circular[ SC CIRCULAR NO. 55-98, September 19, 1998 ] 1998-09-19

[ SC CIRCULAR NO. 55-98, September 19, 1998 ]

Untitled Document

TO :

All Officials and Employees of the OCAD All Judges and Employees, Lower Courts

SUBJECT: Philippine Health Insurance Corporation Circular No. 20, S 1998

Quoted hereimder is Philippine Heaiih Insurance Corporation (PH1C) CIRCUI AR NO. 20, S 1998, for the information and guidance of all concerned:

"PHIC CIRCULAR NO. 20, S 1998

TO :

ALL ACCREDITED INSTITUTIONAL AND PROFESSIONAL HEALTH CARE PROVIDERS, NATIONAL GOVERNMENT AGENCIES, INSTRUMENTALITIES, GOVERNMENT OWNED AND CONTROLLED CORPORATIONS, SELF GOVERNING BOARDS, STATE COLLEGES AND UNIVERSITIES

"EFFECTIVE April I, 1998, all claims for the National Health Insurance Program (NH1P) benefits with incomplete documents or insufficient information will automatically be denied payment and returned to hospitals for completion of the documentary requirements.

"All claims requiring submission of additional documents and which are returned to hospitals should be forwarded to PhilHealth within 120 calendar days from the receipt of such claims.

"PhilHealth will return incomplete claim documents to the hospitals onjy once If these returned claims are re-submitted without full compliance, this will also be disapproved. Re-submitted claims will be processed according to first in, first out policy.

"This rule applies to all claims filed in behalf of government sector employees, retirees and their dependents.

"PhilHealth will indicate the reasons for the denial or the disapproval ot claims These will be in the fonn of codes which will be indicated on the PhilHealth benefits voucher, PhilHealth Form No. 2 and the accompanying letter addressed to the hospital where the claims will be returned. Attached is "Annex A" to guide hospitals and NHIP members in evaluating the reasons for claims denial or approval.

"We enjoin all concerned to observe these new policies to help expedite the processing of NHIP claims.

Please be guided accordingly. October 19, 1998.

(SGD.) ALFREDO L. BENIPAYO

Court Administrator

AnnexA

REASONS FOR DENIAL/DISAPPROVAL OF PAYMENT OF NATIONAL HEALTH INSURANCE PROGRAM (NHIP) CLAIMS FOR GOVERNMENT EMPLOYEES/RETIREES DESCRIPTION OF DEFICIENCY/REQUIREMENT

CODE NO.

DESCRIPTION OF DEFICIENCY/REQUIREMENT

BOX/FORM NO.

Incomplete member's name; Please submit birth certificate certified by the Local Civil Registry

Box 1, Form 1

Without or incomplete member's date of birth; Please submit birth certificate certified by the Local Civil Registry

Box 3, Form 1

Conflicting or different member's date of birth as verified from previous claims; Submit birth certificate certified by the Local Civil Registry

Box 3, Form 1

Incomplete patient's name; Please submit birth certificate certified by the Local Civil Registry

Box 11, Form 1

Without or incomplete patient's date of birth; Please submit birth certificate certified by Local Civil Registry

Box 13, Form

Name of spouse not indicated

Box 8, Form 1

Spouse's employer and address not indicated

Box 9, Form 1

Member's relationship to patient not indicated

Box 15, Form 1

Without member's signature

Box 17, Form 1

Without printed namo, signature and relationship to member of witness to thumbmark when member cannot sign

Box 17, Form 1

Without registered name and address of employer and branch/station

Boxes 18-21, Form 1

Without printed name and signature of Employer's Authorized Representative (EAR)

Box 22, Form 1

Inconsistent signature of Employer's Authorized Representative; Submit specimen signature

Box 22, Formi

Official capacity of Employer's Authorized Representative not indicated

Box 22, Form 1

Date when certification ol employee's coiiliibulion wjs signed "not indicated-

Box 22, Form 1

Incorrect hospital accreditation number/no hospital accreditation number indicated

Box 2, Form 2

Address of member not indicated

Box 12, Form 2

Confinement period not indicated/inconsistent/tampered date of confinement - Please submit Philhealtg Form 3 and Clinical Chart

Box 14, Form 2

Hospital charges not properly filled-up

Box 15, Form 2

Claim is without admission or final diagnosis

Box 13,17 Form 2

Printed name and official capacity of Hospital's Authorized Representative not indicated (HAR)

Box 16, Form 2

Without sianature of Hospital's Authorized Representative

Box 16, Form 2

Inconsistent signature of Hospital's Authorized Representative, Submit specimen signature

Box 16. Form 2

Without signature of attending physician/surgeon/anesthesiologist

Boxes 19, 24, 29, Form 2

Incorrect accreditation number of physician/surgeon/anesthesiologist or no accreditation number indicated

Boxes 20,25,30 Form 2

Doctors not accredited (NA)/did not renew accreditation (NLA)

Doctor's charges not properly filled up

Boxes 23,28,33, Form 2

Part HI/IV not properly filled up/not specified/itemized

Form 2

Hospital not accredited/did not renew accreditation

Hospital's change of name not yet approved by PHIC

Without PhilHeaith Form 1

Regular employees-without copy/matured member's GSIS Policy Contract; Submit renewed GSIS Policy Contract/Service Record

GSIS Retirees / Pensioners without copy of Retirement Voucher or latest Retirement Certificate from GSIS or latest Pension Check Acknowledgement Receipt or Pension Voucher or Bank Account Passbook

Other Retirees/Pensioners-without copy of Retirement Voucher or Certificate/latest Pension Check or Voucher/Bank Account Passbook and Service Record or Summary of Services or Certification of 120 monthly NHIP contribution

GSIS Retirees under PD 1184, PD 1146 and RA 1616 who are less than 60 years old not covered (except under RA 660 & Disability Retirement) - DISAPPROVED

Retired judges/members of the judiciary who are less than 70 years old not covered - DISAPPROVED

Retired AFP/PNP personnel below 56 years old not covered -DISAPPROVED

Casual/Temporary employee's Term Insurance (TR) expired; Submit renewed TR or certification.of monthly premium contribution with specific amount, O.R. # and date of payment by the employer

Barangay Officials/CAFGU members not covered - DISAPPROVED

Ciaim filed beyond the 60-day statutory period - DISAPPROVED

Dependent parents below 60 years of age not covered-DISAPPROVED

Children 21 years and above of age not covered - DISAPPROVED

Claim should be filed under the membership of the father who is employed

Claim should be filed under employed patient's own membership

Illness not compensable under Medicare - DISAPPROVED

The 45 days room and board benefit allowable for the year has been exhausted - DISAPPROVED

Claim is forwarded to OWWA/SSS

Veterans not covered as member- - DISAPPROVED

Survivorship benefit-Dependents not covered - DISAPPROVED

Primary Hospital - without PhilHealth Form 3 and Clinical Chart

Others

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