Question & AnswerQ&A (PHILHEALTH CIRCULAR NO. 2017-0030)
The Electronic Claims System (eClaims) is an interconnected modular information system for claim reimbursement transactions starting from when a patient signifies the intention to use a PhilHealth benefit and ending when the claim is paid. It enables electronic submission, tracking, verification, and reimbursement of claims for health care institutions.
The purpose is to improve data quality, increase efficiency in claims processing, minimize duplication of data entry, reduce the turnaround time (TAT) for claims reimbursement, improve fraud detection and prevention, and enhance the overall benefits for PhilHealth, health care institutions, and members.
HITPs are service providers accredited by PhilHealth who offer software solutions such as Hospital Information Systems (HIS), Electronic Medical Records (EMR), or electronic claims transporters that comply with PhilHealth's requirements for claims submission.
The hybrid approach allows Health Care Institutions (HCIs) to implement eClaims by either continuing with HITPs or by direct transmission from their existing in-house or outsourced software solutions certified by PhilHealth, providing flexibility based on their needs, environment, capacity, and costs.
eClaims became mandatory for all HCIs starting January 1, 2018. Prior to that, compliance was extended up to December 31, 2017 to allow preparatory activities.
The HCI heads are accountable for data quality, security, storage, transmission, and overall compliance related to electronic claims processing within their institutions.
They must comply with Republic Act 8792 (Electronic Commerce Act of 2000), Republic Act 10173 (Data Privacy Act of 2012), Republic Act 9470 (National Archives of the Philippines Act of 2007), and related laws governing electronic transactions, data privacy, and security.
Violations may result in termination of participation rights, revocation of privileges, and administrative, civil, and criminal liabilities under applicable laws including the Electronic Commerce Act, Cybercrime Prevention Act, and Data Privacy Act.
Covered claims include reimbursement claims on All Case Rates (ACRs), special benefit packages (Z Benefits), outpatient benefit packages such as Maternal Care Package, Newborn Care Package, TB-DOTS, Outpatient Malaria Package, Animal Bite Treatment Package, Dialysis, HIV/AIDS Treatment Package, and others as defined by PhilHealth but excludes Primary Care Benefit/Tsekap, readjustment claims, and directly-filed claims.
HCIs must have legally binding Memorandum of Agreements (MOAs) or Contracts and Service Level Agreements (SLAs) that specify the scope of services, compliance with PhilHealth standards, data privacy, confidentiality, data security, responsibilities, fees, term and effectivity, problem management, and other pertinent terms.
PhilHealth requires all software solutions used in submitting eClaims, whether outsourced or in-house developed, to undergo a certification process to ensure compliance with technical specifications and standards for claims submission and data validation.
The transmitted electronic claims data shall be stored in PhilHealth's data center and/or compliant service providers' facilities and are owned by PhilHealth. Data storage must comply with regulations from the National Privacy Commission and other regulatory agencies.
The eClaims Eligibility Web Service (eCEWS) using standard Application Programming Interfaces (APIs) is the electronic method for verifying member eligibility. Once a 'YES' response with a tracking reference number is received, the PBEF is no longer required as proof of eligibility.
The Claim Signature Form, duly accomplished and signed by appropriate signatories, is mandatory for all claims prior to scanning and submission. Other supporting documents as needed may include official receipts, diagnostic results, operative records, PhilHealth Membership Registration Form, Statement of Accounts, and others.
No. PhilHealth shall not be held liable for any disputes, damages, or injuries arising from the contractual relationship between HCIs and their service providers related to the implementation of eClaims.