MANILA – The Philippine Health Insurance Corporation (PhilHealth) recently introduced a policy to ensure that its members who seek treatment in hospitals are provided with health care services that are of the desired quality and at par with existing medical standards.
In its PhilHealth Circular No. 2019-0002 entitled “Documentary Requirement for Claims Reimbursement and Medical Prepayment Review of Claims (Revision 2),” the state health insurer prescribes a medical prepayment review and requires the use of Claim Form 4 (CF4) for all admissions starting March 1, 2019.
Medical pre-payment review is a process that takes place prior to actual processing , wherein claims that are not compensable as well as those that are not compliant to existing policies and standards on quality of care will no longer be processed. It relies on the CF4 which summarizes a patient’s pertinent clinical information, eliminating the submission of complete clinical charts for claims reimbursements.
The new policy shall cover claims using case rates with the exception of directly filed claims and those for confinements abroad, claims for Z Benefits, among others.
The new system will enable PhilHealth to efficiently assess provider claims and to detect irregular practices such as over utilization or under-utilization of services; unnecessary use of diagnostic and therapeutic procedures and interventions; irrational medication and prescriptions; fraudulent, false or incorrect information; gross or unjustified deviations from currently accepted standards of practice and/or treatment protocols; inappropriate referral practices; use of fake, adulterated, misbranded or unregistered drugs; among others.
“With this new policy, we aim to maximize our limited manpower and financial resources to promptly act on good and compliant claims. This also saves much on time which translates to faster turnaround time for claims processing, and good health outcomes for our patients.” PhilHealth Acting PCEO Dr. Roy B. Ferrer explained.
To help HCIs to adapt to the new system, PhilHealth said that facilities with eClaims systems may transmit the encoded CF4s of admissions starting March 1, 2019, while other HCIs can use available offline applications provided by PhilHealth. Those still enhancing their eClaims shall submit encoded CF4s as attachment to claim applications, while those using PhilHealth Information and Claims System (PHICS) or Softcopy Claims (SClaims) shall submit the encoded CF4s. On the other hand, those manually submitting claim applications shall submit soft copy of encoded CF4 together with manually transmitted claim application./PN
CF4 nagpapa delay ng claims sa mga Ospital sa Pilipinas
yang cf4 na yan ay nagpapa delay lang yan talaga, tsaka redundant na kasi may clinical chart na ginagawa. ang bobo ng nakaisip nyan!