CLAIMS FOR REIMBURSEMENT and COMPLIANCE The Claim Form 4 (CF 4) replaces Part 1 of the Claim Form 3

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  • BERNADETTE CLEMENTE-LICO MD HEAD PMT for Claims

    Philippines Hospital Association

    The Challenge of Change: Building Bridges Together

    1

    CLAIMS FOR REIMBURSEMENT and COMPLIANCE

  • BENEFITS AND CLAIMS (Updates)

  • Top 10 Paid Medical Claims

  • Circular 2017-0028 Length of Stay (LOS) removed as basis for payment of claims for:

    Pneumonia

    AGE

    UTI

    • All claims require submission of certified true copy of complete clinical chart (including SEPSIS)

    – Claims without complete clinical chart will be returned

  • CLAIM FORM (CF) 4 (PC No.2018 – 0007)

     Issues and concerns on patient privacy, administrative cost ,

    tedious process etc.

  • tool containing clinical

    (including results of diagnostic tests)

    and administrative data

    Attached:

     laboratory and/or imaging results (scanned or photocopy)

     operative room (OR) technique

    IMPORTANT POINTS: CF4

  • Improperly accomplished or illegible CF4

    and/or incomplete attachments

    shall be RETURNED to Hospital.

    IMPORTANT POINTS: CF4

  • ****All claims should be accompanied by CF4

    IMPORTANT POINTS: CF4

     CF 4 along with attached lab results and OR record shall replace clinical charts

     All claims shall still require CF1 and CF2 or CSF and SOA

     The Claim Form 4 (CF 4) replaces Part 1 of the Claim Form 3 (CF 3).

     Part 2 of the Claim Form 3 (CF 3) is retained for maternity claims reimbursement

  • What is not covered by this Circular?

    Claims directly filed with PhilHealth

    Confinements abroad

    Specific packages/ benefits (current requirements still apply):

    Z-Benefit packages Outpatient

    HIV/AIDS Treatment (RVS 99246)

    Animal Bite Treatment (RVS

    90375)

    TB-DOTS (RVS 89221 and 89222)

    Normal Spontaneous

    Delivery ( NSD01)

    Maternity Care Package (MCP01)

    Newborn Care Package (RVS

    99432)

    Resuscitation Package (P00000)

    Referral Package (P00001)

  • Medical Prepayment Review : (initial phase)

     Pneumonia

    AGE

    UTI

     Sepsis

    IMPORTANT POINTS: CF4

    ***PhilHealth reserves the right to subject any and/ or all claims

    to medical prepayment review.

  • PhilHealth shall DENY claims:

     over-utilization or under- utilization of services;  unnecessary diagnostic and therapeutic

    procedures and intervention;  irrational medication and prescriptions;

  • PhilHealth shall DENY claims:

     fraudulent, false or incorrect information as determined by the appropriate office;

     gross deviations from currently accepted

    standards of practice;  inappropriate referral practices;

  • PhilHealth shall DENY claims:

     use of fake, adulterated or misbranded pharmaceuticals, or unregistered drugs;

     use of drugs other than those recognized in the

    latest PNF and those for which exemptions were granted by the Board

     unethical patient recruitment

  • Monitoring of HCPs

    • PhilHealth Circular No. 54, s-2012 (Provider Engagement through Accreditation and Contacting for Health Sevices (PEACHes)

    • PhilHealth Circular No. 2016-0026 re: (Health Care Provider Performance Assessment System (HCP PAS) Revision 1).

  • Effectivity of CF4

    • All admissions starting May 1, 2018 onwards. DEFERRED UNTIL FURTHER NOTICE

    as per ADVISORY 0043 2018

    May submit any of the Following:

     Photocopy of clinical chart

     Claim Form 3

     Clinical Abstract

     Discharge Summary

  • PhilHealth Advisory 2018 – 0017

    Philippine National Formulary (PNF) 8th Edition Essential Medicines List (EML) 2017

    posted and can be accessed at:

    https//www.philhealth.gov.ph/partners/providers/pdf/PNF8thEd_2017.pdf

    The new PNF shall be basis for claims reimbursement and performance

    monitoring for all admissions starting March 1, 2018.

  • Download at:

    https://www.philhealth.gov.ph/partners/providers/pdf/

    PNF8thEd_2017.pdf

  • PCB1 Package PCB1 Package

    Sponsored Program

    Organized Groups

    Overseas Workers Program

    DepEd Personnel

    M E M B E R S a n d D E P E N D E N T S

  • Expansion of PCB 1

    PhilHealth shall expand the Primary Care Benefit to all members and dependents

    of the formal sector,

    lifetime and senior citizen members

  • Expansion of PCB 1

    private and government health care institutions, including out patient department of hospitals

    may proceed to their

    respective PhilHealth Regional Offices

    for inclusion in their Performance Commitment as an

    Accredited Provider for the PCB1 Expansion.

  • Expansion of PCB 1

    coordination with the IT of the

    PhilHealth Regional Office

    to gain access of the ePCB Module

  • “PhilHealth ACR Search”

    Mobile Application

  • “PhilHealth ACR Search”

    Mobile Application

  • How to install?

  • 1. Enter the ICD 10 Code/RVS

    Code/Description then press

    “Search”

    2. No. of record/s

    will display

    then select “Ok”

    3. Search results will

    display. Select the final

    diagnosis you are

    looking for.

    How to use?

  • 4. Case rate details will display.

    There is an option to choose the

    type of HCI.

  • UPDATES ON PHILHEALTH ADVISORIES

  • PhilHealth Advisory 2017 – 0050

    • REGISTRATION OF BANK ACCOUNTS FOR THE MANDATORY IMPLEMENTATION OF AUTO CREDIT PAYMENT SCHEME (ACPS)

    all accredited Health Care Institutions (HCIs) are required to be ACPS compliant for purposes of claims reimbursements.

  • What is ACPS?

    a payment mechanism where HCI claims are

    reimbursed directly into their bank accounts

    shortens the time for processing claims by

    eliminating check preparation

  • mandatory to all HCIs

    including PCB and MDGs providers

    does not cover member-filed claims

    Which HCIs should enroll in ACPS?

  • What are the requirements to register

    the HCI bank account?

    HCI shall submit details of its servicing bank with

    PhilHealth for ACPS registration:

    - Notice of ACPS Compliance

    - Bank certificate

    HCI servicing bank may be Landbank or any other

    bank

    format of the bank account name:

    - Private HCI -

    - Government HCI

  • Is there a format for the name of the HCI bank

    account?

    Private HCI – „Name of HCI‟ for HCI Charges

    Government HCI – two (2) bank accounts:

    1.‘Name of HCI’ for HCI Charges

    2.‘Name of HCI’ for Professional fees designated

    for Pooling

    LGUs have two (2) options in registering its bank

    accounts:

    one (1) bank account EACH for every HCI and every HCI chief

    one (1) bank account that covers all HCI under its jurisdiction

    and another one for PFs under pooling

  • Will there be transaction charges?

     PhilHealth shall not charge fees for auto-credit

    payment.

     Real-Time Gross Settlement Fees (RTGS)

    - Since PhilHealth servicing bank is Landbank,

    - HCIs may be charged with RTGS fees if their

    servicing bank is not Landbank

    RTGS fees shall be shouldered by the HCI

  • What is the schedule for auto-credit payments?

    Every Wednesday

    - or the next working day in case crediting day falls

    on a non-working holiday

    Cut-off time: all claims processed up to 1 day prior

    to generation of the auto-credit list

  • What is the implication of ACPS Noncompliance?

    PhilHealth Circular No. 2017-0020

    All Claims of noncompliant facilities to ACPS

    shall be processed by the PROs until check

    generation but the printed checks shall not be

    released to the HCIs until they have complied

    with the requirements of the ACPS policy.

  • PRO AUTO CREDIT PAYMENT MONITORING REPORT

    Accredited HCIs HCIs on ACPS % Compliance to ACPS CAR 369 206 56%

    I 492 449 91%

    II 441 261 59%

    IIIA 556 346 62%

    IIIB 502 284 57%

    NCR North 426 311 73%

    NCR Central 460 337 73%

    NCR South 503 299 59%

    IVA 635 461 73%

    IVB 388 364 94%

    V 445 364 82%

    VI