Ric Ore Process Flow
Ric Ore Process Flow
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
A
A
MSWS
Assesses
Patient
Medical
Social
Work
Service
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
Generate PSD
B
B
identified
3.
Pin
generation
and
updating/shifting of member
category
Processing
Medicalof premium
Social payments
Work
Service
B
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
LHIO issues
Official
Receipts
5. Payment of Premium
Prepares Claim
Forms in batches
and attaches PSD
PRO /LHIO
and OR
Faster Claims
Processing
BAS
TFI
OVP-MMG to formally
endorse data to
NHTO- DSWD Central
A
OVP-MMG
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.
A
1. Extraction of Data
DSWD conducts
Validation
DSWD
DSWD incorporates
validated HSMs to
roster of NHTS-PR
DSWD
2. Endorsement to
DSWD
a. DSWD conducts
Validation
b. DSWD
incorporates
validated HSM to
NHTS-PR