PhilHealth Claim Submission Requirements

Rule VIII Section 47 of the Implementing Rules and Regulations of Republic Act No. 7875 as amended provides the legal basis for requiring the Statement of Accounts (SA) or Billing Statements (BS) (or its equivalent) in relation to claim processing.
PhilHealth Circular No. 22, s. 2007 requires submission of SA/BS (or equivalent) together with the Official Receipt to ensure reimbursements are provided to the rightful beneficiary.
The SA/BS and attached payment proof serve as the basis for reimbursement of:
- the hospital for the actual benefit amount deducted from hospitalization charges; and
- the member for the remaining benefit (the difference between the amount deducted by the facility and the maximum allowable benefit for the illness case type and hospital category).
The requirement also helps prevent accredited institutional health care providers from accumulating unclaimed or unrefunded PhilHealth reimbursements to members.

A PhilHealth claim application must have attached:
- the Statement of Accounts (SA) or Billing Statements (BS) (or its equivalent), and
- the Official Receipt (OR) of payment by the member to the hospital.
The SA/BS (or equivalent) must be the final BS/SA issued on the day of patient’s discharge.
The final BS/SA must indicate the PhilHealth deductions on both:
- hospital charges, and
- professional fees.
The SA/BS must be duly signed by the member or the member’s authorized representative with:
- printed name,
- relationship to member, and
- contact number.
The signatory in the SA/BS should be the same person as the signatory in PhilHealth Claim Form 1 item No. 13.
If the signatory in Claim Form 1 item No. 13 differs from the SA/BS signatory, the SA/BS must include information on the authorized representative, specifically:
- name,
- relationship to member, and
- contact number.
The SA/BS must include signature over printed name and position of the accountant or billing clerk.

A copy of the SA and the corresponding Official Receipts (OR) of payment must be provided to the member upon discharge.
The member has the option to attach the OR as the basis for appropriate reimbursement of remaining benefits (if any).

Submission of SA/BS and OR is without prejudice to the proper accomplishment of PhilHealth Claim Form 2, specifically Parts 3 and 4.
Proper completion of Claim Form 2 must cover SA/BS formatting requirements, including cases where SA/BS format is without itemization of charges.
When there is a discrepancy between the amount claimed in Claim Form 2 and the amount in the SA/BS:
- the actual amount deducted by the provider as stated in the SA, supported by the Official Receipt, is used as the basis for reimbursement.

After the effective date applicable to a provider’s PRO and hospital category, PhilHealth returns all claim applications without SA or BS for compliance.
Claims for the TB-DOTS package are not returned even if the required SA/BS is not included, during the period covered by the circular’s enforcement rule.

NCR and PRO VI for Levels 3 & 4 admissions are covered beginning February 1, 2008.
Remaining PROs (CAR I, II, III, IVA, IVB, V, VII, VIII, IX, X, XI, XII, CARAGA) for Levels 3 & 4 admissions are covered beginning April 1, 2008.
All PROs for all levels are covered beginning June 1, 2008.
From the respective effective date onwards, the SA/BS and OR attachment requirement applies to claim submissions for the covered providers based on the schedule.

Providers and concerned parties are directed to comply with the circular’s requirements and implementation schedule.
The circular’s instructions govern the submission of SA/BS (or equivalent) and related payment proof as attachments to PhilHealth claims for the covered admissions dates and provider categories.