PhiHealth denies all claims filed beyond 60 days after the patient has been discharged from the hospital.

In a press release sent to The News Today, the Philhealth 6 revealed that as of the period of January to December 2011, out of the total 322,406 claims received there were 2,511 claims denied due to late filing and 908 claims were also denied due to non-compliance to the requirements.

Incomplete claims are returned to the hospital (RTH) for the reason that PhilHealth requirements are not properly accomplished. There are about 13,498 claims evaluated to have discrepancies in Claim Form 2 being prepared by the Health Care Provider’s Philhealth in-charge personnel while 5,811 were returned due to non-submission of medical documents and overlapping of confinement.

Other reasons of RTH were attributed to inconsistencies of the member’s data in the Claim Form 1, no proof of contribution, no proof of dependency, no proof of hospital billing and other discrepancies.

Other causes of claims denial were confinement not within the accreditation period of facility, exhausted 45 compensable days, case not compensable, double filing, confinement not within eligibility period and benefits already exhausted.

Although allowable, some health care providers submit their claims maximizing the 60-day period which causes a delay in the processing of claims.

“Obviously, the incomplete claims as well as claims with attached numerous Official Receipts of supplies and medicines procured outside the hospital are factors that hindered the prompt processing of claims, which do not only affect the Corporation’s human and financial resources but also that of the health care provider, for they have to review the claim document for several times,” PhilHealth stated.

PhilHealth Implementing Rules and Regulations on payment of claims stipulates that the health care provider shall file the claim for payment of services rendered within 60 calendar days from the date of discharge of the patient. The same period is given to members who opt to directly file the claim to PhilHealth. In effect, claims submitted after the required period, shall be automatically denied payment.

PhilHealth maintains that the denial will not affect the members for as long as the benefits were already deducted from the member’s bill upon discharge rather, the health care provider will not be refunded with the services availed by the patient. However, in the case where PhilHealth benefits were not deducted, it will be paid or reimbursed directly to the member chargeable to the future claims of by the health care provider.*