Question & AnswerQ&A (PHILHEALTH CIRCULAR NO. 2018-0014)
The National Health Insurance Act of 2013 (RA 7875 as amended by RA 9241 and RA 10606) mandates quality assurance in health care providers under Article VIII, Section 37.
Claim Form 4 (CF4) is a summary of pertinent clinical information of a patient/member during hospitalization used by PhilHealth to conduct evaluation and medical prepayment review of claims.
All Case Rate (ACR) claims of eligible PhilHealth beneficiaries in PhilHealth-accredited health care institutions, except for certain packages and claims mentioned under General Guidelines, are covered.
Claims filed directly with PhilHealth, those involving confinements abroad, and specific packages like Z-Benefit, outpatient HIV/AIDS treatment, outpatient malaria package, animal bite treatment, TB-DOTS, antenatal care, normal spontaneous delivery, maternity care, newborn care, contraceptive implants, vasectomy, resuscitation, and referral packages are exempted.
The claim will be returned to the health care provider, and a properly accomplished CF4 along with relevant supporting documents must be re-filed within 60 days from receipt of the Health Care Institution.
PhilHealth may deny or reduce claim payments and impose penalties for over-utilization or under-utilization of services, unnecessary procedures, irrational medications, fraudulent or false information, unjustified deviation from standards, inappropriate referrals, use of fake or unregistered drugs, and failure to comply with laws and regulations.
Medical Prepayment Review is the process of reviewing and evaluating clinical data before claims payment to ensure compliance with corporate policies and accepted medical practice.
The Claim Form 4 (CF4) in the prescribed format, photocopies of corresponding laboratory and imaging results, and the Statement of Account are required to accompany all claims.
Yes, PhilHealth reserves the right to request certified true copies of complete clinical charts when additional information is necessary; non-compliance will result in claim denial.
It took effect for admissions starting September 1, 2018 onwards.