Policy, purpose, and rationale
- The Electronic Claims System (eClaims) is an interconnected modular information system for claim reimbursement.
- eClaims begins when a patient signifies intention to use a PhilHealth benefit and ends when the claim is paid.
- eClaims enables a Health Care Institution (HCI) to determine patient eligibility for insurance, submit claims electronically/online, and track and verify claim status for reimbursement.
- eClaims removes duplication in entering claims data, especially when HCIs have existing Hospital Information System (HIS) or Electronic Medical Record (EMR).
- eClaims improves efficiency and turnaround time by eliminating physical submission of claim forms to PhilHealth offices and replacing manual encoding, printing, transmittal list preparation, and storage device transfer.
- eClaims enhances fraud detection, monitoring, and prevention, and improves data quality by minimizing manual encoding and preventing duplicated encoding.
- PhilHealth participation also aims to minimize warehousing of claims forms and supporting documentation by using electronic or imaged documents for adjudication.
- The circular authorizes a hybrid approach to support EMR use in all health facilities and to prepare HCIs for data harmonization between the Department of Health and PhilHealth.
- The hybrid approach aligns with the Philippine Health Agenda’s eHealth and decision-making data thrust.
Definitions and key terms
- Direct Data Transmission (DDT) is the transfer of data from an HCI’s existing software solution/product to PhilHealth.
- eClaims Eligibility Web Service (eCEWS) is the set of standard Application Programming Interfaces (APIs) provided by PhilHealth for electronic claim transactions.
- Electronic Claims Transporter (EC1) is the software solution/product that electronically transmits extracted data from an HCI’s existing software solution/product to PhilHealth.
- Electronic Document (ED) is information or representation of information received, recorded, transmitted, stored, processed, retrieved, or produced electronically, used to establish a right or obligation or to prove and affirm a fact.
- Electronic Medical Record (EMR) is a software solution/product that enables entry, management, and consultation of a patient’s health-related data by authorized health care providers within an organization.
- Hospital Information System (HIS) is a software solution/product designed to manage hospital operations such as Outpatient Department, Emergency Room, Admission, Billing, Cashiering, Medical Record, Laboratory, Radiology, Dietary, and other revenue centers.
- Service Provider (SP) is a company, firm, organization, institution, or individual that provides or offers software solutions/products and other IT services; Health Information Technology Provider is also a service provider.
- Software Solution/Product (SSP) is a set of related software programs/services developed or sold as a single package, including HIS, EMR, and Electronic Claims Transporter, and others.
Coverage and what eClaims covers
- The circular applies to all HCIs, health care providers, service providers, and PhilHealth national and regional offices, Local Health Insurance Offices (LHIOs), and other concerned parties.
- eClaims applies to reimbursement claims for:
- all case rates (ACRs);
- special benefit packages (Z Benefits);
- outpatient benefit packages including Maternal Care Package (MCP), Newborn Care Package (NCP), TB-DOTS Package, Outpatient Malaria Package, and Animal Bite Treatment Package;
- Dialysis and Outpatient HIV /AIDS Treatment Package; and
- other benefit packages defined by PhilHealth.
- The circular requires mandatory eClaims use for all HCIs beginning January 1, 2018 for new claims submitted on or after that date in electronic form.
- The circular establishes interim and transition arrangements up to December 31, 2017 while HCIs prepare for mandatory electronic submission.
Core compliance rules for HCIs
- Compliance to eClaims is extended to December 31, 2017 to allow preparation and transition to mandatory use on January 1, 2018.
- During the transition, HCIs must maintain the status quo of claims submission modes: Manual using NClaims, eClaims using HITP, and PHICS/SCLAIMS.
- Beginning January 1, 2018, eClaims is mandatory to all HCIs and all submitted new claims must be in electronic form.
- PhilHealth requires all HCIs to use HIS/EMR to improve internal workflows/processes, data quality, efficiency, and client satisfaction.
- Only HCIs using software solutions/products certified by PhilHealth may implement eClaims.
- PhilHealth certifications apply to specific versions of benefit packages, with multiple certifications granted to specific version(s) of benefit packages.
- Certified in-house or outsourced software endorsed by one (1) HCI may be used by other HCIs through agreements, terms, and/or conditions directly between the service provider and the HCI.
- PhilHealth is not held liable for actions of the service provider arising from engagement with the HCI or vice-versa that result in damage or injury to the HCI or its clientele.
- eClaims is no longer exclusive to HITPs; HCIs may continue upload through certified software solutions/products (HIS/EMR or electronic claims transporter) or consider direct transmission from their existing software solutions/products.
- HCIs must communicate in writing to PhilHealth to confirm or validate compliance with PhilHealth requirements.
- HCIs may implement eClaims using the available implementation options set out in the circular and associated certification rules.
- PhilHealth does not charge any cost for use of eClaims services; investments in software solutions/products, whether in-house or outsourced, are borne by the HCIs.
- A separate issuance governs procedures and guidelines on direct transmission and certification of software solutions/products as compliant to PhilHealth claims submission requirements.
- HCIs and/or service providers must develop and maintain policies and procedures compliant with applicable statutory laws including Republic Act No. 8792, Republic Act No. 10173, and Republic Act No. 9470.
- The HCI head (including Hospital Director, Chief of Hospital, Hospital Administrator, and the like) is accountable for data quality (validity, accuracy, completeness) and for security, storage, and transmission from the HCI’s end.
- The PhilHealth Electronic Claims Implementation Guide (PeCIG) serves as the technical reference manual on eClaims compliance, including standards on semantic security, data security compliance such as encryption at rest and in transit, transmission protocol, and technical specifications for electronic claims and scanned supporting documents.
- HCIs and/or service providers are accountable for ensuring conformance to updated PeCIG specifications.
- Transmitted claims must be stored in PhilHealth’s data center and/or a service provider’s cloud provider storage that complies with requirements of the National Privacy Commission, Department of Information and Communications Technology, Department of Health, and other national regulatory agencies or offices.
- Transmitted claims are owned by PhilHealth.
- Electronic claims review, adjudication, and payment must be conducted in compliance with existing policies, and necessary electronic supporting documents must be made available and readable to PhilHealth during adjudication.
- Information/data exchanged between systems accessed by HCIs must not be used outside the intended use stipulated under the circular.
- PHICS and SCLAIMS serve as interim solutions up to December 31, 2017, and implementation of PHICS/SCLAIMS must cease thereafter.
Transition plan and eClaims models
- HCIs are granted up to December 31, 2017 to plan and perform activities to comply with mandatory eClaims use beginning January 1, 2018.
- Existing systems, including eClaims with HITPs currently used to transmit claims to PhilHealth, remain as-is while HCIs prepare to move to eClaims.
- HCIs must submit a Transition Plan (TP) that lays out tasks and activities to comply with eClaims requirements and to implement EMR systems.
- The circular defines EMR as an electronic record of health-related information that can be created, gathered, managed, and consulted by authorized health care providers within an organization.
- HCIs submit the Transition Plan to their respective PhilHealth Regional Offices for information and monitoring.
- HCIs select the appropriate eClaims implementation option and must perform cost-benefit analysis to determine strengths and weaknesses of modes and identify the option providing greater benefits.
- Implementation options include:
- Outsourced to Service Providers, where the HCI requires service-provider compliance efforts to PhilHealth technical specifications and software certification, and where the HCI may use another certified service provider; and
- In-House Developed, where the HCI may directly transmit claims data to PhilHealth while coordinating technical specifications and seeking software certification, and may still use a service provider whose software is certified.
HCI–service provider agreements and certification
- HCIs must ensure appropriate Memorandum of Agreements (MOAs) or Contracts, and Service Level Agreements (SLAs), are executed between HCI management and the service provider.
- The MOA/Contract must define working relationships and services covered and must require compliance with PhilHealth standards, data integrity, data privacy and confidentiality, non-disclosure, data management, and reporting.
- The MOA/Contract must address data security (including encryption), data storage, data backup, data/database portability, and data ownership.
- The MOA/Contract must address connectivity, data sovereignty in cloud environments, data audit, data breach, termination of the agreement, transfer to other service provider, and problem management.
- The MOA/Contract must include duties/responsibilities of parties and related fees/costs, term, effectivity, and other vital requirements.
- The SLA must formally define the scope, quality, and responsibilities of the service provider, including measurable items such as contracted delivery time, system uptime, mean time between failures, mean time to repair/recovery, fault reporting responsibilities, fees (if any), data rates, and throughput.
- MOA/Contract and SLA bind only the contracting parties, and PhilHealth is not held liable for actions of the service provider arising from engagement with the HCI or vice-versa resulting in damage or injury.
- HCIs and service providers must hold PhilHealth, its personnel, and instrumentalities free from liability related to their engagement.
- All software solutions/products submitting eClaims—outsourced or in-house—must undergo PhilHealth Software Certification.
- The certification procedures are governed by a separate issuance.
- For registration, HCIs submit an engagement form and a photocopy of the software certification to the nearest PhilHealth office; HCIs already engaged with HITPs that submitted engagement forms are deemed registered.
Data entry, eligibility checks, and required documents
- All data required for claims must be entered and processed within the HCI.
- HCIs must call the eCEWS for eligibility.
- HCIs must cease using the PhilHealth Benefit Eligibility Form (PBEF) generated from the PhilHealth HCI Portal.
- For cases with a “YES” response in eCEWS and issuance of a tracking reference number, HCIs must no longer attach the PBEF as proof of eligibility.
- For cases with a “NO” response, the system-designated document list must be attached to the claim.
- The Claim Signature Form must be duly accomplished and signed by appropriate signatories prior to scanning.
- The Claim Signature Form is mandatory to all claims.
- Other prescribed documents needed for adjudication and audit—including official receipts, diagnostic results, operative records, PhilHealth Membership Registration Form, PhilHealth Official Receipt, Statement of Accounts, and others needed—must be scanned and saved in the HCI and/or service-provider facilities.
- Such scanned documents may be uploaded as necessary based on existing policies.
Transmission, status verification, and payment
- HCIs may submit electronic claims anytime in real-time, whether singly or in batch.
- HCIs receive a system-generated receipt ticket number as notification of successful transmission.
- Claims received by PhilHealth are deemed final and actionable by PhilHealth.
- HCIs must be able to verify the status of transmitted claims, including returns, reasons, needed documents, and other requirements.
- For Return to Hospital (RTH) claims, PhilHealth must provide reasons for return and the required missing documents.
- For Denied Claims, PhilHealth must provide the reasons for denial.
- For Good Claims, the current processing stage must be provided.
- For Paid Claims, payment details such as amount and dates must be provided, and these details must be used by the facility to reconcile claims records.
- Checks are released to the HCIs for claim payment.
- Future enhancements to payment modes are governed by a separate issuance.
Monitoring, evaluation, and sanctions
- PhilHealth monitors HCI compliance to eClaims through PhilHealth Central and/or Regional Offices.
- PhilHealth Central Office/Regional Offices may conduct random or unscheduled visits to verify use of certified HIS/EMR software, compliance with standards, and other defined criteria or indicators.
- Reports on abuse and misuse of eClaims are investigated and evaluated by PhilHealth.
- Appropriate actions and sanctions are imposed for abuse and misuse.
- Any participating HCI and/or service provider that fails to comply with the circular or commits acts violating Republic Act No. 8792, Republic Act No. 10175, and Republic Act No. 10173 in relation to eClaims operations is penalized by termination of the right to participate and revocation of all privileges under the participation.
- Penalties under the circular do not prejudice administrative, civil, and criminal liability of owners, directors, or responsible officers under pertinent laws and rules.
- Any individual involved in processing health information who violates the circular’s policies or fails to observe internal policies or regulations implemented pursuant to the circular loses authorization to access eClaims, without prejudice to administrative, civil, and criminal liability under pertinent laws and rules.
- A finding of guilt for violation of the circular does not bar criminal prosecution for violation of Republic Act No. 8792, Republic Act No. 10175, Republic Act No. 10173, the Revised Penal Code, or other special laws, whenever applicable.
Separability and repealing rules
- Provisions of previous issuances inconsistent with PhilHealth Circular No. 2017-0030 are repealed accordingly.