Philhealth clarifies rules on direct filing of claims

EARLIER this year, the Philippine Health Insurance Corp. (Philhealth) restricted direct filing of claims except for confinements abroad and for emergency confinements in non-accredited health care institutions (HCIs).

As a general rule, Philhealth-accredited HCIs are expected to deduct the entire amount of the benefit from the total hospital/facility bill as members submit the necessary claim documents upon discharge.

In cases where the maximum benefits were availed, members no longer have to wait for reimbursement.

However, due to the clamor from some members requesting Philhealth to allow direct filing of claims for reasons beyond those mentioned above, the state-run health insurance expands the conditions allowed for direct filing of claims.

In addition to the cases enumerated in Circular 35-2013, Philhealth clarifies through Circular 20-2014 that direct filing of claims shall be allowed when a member is unable to secure the required documents when confinement falls on a weekend or declared holiday.

Animal bite package

Philhealth also allows direct filing of claims for peritoneal dialysis; animal bite package; and other circumstances as maybe determined by the corporation.

Deadline of submission of directly filed claims (except for confinements abroad and emergency confinements in non-accredited HCIs) shall be 60 days after date of discharge from the HCI.

When availing of benefits, Philhealth members shall submit a duly accomplished claim form 1 (CF1), together with a copy of the member data record (MDR), to the HCI.

Aside from the member’s signature, employed individuals need to have the CF1 signed by their employer.

Philhealth encouraged members to always provide accurate information and submit all required documents to the hospital/facility on time.