Objectives of the Policy
- Establish guidelines requiring the submission of the CF4 to systematize data collection and claims evaluation.
- Use clinical and administrative data in CF4 plus diagnostic test results to assess healthcare quality delivered by providers.
Scope of Application
- Policy applies to All Case Rate (ACR) claims for eligible PhilHealth beneficiaries in accredited healthcare institutions.
- Exceptions indicated under General Guidelines are recognized.
Definitions
- Medical Prepayment Review: Evaluation of clinical data before claims payment to verify compliance with corporate policies and accepted medical practice.
- Claim Form 4 (CF4): A summary of critical clinical patient information during hospitalization/episode of care, used by PhilHealth to evaluate claims.
General Guidelines
- All reimbursement claims must be accompanied by CF4 in prescribed format with photocopies of corresponding lab and imaging results.
- Statement of Account must still be submitted alongside these documents.
- CF4 replaces the prior requirement for complete clinical chart copies for pneumonia, urinary tract infection, acute gastroenteritis, and sepsis claims.
- eClaims compliant institutions must scan and attach required documents electronically during claim submission.
- Claims filed directly with PhilHealth, confinements abroad, and certain specific benefit packages are excluded from this policy.
- Deliveries and related claims shall use Claim Form 3 instead of CF4.
- Illegible or incomplete CF4s and attachments result in return to the HCP for re-filing within 60 days.
- PhilHealth may subject any claims to the medical pre-payment review process at its discretion.
- Specific acts such as over/under-utilization, unnecessary procedures, fraudulent information, deviation from standards, inappropriate referrals, and use of unregistered or counterfeit drugs attract penalties.
- Drug reimbursement is based on the Philippine National Formulary; amounts for non-formulary drugs will be deducted.
- PhilHealth may request certified true copies of complete clinical charts for additional information; non-compliance leads to claim denial.
Penalty Clause
- Claims with false or incorrect information may be denied or have reduced payment.
- Non-compliance with rules and regulations without justifiable cause subjects claimants to penalties as per relevant laws.
Monitoring and Evaluation
- Healthcare providers are subject to monitoring and performance evaluation under existing PhilHealth Circulars (No. 54, s-2012 and No. 2016-0026).
Separability Clause
- Invalidity of any provision or its application to certain persons or circumstances does not affect the validity or application to others.
Repealing Clause
- This Circular amends and supersedes PhilHealth Circulars No. 2017-0028, No. 35, s.2013, and No. 8, s.2015.
- All inconsistent prior issuances are amended, modified, or repealed accordingly.
Date of Effectivity
- The Circular takes effect for admissions starting September 1, 2018.
- Required to be published in a newspaper of general circulation and deposited with the National Administrative Register.
This comprehensive policy framework governs documentary requirements and prepayment review procedures to ensure quality, ethical, and appropriate PhilHealth claims processing.