Outpatient Basic Consultation / Maternity-Consultation:

A visit to a general doctor (like a family or internal medicine physician) for routine checkups or minor health concerns, without being admitted to a hospital.

Outpatient - Referral to Specialist:

When a primary care doctor sends a patient to a specialist (like a cardiologist or dermatologist) for further evaluation or treatment.

Outpatient Clinic Setting:

Medical care provided in a clinic where patients receive diagnosis and treatment without staying overnight.

Outpatient - Laboratory:

Lab tests (like blood or urine tests) done without being admitted to a hospital, usually after a doctor's consultation.

Emergency:

Immediate medical care for serious or life-threatening conditions (e.g., severe injuries, chest pain, breathing problems).

OPD -OR (Outpatient Department - Operating Room):

Minor surgical procedures done in a hospital setting where the patient is not required to stay overnight.

Inpatient Discharge:

When a patient who was admitted to the hospital for treatment is officially released and allowed to go home.

🩺 CONSULTATION / CLINIC-SETTING CLAIMS

• LOA (Letter of Authorization) – Required only
  
  

🛠️ LABORATORY / EMERGENCY / OPD-OR / IPD CLAIMS

• LOA (Letter of Authorization)
• Charge Slip / Itemized Charges
• SOA / Transmittal (Statement of Account)

1. Incomplete Documents
   
   
2. Revisions Required
   
   

• Discrepancies in claim amounts between:
  
  
• • Statement of Account (SOA) / Transmittal
    
    
  • Charge Slip
    
    
  • Billing Amount
    
    
• Claim amount exceeds the approved and issued Letter of Authorization (LOA)
  
  

1. Verification of Claim Details
   
   

• Consultation / Clinic-Setting Claims:
  
  
• • Unreadable or missing name of the attending doctor
    
    
• Laboratory / Emergency / OPD-OR / IPD Claims:
  
  
• • Unreadable amounts on SOA or charge slip

❌ No Approved/Issued LOA

🔍 What to Check

• Missing Written LOA:
  If there is no written LOA in the designated section, check other parts of the documents for it.
• Member Utilization:
  Verify if there is a utilization record on the same availment date, with matching procedures as stated between the LOA and the billing.

🏷️ Proper Tagging for Maternity Consultations

This applies specifically to maternity consultations that are:

• Incorrectly tagged as Basic Consultation, or
• Marked as Referral to Specialist

🔎 Why Correct Tagging Matters:

• Maternity benefits vary by account
• Accurate tagging ensures correct benefit application and avoids claim issues.

✅ Always verify and tag maternity consultations correctly.

✍️ Missing Signature(s)

For Consultation / Clinic-Setting:

• Both the Doctor and the Member must sign the LOA.

For Procedures:

Only the Member's signature is required.

⏰ Stale Claim (Late submission)

🔍 Review of Provider Information

Submission of Claims Based on Stale Computation

• Please verify the provider’s information under this section.

The number of days for late submission is computed from the Availment Date up to the Billing Received Date.

🔁 Double Billing

🩺 Consultation 

A patient cannot undergo consultation with the same doctor on the same date.

⚙️ Procedure Billing

If the same procedure is billed twice, verify using the following criteria:

✅ Same LOA

✅ Same Procedure

✅ Same Date of Availment

✅ Different Document Reference Numbers

    ⚠️ If all the above match, it's likely a duplicate billing.

1. Cross-Check: LOA (System) vs. Provider's Documents

Compare the following details between the system-generated Letter of Authorization (LOA) and the provider’s submitted documents(e.g., Statement of Account, Transmittal, or Charge Slip):

✅ Provider’s Name

✅ Patient’s Name

✅ Type of Availment.

2. Additional Requirements Based on Claim Type

For Consultation / Clinic-Setting Claims:

• LOA must include both the doctor's and the member's signatures.

For Procedure Claims:

• LOA must include the member’s signature.

TYPE	Effective August 1, 2024
CONSULTATION RATE	600
CP CLEARANCE	1,150
READER'S FEE	AS CHARGED
CLINIC-SETTING	130 / AS CHARGED

DOCTOR	RATE
PATHOLOGIST'S FEE	AS CHARGED
INSTRUMENT FEE	AS CHARGED

INTRA-OPERATIVE MONITORING

1,800

ROOM/TYPE	DAILY VISIT PER DAY	RVS MULTIPLIER
WARD	900	140
SEMI PRIVATE	1100	145
PRIVATE	1200	150
SUITE	1600	155
ICU	1800	155
OPD-OR	N/A	130

 

DOCTOR	COMPUTATION
ANESTHESIOLOGIST	50% OF SURGEON'S FEE
ASSIST SURGEON	25% OF SURGEON'S FEE

DOCTOR	NOTES
ANESTHESIOLOGIST	UNLESS OTHERWISE STATED IN SOB / MINIMUM PF IS 2K
ASSIST SURGEON	APPLICABLE ONLY IF THE PROCEDURE IS LAPCHOLE OR 250 UNITS AND ABOVE

COMPUTATION FOR MULTIPLE PROCEDURES (FROM HIGHEST TO SMALLEST RVS UNITS)

100%

50%

25% FOR THE SUCCEEDING RVS

BUT IF THE PROCEDURES HAVE DIFFERENT ENTRY POINT, COMPUTE PF 100% EACH PROCEDURE

COMMON EXAMPLE IS EGD AND COLONOSCOPY

EGD - 60 UNITS

COLONOSCOPY - 80 UNITS

DIFFERENT SCENARIO COMPUTATION:

- 2 PROCEDURES DONE WITH DIFFERENT SURGEON BUT THE SAME DAY

100% COMPUTATION FOR THE HIGHEST RVS CODE UNIT EQUIVALENT; 80% FOR THE SECOND SURGEON

- 2 PROCEDURES DONE WITH DIFFERENT SURGEON BUT DIFFERENT DAY

COMPUTATION FOR BOTH SURGEONS ARE 100%

- PATIENT WAS ADMITTED FOR A LONG TIME WITH PROCEDURE DONE

COMPUTATION FOR PF IS PROCEDURE PLUS VISIT 2 DAYS BEFORE AND 5DAYS AFTER THE PROCEDURE

🔍 Scenario 1: LOA is in AMAPHIL Form

What to Check:

1. Verify in System Tracker

✅ If the tracker details match the received documents:

→ You may proceed to correct the details.

→ Coordinate with the Claims Department Team Leader.

❌ If the tracker details do not match the received documents but match the LOA in the system:

→ This requires further investigation.

2. Identify the Tracker Source (How the Request Was Received)

If via phone call:

→ Request the call recording from the Team Leader or Dev Team.

If via email, Viber, or Mobile App:

→ Confirm the request with the Team Leader or Medical Officers.

📄 Scenario 2: LOA is in Printed PDF Format

What to Check:

1. Member Utilization History

✅ If there's a matching LOA for the same date of availment:

→ Escalate and request the correct LOA.

2. No Matching LOA in System

❌ If no LOA is found with matching billing details:

→ Return to Provider (RTP) due to absence of LOA.

• THE MEDICAL CITY is different from The Medical City Clinics
• Be careful of the following providers
• • ST. LUKE'S MEDICAL CENTER, INC. and ST. LUKE'S MEDICAL CENTER (GLOBAL CITY), INC.
  • THE MEDICAL CITY and THE MEDICAL CITY CLINIC - PASIG (EAST ORTIGAS)
  • OUR LADY OF LOURDES HOSPITAL - STA. MESA and OUR LADY OF LOURDES HOSPITAL-DAET
  • ACE Clinics
  • GLOBAL CARE MEDICAL CENTER OF BAY INC. and GLOBAL CARE MEDICAL CENTER OF CANLUBANG, INC.
• Wellcare -   For consultation, please refer to the indicated payable physician in SOA/transmittal, rather than the physician who signed the LOA.

The Medical City Clinics (Proser)

Wellcare Clinics & Lab. Inc.

KERALTY CLINIC - TOPHEALTH

De La Salle University Medical Center

ST. LUKE'S MEDICAL CENTER (GLOBAL CITY), INC.

ST. LUKE'S MEDICAL CENTER, INC.

MANILA DOCTORS HOSPITAL

THE MEDICAL CITY

UNIVERSITY OF SANTO TOMAS HOSPITAL

STALE CLAIM

Hi Ma'am/Sir,

Good day!

I hope this email finds you well. This is to formally request the processing of late-submitted claims from our provider. We have received a reconsideration letter requesting that these claims be processed despite the delay,  which includes their explanation for the late submission. We apologize for any inconvenience caused by the late submission and assure you that we are taking steps to prevent such delays in the future.

Thank you for your attention to this matter. We look forward to your favorable response and appreciate your continued support.