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.

The Medical City Clinics (Proser)

Wellcare Clinics & Lab. Inc.

KERALTY CLINIC - TOPHEALTH

De La Salle University Medical Center