Irrational medication and prescriptions;
4. Fraudulent, false or incorrect information as determined by the appropriate office;
5. Gross, unjustified deviations from currently accepted standards of practice and/or treatment protocols;
6. Inappropriate referral practices;
7. Use of fake, adulterated or misbranded pharmaceuticals, or unregistered drugs;
8. Use of drugs other than those recognized in the latest PNF and those for which exemptions were granted by the Board; and,
9. Unethical patient recruitment,
H. The Corporation reserves the right to request certified true copies of the complete clinical charts when additional information is necessary. Non- compliance to the request shall result in denial of the claim;VI. MONITORING AND EVALUATION
I. Any validated report involving violation of PhilHealth policies or abuse of the
National Health Insurance Program shall result in the denial of the claim.