Date Filed: 29 August 2018

I.    RATIONALE

The National Health Insurance Act of 2013 (RA 7875 as amended by RA 9241 and  10606)  under  Article  VIII  (Health  Care  Providers)  Section  37  (Quality Assurance), provides that œthe performance of medical procedures and the administration   of   drugs   are   appropriate,   necessary   and  unquestionably consistent with accepted standards of medical practice and ethics. Drugs for which payments will be made shall be those included in the Philippine National Drug Formulary, unless explicit exception is granted by the Corporation. 

PhilHealth, as the administrator of the National Health Insurance Program, is mandated to ensure that quality health services are provided to its beneficiaries. The Corporation may set standards, rules and regulation that will ensure quality of care, appropriate utilization of services, fund viability, member satisfaction and overall accomplishment of Program objectives. Furthermore, it is also incumbent upon the Corporation to protect the Program and set safeguards to ensure that reimbursement of services are correct, appropriate, and ethical.

In order to sufficiently measure and assess the quality of care, PhilHealth developed and implemented policy statements that defined the standards of care to ensure better health outcomes. These are based on clinical practice guidelines and acceptable/ established standards of care. To complement efforts to improve quality, PhilHealth shall employ medical pre-payment review using Claim Form (CF4) in order to assess the quality of care.

II.   OBJECTIVES

To establish the guidelines on requiring the CF4 to facilitate systematic data collection and evaluation of claims for payment. The clinical and administrative data contained in the Claim Form 4 (CF4) together with the results of diagnostic tests will be vital to assess the quality of care delivered by health care providers (HCPs).

III.  SCOPE

This policy shall cover All Case Rate (ACR) claims of eligible PhilHealth beneficiaries in PhilHealth accredited health care institutions, with exceptions indicated under General Guidelines of this issuance.

IV.  DEFINITION OF TERMS

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.

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.

V.   GENERAL GUIDELINES

A.   All claims for reimbursement should be accompanied by the CF4 following the prescribed format (Annex œA ) 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 HCIs 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 (P0000); and,
14. Referral Package (P0001)

E.  Claims related to deliveries such as normal deliveries (NSD01, MCP01); Cesarean  section  (59620,  59513,  59514);  other  methods  of  deliveries (59409, 59411, 59612); and intrapartum monitoring (59403, ANC02) shall use Claim Form 3.

F.   Improperly accomplished or illegible CF4 and/ or incomplete attachments shall be returned to the HCP. To process the claim, a 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);

G.  The  Corporation  reserves  the  right  to  subject  any  and/or  all  claims application to medical prepayment review;

H.   The Corporation shall penalize claims attended by any, but not limited to the following circumstances (Section 47.e, IRR of RA 7875, at amended by RA 9241 and RA 10606):

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; and

8.   Failure to comply without justifiable cause with the pertinent provision of the law, IRR and any issuance of the Corporation.

I.    Phi/Health reimbursement of drugs shall be based on the latest edition of the Philippine National Formulary (PNF). For claims with non-PNF drug, the applicable amount shall be deducted from the Case Rate.

J.    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.  PENALTY CLAUSE

The Corporation may deny or reduce the payment of claims when such claims are  attended  by  false  or  incorrect  information  and  when  the  claimants  fails without justifiable  cause to comply with pertinent rules and regulations of this Act (Section 38 of RA 7875, as amended by RA 9241 and RA 10606).

VII. MONITORING AND EVALUATION

All  HCPs  shall  be  subject  to  the  rules  on  monitoring  and  evaluation  of performance as stipulated in PhilHealth Circular No. 54, s-2012 (Provider Engagement through Accreditation and Contracting for Health Services (PEACHes) and PhilHealth Circular No. 2016-0026 re: HCP PAS Revision 1.

VIII.   SEPARABILITY CLAUSE

In the event any provision of this Circular or the application of any provision to any person or circumstance is declared invalid, the remainder of this Circular or the application of said provision to other person or circumstance shall remain to be valid and effective.

X.   REPEALING CLAUSE

This issuance amends PhilHealth Circular No. 2017-0028, No. 35, s.2013 and No. 8, s.2015. All other previous issuances that are inconsistent with any of the provisions of this are hereby amended, modified or repealed accordingly.

X.   DATE OF EFFECTIVITY

This  Circular  shall  take  effect  for  admissions  starting  September  1,  2018 onwards. This Circular shall be published in a newspaper of general circulation and shall be deposited thereafter with the National Administrative Register at the University of the Philippines Law Center.

(SGD) ROY B. FERRER, M.D., MSc
Acting President and Chief Executive Officer (CEO)