THE Philippine Health Insurance Corp. (PhilHealth) has denied P71.17 million in claims filed in 2020 by the Philippine Heart Center for alleged non-compliance with the provisions of the Revised Implementing Rules and Regulations of RA 7875 or the National Health Insurance Act.
Government auditors said unless reversed, the denied claim will be recorded as income loss for the government hospital.
According to the 2020 audit of the PHC released April 28, 2021, the amount represented 3,907 claims submitted to the PhilHealth from January 1, 2020 to September 30, 2020.
“Based on the information provided by the PhilHealth Regional Office, National Capital Region (NCR)-Central, there were about 3,907 claims totaling P71.170 million for reimbursement of benefits submitted by the PHC to …that have been denied and returned,” the audit team said.
PhilHealth Circular No. 2019-001 defines denied claims as those that are found to be invalid and unworthy of reimbursement due to an “absolute deficiency or an unmet requirement.”
The deficiency is deemed unresolvable hence no longer returned to hospital (RTH) for possible adjudication.
RTH claimed those that are deficient in documentation or other requirements are sent back to the health care institution for compliance and further validation. If the deficiency is remedied, the denial will be reversed and paid.
