PhilHealth Cataract Package

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PhilHealth Hemodialysis Benefits

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PhilHealth service desks at Robinsons Malls

You may now avail of general member-related services such as submission of membership forms, PIN verification, and updating of MDR information at PhilHealth's service desk in Robinson's Galleria, along Ortigas Ave., in Quezon City, Robinsons Otis and Robinsons Place Manila in Manila, and Robinsons Nova Market, in Novaliches. Robinsons Metro East will soon follow in have a service desk of its own.

These service desks are open from 9:00 AM to 6:00 PM, Mondays-Fridays.

For further details, you may read PhilHealth's news release here.

Duties and Responsibilities of a PhilHealth Member

The duties and responsibilities of a PhilHealth member are:

Have in possession at all times your PhilHealth Number Card or Identification Card;

It pays to be prepared in emergency situations such as accidents or illness. Members should always have their PhilHealth ID card or PhilHealth number card ready for presentation at the accredited health care provider to prevent delay in the availment of benefits.

Update your Member Data Record (MDR) for any change in personal information such as change in civil status or addition of a new dependent;

The Member Data Record is a document required during availment of PhilHealth benefits or claiming reimbursement. Members should keep the MDR up-to-date to prevent any inconsistency from being reflected in the MDR. The address in the MDR will be used to send the check payment and any other correspondence that will be issued by PhilHealth. There are instances when health care providers will require that the name reflected in the MDR be the same with their records in order to automatically avail the benefits and others such cases.

Request for a replacement in case of loss of PhilHealth Number Card or Identification Card;

This is in reference to the first discussed responsibility of a PhilHealth member where the PhilHealth Number Card or Identification Card should always be made available as this will be presented to the health care provider when undergoing an emergency admission or surgery. Members should not wait for the need to arise to get a replacement of their lost PhilHealth number card or identification card.

Ensure that you promptly and regularly pay your contributions (for individually paying members and Overseas Workers Program members) to avoid suspension of benefits;

Individually paying members should have a qualifying contributions in order to avail PhilHealth benefits. Moreover, some benefits require nine monthly contributions within a twelve month period prior confinement to avail the benefit, hence, if the member should miss payment for a given quarter or period, this will affect the availment of the benefit. This is the same with OWP members. Although OWP members are covered within their validity period and do not require qualifying contributions, continuous coverage or validity period should be ensured for uninterrupted eligibility for benefits.

For newly hired employees, check if your name is reported by your employer to PhilHealth in the ER2 Form (Report of Employee-Members);

The ER2 form is being submitted by the employers to PhilHealth which is basically a list that certifies the employees of the company. It should also be noted that the date of employment is required information that should be reflected in the ER2. The ER2 will serve as the baseline of the employer in the preparation of their monthly remittance report. Employed members should ensure that their employers have included their names in the ER2 and have properly reported it to PhilHealth as this serves as protection of the employees from employers that are not remitting their premium contributions to PhilHealth.

Ensure that your monthly premium contributions are deducted from your salary and promptly remitted and reported by your employer to PhilHealth;

Every month the employers are submitting a monthly remittance report which includes all employees and corresponding premium contributions that have been deducted. This report is used by PhilHealth to post the contributions to the employees' member accounts. Hence, employees should keep their payslips reflecting premium contribution deductions as this will serve as proof of deduction which may be presented to PhilHealth if a discrepancy in the number of contributions was found.

Report to PhilHealth at once an employer who does not remit premium payments;

Employers are mandated by law to deduct PhilHealth premium contributions and it is also the responsibility of the employer to report the members that have been deducted and how much premium contribution each employee has paid. Hence, if an employee found out that their employer is not remitting their premium payments, PhilHealth should immediately be notified so that they may coordinate with the employer.

Ensure that you have sufficient qualifying contributions to avail of PhilHealth benefits anytime;

Members should not start paying or continue payment when they are expected to use or avail PhilHealth benefits, it should be done regularly.

Secure an updated list of accredited facilities from any PhilHealth office wherein you can avail of benefits;

This is similar to the health management organizations (HMO) where they are providing a list of accredited partners in which the members may be able to go to. It is the responsibility of the member to keep in mind the available health care facilities and hospitals that they may go to in case of illness to prevent denial of PhilHealth benefits.

Others are:

• Submit a properly and completely filled-up PhilHealth Claim Form 1 to the hospital and ensure that all the information you stated in the said form are true and factual;

• Ensure that you properly and completely submit all the necessary documents to the hospital including a copy of your Member Data Record (MDR) to avail of PhilHealth benefits;

• Clarify with providers (hospital/doctor), the appropriate and final benefits deducted upon settlement of bills and charges;

• Ask for a copy of your Statement of Account/Billing Statement from the hospital upon discharge;

• Ask for an Official Receipt (OR) and Waiver from the hospital and doctor for payments made in full;

• Ensure that your claim, if opt for direct filing, is filed at PhilHealth within sixty (60) days from the date of discharge for local confinements and within one hundred eighty (180) days for confinements abroad;

• Be aware of amendments and updates on PhilHealth policies and benefits schedule;

• Seek clarification from any PhilHealth office on any unclear policy or guideline;

• Report at once to PhilHealth any hospital that fails, without valid reason, to accommodate a PhilHealth member who wishes to avail of benefits;

• Report at once to PhilHealth any fraudulent transactions that you know about;

• Observe and comply with PhilHealth rules and regulations as there are offenses in its Implementing Rules and Regulations that a member may be held liable for.

We hope that members are guided accordingly in order to prevent any negative experiences from occurring when transacting with PhilHealth.

Source: http://www.philhealth.gov.ph/forms/others/member_duties.pdf

Issuance of PhilHealth ID Cards and MDR to Employed Members

An official advisory has been released by PhilHealth informing the public that transactions for members belonging to the Private and Government Sectors should be facilitated by their respective Human Resource Departments (HRD).

Employees that are not yet registered with PhilHealth and those without PhilHealth Identification Numbers (PIN) should submit a fully accomplished PhilHealth Membership Registration Form (PMRF) with attached supporting documents:

• Clear copy of employee's birth certificate/baptismal certificate or one (1) valid ID;
• Clear copy of legal supporting documents of declared dependent/s such as birth certificate, marriage certificate and others as necessary.

Submit all the requirement to the HRD of the company you are in. They will in turn submit the documents together with the ER2 (Employer-Employee List) to PhilHealth. PhilHealth in turn will process your documents and forward your PhilHealth ID Card (PIC) and Member Data Record (MDR) to your office's HRD for distribution.

New employees whether newly employed or transferred who are existing PhilHealth members would just need to inform their current employer of their PhilHealth Identification Number (PIN) for the preparation of the Monthly Employer's Remittance Report (RF-1).

Source: PhilHealth Advisory No. 08-01-2011

What is a PhilHealth MDR (Member Data Record)?

Whenever you need to avail of your PhilHealth benefits, you will always be asked to provide the health care institution (hospital) a copy of your MDR to be attached to the claim forms. For those who are new to the term, an MDR, short for the Member Data Record is a system-generated document being issued by PhilHealth as a primary attachment to the Claim Form 1.

What does the MDR contain?

The document contains the member's basic information such as the PhilHealth Identification Number, full name, address (local and/or foreign), civil status, date of birth, contact information and for those employed or under the KaSAPI Program the PhilHealth number, name and address of the employer or organized group is reflected.

Aside from the basic information of the member, a list of valid dependents (with their complete name, birth date and other info) who may avail PhilHealth benefits are also displayed along with payment information for OFW members and the validity or effectivity date for sponsored members.

What is the purpose of the document?

With the release of PhilHealth Circular No. 07 s-2007, the Member Data Record (MDR) was made a primary document for claim applications which aims to:

• Reduce incidents of returned claims due to lacking supporting documents;
• Lessen claims that are doubtful in nature.

In addition to this, prior the implementation of the MDR requirement, members are required to submit supporting documents (e.g. birth certificate of dependent who was confined, marriage contract etc.) to be attached to their claim form in order to avail PhilHealth benefits. Supporting documents are necessary for PhilHealth to establish the relationship of the member and the patient or the person that was confined to prevent unauthorized usage of the member's annual 45-days allowable period. Hence, there is no need for a member with an updated MDR to attach several supporting documents to avail PhilHealth benefits as hospitals may refer to the MDR to establish the relationship of the patient to the member.

What to do if you are not able to get the document?

Although the MDR is a primary document, PhilHealth does not say that a member cannot avail benefits if this document was not provided. For those members that are unable to provide the MDR, the corresponding supporting documents must be attached to the claim forms in order to avail the benefits.

Where do you get this document?

Any PhilHealth Office (with system access) can provide or issue the MDR.

For purposes of consistency and to prevent any problems during availment of benefits, ensure that the MDR is always updated. To update your PhilHealth record refer to this post "How to Update Your Membership Record with PhilHealth".

Sample PhilHealth Request Letter

Due to numerous requests for a sample request letter that may be used for PhilHealth transactions, we have devised this template for requesting:

• Issuance of PhilHealth ID Card;
• Issuance of Member Data Record (MDR);
• Certificate of Premium Payment (CPP);
• Certification for lost payment receipt.

This is free to download and use, however, note that this template did not come from nor is it mandated or required by PhilHealth. The letter is in PDF format so you may need a PDF reader if your PC doesn't have one installed like Adobe Reader.

You may download the template here or click the image below.

How to Update Your Membership Record with PhilHealth

In our previous post, we discussed about the instances on when to update our membership record with PhilHealth and its importance. Here we will discuss the procedure and required documents to update your membership record.

Steps in updating your member record:

1. Fill-out the PhilHealth Membership Registration Form (PMRF);
2. Submit the PMRF with attached supporting documents to any PhilHealth Office near you;
3. Validate that the changes requested have been correctly reflected in your newly released Member Data Record (MDR);
4. For correction/change in your name, ensure that you are issued a new PhilHealth ID Card (PIC) reflecting the corrected/updated name.

Accomplishing the PMRF:

• Accurately write your PhilHealth Identification Number (PIN) in the form;
• Put a check mark in the "For Updating" under the PURPOSE;
• Write your name and date of birth. This will be used by PhilHealth to verify the member record retrieved using the PIN. If purpose is for correction of your name, write your correct name;
• Write the necessary information that you would need to update or correct, there is no need to provide all the information in the form. If you are going to update your address, just write in the address portion, to register new dependents, just write your dependent's information and so on;
• Affix your signature and write the date the form was accomplished.

Documents that are normally being required:

• ID card/s issued by a government official authority;
• Birth Certificate for correction on member's/dependent's name or date of birth and/or for declaring of new dependents;
• Marriage Certificate or Contract / Affidavit of Marriage issued by Office of Muslim Affairs to update your civil status, change your last name (for females) and/or to declare your spouse as a dependent.

Other documentary requirements can be found in the second page of the PMRF.

Cases for Amending or Updating Your PhilHealth Records

As PhilHealth Members, it is your responsibility to ensure that your information recorded in PhilHealth's database is up-to-date and accurate. If you want to know how to go about updating your information then read on.

When should you update your information?

• Correction in member profile
If you are issued a Member Data Record (MDR), immediately validate the accuracy of the reflected information. If you find that there is a discrepancy in your name, date of birth or any other information, you should amend or update your record immediately;


• Correction in dependent's profile
This can also be checked in the MDR. Check whether the name and date of birth of your declared dependents have been accurately recorded by PhilHealth as this might become a problem in availment of benefits;


• Change in address
If you relocated to another residence or address, immediately amend your PhilHealth record. It is important for PhilHealth to have your current address as notices/letters are being mailed based on your location registered in PhilHealth;


• Change in civil or marital status
PhilHealth will require a copy of your marriage certificate, or Affidavit of Marriage issued by the Office of the Muslim Affairs, or annulment papers in order to effect the change in your last name. You should also request for a new PhilHealth ID Card and MDR.
Males should likewise update their membership record to reflect the change in civil status and to include their spouse as a dependent;


• Change in membership category
For separated employees wishing to continue their coverage with PhilHealth, they should amend their record to be under the Individually Paying Member category (refer to this post for distinction between Professional and Non-Professional). The premium amount that you will be required to pay would depend on your membership category, so it is important for you to update it;


• Adding new dependents
If you wish to include your parents, spouse or child/ren under your PhilHealth coverage, they should be registered with PhilHealth as your dependents. For guidance on the declaration of dependents you may refer to this post. Siblings however cannot be declared as a dependent.

There are instances when you will no longer be required to go to PhilHealth in order to update your PhilHealth MDR. Among them are:

• If your member profile reflected in Claim Form 1 (CF1) is different from your membership record, PhilHealth will use the information contained in the CF1 to update your membership record. (Pursuant to PhilHealth Circular No. 08 s-2007);

• For the employed sector, if you are reported as a newly hired employee, then your membership category will automatically be updated to Private/Government depending on your company type. For separated employees, your membership record will reflect that you are already separated from the company. Those who transferred from another company, your record will display the new company. These information shall be captured using the Employer Remittance Report (RF-1). (Pursuant to PhilHealth Circular No. 13 s-2010);

• Retiring employees in the private/government institutions will be covered as Lifetime Members provided that the member is at least 60 years of age, has met the 120 monthly contributions and that their employer facilitated their enrolment at least three months prior to the date of retirement. (Pursuant to PhilHealth Circular No. 28, s-2010.

However, it is still recommended that you to check your current MDR so that any further discrepancies can be immediately amended. To know how to amend / update your membership information click here.

Members: Declaring PhilHealth Dependents - Qualifications for Valid Dependents

This blog post is for those:

• Members who are wondering who to declare as PhilHealth dependents in the PhilHealth Membership Registration Form (PMRF), and;
• Those whose Member Data Record (MDR) did not reflect the dependents previously declared.

Who to Declare as a Dependent:

1. Biological Mother;
2. Biological Father;
3. Step Mother (if biological mother already deceased);
4. Step Father (if biological father already deceased);
5. Adopted Mother (with adoption papers or Court Decree/Resolution of Adoption);
6. Adopted Father (with adoption papers or Court Decree/Resolution of Adoption);
7. Biological Son/Daughter;
8. Step Son/Daughter;
9. Adopted Son/Daughter (with adoption papers or Court Decree/Resolution of Adoption);
10. Legal spouse (non-member or membership is inactive).

Qualifications of a valid dependent:

1. For Parents (birth certificate)

• Should be 60 years old and above;
• Non-member or inactive member;
• Unemployed.

2. For Spouse (with marriage certificate/contract)

• Non-member or inactive member;
• Unemployed;
• A Muslim member can declare more than one wife (with attached Affidavit of Marriage issued by OMA).

3. For Children

• Should be below 21 years old;
• Unmarried;
• Unemployed;
• 21 years old and above with congenital disability either physical or mental;

Additional Guidelines:

• A dependent is qualified if they are not registered as PhilHealth members or if their membership is no longer active;
• Generally, PhilHealth requires the submission of supporting documents to establish the relationship of the declared dependents to the member. Dependents without supporting documents will not be visible in the Member Data Record (MDR);
• A dependent cannot be declared more than once, as in the case of both parents declaring the same child as their dependent, or siblings both declaring their parent;
• There is no limit as to the number of dependents that you can declare. However, you should take note of the 45 days allowable limit shared by your dependents.

OFWs: How to Avail PhilHealth Benefits (Local Confinement)

Are you currently out of the country and want to know how to avail your PhilHealth Benefits? Then read on.

Am I eligible to avail of PhilHealth Benefits?

1. You and your dependents are covered for one year per payment of 900.00 Php starting from the date of your payment. This is shown in your Member Data Record (MDR) provided by PhilHealth upon registration or updating of your membership record;
2. You have not exhausted the 45 days allowable period (explained here);
3. The hospital and doctor are accredited by PhilHealth;
4. Confinement period should not be less than 24 hours except in emergency cases;
5. The laboratory procedures, surgical procedures and medicines are compensable with PhilHealth; and
6. Claim is not within the single period of confinement (to be explained in succeeding posts).

The same is true for the other membership categories, except for item no. 1 where other categories would qualify if there is a 9 month contribution within a 12 month period prior confinement (starting July 2011).

Requirements for Local Confinement:

1. Automatic Deduction from Hospital

• Hospital may require you to present your PhilHealth Identification Card (PIC);
• Fully accomplished PhilHealth Claim Form 1 (PCF 1);
• Updated Member Data Record (MDR) or in case of undeclared dependents attached supporting documents such as birth certificate;
• Submission to the hospital's billing section the PCF 1 and MDR;
• Receipts for payment of the balance of the professional fees (should display amount deducted from PhilHealth);

Some hospitals would request you to submit the original receipts from medicines/drugs purchases, receipts for payment of laboratory and/or surgical procedures and doctor's fees for them to complete the PhilHealth Claim Form 2. Be sure to retain a photocopy of what you will give them and request for a copy of the Statement of Account from the Hospital. The receipts that was paid fully by you should be reflected in the Benefit Payment Notice as "Pay to Member" so that reimbursement will be directly made to you through check.

2. Direct Filing of Claims / Direct Reimbursement

• Payment of the hospital bill and doctor's fee in full;
• Disclaimer/waiver of full payment from the doctor/surgeon/anesthesiologist;
• All receipts from drugs/medicines (purchased within confinement period), laboratory procedures, surgical procedures and hospital bills;
• Fully accomplished and original PhilHealth Claim Form 1 (PCF 1) and an updated MDR;
• Fully accomplished and original PhilHealth Claim Form 2 (PCF 2) by the doctor's and hospital;
• Fully accomplished and original PhilHealth Claim Form 3 for confinement in Primary Hospitals;
• Operative Record (if applicable); and
• Hospital Statement of Account (this includes breakdown of charges).

The Hospital may request for you to submit all receipts to prepare the PhilHealth Claim Form 2. Just provide them a photocopy of the documents they would need and do not give the original. Be sure to go back to the hospital to retrieve the Claim Form and then submit the form and corresponding required attachments to the PhilHealth Office assigned to the area of the hospital. This should also be filed within 60 days from date of discharge. Ensure that the PhilHealth Claim Form 2 waiver portion for full payment is accomplished by the Hospital. You will need this to be reimbursed.

For inquiries on the status of your claim, you may call PhilHealth's call center or the PhilHealth Office - Claims Department.