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CHECK BEFORE FILING: the 15-day period below comes from PhilHealth Circular No. 03, s. 2008. Confirm with the PhilHealth office that issued the denial that this period still applies, and follow any period stated in the denial notice itself.
[DATE]
The Regional Vice-President
PhilHealth Regional Office [NUMBER]
[THROUGH: THE HEAD, LOCAL HEALTH INSURANCE OFFICE, [PLACE]]
[ADDRESS]
Subject: MOTION FOR RECONSIDERATION — Denied claim of [FULL NAME OF PATIENT], Claim/Transmittal No. [NUMBER], notice of denial dated [DATE]
Dear Sir/Madam:
I, [FULL NAME], [THE MEMBER / THE PATIENT / AUTHORIZED REPRESENTATIVE OF THE MEMBER], PhilHealth Identification Number [PIN], respectfully move for the reconsideration of the denial of the claim described below.
1. The claim and the denial
Patient · member [FULL NAME OF PATIENT] · [FULL NAME OF MEMBER], PIN [NUMBER]
Hospital · confinement [HOSPITAL] · [DATE OF ADMISSION] to [DATE OF DISCHARGE]
Filed by · on [HOSPITAL / MEMBER (DIRECT FILING)] · [DATE FILED]
Claim / transmittal no. [NUMBER]
Notice of denial dated [DATE], received on [DATE OF RECEIPT]
Reason given “[COPY THE REASON EXACTLY AS WRITTEN IN THE NOTICE]”
Amount claimed PHP [AMOUNT]
2. Why the denial should be reconsidered
[KEEP THE GROUNDS THAT APPLY, DELETE THE OTHERS, AND STATE THE FACTS BRIEFLY:]
1. The claim was filed on time. The patient was discharged on [DATE] and the claim was received on [DATE], within [60/180] days, as shown by the receiving stamp (Annex “A”).
2. The delay was not my fault. The claim was late because [NATURAL CALAMITY / FORTUITOUS EVENT / THE HOSPITAL FILED LATE / RETURN-TO-SENDER NOTICE RECEIVED ON [DATE]] (Annex “B”). [STATE THE FACTS AND DATES.]
3. The missing documents are now complete. The notice cited [MISSING DOCUMENT/DEFICIENCY]. The complete document is attached as Annex “C”.
4. The member was eligible. Contributions were paid for [PERIOD], as shown by [PROOF OF PAYMENT/MDR] (Annex “D”).
5. The condition is covered. [CASE RATE / PACKAGE AND CODE] applies because [REASON] (Annex “E”).
6. [OTHER GROUND.]
3. Filed within the period
I received the notice of denial on [DATE OF RECEIPT]. This motion is filed on [DATE], within fifteen (15) days from receipt. [CHECK: PhilHealth Circular No. 03, s. 2008 — confirm that the 15-day period still applies.]
4. Request
I respectfully ask that the denial be reconsidered and that the claim for PHP [AMOUNT] be [PAID TO [PAYEE] / RETURNED FOR PROCESSING]. Should any further document be needed, please inform me at [ADDRESS / E-MAIL / MOBILE NUMBER].
Respectfully,
______________________________ [FULL NAME] PIN [NUMBER] · [RELATIONSHIP TO PATIENT] [MOBILE NUMBER] · [E-MAIL]
Annexes: “A” receiving copy of the claim; “B” proof of the cause of delay; “C” completed documents; “D” proof of contributions; “E” [OTHER]; copy of the notice of denial; authorization letter and IDs (if filed by a representative).
RECEIVED BY (PhilHealth): ____________________ Date and time: __________
NOTES — delete this page before filing
• Period: PhilHealth Circular No. 03, s. 2008 is commonly cited for a 15-day period to file a motion for reconsideration from receipt of the denial. Its current status was not confirmed when this template was written (19 October 2026) — check with PhilHealth and follow any period written in your notice of denial.
• Members whose directly filed claims are denied may file a motion for reconsideration (PhilHealth Circular No. 20, s. 2014, Part III, item 6). Hospitals file their own motions for claims they filed.
• If the motion is denied, ask about an appeal to the PhilHealth Board and its period — it is not covered by this template.
• Keep your statements factual. Attach proof for every fact you state; keep a stamped receiving copy.
Field labels in [SQUARE BRACKETS, CAPITALS] must be completed or deleted. Alternatives are separated by a slash. © Layers (layers.md), licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Template and deadlines for information only — check your own case with the agency or insurer, and have documents with legal effect reviewed by a lawyer. Not legal advice.
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Template — check your case with the agency; review by a lawyer. Not legal advice. © Layers (layers.md) · CC BY 4.0