QuestionsQuestions (PHILHEALTH CIRCULAR NO. 03, S. 2008)
It removed the initial appeal to the Claims Review Office (CRO) and replaced it with (1) an initial remedy of a motion for reconsideration (M/R) with the PhilHealth Regional Offices (PROs), and (2) a final appeal with the Protests and Appeals Review Department (PARD) for decisions by the PROs that deny or reduce the claim.
Any aggrieved member, beneficiary, or health care provider whose benefit claim was originally denied or reduced by the PROs (including the NCR-Central, NCR-North, and NCR-South).
The M/R must be filed within fifteen (15) calendar days from receipt by the movant of the PRO’s written notice of denial or reduction.
Any error of fact or law (or both) on the part of the PRO in denying or reducing the benefit claim.
It should be in writing, duly signed by the movant, state the grounds, and be accompanied by all original claim documents returned by the concerned PRO, if any. The PRO/Area Head may require additional documents.
Within fifteen (15) calendar days from receipt, the PRO either (1) denies the M/R by issuing an order stating reasons, or (2) recommends to the concerned Office of the Area Head the grant of the M/R.
The Office of the Area Head must, within fifteen (15) calendar days from receipt of the forwarded order/case file, approve or disapprove it through an order, furnishing copies to the movant and the PRO for implementation.
No. The order on an M/R is final and executory subject only to a final appeal with the PARD, and no second M/R under any name shall be entertained.
A final appeal may be filed by a movant whose M/R was denied by an order of the PRO or the Office of the Area Head.
It must be filed with the PARD (acting for the President and CEO) within fifteen (15) calendar days from receipt by the movant of a copy of the order denying the M/R.
Any error of fact or law (or both) on the part of the PRO or Office of the Area Head in denying the M/R.
The final appeal must be in writing, duly signed, state the grounds, and be accompanied by all original claim documents, including a copy of the order of the PRO or Office of the Area Head being appealed. Additional documents may be required by the PARD.
Within an average of fifteen (15) calendar days from receipt of a complete final appeal, the PARD either dismisses or grants it through a resolution stating facts, issues, and legal provisions. It provides copies to the movant and concerned PRO/Office for implementation.
The PARD resolutions on final appeals are final and executory, subject to judicial appeals on final resolutions/orders of quasi-judicial agencies under Rule 43 of the Revised Rules of Court.
It allows liberal interpretation and application in meritorious cases to serve substantial justice and equity and for expeditious resolution of M/Rs and final appeals.
No. The existing procedure on appeals with the CRO and PARD on denied or reduced benefit claims continues to remain in force until the effectivity of these guidelines (with the Circular effective on 31 March 2008).
It took effect on 31 March 2008.