Thursday, October 6, 2011

Duties and Responsibilities of a PhilHealth Member

The duties and responsibilities of a PhilHealth member are:

Have in possession at all times your PhilHealth Number Card or Identification Card;
It pays to be prepared in emergency situations such as accidents or illness. Members should always have their PhilHealth ID card or PhilHealth number card ready for presentation at the accredited health care provider to prevent delay in the availment of benefits.

Update your Member Data Record (MDR) for any change in personal information such as change in civil status or addition of a new dependent;
The Member Data Record is a document required during availment of PhilHealth benefits or claiming reimbursement. Members should keep the MDR up-to-date to prevent any inconsistency from being reflected in the MDR. The address in the MDR will be used to send the check payment and any other correspondence that will be issued by PhilHealth. There are instances when health care providers will require that the name reflected in the MDR be the same with their records in order to automatically avail the benefits and others such cases.

Request for a replacement in case of loss of PhilHealth Number Card or Identification Card;
This is in reference to the first discussed responsibility of a PhilHealth member where the PhilHealth Number Card or Identification Card should always be made available as this will be presented to the health care provider when undergoing an emergency admission or surgery. Members should not wait for the need to arise to get a replacement of their lost PhilHealth number card or identification card.

Ensure that you promptly and regularly pay your contributions (for individually paying members and Overseas Workers Program members) to avoid suspension of benefits;
Individually paying members should have a qualifying contributions in order to avail PhilHealth benefits. Moreover, some benefits require nine monthly contributions within a twelve month period prior confinement to avail the benefit, hence, if the member should miss payment for a given quarter or period, this will affect the availment of the benefit. This is the same with OWP members. Although OWP members are covered within their validity period and do not require qualifying contributions, continuous coverage or validity period should be ensured for uninterrupted eligibility for benefits.

For newly hired employees, check if your name is reported by your employer to PhilHealth in the ER2 Form (Report of Employee-Members);
The ER2 form is being submitted by the employers to PhilHealth which is basically a list that certifies the employees of the company. It should also be noted that the date of employment is required information that should be reflected in the ER2. The ER2 will serve as the baseline of the employer in the preparation of their monthly remittance report. Employed members should ensure that their employers have included their names in the ER2 and have properly reported it to PhilHealth as this serves as protection of the employees from employers that are not remitting their premium contributions to PhilHealth.

Ensure that your monthly premium contributions are deducted from your salary and promptly remitted and reported by your employer to PhilHealth;
Every month the employers are submitting a monthly remittance report which includes all employees and corresponding premium contributions that have been deducted. This report is used by PhilHealth to post the contributions to the employees' member accounts. Hence, employees should keep their payslips reflecting premium contribution deductions as this will serve as proof of deduction which may be presented to PhilHealth if a discrepancy in the number of contributions was found.

Report to PhilHealth at once an employer who does not remit premium payments;
Employers are mandated by law to deduct PhilHealth premium contributions and it is also the responsibility of the employer to report the members that have been deducted and how much premium contribution each employee has paid. Hence, if an employee found out that their employer is not remitting their premium payments, PhilHealth should immediately be notified so that they may coordinate with the employer.

Ensure that you have sufficient qualifying contributions to avail of PhilHealth benefits anytime;
Members should not start paying or continue payment when they are expected to use or avail PhilHealth benefits, it should be done regularly.

Secure an updated list of accredited facilities from any PhilHealth office wherein you can avail of benefits;
This is similar to the health management organizations (HMO) where they are providing a list of accredited partners in which the members may be able to go to. It is the responsibility of the member to keep in mind the available health care facilities and hospitals that they may go to in case of illness to prevent denial of PhilHealth benefits.

Others are:
  • Submit a properly and completely filled-up PhilHealth Claim Form 1 to the hospital and ensure that all the information you stated in the said form are true and factual;
  • Ensure that you properly and completely submit all the necessary documents to the hospital including a copy of your Member Data Record (MDR) to avail of PhilHealth benefits;
  • Clarify with providers (hospital/doctor), the appropriate and final benefits deducted upon settlement of bills and charges;
  • Ask for a copy of your Statement of Account/Billing Statement from the hospital upon discharge;
  • Ask for an Official Receipt (OR) and Waiver from the hospital and doctor for payments made in full;
  • Ensure that your claim, if opt for direct filing, is filed at PhilHealth within sixty (60) days from the date of discharge for local confinements and within one hundred eighty (180) days for confinements abroad;
  • Be aware of amendments and updates on PhilHealth policies and benefits schedule;
  • Seek clarification from any PhilHealth office on any unclear policy or guideline;
  • Report at once to PhilHealth any hospital that fails, without valid reason, to accommodate a PhilHealth member who wishes to avail of benefits;
  • Report at once to PhilHealth any fraudulent transactions that you know about;
  • Observe and comply with PhilHealth rules and regulations as there are offenses in its Implementing Rules and Regulations that a member may be held liable for.

We hope that members are guided accordingly in order to prevent any negative experiences from occurring when transacting with PhilHealth.

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