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Introduction

The MMG SIHAY eClaims System

The PhilHealth eClaims Management System is designed to help hospitals and clinics manage PhilHealth claims accurately, efficiently, and in compliance with PhilHealth standards. The system centralizes patient eligibility checking, claim encoding, document management, transmittal, tracking, and reporting into one secure platform.

By reducing manual processes and organizing claim data in a structured workflow, the system helps minimize errors, avoid returned or denied claims, and improve reimbursement turnaround time. It supports daily operations of billing and claims staff while providing real-time visibility into claim status and performance.

This manual serves as a guide for users to understand the system features, workflows, and proper usage to ensure smooth and compliant PhilHealth claims processing.

Mission

To provide hospitals and clinics with a reliable and efficient system that simplifies PhilHealth claims processing, reduces errors, and supports timely reimbursement through accurate, standardized, and compliant workflows.

Vision

To be a trusted eClaims solution that empowers healthcare facilities to deliver better service, improve operational efficiency, and achieve zero returned or denied PhilHealth claims through technology and process excellence.

Purpose of the Manual

This manual aims to:

Guide users in navigating and using the system correctly
Explain system features and workflows clearly
Ensure proper encoding, transmittal, and monitoring of claims
Support compliance with PhilHealth rules and requirements

Intended Users

This manual is intended for:

Billing and claims staff
PhilHealth coordinators
Administrative users
System administrators

Each user role should follow the procedures described in this manual to ensure accurate and consistent system use.

Scope of the System

The PhilHealth eClaims Management System covers:

Patient eligibility checking
CF2 and CF4 encoding
Document and attachment management
Claim transmittal and monitoring
Reporting and reconciliation
User and facility setup

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Welcome

Medical Mission Group Hospitals and Health Services Cooperative of the Philippines Federation

MMG SIHAY eClaims System

@2026 MMGHHSCP FEDERATION - FEDCIS 20231223.002

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Getting Started

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System requirements

MMG SIHAY eClaims System Requirements

System Requirements

Hardware Requirements

1. Workstations

Minimum Intel Core i3 processor (or equivalent)
Minimum 8 GB RAM
Minimum 256 GB storage

2. Networking

Reliable LAN/WAN infrastructure with high-speed internet access
Wireless access points for mobile device connectivity
Network security appliances such as firewalls and intrusion detection/prevention systems

Software Requirements

1. Operating System

Windows 10 or later

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The SIHAY eClaims System

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Login Interface

(MMG SIHAY Image 1 Login)

Login Interface

The Login Interface serves as the secure entry point to the PhilHealth eClaims System. This screen allows authorized hospital personnel to access the system using their assigned username and password. To begin, the user must enter their login credentials in the provided fields and click the Login button. Once validated, the system will grant access to the available modules based on the user’s role and permissions.

This interface ensures that only authorized users can process, view, and manage PhilHealth claims, helping protect patient data and maintain compliance with data privacy and security standards. The progress indicator below the Login button shows the system’s status while verifying the credentials. If incorrect information is entered, the user will be prompted to recheck their details before proceeding.

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Dashboard

(MMG SIHAY Image 1.1.1 Dashboard)

1. Main Navigation and Claims Management Area

This section of the system contains the primary navigation tabs used for managing PhilHealth eClaims. Each tab provides access to specific functions that support the full lifecycle of claim processing—from initial encoding to final claim status monitoring.

1.1 Main Menu / Feature Navigation

This area displays the main system menu and available features based on the user’s access level. It serves as the central navigation point of the system, allowing users to switch between different claim processing stages, documents, and reports. Additional system tools and shortcuts may also appear here depending on user role and system configuration.

1.2 Queue Tab (Start of Claims Processing)

The Queue tab is the starting point for processing PhilHealth claims. This is where users can:

Create new claims for admitted patients
Edit or update existing claim records
Delete invalid or duplicate entries (subject to user permissions)
Check patient eligibility with PhilHealth
Prepare and manage CF2 and CF4 documents
Process claims for transmittal or remove them from an existing transmittal if needed

All claims listed under this tab are considered active and under preparation, making it the primary workspace for claims processors.

1.3 Transmitted Tab (Claims Status Monitoring)

The Transmitted tab allows users to monitor the status of claims that have already been submitted to PhilHealth. This section provides visibility on claims that are:

Unprocessed
In process
With voucher
With cheque
Returned to Hospital (RTH)
Denied

This tab helps users track claim progress and identify actions needed, such as correcting returned claims or following up on pending reimbursements.

1.4 Documents Tab (Claims Forms and Attachments)

The Documents tab contains all required claim-related forms and supporting documents. Users can view, review, and print the following:

Claim Forms
Electronic Statement of Account (eSOA)
PhilHealth Benefit Eligibility Form (PBEF)
Claim Signature Form (CSF)
Claim Summary
Attached Lists and supporting files

This tab ensures that all required documents are complete and properly prepared before and after claim submission.

1.5 Submitted Tab (Claims Overview by Status)

The Submitted tab provides an organized view of all submitted claims based on their current processing status. Users can easily review claims categorized as:

In process
Returned to Hospital
Vouchering
With voucher
With cheque
Denied

This section is mainly used for monitoring, reporting, and follow-up purposes, allowing users and administrators to assess claim performance and reimbursement outcomes.

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Navigational Menu

(MMG SIHAY Image 1.2.1 Submission Tab)

(MMG SIHAY Image 1.3.1 Reports Tab)

The Reports tab provides access to all system-generated reports related to PhilHealth eClaims processing. This section allows users to view, generate, and review reports that summarize claim activities and financial transactions within the system. Available reports include PhilHealth Reconciliation, IBNR (Incurred But Not Reported), Transmittal Reports, Claim Summary, PhilHealth Claims, Unsubmitted Claims, and Claims and Service Fee Reports.

These reports support monitoring, auditing, and reconciliation of submitted and processed claims. They help hospital staff track claim status, validate reimbursements, identify pending or unsubmitted claims, and ensure accurate reporting for management and PhilHealth compliance purposes.

(MMG SIHAY Image 1.4.1 Mapping Tab)

The Mapping tab is used to align the hospital’s internal items with the corresponding PhilHealth Item Codes. This ensures that all charges included in a claim are properly recognized and processed by PhilHealth. In this section, users can map items under the following categories: Room and Board, Drugs and Medicines, Laboratory and Diagnostics, Operating Room, Medical Supplies, and Other Chargeable Items.

By mapping each hospital product or service to its correct PhilHealth Item Code, the system helps prevent claim errors, reduce returned claims, and support accurate benefit computation. Proper mapping should be completed before claim submission to ensure that all charges are correctly classified and accepted by PhilHealth. Go to Mapping Section to see how to map.

(MMG SIHAY Image 1.5.1 Settings Tab)

The Settings tab is used to configure and maintain essential system and facility information. In this section, users can set up and manage the Health Care Institution (HCI) Information, PhilHealth Account details, File Domain, and other General system settings required for proper system operation.

This tab also allows authorized users to create, update, and manage user accounts for system access. Changes made in the Settings tab help ensure accurate facility information, secure system access, and compliance with PhilHealth requirements. For instructions on updating facility details, refer to the Setup section. For user account management, see Register or Update User for guidance.

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How to:

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Encode or Edit CF2

(MMG SIHAY Image 2.1.1 CF2)

To encode Claim Form 2 (CF2), go to the Queue tab (see 2.1), select the patient record you want to process (see 2.2), then click the CF2 button (see 2.3) to open the Claim Form 2 encoding window.

(MMG SIHAY Image 2.1.2 CF2)

The Claim Form (CF2) window (see 2.4), where all patient confinement and billing information is entered and edited. This window displays the selected claim number and allows users to input, review, and save patient details required for PhilHealth claims processing. The Save button confirms that any changes made are successfully recorded.

The navigation panel of the Claim Form (see 2.5). It allows users to move between different sections of the claim, such as Patient Information, Confinement, Diagnosis, Medical Packages, Medical Billing, Fees and Charges, Consumables, and Attachments/Documents. Clicking on each menu item will display the corresponding form on the main screen for easy and organized data entry. Complete all this sections from top to bottom to complete the CF2 form.

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Upload Documents

(MMG SIHAY Image 2.2.1 Uploading)

To upload necessary files, on the Claim Form 2 window, click the Attachments / Documents tab (see 2.5) to upload/attach documents.

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Process Transmittal

(MMG SIHAY Image 2.3.1 Transmittal)

To process a transmittal, ensure that Claim Form 2 (CF2) is 100% completed. Select the patient record you want to include in the transmittal (see 2.6), then click Create Transmittal (see 2.7).

The system will display an indicator or notification if the CF2 is not yet fully completed, preventing the transmittal from being processed until all required fields are filled.

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Encode or Edit CF4

(MMG SIHAY Image 2.4.1 Transmittal)

To encode Claim Form 4 (CF4), select the patient record you want to process and click the CF4 button (see 2.8). The CF4 window will then open, allowing you to enter the required information in the main form area (see 2.9).

Use the side navigation tabs (see 2.10) to access additional sections such as Profiling, Subjective, Examination Findings, Course Ward, and Medicine. Complete all required fields in each section to fully accomplish the CF4.

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Process Claims

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Submit Claims

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Register or Update User

(MMG SIHAY Image 2.1.1 User)

To register a new user, navigate to the Account Settings tab. From the Select Account to View drop-down menu (see 2.1), choose New User. Enter the required user information in the provided fields (see 2.2), then assign the appropriate access level or permissions based on the user’s role (see 2.3).

Once all required details have been completed and reviewed, click the Save User button to create the new account.

(MMG SIHAY Image 2.1.2 User)

To update a user’s information or change a password, go to the Account Settings tab and select the user account from the Select Account to View drop-down menu. Once the account is loaded, modify the necessary details such as user information or password.

After completing the changes, click the Save User button to apply and store the updates.

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Mapping

(MMG SIHAY Image 3.1.1 Mapping)

Mapping Items to PhilHealth Codes

In the Mapping tab, begin by selecting the appropriate category to map (see 3.1). From the Hospital Category drop-down menu (see 3.2), choose the category where the item belongs. Next, select the Hospital Item Code from the drop-down list (see 3.3). Once selected, the item description will be displayed below the menu. If the item has not yet been mapped, a notification message will appear indicating that the item code is not in the list.

After selecting the hospital item, choose the corresponding PhilHealth Item Code from the PhilHealth drop-down menu (see 3.4). Ensure that the selected code exactly matches the item provided by PhilHealth. Click the Add button (see 3.5) to save and complete the mapping.

To remove an item from the mapping list, select the item using a left click, then right-click to display the Delete option (see 3.6). Click the Delete button to remove the item from the mapping.

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Setup

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Report

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View/Download/Print

(MMG SIHAY Image 1 Report)

Report Viewing and Generation

Most report screens in the system share the same set of features for generating and viewing reports. Users can select the required date range by setting the Date From and Date To fields (see 1.1), then click the Generate button (see 1.2) to display the report data in the table below.

Some report screens also provide additional filtering options (see 1.3), allowing users to narrow down the report results based on specific criteria, depending on the report type. Once the report is generated, users may choose to save the report for future reference or click the Print button to produce a hard copy (see 1.4).

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