Process (LEVEL 2)

Document Reference Code

Member Registration

Revision No.

Eff. Date

Sub-Process (LEVEL 3)
Enrolment at the Point of Care

Page

Approved by:

Procedure Description:
Purpose To ensure PhilHealth coverage of the poor thru enrolment at the point of care
Scope Admitted patients and their dependents in a DOH Retained hospital
Definition of Terms
A. Hospital-Sponsored Members (HSM) - Patients for admission who were assessed and
identified as poor by the hospital Medical Social Worker who are not covered by
PhilHealth at the time of confinement
B. No Balance Billing No other fees or expenses shall be charged to or paid for by the
patient-member above and beyond the packaged rates / hospital bill
C. IHCP - a system deployed by PhilHealth in Health Care Institutions which is capable of
providing membership and eligibility details necessary for benefit availment
D. Onsite Rapid Enrollment System (ORE) an application utilized by hospital personnel
which allows membership, eligibility validation and enrollment of Hospital-sponsored
members
E. Payment Slip Details a user-generated report in ORE whereby all patients enrolled on
particular period is listed. These shall be the basis for premium payments.
Areas of Responsibility: Hospital Admitting Section/Medical Social Work Service/PhilHealth
CARES/Hospital Accounting Section/LHIO Cashier/PRO-Branch MemSec/BAS/TFI/OVP-MMG/DSWD
Procedure Details:
Responsibl
e
Office/Pers
on
Admitting
Section
(AS)/PhilHe
alth
Section
(PS)

Activity Flow

Patient from
ER/ OPD

Mem
ber
Eligib
le?
NO
PhilHealth
Section

YE
S

Usual
Processing of
Claims

Activity Details

Reference
s

1. Verification of PhilHealth
eligibility

A.
Joint
Circular
:
Enrolment
of
Critical
Poor under
the
Sponsored
Program of
the National
Health
Insurance
Program at
Point-OfService
B. Manual of
Operations
and
Procedures
POINT OF
CARE

A. Patient/companion of the
patient
coming
from
the
Emergency Room (ER/OPD) for
admission will be referred to
the AS
B. AS/PS Staf will verify if
patient is already a member or
dependent using the IHCP Portal
/ ORE.
C.
If
covered
for
that
hospitalization, AS/PS provide
Claim Forms and detailed
instruction on how to fill up
forms,
documentary
requirements needed and other
pertinent details to facilitate
benefit availment.
D. If not covered during the time
of hospitalization, i.e. patient is
non-member or was once a

member but does not have a

qualifying contribution, active
sponsorship, AS/PS Staf refers
the
patient/companion
to
Medical Social Services for
assessment if qualified to be
enrolled as Hospital-Sponsored
Member.

A
A

MSWS
Assesses
Patient

Medical
Social
Work
Service

2. Medical Social Workers

Assessment

Qualifi
ed as
HSM?

NO
YE
S

CARES

HS<

Register through
ORE and tag
Documents with
HSM-NBB

CARES
conduct IEC
for Informal
Sector
Enrollment

MemSec process
registered HSMs
(Pin Generation)
and load data in
MCIS
PRO/BRAN
CH/
LHIO
MEMSEC

Send Members PIN

to Hospital
(System
generated)

Generate PSD

B
B

1.2. Patients classified as Class

A, B, C1 and C2 shall be
referred to PhilHealth CARES for
IEC on membership as part of
the informal sector.
1.3 CARES shall issue PMRF to
the patient and assist them on
filling up the form
1.4 CARES shall refer the
patient to the nearest LHIO for
payment
C.
MSW
enrolls
patients using ORE.

identified

D. Upon enrollment to ORE, the

MSW shall stamp Hospital
Sponsored Member at the
Patients Data Sheet (PDS).

3.
Pin
generation
and
updating/shifting of member
category

Processing
Medicalof premium
Social payments
Work
Service
B

A. The MSW shall assess and

evaluate all admitted service
patients
using
the
MSWS
Assessment Tool based on DOH
Administrative Order no 51-A s.
2001
and
other
issuances
relative to it.
B. The MSW shall validate and
verify identified Class C3 and
Class D patients at E-portal.
1.1 Patients classified as Class
C3 and Class D shall be enrolled
mandatorily.

Upon receipt of generated PIN,

the MSW issues the HSM
Certificate signed by the Chief
Medical Social Work Service and
Chief of the Hospital for
patients use in claiming their
MDR / ID. The same may also

ENROLLMEN
T PROGRAM

Accounting
Section

be
used
for
subsequent
confinements in any accredited
facility.

Generation of Payment
Slip Details
4.

Remittance of
premium
payment to
LHIO

A. The MSW generates PSD on a

weekly basis.
B. Generated PSDs shall be
submitted to PS / Accounting
Department

LHIO issues
Official
Receipts

5. Payment of Premium

Prepares Claim
Forms in batches
and attaches PSD
PRO /LHIO
and OR

Tag batch of HSM

Claims and submit it
PhilHealth
to LHIO
Section

Faster Claims
Processing

BAS

TFI (Task Force

Informatics)
generates enrolled
HSMs on a quarterly
Endorsement of
Extracted data to

TFI

OVP-MMG to formally
endorse data to
NHTO- DSWD Central
A

OVP-MMG

A. The PS Staf shall receive and

process the list submitted by
MSW. This shall be endorsed to
the accounting department for
voucher
preparation
and
disbursement of fund.
B. Payment shall be made in
LHIOs with the batch list as
attachment. The POR issued
shall be attached to the claims
transmittal.

6. Claims Submission
A. PS Staf submits claims of
HSMs separately from regular
claims.
B. PS tags the entire batch as
HSM Claims, attaches the PSD
and OR.

7. Backroom MemSec to
process the data encoded by
the MSWs including PIN
generation and loading of
data to MCIS on a daily basis
except
weekends
and
holidays.
8.
MemSec
to
inform
hospital thru e-mail the PIN
and status of enrolled HSMs.
9. ColSec to post-paid HSMs
and coordinate with MemSec
to indicate validity of HSMs
in MDR.

10. BAS to process claims

reimbursement within 30
days.

A
1. Extraction of Data

DSWD conducts
Validation

DSWD

DSWD incorporates
validated HSMs to
roster of NHTS-PR

a. TFI to generate list

of enrolled HSMs on
a quarterly basis
b. TFI endorse
extracted data to
OVP-MMG

DSWD

2. Endorsement to
DSWD
a. DSWD conducts
Validation
b. DSWD
incorporates
validated HSM to
NHTS-PR