NINETEENTH CONGRESS )
REPUBLIC OF THE PHILIPPINES )
Third Regular Session )

HOUSE OF REPRESENTATIVES

Introduced by Representative Rufus B. Rodriguez
House Bill No. 11398
EXPLANATORY NOTE

Article II Section 11 of the 1987 Philippine Constitution state that “The State shall adopt an
integrated and comprehensive approach to health development which shall endeavor to make
essential goods, health and other social services available to all the people at affordable cost.
There shall be priority for the needs of the under-privileged, sick, elderly, disabled, women,
and children. The State shall endeavor to provide free medical care to paupers.”

To assist the state in pursuing the aforementioned policy, health institutions were granted the
privilege of applying for accreditation as health facilities (HFs). Under the rules as promulgated
is consonance with RA 7875, Accredited HFs shall extend PhilHealth benefits to PhilHealth
members in the availment of health services and shall reimburse the same with PhilHealth

PhilHealth currently enforces a strict 60-day filing deadline for benefit claims, as mandated
under Section 35 of RA 7875, as amended by RA 10606, and its Implementing Rules and
Regulations (IRR). While the deadline aims to streamline claims processing, it has
inadvertently resulted in:

+ Claims denied from 2018-2024 due to late submission. amounting to approximately
20 billion in value

+ Financial strain on Health Facilities, particularly those in underserved area
«Increased administrative burden due to returned claims (RTH) and appeals

It must also be noted that in the recent Supreme Court decision (G.R. No. 163123 PhilHealth
vs. Chinese General Hospital and Medical Center), the Court highlighted the necessity of
adopting a more flexible approach to claims processing. It also emphasized that strict
procedural rules should not undermine the core objective of the National Health Insurance
Program (NHIP), which is to ensure financial access to essential health services for all
Filipinos. It also upheld the Decision of the Court of Appeals and ordered PhilHealth to pay
the belatedly filed claims of Chinese General Hospital and Medical Center.

This bill seeks to address the countless PhilHealth claims of Health Facilities which were
denied due to late filing, giving significance to the principle of equitable payment of services
that were already rendered. This bill also aims to support the role of Health Facilities in the
realization of universal health of the country, thus, the need to support them.

In view of the foregoing, approval of this bill is earnestly sought

RUFUS B. RODRIGUEZ


NINETEENTH CONGRESS )
REPUBLIC OF THE PHILIPPINES )
Third Regular Session )

HOUSE OF REPRESENTATIVES

Introduced by Representative Rufus B. Rodriguez

House Bilt No. 11398

AN ACT
MANDATING THE PHILIPPINE HEALTH INSURANCE CORPORATION (PHILHEALTH) TO
PAY CLAIMS DENIED BY REASON OF LATE FILING

Be it enacted by the Senate and House of Representatives of the Philippines in Congress
assembled:

SECTION 1. Short Title - This act shall be known as the “Late PhilHealth Claims Amnesty
Act”

SECTION 2. Declaration of Principle - It is the policy of the State to adopt an integrated and
comprehensive approach to health development which shall endeavor to make essential
goods, health and other social services available to all people at affordable cost. The State
also frowns upon unjust enrichment due to the non-payment of services already rendered and
had, time and again, upheld the principle of quantum meruit.

SECTION 3. Definition of Terms. - The following terms, as used in this Act, shall mean:

Administrative Protest - the administrative remedy of healthcare providers or member
against notice of denial from Benefits Administration Section.

Appeal - the administrative remedy of healthcare providers or member against notice of
denial of PhilHealth Regional Office,

Benefit Claims - Refers to the claims / requests submitted by Health Facilities to PhilHealth
for reimbursement of healthcare services provided to PhilHealth members. These claims
include inpatient, outpatient, and emergency care services, among others, as defined by
PhilHealth’s existing policies.

Denied with Finality - a claim that has been determined to be invalid and unworthy of
payment or reimbursement due to an absolute deficiency that cannot be remedied through
return to sender or due to a finding of an unmet requirement

Health Facilities - Refers to hospitals, clinics, and other healthcare institutions accredited
by PhilHealth to provide healthcare services to PhilHealth members. These facilities are
responsible for the submission of claims for reimbursement of services rendered to
PhilHealth members.

Refiling - a claim that has been previously submitted by a HFs or member but returned
due to deficiency and compliance of documentary requirements, and must be refiled within
a certain number of days.

Claims that were Filed Late— Refers to PhilHealth benefit claims of health facilities and
member filed from 2018 to present, coinciding with the PhilHealth implementation of e-
claims or electronic filing of claims, that exceeded the mandated period (60-days, 90-days,


or 120-days, whichever is applicable) at the time of filing or refiling, which were denied
payment due to late filing.

SECTION 4. Payment of Claims that were Filed Late — In the interest of faimess and equity
regarding the services rendered by Health Facilities to PhilHealth members, PhilHealth shall
implement a total amnesty and pay all Claims that were Filed Late, whether the claims are at
the level of Refiling, Administrative Protest, Appeal, or Denied with Finality

SECTION 5. Implementing Rules and Regulations - PhilHealth shall promulgate the
necessary rules and regulations for the proper implementation of this Act not later than thirty
(30) days from its effectivity.

SECTION 6. Separability Clause - If any provision or part of this Act is declared
unconstitutional, the remaining parts or provisions not affected shall remain in full force and
effect.

SECTION 7. Repealing Clause. - All laws, executive orders, rules and regulations, and
issuances or parts thereof which are inconsistent to and contrary with the provisions of this
Act are hereby repealed and amended accordingly.

SECTION 8. Effectivity. - This Act shall take effect fifteen (15) days after its publication in
the Official Gazette or in a newspaper of general circulation.

Approved,