PHILHEALTH is set to address a significant backlog of 1.1 million denied claims stemming from late filing issues of hospitals, with the PhilHealth Board and Management demonstrating a serious commitment to streamlining administrative processes.
The massive undertaking represents a crucial step towards improving healthcare access and reducing bureaucratic obstacles for patients and healthcare providers. By focusing on resolving these delayed claims, PhilHealth aims to enhance its service efficiency and rebuild trust in the national health insurance system, potentially providing much-needed financial relief to the affected providers and patients who have been waiting for claim resolutions.
“Alam nating matagal nang hinaing ng iba’t ibang mga ospital ang denied claims. Marami sa mga sinumiteng claims na ito ay denied dahil lagpas na sa deadline o iba pang mga administrative reasons at hindi naman dahil sila ay fraudulent. Ang mga ito ay ating muling ipo-proseso upang ang mga ospital na naghatid ng serbisyong kinakailangan ng ating mamamayan ay mabayaran,” explained Dr. Edwin M. Mercado, PhilHealth acting president and CEO.
From 2018 to 2024, 30% of the total denied claims were due to late filing. In response, Dr. Mercado has committed to President Ferdinand Marcos Jr. that the Social Health Insurance will reconsider these denied claims to ensure that our healthcare providers are properly remunerated.
Based on this new policy, PhilHealth is giving all concerned health facilities a six-month period – commencing on the effectivity of the published Circular – to submit their previously denied claims due to late filing. Claims filed within the period of Jan. 1, 2018 to Dec. 31, 2024, that were unprotested and unappealed or the health facilities are still in the possession of will be considered for re-processing.
The following claims denied for the same reason will similarly be subjected to re-processing:
- Those that are in the possession of the PhilHealth Regional Office Benefit Administration Section;
- Denied claims under administrative protest in the PhilHealth Regional Office – Claims Review Committee and/or on appeal with Protest and Appeals Review Department;
- Claims previously denied with finality according to the current Implementing Rules and Regulations from January 1, 2018 up to December 31, 2024; and
- Claims previously denied with finality due to late submission from January 1, 2018 up to December 31, 2024, that have been elevated and are pending before the regular courts, provided that the appellants withdraw their petition against the Corporation.
Nevertheless, the PhilHealth chief underscores the importance of prompt filing so as not to delay the appropriate compensation that providers should receive the moment that their services have been rendered.
“Ang pagpaparamdam ng alagang pangkalusugan ay isang coordinated effort kung saan ang PhilHealth ay tumutulong na pagaanin ang gastos para rito. Sa kabilang banda, kinakailangan din na alam ng PhilHealth ang mga serbisyong inihatid ng ating providers. Kaya naman, patuloy pa rin nating pinaaalala ang agarang pag-file ng claims upang mas mabilis nating mabayaran ang mga ito,” added Dr. Mercado.
For more information and guidance, health facilities may link up with their respective PhilHealth Regional Offices/Branches/Local Health Insurance Offices. Other queries may be directed to the PhilHealth 24/7 hotline at (02) 866-225-88 or at mobile numbers (Smart) 0998-857-2957, 0968-865-4670, (Globe) 0917-1275987 or 0917-1109812.
