SOP No: HR-PB51

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SOP NO: HR-PB51 (List of Exhibits/Attachments)

Mission: Finance and Administration

Area: Human Resource (HR)

Activity: Personnel Benefits and Services (HR-PB)

Title: Guidelines on the Regionalized Processing & Approval of Hospitalization Assistance Claims of Field Office Employees

Date Approved/Issued: 10/01/2007

Date Effective: 10/01/2007

Digest:

I. TERMS OF REFERENCE

A. Rationale

B. Objective

C. Scope

D. Basis

II. IMPLEMENTING GUIDELINES

A. GENERAL POLICIES

1. Employees Covered

Regular members - employees who were hired before

June 30, 1989

, PROVIDED, they have paid their contribution to the 2007 NFA Bereavement Assistance Program fund.

Optional members - employees who are hired

after June 30, 1989

but have paid the total contribution to the 2007 NFA Hospitalization Program Assistance Program fund, based on the following Schedule of Contribution:

Classification of member Amount of Contribution

a. Married Php 3,496

b. Single with 2 dependents 2,987

c. Single with 1 dependent 2,241

d. Single without dependent 1,583

2. Qualified Dependents

Dependent(s) listed in the Masterlists for the 2007 NFA Hospitalization Assistance Program who was verified/certified by each employee covered by the program.

2.1 For married employees :

a. legal spouse until age 65

children with ages 0 (from birth) until age 21 who are unmarried and not gainfully employed

2.2 For single employees (maximum of two dependents) :

a. both parents until age 65

in the absence of both parents, any two unmarried brothers or sisters until age 21 who are not gainfully employed

in the absence of a parent, any brother or sister as qualified above may replace the parent

3. Updating of Masterlist

3.1 Change(s) in the employees’ marital status and designated dependent(s) or additional dependent(s), if any, shall be immediately reported (Exhibit 1) by the employee to the Administrative and General Services (AGS) Section of the Provincial Office (for Provincial Office employees)/Regional Office (for Regional Office employees). Supporting documents (marriage contract, birth certificate, etc.) shall be attached to the report. Said report shall be the basis for updating the masterlist and claim for reimbursement of hospitalization expenses.

3.2

Any claim for hospitalization benefits of undeclared/ unreported dependents shall be invalidated. The concerned PAO and Provincial Manager (PM) should see to it that updates submitted by employees are immediately reported to the AGS Section of the Regional Office.

3.3

The Regional Office shall report immediately to HRMD-DMS-Personnel Benefits Unit (PBU) any changes/updates on the masterlist and submit corresponding supporting documents as bases to update the masterlist.

4. Hospitalization Benefits

The program shall reimburse actual, necessary, reasonable and customary hospitalization expenses which the member-employee and the eligible dependents may incur

based on the

2006 GHIP Contract with AsianLife, particularly the Schedule of Benefits and Exclusions

subject to the

evaluation of the Administrative and General Services Section of the Regional Office. Hence, all expenses may not be fully reimbursed.

5. Administration of the Program

The program shall be administered in the field offices by the Administrative and General Services Section of the Regional Office.

6. Fund Management

An NFA Welfare Fund has been set up where all collections from contributions for the 2007 NFA Hospitalization Assistance and 2007 NFA Bereavement Assistance Programs are deposited and where all claims shall be charged against. It shall be managed by the Department for Treasury, Budget and Fund Management (DTBFM). Any disbursement from the fund shall be authorized by the DTBFM.

Funds from contributions for the 2007 NFA Hospitalization Assistance Program shall not be utilized for claims from the NFA Bereavement Assistance Program and vice versa.

c. Any fund balance at the end of the year shall be carried over to the next year’s fund.

7. Advocacy

The Regional Administrative Officers (RAOs) and the Regional Accountants shall brief their personnel and the employees of the region, as much as practicable, on the details of the self-administered program specifically the Schedule of Benefits and Limitations and claim settlement procedures.

B. IMPLEMENTING GUIDELINES

1. Hospitalization Benefits

Hospitalization benefits that may be claimed from this program shall be

net of Philhealth benefits, Senior Citizen Discounts, GSIS Discounts and other discounts

1.1

The employee should see to it that Philhealth benefits are deducted from his/her hospital bills upon discharge from the hospital; otherwise, the claim shall not be processed.

1.2

In case the patient was hospitalized/confined in a hospital

not accredited by Philhealth

, the claimant must submit a certification from the hospital that it is not Philhealth-accredited; otherwise, the claim shall not be processed.

1.3

For claims supported with a certification that the hospital is not Philhealth accredited, the Regional Administrative Officer shall then compute/deduct the

corresponding Philhealth benefits (Exhibit 2 )

from the employee’s actual charges as indicated in the hospital Statement of Account.

1.4

Claims shall finally be subjected to evaluation/processing using the Schedule of Benefits and Exclusions and other provisions of the 2006 GHIP Contract. Hence, the total actual expenses may not be fully reimbursed.

2. Filing, Receipt and Processing of Claims

2.1 Employee-claimant shall fill-out a

claim form (Exhibit 3)

which shall be available at Administrative and General Services Section of the regional and provincial offices. The claim form has two (2) parts which should be filled out as follows:

Part I - By Claimant

Part II - By Attending Physician/Hospital Representative

2.2 The original copy of the following documents shall be submitted together with the accomplished claim form:

Statement of Account with

itemized

list of hospital/clinic charges and corresponding Philhealth deductions

Official Receipts (ORs)

for professional fees, ORs for medicines bought outside the hospital pharmacy and the corresponding prescriptions,

charge slips/requests slips

for medicines administered and laboratory procedures/services availed, etc.

c. Certified true copy of Marriage Contract/ Birth Certificate (for dependent's claim)

If confined in a hospital not accredited by Philhealth,

certification

from the hospital that it is not Philhealth-accredited.

2.3 The concerned organization/ party who has the possession of the original copies of hospitalization documents, shall authenticate photocopies of documents submitted to the RAO:

2.3.1 Health Maintenance Organization (HMO) such as . Fortune Care, Medicard, Maxicare, and the like,

2.3.2 GSIS (if the employee-claimant opted to file his/her claim to GSIS)

2.4 Filing of claims shall be made within sixty (60) calendar days after discharge from the hospital/clinic. Claims filed after the 60-day period shall be disapproved outright.

2.4.1 In case of any lacking document, the employee-claimant is given

thirty (30) calendar days

to submit the lacking document,

reckoned on the 60th day from date of discharge from the hospital, as the final deadline

; otherwise the following actions, and depending on the lacking document, shall be undertaken by the RAO:

2.4.1.1 If no doctor’s

prescription

is submitted for medicines bought

outside the hospital pharmacy, expenses for the same shall

not be paid;

2.4.1.2 If no

OR for the professional fee

is submitted, professional

fee shall not be paid.

2.5 Hospitalization assistance claims shall be submitted to the Regional Office Administrative and General Services Section (AGS) for processing. The Provincial Administrative Officer (PAO) shall initially check the completeness and authenticity of documents for claim settlement submitted by employee-claimant prior to endorsement to the Administrative and General Services Section of the Regional Office. The documents shall be endorsed to the Regional Office using the pro-forma checklist/transmittal letter.

2.6 Claims shall be processed on a “First Come, First Served Basis”. Each claim must be assigned a tracking number.

2.7 The Regional Office Administrative and General Services Section shall recheck the validity of claim and the completeness and authenticity of required documents. Using the

NFA Hospitalization Assistance Program

Computation of Benefits Form (Exhibit 4),

the allowable amount of benefits shall be computed by the RAO based on the Schedule of Benefits and Exclusions. Only allowable hospitalization expenses shall be authorized. Whenever necessary, HRMD-DMS-PBU, HRMD-Health Services Unit/Regional Nurse shall be consulted.

2.8 The individual Hospitalization Assistance Program Computation of Benefits shall be recommended for approval by the Regional Administrative Officer (RAO), pre-processed by the Regional Accountant and approved by the Regional Manager.

2.9 If necessary, the RAOs/Regional Accountants may elevate to the HRMD-DMS-PBU, issues and problems that they may encounter in the regionalized implementation of NFA Hospitalization Assistance Program. In turn, HRMD-DMS-PBU may consult the NFA Welfare Committee created per Special Order AO-2K7-05-003 dated May 2, 2007.

3. Settlement of Claims

For RO employees’ claim:

�

The RAO

shall evaluate/review all claims, compute for the allowable benefits payable for the hospitalization claims received and recommend its approval to the Regional Manager;

� The Regional Accountant shall pre-process the claims evaluated/reviewed by the RAO;

�

The Regional Manager shall sign the approved portion of the Computation of Benefits Sheet;

�

The Regional Budget Officer shall prepare the wire addressed to CO-DTBFM copy furnished HRMD for the remittance of funds to the Regional Office;

�

The RAO shall prepare the Disbursement Voucher and the Budget Utilization Slip (BUS);

�

The Regional Manager shall certify In the BUS that the charges to budget are necessary, lawful and under his direct supervision;

�

The Regional Budget Officer shall certify in the BUS as to funds availability and funds earmarked obligated to the purpose;

�

The Regional Accountant shall process the Disbursement Voucher and certifies the completeness of the supporting documents;

�

The Regional Manager shall sign the portion of “approved for payment” of the Disbursement Voucher;

�

The Cashier shall prepare the cheque and release the same to the concerned R.O. Employee;

�

Approval of voucher and signing of checks shall follow the specs of authority. Voucher/check shall be in the name of employee-claimant or his/her legal heir(s), in case of death of employee.

For PO employees’ claim:

�

The RAO shall evaluate/review all claims, compute for the allowable benefits payable for the hospitalization claims received from the provincial offices ; and recommend its approval to the Regional Manager;

� The Regional Accountant shall pre-process the claims evaluated / reviewed by the RAO ;

� The Regional Manager shall sign the approved portion of the Computation of Benefit Sheet;

�

The Regional Budget Officer shall prepare the wire addressed to CO-DTBFM copy furnished HRMD for the remittance of funds to the Regional Office. The funds shall be subsequently transferred to the Provincial Office;

�

The RAO shall return to the concerned employee’s place of assignment, all original copies of hospitalization documents together with the approved Computation of Benefits;

�

The Provincial Administrative Officer (PAO) shall prepare the Disbursement Voucher and the Budget Utilization Slip (BUS) and attach all original hospitalization documents returned by the RAO;

�

The Provincial Manager shall certify In the BUS that the charges to budget are necessary, lawful and under his direct supervision;

�

The Provincial Accountant shall process the Disbursement Voucher, certifies the completeness of the documents and funds/cash availability;

�

The Provincial Manager shall sign the “approved for payment” portion of the Disbursement Voucher;

�

The Cashier of the provincial office shall prepare the cheque and release the same to the concerned P.O. Employee;

�

Approval of voucher and signing of checks shall follow the specs of authority. Voucher/check shall be in the name of employee-claimant or his/her legal heir(s), in case of death of employee.

Monitoring / Reporting System

4.1 To closely monitor the utilization of the NFA Welfare Fund, the Regional Administrative Officer (RAO) shall prepare a

Monthly Report on Status of Hospitalization Assistance Claims

(Exhibit 5)

for submission to the HRMD-DMS-PBU and DTBFM, not later than the

3rd working day of the succeeding month.

The individual approved

Hospitalization Assistance Computation of Benefits (Exhibit 4)

shall be attached to the report.

4.2 The HRMD shall conduct spot checking of settled and unsettled hospitalization assistance claim documents.

4.3 The implementation of this program shall be included in the regular audit of the Internal Audit Services (IAS) Department.

C. SANCTIONS

Appropriate administrative charges shall be filed against employees who will violate these guidelines.

Procedure for filing complaints and imposing administrative sanctions shall be in accordance with the SOP on Administrative Discipline and the Uniform Rules in the Conduct of Administrative Investigation.

This implementing guidelines shall take effect October 1, 2007.

Date Approved: October 1, 2007.

III. RESPONSIBILITIES

IV. FLOW CHART
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