Philippine Creative Industries Development Act

PhilHealth Circular No. 03, s. 2008 implements administrative remedies consistent with the administrative reengineering of PhilHealth’s organization.
PhilHealth Circular No. 03, s. 2008 is based on PhilHealth Board Resolution No. 842, s. 2005, which removed the remedy of an initial appeal with the Claims Review Office (CRO) on denied or reduced benefit claims.
PhilHealth Circular No. 03, s. 2008 replaces the initial appeal with a motion for reconsideration before the PROs, and provides for a final appeal before the PARD for decisions by the PROs that deny or reduce benefit claims.

Section 1 allows any movant who is an aggrieved member, beneficiary, or health care provider whose benefit claim was originally denied or reduced by the PROs to file a motion for reconsideration (M/R).
The PROs that are covered for this remedy include NCR-Central, NCR-North, and NCR-South.
Section 2 requires filing the M/R with the PRO that denied or reduced the benefit claim within fifteen (15) calendar days from receipt by the aggrieved party of the PRO’s written notice of denial or reduction.
Section 3 limits the grounds for the M/R to any error of fact or law or both committed by the PRO in denying or reducing the benefit claim.
Section 4 requires the M/R to be in writing, duly signed, state the grounds, and be accompanied by all original claim documents returned by the concerned PRO, if any.
Section 4 authorizes the PRO and the Office of the Area Head to require additional documents for a more proper evaluation and resolution.

Section 5 requires that within fifteen (15) calendar days from receipt of the M/R, the PRO shall either:
- deny the M/R and issue an order briefly stating the reasons for denial; or
- recommend to the concerned Office of the Area Head the grant of the M/R.
Section 5 provides that if the PRO denies the M/R, a copy of the denial order is issued to the movant.
Section 5 provides that if the PRO recommends granting the M/R, the PRO forwards the order (with the case file) for review to the Office of the Area Head, which must approve or disapprove the same through an order within fifteen (15) calendar days from receipt.
Section 5 requires furnishing the movant and the PRO with a copy of the Office of the Area Head order for implementation.
Section 5 requires that if the M/R is denied by the PRO or the Office of the Area Head, the original claim document shall be returned to the movant together with the order of denial.
Section 6 establishes that the order of the PRO and the Office of the Area Head on an M/R is final and executory, subject to a remedy of a final appeal with the PARD.
Section 6 prohibits the filing and entertaining of a second M/R under any form or nomenclature by the PRO and Office of the Area Head.

Section 7 allows any movant whose M/R was denied by:
- an order of the PRO (including NCR-Central, NCR-North, NCR-South), or
- an order of the Office of the Area Head
  to file a final appeal.
Section 8 requires filing the final appeal with the PARD (acting for the President and CEO) within fifteen (15) calendar days from receipt by the movant of a copy of the denial order.
Section 9 limits the grounds for a final appeal to any error of fact or law or both committed by the PRO or the Office of the Area Head in denying an M/R.
Section 10 requires the final appeal to be in writing, duly signed, state the grounds, and be accompanied by all original claim documents, including a copy of the order being appealed.
Section 10 allows the PARD to require additional documents for proper evaluation and resolution.

Section 11 requires the PARD to decide within an average of fifteen (15) calendar days from receipt by the PARD of a complete final appeal.
Section 11 requires the PARD’s decision by resolution to either dismiss or grant the final appeal.
Section 11 requires the PARD’s resolution to concisely state the facts, issues, and legal provisions on which it is based and to copy-furnish the movant and the concerned PRO or Office of the Area Head for implementation.
Section 12 provides that PARD resolutions on final appeals are final and executory, subject only to judicial appeals on the final resolutions and orders of quasi-judicial agencies under Rule 43 of the Revised Rules of Court.

Section 13 authorizes a liberal interpretation and application in meritorious cases to serve the ends of substantial justice and equity over matters of form and technicality, and to promote the expeditious resolution of M/Rs and final appeals.
Section 14 provides a transitional rule that the existing procedure on appeals with the CRO and PARD on denied or reduced benefit claims continues to remain in force and effect until the effectivity of these guidelines.