Benefits and Advantages
- PhilHealth benefits: enhanced fraud detection, improved efficiency and data quality, reduced physical documentation, and better claim processing turnaround time.
- HCIs benefit from automated workflows, improved data integrity via HIS/EMRs, reduced documentation storage, faster payments, and fewer return-to-hospital claims.
- Members benefit from improved service quality, timely verification of eligibility, and clear understanding of costs.
Accreditation and Technical Framework
- PhilHealth accredits Health Information Technology Providers (HITPs) for compliant software solutions.
- HITPs may provide Hospital Information Systems (HIS), infrastructure support, electronic claims transmission, secured connections, and help desk support.
- The system encourages hybrid implementation allowing HCIs to use HITPs or directly transmit from certified in-house or outsourced software.
Terminology Definitions
- Direct Data Transmission (DDT): transfer of data from an HCI's software directly to PhilHealth.
- eClaims Eligibility Web Service (eCEWS): API set for electronic claim transactions.
- Electronic Claims Transporter (ECT): software enabling electronic transmission of claims data.
- Electronic Medical Record (EMR) and Hospital Information System (HIS): software solutions managing medical records and hospital operations respectively.
- Service Provider (SP) and Software Solution/Product (SSP): entities and software facilitating eClaims.
Coverage and Application
- Applies to all HCIs, health care providers, service providers, PhilHealth offices.
- Covers claims for all case rates, special benefit packages, outpatient packages, dialysis, HIV/AIDS treatment, etc.
- Excludes Primary Care Benefit/Tsekap Scheme, readjustment claims, and directly filed claims.
Implementation Guidelines
- Compliance deadline extended to December 31, 2017; mandatory eClaims use starting January 1, 2018.
- Only PhilHealth-certified software solutions allowed for eClaims.
- HCIs may continue partnerships with HITPs or opt for direct transmission.
- No cost charged by PhilHealth for eClaims services; investments borne by HCIs.
- HCIs and service providers must comply with laws including Electronic Commerce Act, Data Privacy Act, and National Archives law.
- Data quality, security, and transmission accountability lie with HCI heads.
- Technical standards detailed in the PhilHealth Electronic Claims Implementation Guide (PeCIG).
Specific Implementation Provisions
- HCIs must plan transition to eClaims with a Transition Plan submitted to PhilHealth regional offices.
- HCIs choose from outsourced or in-house developed software solutions for eClaims.
- MOAs and Service Level Agreements (SLAs) must govern relations between HCIs and service providers, covering services, data privacy, security, and liability.
- PhilHealth not liable for disputes between HCIs and service providers.
- All software must undergo PhilHealth certification.
- HCIs to submit engagement forms and software certifications for registration.
- Claims data entered at HCIs, with eligibility verified via the eClaims Eligibility Web Service.
- Claims processed electronically with scanned supporting documents; real-time transmission and acknowledgment required.
- HCIs can verify claim statuses, including Returns to Hospital, denial reasons, processing stages, and payment details.
Monitoring, Evaluation, and Penalties
- PhilHealth Central and Regional Offices monitor compliance through audits and site visits.
- Abuse or misuse reports investigated, with sanctions applied.
- Non-compliant HCIs or service providers face termination of participation rights and revocation of privileges.
- Individuals violating policies lose access authorization and may face administrative, civil, or criminal liability.
- Criminal prosecution under relevant laws not precluded by internal findings.
Legal and Transitional Provisions
- Repeals inconsistent prior issuances.
- Effective 15 days after publication and registration.
This detailed framework governs the implementation of the electronic claims system for PhilHealth, standardizing procedures, enhancing data security and quality, and ensuring efficient medical claims processing in compliance with Philippine laws and regulations.