Availing PhilHealth Benefits for Direct Filing of Claims

Eligibility for Direct Filing:

• You have paid the hospital and doctor's fee in full (without PhilHealth benefit);
• You have the required number of premium payment (for employed and individually paying members) or date of availment is within your membership coverage (for sponsored and ofw members). Lifetime members are eligible to avail PhilHealth benefits and need not pay premiums;
• The hospital/facility is accredited from the time of confinement/admission;
• The doctor is accredited from the time of confinement/admission.

Documents Required to Submit:

• Fully accomplished and original PhilHealth Claim Form 1;
• An updated Member Data Record (MDR) or required supporting documents;
• Waiver from the Hospital and Doctor/s specifying fees are paid in full;
• Official Receipts from drugs/medicines (purchased within confinement period), laboratory procedures, surgical procedures, hospital bills and doctor's fee;
• Fully accomplished and original PhilHealth Claim Form 2 (to be provided by the hospital/facility);
• Fully accomplished and original PhilHealth Claim Form 3 for confinement in primary hospitals or availment of maternity benefit;
• Operative record (if applicable);
• Hospital Statement of Accounts which contains breakdown of charges;
• Authorization or Special Power of Attorney (SPA) for transactions made through an authorized representative (immediate family member).

The Hospital may request for you to submit all receipts to prepare the PhilHealth Claim Form 2. Just provide them a photocopy of the documents they would need and do not give the original. Be sure to go back to the hospital to retrieve the Claim Forms and then submit the form and corresponding required attachments to the PhilHealth Office assigned to the area of the hospital. This should also be filed within 60 days from date of discharge. Ensure that the PhilHealth Claim Form 2 waiver portion for full payment is accomplished by the Hospital. You will need this to be reimbursed.

For inquiries on the status of your claim, you may call PhilHealth's call center or the PhilHealth Office - Claims Department.

Alternatives for Availment of PhilHealth Benefits - Direct Filing

Did you know that there are two ways which we could avail of your PhilHealth benefits? You already know the most common method which is for the hospital and/or doctor to immediately deduct your PhilHealth benefits from their bills and then later the hospital and/or doctor would file a claim to PhilHealth reimbursing the amount deducted from your total charges. The not so common alternative is to pay the hospital and doctor's bill in full and then directly file the claim with PhilHealth - direct filing.

In practice, the direct file method is preferable if you are capable of paying your bills in full. This is because you can maximize the amount that you can reimburse from PhilHealth though it would still take the same processing time of 3 months before you can expect to receive a check from PhilHealth.

Do you know that in some cases, hospitals and doctors are not actually deducting the maximum amount of your benefit? This is a safety net for them as they are not certain if the medicines, procedures etc. will be slashed (reduced cost) or if you have fully used up your PhilHealth benefits. Then later they will reimburse the full amount from PhilHealth meaning they will reimburse more than they actually deducted from your bill.

How will you know that what they deducted from your bill is less than their actual reimbursement? You can validate this through the Benefit Payment Notice (BPN) that will be mailed every time a claim or request for reimbursement under your record is filed. This notice illustrates or details the amount paid to the hospital and/or doctor. You can use this to compare the amount that was deducted from your bill using the Statement of Accounts provided by the hospital and the actual amount the hospital/doctor received from PhilHealth as reflected in the BPN. You will know if the doctor or hospital maximized their deduction if the amount received matches with the deduction from your bill.

Now, what happens when the amount received from PhilHealth is more than the amount that was actually deducted from you? You can go to the hospitals to get the remaining amount or in cases when the hospitals have already returned the excess amount to PhilHealth, you can go to PhilHealth to claim your benefits. PhilHealth usually announces the claiming of refunds through a publication. The links below will take you to more information for this case.

• SunStar "Aquino: Keep those billing statements" contains additional guides.
• PhilHealth Circular No. 42, s-2009: Revised Provision for the Recovery and Disposition of the Unclaimed Refunds from Accredited Institutional Health Care Providers (IHCPs)
• PhilHealth Circular No. 14, s-2007: Granting of Reward for Information Leading to the Discovery and Recovery of Unclaimed PhilHealth Reimbursements

Take note, you should always have a copy of the Statement of Accounts and official receipts from the hospital and doctor and compare it to the mailed Benefit Payment Notice (BPN). Make sure that you have an updated member record, particularly your current address so that you will receive the BPN in your mailbox.