TAMANG SAGOT

PhilHealth Circular 2016-016

Full Implementation of the Electronic Claims System

1. What is eClaims?

EClaims is the electronic way of claims submission to PhilHealth by accredited HCIs. It

involves the transmission of electronic documents and data.

2. What is the eClaims system?

The eClaims system is an interconnected modular information system for claim

reimbursement transaction beginning from the time a patient signifies the intention of
using a PhilHealth benefit, and ends when the claim is paid. It possesses the following
electronic features, to wit: 1) ability for HCI to determine eligibility of patient to avail of
insurance; 2) ability to submit a claim online; 3) ability for HCI to track and verify the
status of its claims; 4) ability for PhilHealth to review and process a claim; and, 5) ability
for HCI to reimburse the claim. The first three (3) are tasks performed at the HCI level
while the rest are performed by PhilHealth.

3. What is the legal basis for eClaims implementation?

eClaims is based on Republic Act 8792 (Electronic Commerce Act of 2000), PC 014-
2011, Office Order No. 0069-2011, PC 038 s.2012, PC 21, s.2014, PC 2016-016.

4. What is the difference between eClaims and N-claims?

N-claims is the existing method of processing manually encoded claims submitted

directly by HCIs. eClaims is the electronic version of claims processing using the N-
claims system.

5. What will happen to N-claims when eClaims is implemented?

N-claims will still remain even if eClaims is already fully implemented because it will still
be the system used for processing eClaims. It will just be enhanced to respond to the
requirements of EClaims processing. In addition, directly filed claims and appealed
claims shall continue to be processed through the N-claims system.

6. What is the eClaims implementation timeline?

EClaims will initially be implemented when the policy is already legally in force or within
15 calendar days from date of publication, reckoning date of which shall be posted on
the PhilHealth official website. Full implementation of eClaims is envisioned by July
2016 depending on how fast HITPs can sign up the HCIs.

7. How will eClaims be implemented?

The eClaims System shall be implemented using the environment and infrastructure
prescribed by PhilHealth. eClaims will be implemented through the HITPs who shall
 market their hospital information systems to the different PhilHealth accredited
healthcare institutions. eClaims implementation shall be governed by the PhilHealth
eClaims Implementation Guide (PeCIG) which shall be regularly updated when new
benefits/packages are approved for implementation by the Corporation’s Board of
Directors.

8. What are covered in eClaims?

eClaims shall cover claims for All Case Rates, Z Benefits (special benefits), outpatient
benefit packages such as, but not limited to, Maternal Care Package (MCP), Newborn
Care Package (NCP), TB-DOTS Package, Outpatient Malaria Package, Animal Bite
Treatment Package and such others as may be decided by PhilHealth in the future.

9. What are not covered in eClaims?

eClaims shall not cover Primary Care Benefit Package (Tsekap scheme), readjustment of
amount claimed, directly filed claims, MERS-COV, and Ebola.

10. What safety/security measures ensure that eClaims/HITP is a safe method for
health facilities to do business with PhilHealth?

a) HITPs shall establish the applicable connectivity with PhilHealth and partner HCIs
depending on their system and infrastructure design.
b) HITPs shall register with PhilHealth to enable them to connect to the eClaims
System. PhilHealth shall provide the HITPs with appropriate forms to be
accomplished and returned to PhilHealth so that configuration details for each of the
HITPs can be specified based on their hardware.
c) HITPs shall provide duly accomplished Non-Disclosure Agreement (NDA)
including that of its partner HCI to PhilHealth.
d) HITP shall notify PhilHealth of its readiness to commence the implementation of
eClaims System.
e) PhilHealth Head Office shall inform the concerned PhilHealth Regional Offices
(PROs) of the HCI clients and their start dates of implementation of their eClaims
System.
f) There shall be two modes by which a HITP and its partner HCI may implement the
eClaims system as follows:
1. Through a connection of PhilHealth to HITP
i. Encoding is done by HCIs through the interface accessed centrally from a
HITP server
ii. The scanned documents and their web location information are stored directly
into the HITP server
2. Through connections of PhilHealth to both HITP and HCI
i. Encoding is done by HCIs through a local application provided by HITP and
the claims data including the scanned documents are sent to the server to store
the scanned documents
ii. HCI sends the web location information of the scanned documents directly to
PhilHealth.

11. Who/What is a HITP?

A HITP or Health Information Technology Provider is a third-party information

technology provider accredited by PhilHealth after having met the minimum
 requirements for managing transactions between HCIs and the Corporation (PC No. 038
series 2012)

12. Who can become a HITP?

Any legal organization that is technically capable of developing and providing a hospital
information system (with full technical support and training) that is eClaims compliant,
both in online and offline mode and passes the PhilHealh system validation criteria can
become a HITP for the purpose of providing eClaims capability to PhilHealth accredited
health care institutions.

13. What rules govern HITPs?

HITPs are governed by the following rules: Republic Act 8792 (Electronic Commerce
Act of 2000) PhilHealth Circular 014-2011, Office Order 0069-2011, PhilHealth Circular
038 series 2013, Republic Act 10173 (Data Privacy Act of 2012.

14. What will be the role of the HITP?

The HITP shall be responsible for providing the front end interface for eClaims Modules
1-3 to an HCI, ensuring connection of an HCI to PhilHealth, and facilitating electronic
transmissions. The HITP acts as a conduit for electronic transactions on claim
reimbursements from the HCI to PhilHealth and vice-versa.

15. Who will set the fees/fee cap for the HITPs?

Currently no cap or floor price has been set either by PhilHealth or by the HITPs for the
services to be offered to HCIs. However, a review shall be conducted after the HITPs
have been engaged for 12 months.

16. How will HCIs know that a HITP is authorized to offer its services/product?

The HCI/prospective customer can check the PhilHealth website for the list of duly
authorized HITPs. The HCI can also ask the HITP to show the original copy of its
PhilHealth System Validation Certificate.

17. What proof will HITPs present to HCIs to prove their legality?

The HITP shall provide a photocopy of their latest PhilHealth System Validation
Certificate when doing marketing calls with HCIs. They shall also bring the original
certification for verification purposes.

18. What supporting documents must be submitted by HITPs so that a facility can
have a valid claim?

These documents shall include, but are not be limited to:

a. CF1, CF2, CF3
b. Laboratory/diagnostic results/findings
c. Surgical/anesthesia record
d. Claim signature form for member, patient and doctor/s

19. What are the minimum requirements for HCIs prior to participation in eClaims?
 HCIs must possess the following minimum requirements for eClaims:
a. Desktop computer
b. Document scanner
c. Internet connection
d. Authorized depository bank account if ACPS-compliant, details of which must be
submitted to its respective PhilHealth Regional Office, in accordance with guidelines
provided under PhilHealth Circular No. 043 series 2012 known as the “auto-Credit
Payment Scheme (ACPS)”

20. Will PhilHealth assign a HITP to a facility? Will HITPs be given geographic
territories or be limited to certain types of facilities?

HCIs shall have the prerogative to choose the HITP it will engage with, based on a roster
of accredited HITPs posted on the PhilHealth website and with valid System Validation
Certificate. HITPs shall be responsible for marketing their services to all accredited
HCIs. PhilHealth shall not assign geographic territories or types of hospitals to any
particular HITP for purposes of marketing their hospital information system. The valid
System Validation Certificate issued by PhilHealth authorizes the HITP to market its
hospital information system to all types of facilities anywhere in the Philippines. Healthy
competition in the delivery of services shall be encouraged among HITPs while
destructive cutthroat competition shall be discouraged.

21. What happens to HCIs with slow or without internet connections?

An offline version of the eClaims System may be provided by the HITPs for HCIs
without or with poor internet connections.

22. How will PhilHealth BAS units know if an accredited HCI has engaged a HITP?

HCIs shall communicate to the PhilHealth Regional Office that has jurisdiction over
them their engagement with a HITP and provide the PRO with a photocopy of their
HITP engagement for record purposes. In the event that it chooses to change its HITP,
it shall provide the PRO a photocopy of the new HITP engagement contract. In case of
contract renewal, it shall also provide the PRO a photocopy of the engagement renewal.

23. Can/When can HCIs change their HITPs?

Yes, HCIs can change their HITPs if their contracted HITP fails to comply with any of
the provisions of their engagement or if the validation certificate of the HITP expires
and is not revalidated by PhilHealth for valid reasons.

24. What mandatory services shall HITPs provide to HCIs?

HITPs are mandated to provide the following:

a. Data center
b. Front-end security and authentication
c. Database security
d. Semantic security (data dictionary and document type definition)
e. Transmission security
f. eClaims utility including URLs
g. after sales service (helpdesk)
h. capability building of HCI personnel assigned to the eClaims system
 i. registration to PhilHealth’s web system

25. What are the duties and responsibilities of HITPs?

a. HITPs shall ensure storage of claim files and scanned documents for its HCI client
b. HITP shall be responsible for ensuring security of the eClaims connectivity
technology with PhilHealth and/or with HCIs
c. HITP shall ensure that only authorized personnel should handle the eClaims modules
d. HITPs are required to develop and maintain policies and procedures protecting the
personal health information (PHI) of patient-member/dependent stored
electronically in accordance with the Data Privacy Law which include those for
backup, archive, and live electronic data management
e. HITPs shall elevate to PhilHealth all other unresolved technical queries/concerns
through its IT Helpdesk

26. Who is responsible for ensuring the quality of the data transmitted electronically?

The HCI Head (hospital director, chief of hospital) shall be responsible for ensuring the
quality (i.e. validity, accuracy, completeness, etc.) of data transmitted electronically.

27. How long should submitted claims be stored?

All electronically submitted claims, together with its attached documents, whether
through a HITP or not, must be stored and archived at the provider end, for a minimum
of ten years. Records involving Medico legal cases are archived forever without disposal.

28. Are submitted claims subject to correction by HCIs?

Submitted claims shall be deemed final, hence, actionable by PhilHealth. Only PhiHealth
authorized personnel shall be given access to retrieve the data for viewing, reviewing,
assessing, and other permissible rights or actions. Electronic claim review, adjudication,
and payment shall be conducted in compliance with existing policies.

29. Who shall be responsible for ensuring security over personal information
processing and transmission?

Security over personal information processing and transmission must be ensured by HCI
and HITP following the standards implemented by PhilHealth in compliance with the
Data Privacy Act of 2012. HCIs are required to develop and maintain policies and
procedures protecting the personal health information (PHI) of patient-
member/dependent stored electronically in accordance with the Data Privacy Law which
include those for backup, archive and live electronic data management.

30. What information needs to be encoded for inclusion in the eClaim?

All information found in Claim Forms 1, 2, and 3(if required) shall be encoded
electronically or extracted with the provided module.

31. What format will be used in saving scanned files?

Scanned files shall be saved in Portable Document Format for Archive (PDF/A)
format.
32. How will electronic claims be submitted, individually or otherwise?

Submission of electronic claims can be done individually in real time during office hours
or in batches during off-peak hours.

33. How will HITPs transmit eClaims to PhilHealth?

HITPs will transmit eClaims to PhilHealth via leased line.

34. How will eClaims be processed?

eClaims will be processed electronically using electronic adjudication using the enhanced
N-claims system.

35. What happens to defective claims submitted?

Defective claims shall be returned to the concerned HCI for compliance of deficiency.
Compliant claims shall then be resubmitted electronically for re-processing.

36. How will claims be paid?

eClaims will be paid via auto credit payment scheme (ACPS) after being processed
through the N-claims system.

37. How will HITPs be monitored and evaluated?

The HITPs will be evaluated based on a set of criteria that includes, but is not limited to:
a) Delivery of contracted services to HCIs
b) Compliance to PhilHealth policies and applicable issuances

38. How will security be enforced during data capture and transmission?

The eClaims system shall ensure that all data collected, including personal information
and health records, and transmitted through the use of information and communications
technology systems provided by juridical entities, are in accordance with Republic Act
No. 10173, otherwise known as the Data Privacy Act of 2012. With such, HITPs will be
connected to PhilHealth through a secured means of connection as prescribed by
PhilHealth. HITP shall also ensure secure data transmission and storage with its HCI
clients. In general, PhilHealth security standards that will govern information exchange
among HCIs, HITPs, and PhilHealth, as specified under PhilHealth Circular No. 038
series 2013, shall cover the following:
a. Data center
b. Front-end security and authentication
c. Database security
d. Semantic security (data dictionary and document type definition)
e. Transmission security

HCIs are required to develop and maintain policies and procedures protecting the
personal health information (PHI) of patient-member/dependent stored electronically in
accordance with the Data Privacy Law which includes those for backup, archived, and
live electronic data management.
39. How will security breaches be dealt with?

Security breaches shall be dealt with in consonance with existing provisions of the Data
Privacy Act and/or applicable PhilHealth policies and such other legal provisions as
necessary and appropriate.

40. What will happen to errant/non-compliant HITP/s?

Errant/Non-compliant HITPs shall have their system validation certificate/PhilHealth

accreditation either revoked or not renewed depending on the findings of a duly
constituted investigation/appraisal team.