Improving operational efficiency through information and communication technology is one of our major thrusts. Towards this end, we are gearing for online transactions aimed at further strengthening our partnerships and linkages with accredited health care providers for the greater benefit of our members.
PhilHealth is introducing the e-Claims Project which features an online connection facility that will enable our accredited hospitals to eventually submit claims online.
The Project's Phase I called Claims Eligibility Web Service (CEWS) will allow the hospital to check whether or not the patients are registered with PhilHealth and has required contributions to avail of benefits. This project is expected to speed up the eligibility verification process at the hospital level and may reduce incidence of return-to-hospital (RTH) claims due to member eligibility concerns.
II. IMPLEMENTATION OF E-CLAIMS PROJECT - CLAIMS ELIGIBILITY WEB SERVICE (CEWS) - PHASE I
A. CoverageIII. EFFECTIVITY
The CEWS shall be implemented exclusively between the participating hospitals and PhilHealth, to serve admitted patients who are PhilHealth members/dependents availing themselves of the health care services of the hospital facility. Verification of information shall be limited to:
The 45 days limit for room and board allowance shall only reflect claims that are processed or paid on the day verification was made and will not include claims in transit or in process. Thus, the 45 days limit will still be subject for verification during the actual processing of claims.
- member's name and date of birth
- declared dependents
- contribution eligibility
- 45 days limit for room and board allowance for members and dependents
B. IT Qualification of HCP
The CEWS requires that hospitals have Information and Communication Technology capability. Network connectivity, software development, hardware installation and configuration shall be the responsibility of the hospitals. In particular, the HCP must meet the following requirements:
PhilHealth may provide temporary technical assistance to the HCP to launch the project.
- Must have an existing hospital information system (i.e., patient information, details of confinement, hospital charges among others)
- Available internet connection; and
- Capability to modify or enhance existing system or develop their own prototype to connect with PhilHealth.
C. Enrolment/Participation of the HCP
The following are the steps in CEWS enrollment/participation:
D. Generation of CEWS Tracking Number
- Hospitals shall submit to PhilHealth written expression of interest to connect with PhilHealth Web Service;
- PhilHealth shall provide guidelines to hospitals on how to connect to the PhilHealth Web Service.
- Hospitals shall develop its own CEWS prototype/system to access/query from PhilHealth Web Service in conformity with the standard parameters set by PhilHealth;
- PhilHealth shall evaluate CEWS prototype developed by hospitals;
- PhilHealth to conduct orientation on Standard Encoding Format for e-Claims transactions among the HCP Technical staff members.
- Sign a Conforme/Undertaking with PhilHealth to implement the e-Claims Project under the terms and conditions such as but not limited to the following:
- The Web Service shall be exclusively used for admitted patients only.
- Information acquired through the CEWS should not be used for other purposes.
- Hospitals shall not charge a fee from patients for the use of the CEWS.
- Hospitals shall conduct a test-run for one (1) month enrollment stating the conditions, privileges, and responsibilities of HCPs that will form part of the warranties of accreditation.
At the hospital level, eligibility verification using CEWS ca be made using PhilHealth Identification Number (PIN) of the member upon admission which will generate responses on the following information:
- PhilHealth Identification Number (PIN);
- Name of member and patient;
- Date of Confinement; and
- PhilHealth Employer Number (PEN) and Employer Name for the employed sector member:4.1 A Tracking Number (TN) shall be generated for queries with YES response while those with NO response, the CEWS shall generate a list of deficiencies which the member needs to comply for benefit availment;E. Provision of "e-Claims Lane"
4.2 Before discharge, a member may comply at any PhilHealth office, the list of documents generated from the CEWS, to qualify for a second call/eligibility check, or such member may submit the required documents directly to the hospital to avail of the PhilHealth benefit;
4.3 Hospital shall accept/honor the documents submitted but shall segregate it from claims with YES response or from claims with TN. The TN may be printed in PhilHealth Claim Form 2 or preferably in a slip to be attached to the claim for filing;
4.4 Properly accomplished PhilHealth Claim Form 1 is still required for all claims. however, there is no need to attach Member Data Record (MDR) and other documentary requirements as proof of eligibility of PhilHealth benefits for those with TN.
4.5 For Individually Paying Members (IPMs), attachment of Proof of Contributions (POC) is mandatory for surgical procedures requiring 9/12 months contributions.
PhilHealth shall provide a special e-Claims lane for all claims filed with TN as proof of eligibility generated under the CEWS. Claims with no TN shall go through the regular process.
The CEWS-Phase I shall be made available fifteen (15) days after publication of his circular in any newspaper of general circulation and deposited thereafter with the National Administrative Register at the University of the Philippines Law Center. Further, participation of HCPs shall be subject to approval of the Corporation.
All other provisions of previous issuances that are inconsistent with any provisions of this circular hereby repealed/modified of amended accordingly.
DR. REY B. AQUINO
President and CEO