QuestionsQuestions (PHILHEALTH CIRCULAR NO. 2017-0030)
It addresses inefficiencies and quality issues caused by physical submission of claim forms to PhilHealth, manual encoding by LHIOs/PROs, duplication of effort, use of flash drives/transmittal lists, reconciliation/validation of paper and electronic copies, and resulting turnaround-time (TAT) delays—by enabling electronic, modular, interconnected claim processing.
eClaims is an interconnected modular information system for claim reimbursement transactions, starting from when the patient signifies intention to use a PhilHealth benefit and ending when the claim is paid. It supports eligibility determination, electronic submission, tracking/verification, and reimbursement.
Covered: reimbursement claims on All Case Rates (ACRs), special benefit packages (Z Benefits), and outpatient benefit packages (examples include MCP, NCP, TB-DOTS, outpatient malaria, animal bite, dialysis outpatient HIV/AIDS), and others defined by PhilHealth. Not covered: Primary Care Benefit/Tsekap Scheme, readjustment of amount claimed, and directly-filed claims.
HCIs were allowed to maintain the status quo up to December 31, 2017; by January 1, 2018, eClaims became mandatory for all HCIs and all submitted new claims had to be in electronic form. Interim systems included manual using NClaims, eClaims using HITPs, and PHICS/SCLAIMS.
It allows HCIs to implement eClaims not only via HITPs but also through options such as direct data transmission (DDT) or electronic claims transporter software from certified solutions, depending on the HCI’s environment, capacity, and cost-benefit. It increases flexibility and supports EMR adoption and data harmonization.
DDT is the transfer of data from an HCI’s existing software solution/product directly to PhilHealth. EC1 (as written in the text) is the software solution/product that allows extracted data from an HCI existing system to be electronically transmitted to PhilHealth.
eCEWS is the set of standard APIs provided by PhilHealth for electronic claim transactions. HCIs must call the eCEWS to determine eligibility; they must cease using the PhilHealth Benefit Eligibility Form (PBEF) generated from the HCI Portal. If eCEWS returns “YES” and issues a tracking reference number, the HCI no longer attaches PBEF as proof of eligibility.
All data required for claims must be entered within the HCIs. The Claim Signature Form must be duly accomplished and signed before scanning and is mandatory for all claims. Other prescribed adjudication documents (e.g., official receipts, diagnostic/operative records, PhilHealth membership registration form, statement of accounts, etc.) must be scanned and saved in the HCI and/or service provider facilities, and uploaded as necessary based on existing policies.
It must be duly accomplished and signed by appropriate signatories before scanning and is mandatory for all claims. Scanned electronic supporting documents (including this form) must be made available and readable for PhilHealth during review/adjudication/auditing.
Submission is allowed anytime in real-time, singly or in batch. The HCI is notified of successful transmission via a system-generated receipt ticket number. Received claims are deemed final and actionable by PhilHealth.
HCIs can verify the status of transmitted claims, including: Return To Hospital (RTH) reasons and required missing documents; Denied claims reasons; Good claims current processing stage; and Paid claims payment details (amount and dates) for reconciliation.
PhilHealth shall not charge any cost for using eClaims services. Investments on software solutions/products—whether in-house or outsourced—are borne by the HCIs.
Only certified software solutions/products by PhilHealth may implement eClaims. All software solutions/products submitting eClaims (outsourced or in-house) must undergo PhilHealth Software Certification (procedures are covered in a separate issuance).
Certified in-house/outsourced software endorsed by one HCI can be used by other HCIs, but agreements/terms/conditions must be made between the service provider and the HCI. PhilHealth is not held liable for actions resulting from the service provider’s engagement with the HCI, or vice versa, that may cause damage or injury to the HCI or its clientele.
HCIs must ensure there are appropriate Memorandum of Agreements (MOAs) or Contracts and Service Level Agreements (SLAs). MOAs/Contracts should cover working relationships, service scope, compliance with PhilHealth standards, data integrity/privacy/confidentiality, non-disclosure, data management, encryption and security, storage/backup, portability, data ownership, connectivity, cloud data sovereignty, data audit, breach handling, termination/transfer, duties/responsibilities, costs/fees, term/effectivity, and other vital requirements. SLAs must define service scope, quality, uptime/response, repair/recovery times, reporting of faults, and measurable performance terms.
The HCI head (Hospital Director/Chief of Hospital/Hospital Administrator, etc.) is accountable for data quality (validity, accuracy, completeness), security, and storage/transmission from the HCI’s end.
The PhilHealth Electronic Claims Implementation Guide (PeCIG) serves as the technical reference manual. It defines standards on semantic security (data definition and document type definition), data security compliance (e.g., encryption at rest and in transit), transmission protocol, and formats/specs for scanned files/documents (e.g., PDF for archive), including files to be scanned/uploaded such as Claim Signature Form and Statement of Account.
Transmitted claims are stored in PhilHealth’s data center and/or a service provider’s (e.g., cloud) facilities that comply with requirements of the National Privacy Commission, DICT, DOH, and other regulators. The transmitted claims are owned by PhilHealth.
A participating HCI and/or service provider that fails to comply or violates relevant laws (Electronic Commerce Act of 2000, Cybercrime Prevention Act of 2012, Data Privacy Act of 2012 as they relate to eClaims) may face termination of right to participate and revocation of privileges, without prejudice to administrative, civil, and criminal liability. Individuals may lose authorization to access eClaims without prejudice to further liability. Criminal prosecution under the cited laws or the Revised Penal Code may proceed.