The Philippine Health Insurance Corporation (PhilHealth) recently introduced a policy to ensure that its members who seek treatment in hospitals are provided with health care services that are of the desired quality and at par with existing medical standards.

In its PhilHealth Circular No. 2019-0002 entitled“Documentary Requirements for Claims Reimbursement and Medical Prepayment Review of Claims (Revision 2),” the state health insurer prescribes a medical prepayment review and requires the use of Claim Form 4 (CF4) for all admissions starting March 1, 2019.

Medical pre-payment review is done prior to actual processing, wherein claims that are not compensable as well as those that are not compliant with existing policies and standards on quality of care shall no longer be processed. The review shall be based on data from the CF4 which summarizes a patient’s pertinent clinical information. The submission of the CF4 eliminates the submission of voluminous complete clinical charts for claims reimbursements. The policy does not preclude submission of other documents if necessary.

The new policy shall cover claims using case rates with the exception of directly filed claims those for confinements abroad and claims for Z Benefits, among others.

The new system enables PhilHealth to efficiently assess provider claims and to detect irregular practices such as over utilization or under-utilization of services; unnecessary use of diagnostic and therapeutic procedures and interventions; irrational medication and prescriptions; fraudulent, false or incorrect information; gross or unjustified deviations from currently accepted standards of practice and/or treatment protocols; inappropriate referral practices; use of fake, adulterated, misbranded or unregistered drugs; among others.

The Policy, signed last Feb 8,2019,allowed for a transition period for the month of March for hospitals to align and update their systems. To help HCIs in adapting to the new system, PhilHealth allowed facilities with eClaims systems to transmit the encoded CF4s of admissions starting March 1, 2019, while other HCIs may still use available offline applications provided by PhilHealth. On the other hand, those manually submitting claim applications shall submit soft copy of encoded CF4 together with manually transmitted claim application. Claims submitted to PhilHealth without the required CF4 shall be returned to the hospital for compliance starting April 1.