Professional Fees and Claims Processing
- Claims lacking signatures of the attending physician, surgeon, and/or anesthesiologist will be processed, but only hospital charges will be paid; professional fees will be denied.
- Claims missing actual charges for professional fees will be returned to the hospital for completion.
- This provision also applies to claims with concomitant HMO benefits.
- Physicians can request payment of professional fees without signature by submitting:
- A letter requesting claim adjustment within 60 days after receiving a refund from PhilHealth,
- Photocopy of PhilHealth Form 2 with original attending physician’s signature,
- Photocopy of the paid claim voucher.
Adjustment of Payment Claims
- Hospitals may request re-evaluation and adjustment of previously paid claims within 60 days of receipt of the PhilHealth Check and Voucher.
- Adjustments can be made for missing original receipts for medicines purchased outside the hospital during confinement, underpaid room and board charges, laboratory procedures, operating room fees, and doctor’s professional fees.
- Adjustments excluded are those related to increases in NHIP benefits as per PhilHealth Circular No. 52, s. 1999.
Declaration of Female Members' Dependents
- Female members may declare their children as dependents even if the husband is employed and covered by NHIP.
- A dependent declared by one parent cannot be declared again as a dependent by the other parent, consistent with IRR, R.A. 7875 (Rule 1 Section 6).
Bank Account Passbook for Retiree Pensioners
- Bank Account Passbooks will be honored regardless of the frequency or consistency of deposits.
Proof of Dependency for Employed Members
- No proof of dependency is required for dependents if the employer signs PhilHealth Form 1 certifying the truth and accuracy of the data.
Processing Claims for Dependent Children Turning 21
- Claims for dependent children reaching age 21 during confinement period will be fully processed.
Submission of Original Official Receipts
- Claims must be supported by original official receipts issued by the hospital, pharmacy, or attending physician if the member or patient paid the hospital bills.
- Tape receipts are not acceptable for payment purposes.