SC CIRCULAR NO. 55-98, September 19, 1998

Circulars September 19, 1998

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TO :	All Officials and Employees of the OCAD All Judges and Employees, Lower Courts

SUBJECT:	Philippine Health Insurance Corporation Circular No. 20, S 1998

Quoted hereimder is Philippine Heaiih Insurance Corporation (PH1C) CIRCUI AR
NO. 20, S 1998, for the information and guidance of all concerned:

“PHIC CIRCULAR
NO. 20, S 1998

TO :	ALL ACCREDITED INSTITUTIONAL AND PROFESSIONAL HEALTH CARE PROVIDERS, NATIONAL GOVERNMENT AGENCIES, INSTRUMENTALITIES, GOVERNMENT OWNED AND CONTROLLED CORPORATIONS, SELF GOVERNING BOARDS, STATE COLLEGES AND UNIVERSITIES

“EFFECTIVE April I, 1998, all claims for the National Health Insurance
Program (NH1P) benefits with incomplete documents or insufficient information
will automatically be denied payment and returned to hospitals for completion of
the documentary requirements.

“All claims requiring submission of additional documents and which are
returned to hospitals should be forwarded to PhilHealth within 120 calendar days
from the receipt of such claims.

“PhilHealth will return incomplete claim documents to the hospitals onjy once
If these returned claims are re-submitted without full compliance, this will
also be disapproved. Re-submitted claims will be processed according to first
in, first out policy.

“This rule applies to all claims filed in behalf of government sector
employees, retirees and their dependents.

“PhilHealth will indicate the reasons for the denial or the disapproval ot
claims These will be in the fonn of codes which will be indicated on the
PhilHealth benefits voucher, PhilHealth Form No. 2 and the accompanying letter
addressed to the hospital where the claims will be returned. Attached is
“Annex A” to guide hospitals and NHIP members in evaluating the reasons
for claims denial or approval.

“We enjoin all concerned to observe these new policies to help expedite the
processing of NHIP claims.

Please be guided accordingly. October 19,
1998.

	(SGD.) ALFREDO L. BENIPAYO
	Court Administrator

AnnexA

REASONS FOR DENIAL/DISAPPROVAL OF PAYMENT OF NATIONAL HEALTH INSURANCE
PROGRAM (NHIP) CLAIMS FOR GOVERNMENT EMPLOYEES/RETIREES DESCRIPTION OF
DEFICIENCY/REQUIREMENT

CODE NO.	DESCRIPTION OF DEFICIENCY/REQUIREMENT	BOX/FORM NO.
1	Incomplete member’s name; Please submit birth certificate certified by the Local Civil Registry	Box 1, Form 1
2	Without or incomplete member’s date of birth; Please submit birth certificate certified by the Local Civil Registry	Box 3, Form 1
3	Conflicting or different member’s date of birth as verified from previous claims; Submit birth certificate certified by the Local Civil Registry	Box 3, Form 1
4	Incomplete patient’s name; Please submit birth certificate certified by the Local Civil Registry	Box 11, Form 1
5	Without or incomplete patient’s date of birth; Please submit birth certificate certified by Local Civil Registry	Box 13, Form
6	Name of spouse not indicated	Box 8, Form 1
7	Spouse’s employer and address not indicated	Box 9, Form 1
8	Member’s relationship to patient not indicated	Box 15, Form 1
9	Without member’s signature	Box 17, Form 1
10	Without printed namo, signature and relationship to member of witness to thumbmark when member cannot sign	Box 17, Form 1
11	Without registered name and address of employer and branch/station	Boxes 18-21, Form 1
12	Without printed name and signature of Employer’s Authorized Representative (EAR)	Box 22, Form 1
13	Inconsistent signature of Employer’s Authorized Representative; Submit specimen signature	Box 22, Formi
14	Official capacity of Employer’s Authorized Representative not indicated	Box 22, Form 1
15	Date when certification ol employee’s coiiliibulion wjs signed “not indicated-	Box 22, Form 1
16	Incorrect hospital accreditation number/no hospital accreditation number indicated	Box 2, Form 2
17	Address of member not indicated	Box 12, Form 2
18	Confinement period not indicated/inconsistent/tampered date of confinement – Please submit Philhealtg Form 3 and Clinical Chart	Box 14, Form 2
19	Hospital charges not properly filled-up	Box 15, Form 2
20	Claim is without admission or final diagnosis	Box 13,17 Form 2
21	Printed name and official capacity of Hospital’s Authorized Representative not indicated (HAR)	Box 16, Form 2
22	Without sianature of Hospital’s Authorized Representative	Box 16, Form 2
23	Inconsistent signature of Hospital’s Authorized Representative, Submit specimen signature	Box 16. Form 2
24	Without signature of attending physician/surgeon/anesthesiologist	Boxes 19, 24, 29, Form 2
25	Incorrect accreditation number of physician/surgeon/anesthesiologist or no accreditation number indicated	Boxes 20,25,30 Form 2
26	Doctors not accredited (NA)/did not renew accreditation (NLA)
27	Doctor’s charges not properly filled up	Boxes 23,28,33, Form 2
28	Part HI/IV not properly filled up/not specified/itemized	Form 2
29	Hospital not accredited/did not renew accreditation
30	Hospital’s change of name not yet approved by PHIC
31	Without PhilHeaith Form 1
32	Regular employees-without copy/matured member’s GSIS Policy Contract; Submit renewed GSIS Policy Contract/Service Record
33	GSIS Retirees/ Pensioners without copy of Retirement Voucher or latest Retirement Certificate from GSIS or latest Pension Check Acknowledgement Receipt or Pension Voucher or Bank Account Passbook
34	Other Retirees/Pensioners-without copy of Retirement Voucher or Certificate/latest Pension Check or Voucher/Bank Account Passbook and Service Record or Summary of Services or Certification of 120 monthly NHIP contribution
35	GSIS Retirees under PD 1184, PD 1146 and RA 1616 who are less than 60 years old not covered (except under RA 660 & Disability Retirement) – DISAPPROVED
36	Retired judges/members of the judiciary who are less than 70 years old not covered – DISAPPROVED
37	Retired AFP/PNP personnel below 56 years old not covered -DISAPPROVED
38	Casual/Temporary employee’s Term Insurance (TR) expired; Submit renewed TR or certification.of monthly premium contribution with specific amount, O.R. # and date of payment by the employer
39	Barangay Officials/CAFGU members not covered – DISAPPROVED
40	Ciaim filed beyond the 60-day statutory period – DISAPPROVED
41	Dependent parents below 60 years of age not covered-DISAPPROVED
42	Children 21 years and above of age not covered – DISAPPROVED
43	Claim should be filed under the membership of the father who is employed
44	Claim should be filed under employed patient’s own membership
45	Illness not compensable under Medicare – DISAPPROVED
46	The 45 days room and board benefit allowable for the year has been exhausted – DISAPPROVED
47	Claim is forwarded to OWWA/SSS
48	Veterans not covered as member- – DISAPPROVED
49	Survivorship benefit-Dependents not covered – DISAPPROVED
50	Primary Hospital – without PhilHealth Form 3 and Clinical Chart
51	Others

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