PhilHealth Guidelines on Filing & Processing of Claims Affected by Typhoon Sendong

Pursuant to Section 47 of the Implementing Rules and Regulation of the National Health Insurance Act of 1995 (Republic Act 7875, as Amended by Republic Act 9241), all PhilHealth claims for payment shall be filed within 60 days from the date of discharge of the patient; except in cases of natural calamities or other fortuitous events. In such cases, the provider shall be accorded an extension period of another 60 days. In view of the damage brought by typhoon Sendong , affected accredited providers with claims applications destroyed by the said typhoon shall be reimbursed by PhilHealth based on the provisions of this Circular.


A. OPTIONS FOR REIMBURSEMENT

Reimbursement of facilities shall be through any of the following options:

1.    Recovery or reconstruction - Accredited providers or members shall be given an extension period of another 60 days to file claims with date of discharge from October 17 to December 31, 2011; or,

2.    Average Reimbursement per Day - For claims that cannot be reconstructed due to destroyed medical records, payment shall be based on average reimbursement per day multiplied by the number of days from the last day of submission of claims up to December 16, 2011. The average reimbursement per day shall be based on calendar year 2010 data.

For example, the last day of filing of a hospital is December 12, 2011; the computed reimbursement is as follows:

= [Average reimbursement per day] x [December 16– December 12]
= [10 ,000 pesos] x [4 days]
= 40,000 pesos

a)    The FMS/BAS Accounting shall generate the voucher and check for release to affected facilities based on the computation subject to compliance with documentary requirements.

b)    The amount paid shall be considered as reimbursement for services rendered and shall not be chargeable to the future claims of the hospital.

c)    Upon receipt of payment, claims filed for admissions prior to December 16, 2011 shall no longer be processed except for claims directly filed by members.

B. NOTIFICATION REQUIREMENTS

1.    Providers affected by typhoon Sendong should submit a written request to PhilHealth Regional Office (PhRO) by 1st of February 2012 to formally state their chosen option for reimbursement.

2.    The letter should include a report stating the following: description of nature of fortuitous event; the extent of damage of facility/hospitals; and, effects of the event on the obligation of the facility in claims filing.

3.    Certification from the local/city coordinating council relative to the extent of damage to property and records of the hospital/facility.

4.    Proper documentation such as, but not limited to, pictures, videos, newspaper clippings, etc.

C. RECOMMENDATION

1.    Upon receipt of the notification requirements, the concerned PhRO shall send a survey team to the facility to document the extent of damage.

2.    A recommendation shall be submitted by the PhRO to the Office of the President for approval. If good cause is not established, a written notice stating that the request for extension of filing period was disapproved shall be sent to the provider, in which case:

a)    Claims shall be filed as usual and are required to be submitted within 60 days from date of discharge. Otherwise, such claims shall be denied.

b)    A Motion for Reconsideration may be filed in the concerned PhROs for denied claims. Determination for payment of claims submitted beyond the required filing period shall be based on existing appeal process guidelines for denied claims.

D. CLAIMS FROM NON-ACCREDITED PROVIDERS

In recognition of the services rendered by health care providers to PhilHealth members affected by typhoon Sendong, claims for treatments, procedures and other services rendered to eligible PhilHealth members that are considered emergency can be reimbursed by non-accredited facilities provided they are licensed from December 16, 2011 to December 31, 2011.

- https://www.affordablecebu.com/