PhilHealth to HCIs: Switch to eClaims

THE Philippine Health Insurance Corporation (PhilHealth) today called on its accredited health care institutions (HCIs) to shift to electronic claims (eClaims) to achieve greater efficiency in claims processing and improve claims data integrity.

PhilHealth Circular 2017-0030 published last January 9, 2018, defines the eClaims as “an interconnected modular information system for claim reimbursement transactions.” It starts from the time a patient expresses intent to avail oneself of the PhilHealth benefits at accredited Health Care Institutions (HCIs) and ends when the claim is paid.

“Our partner-HCIs can actually benefit from using the eClaims since they can readily check on the member’s eligibility to avail themselves of the benefits, submit their claims electronically or online, and even track their claim status,” said Dr. Celestina Ma. Jude P. de la Serna, Interim/Officer-in-charge, PhilHealth President and CEO.

She added that through the eClaims, HCIs are assured of superior efficiency in recording, transmitting, and processing of their claim documents, while saving up on physical space in which to store the voluminous documents. “More importantly, the HCIs can also benefit from data integrity using data systems provided for in their own Hospital Information Systems (HIS) or through Electronic Medical Records (EMR). We expect that by this time, our HCIs are fully compliant to eClaims, and all submitted new claims are in electronic form already,” de la Serna said.

While PhilHealth first introduced the eClaims approach in 2012, it granted HCIs ample time to prepare for the transition to eClaims which use became mandatory last January 1, 2018. Facilities are expected to have their respective Transition Plans (TPs) listing activities compulsory to eClaims requirements compliance. Once satisfied, the TPs must be submitted to PhilHealth Regional Offices (PROs) for information and monitoring.

To successfully implement the eClaims, HCIs may engage with Health Information Technology Providers (HITPs), or use their existing HIS, EMR or outsourced solutions software or products that are capable of direct data transmission to PhilHealth, so long as these software solutions are certified by PhilHealth. “The move to allow the hybrid approach to eClaims implementation allows HCIs to choose the option that is appropriate to their needs, environment, capacity and cost benefits,” de la Serna said.

Furthermore, HITPs whose application softwares have earlier been certified by PhilHealth for the implementation of the eClaims, are no longer required to undergo another accreditation process.

Through Advisory 2018-0005, PhilHealth announced that instead, the HITPs need only to secure a certification from PhilHealth following a specified software certification process. The software certification is based on the compliance of accredited HCIs’ data collection services, such as HIS and EMR, to claim transmission standards and other requirements defined by PhilHealth.

“Service providers who were certified for the current version of eClaims Web Service (eCWS) will be required to undergo the certification process only once for each version of the eCWS that we release,” said de la Serna.

The mandatory use of the eClaims applies to reimbursement claims under the All Case Rates (ACR) provider payment mechanism, outpatient benefit packages but not limited to Maternity Care, Newborn Care, TB-DOTS, Outpatient Malaria, Animal Bite, and Dialysis. It does not, however, apply to claims filed for Primary Care Benefit Package including readjustment of claims and directly-filed claims. The Z Benefit Packages and claims for Outpatient HIV/AIDS Treatment are excluded from the eClaims until further notice.

The use of HIS and EMR provides HCIs with optimum solutions to their data-entry and operational needs, and further reinforces the services they offer to PhilHealth beneficiaries. While the EMR serves as patients’ medical information databank, the HIS manages the facilities’ day-to-day operations, from cashiering to billing, as well as admissions and discharges. These tools are essential complements to eClaims.

For PhilHealth, the implementation of the eClaims also presents opportunities for fraud detection, monitoring, and prevention. At the same time, the system does away with manual encoding of claims, allows claims adjudication online and enables the shift of work of encoders and document administrators to high-value tasks. “We are seeing improved turnaround time for claims with the full implementation of the eClaims,” the PhilHealth Chief said.

Strengthening partnership with HCIs is an opportunity for PhilHealth to increase stakeholders’ contribution in the achievement of Universal Health Care.

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