Question & AnswerQ&A (PHILHEALTH CIRCULAR NO. 03, S. 2008)
The initial administrative remedy is filing a Motion for Reconsideration (M/R) with the PhilHealth Regional Offices (PROs) within fifteen (15) calendar days from receipt of the notice of denied or reduced claim.
Any aggrieved PhilHealth member, beneficiary, or health care provider whose benefit claim has been denied or reduced by the PROs may file a Motion for Reconsideration.
The Motion for Reconsideration must be filed within fifteen (15) calendar days from receipt of the written notice of denial or reduction by the PRO.
A Motion for Reconsideration may be filed on the grounds of any error of fact or law, or both, committed by the PRO in denying or reducing a benefit claim.
The Motion for Reconsideration must be in writing, duly signed by the movant, state the grounds for reconsideration, and be accompanied by all original claim documents returned by the PRO. Additional documents may be required for proper evaluation.
The PRO must act on a Motion for Reconsideration within fifteen (15) calendar days from receipt either by issuing an order denying the M/R with reasons or recommending its grant to the Office of the Area Head.
If the Office of the Area Head disapproves the Motion for Reconsideration within fifteen (15) calendar days, it issues an order of denial with a copy furnished to the movant and PRO, and the original claim documents are returned to the movant.
No, no second Motion for Reconsideration or similar remedy is allowed or entertained by the PRO or the Office of the Area Head after the order on the first M/R.
The movant may file a final appeal with the Protests and Appeals Review Department (PARD) within fifteen (15) calendar days from receipt of the denial order.
The final appeal must be in writing, duly signed by the movant, state the grounds for appeal, and be accompanied by all original claim documents and a copy of the denial order from the PRO or Office of the Area Head. Additional documents may be requested.
The PARD shall act on the final appeal within an average of fifteen (15) calendar days by either granting or dismissing the appeal through a resolution stating the facts, issues, and legal bases.
The resolutions of the PARD are final and executory but may be subject to judicial appeal under Rule 43 of the Revised Rules of Court for final decisions of quasi-judicial agencies.
The liberal interpretation clause allows the provisions to be interpreted and applied liberally in meritorious cases to serve substantial justice and equity over matters of form and technicality and to expedite resolution of motions and appeals.
These guidelines took effect on 31 March 2008.