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 which were filed within the period of
January 1, 2018 to December 31, 2024 that were unprotested and unappealed and that
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.
