Availing PhilHealth Benefits for Direct Filing of Claims

Eligibility for Direct Filing:

• You have paid the hospital and doctor's fee in full (without PhilHealth benefit);
• You have the required number of premium payment (for employed and individually paying members) or date of availment is within your membership coverage (for sponsored and ofw members). Lifetime members are eligible to avail PhilHealth benefits and need not pay premiums;
• The hospital/facility is accredited from the time of confinement/admission;
• The doctor is accredited from the time of confinement/admission.

Documents Required to Submit:

• Fully accomplished and original PhilHealth Claim Form 1;
• An updated Member Data Record (MDR) or required supporting documents;
• Waiver from the Hospital and Doctor/s specifying fees are paid in full;
• Official Receipts from drugs/medicines (purchased within confinement period), laboratory procedures, surgical procedures, hospital bills and doctor's fee;
• Fully accomplished and original PhilHealth Claim Form 2 (to be provided by the hospital/facility);
• Fully accomplished and original PhilHealth Claim Form 3 for confinement in primary hospitals or availment of maternity benefit;
• Operative record (if applicable);
• Hospital Statement of Accounts which contains breakdown of charges;
• Authorization or Special Power of Attorney (SPA) for transactions made through an authorized representative (immediate family member).

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 Forms 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.

PhilHealth Case Payment - The Hemodialysis Package

Another package offered under the Case Payment Scheme is the Hemodialysis Package for a total of Php4,000.00 with Php500.00 professional fee for every treatment inclusive in the package.

Coverage of Hemodialysis

• Covers all outpatient hemodialysis procedures with RVS code 90935;
• Includes payment per session for:
• Facility use and hemodialysis machine;
• Drugs and medicines (0.9% sodium chloride, heparin, bicarbonate or acetate hemodialysis solution, e-cart drugs and epoetin alfa or beta);
• Supplies and others (fistula kits, blood tubing set, dialyzet. syringe, and gauze).

Excluded in the package will be paid for through the fee-for-service scheme such as:

• Hemodialysis performed during hospital confinement;
• Other renal replacement therapy (e.g., CAPD, automated peritoneal dialysis);
• Emergency dialysis procedure for Acute Renal Failure (e.g., ARF secondary lo leptospirosis);
• Creadon of fistula for hemodialysis.

Source: PhilHealth Circular No. 011-B-2011

PhilHealth Outpatient Anti-Tuberculosis Directly Observed Treatment Short-Course (TB-DOTS) Benefit Package

The Anti-Tuberculosis Directly Observed Treatment Short-Course or more commonly known as TB-DOTS is a benefit package under the case payment scheme being implemented by PhilHealth since 2003. The said benefit amounts to Php 4,000.00 per case where payment of Php 2,500 will be given after completion of the intensive phase and the remaining Php 1,500 at the end of the maintenance phase.

Eligibility requirements for utilization of this package are:

• All primary members and valid dependents who meet the required number of premium contributions for employed and individually paying members;


• All primary members and valid dependents whose enrollment in the DOTS center is within the coverage or validity period of membership effectivity for sponsored, lifetime and Overseas Filipino Workers (OFWs);


• Treatment of new cases of pulmonary and extrapulmonary tuberculosis for children and adults. New cases denotes that a patient has never had a treatment for TB or taken anti-tuberculosis drugs for less than one month.

PhilHealth shall not pay for:

• Failure case;


• Relapse case;


• Return after default (RAD) case;


• Additional services or extension of treatment.

Outpatient Services covered for the package:

• Diagnostic work-up;


• Consultation services;


• Anti-TB drugs.

Documents required by PhilHealth:

• Claim Form 1;


• Claim Form 2;


• NTP Treatment Card (to be submitted upon registration to TB Management Information System and an updated NTP card upon claiming of benefit).

Date of filing: 60 days from end of every treatment phase

Payable to: PhilHealth accredited TB-DOTS facility

Submit to: Any PhilHealth office corresponding to your area

Other references:

1. PhilHealth Circular No. 19 s-2003


2. How to fill-out the Claim Forms


3. TB-DOTS Benefit

PhilHealth Benefit Packages - Case Payment Rates

This post contains a list of benefit packages, under the case payment scheme, that are available to active PhilHealth members.

Name of Benefit Package	Case Rate (Php)
Maternity Care Package (MCP)	6,500.00
Normal Spontaneous Delivery (NSD) Package	6,500.00
TB-DOTS Package	4,000.00
SARS Package	50,000 - 100,000
Avian Influenza Package	50,000 - 100,000
New Born Care Package (NCP)	1,000.00
Bilateral Tubal Ligation (BTL) Package	4,000.00
Vasectomy Package	4,000.00
Malaria Package	600.00
Influenza A (H1N1) Package	75,000 - 100,000
NSD with BLT Package	10,500.00
Outpatient HIV / AIDS Treatment Package	30,000.00
Dengue I (dengue fever and DHF Grades I and II)*	8,000.00
Dengue II (dengue hermorrhagic fever grades III and IV)*	16,000.00
Pneumonia I (moderate risk)*	15,000.00
Pneumonia II (high risk)*	32,000.00
Essential Hypertension*	9,000.00
Cerebral Infarction (CVA I)*	28,000.00
Cerebro - vascular Accident with Hemorrhage (CVA II)*	38,000.00
Acute Gastroenteritis (AGE)*	6,000.00
Typhoid Fever*	14,000.00
Asthma*	9,000.00
Cesarian Section (CS)*	19,000.00
Dilatation and Curettage (D&C)*	11,000.00
Hysterectomy*	30,000.00
Mastectomy*	22,000.00
Appendectomy*	24,000.00
Cholecystectomy*	31,000.00
Herniorrhaphy*	21,000.00
Thyroidectomy*	31,000.00
Radiotherapy*	3,000.00
Hemodialysis*	4,000.00
Cataract Package*	16,000.00

* PhilHealth will be directly paying the health care facility inclusive of the professional fee, hence, this is directly deducted to the bill of the eligible PhilHealth member. Will also take effect for claims with admission date September 1, 2011.

This list will be updated once additional benefit packages become available. We shall also be discussing each of these packages in detail in succeeding posts so stay tuned.

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".

Paid PhilHealth for the first time, can I use it immediately?

No.

Addendum: Unless you're an OFW.

Avail PhilHealth Benefits for Confinements Abroad

Here are some things you need to know in order to avail PhilHealth benefits for confinements abroad. This is applicable to OFWs, lifetime, individually paying and employed members of the NHIP.

Documentary Requirements

• PhilHealth Claim Form 1 (signed by member or authorized representative);
• Member Data Record (MDR) or supporting documents;
• Proof of applicable premium payments;
• Original official receipts for hospital, doctor, medicines and services (in English);
• Statement of Account with itemized charges (in english) should reflect rates for room and board, medical supplies, laboratory procedures, operating room fee and others;
• Medical Certificate (indicating final diagnosis, confinement period, services rendered in English).

Things you need to know:

• Claim should be filed within 180 days upon discharge in any PhilHealth Regional and Branch Offices;
• You will be paid equivalent to the level 3 hospital benefit rates;
• You may still file for PhilHealth reimbursement even if your employer abroad has a health insurance benefit;
• If you are unavailable to sign or submit your claim application for reimbursement, the person/s below may act as your representative. The members should provide an authorization letter (indicating your name and name of your authorized representative), and a photocopy of two (2) valid IDs of both the member and representative. PhilHealth might require your representative to present the original ID for authentication purposes.
• Spouse;
• Children 18yrs and above;
• Parents for unmarried member;
• Brother / Sister / Guardian;
• Other individuals as duly authorized representative.
• You may verify the status of your claim application by emailing philhealth_hk@philhealth.gov.ph or calling +63 917 5129149 for OFW members or 441-7442 and info@philhealth.gov.ph for non-OFW members. In your inquiry state the following information:
• Patient's complete name;
• Date of confinement;
• Hospital information.
• If you wish to name the cheque to your spouse you would need to submit a Special Power of Attoryney (SPA) or a letter authorizing PhilHealth to use the name of your spouse for the cheque with attached two (2) valid IDs of you and your spouse and Marriage Contract.

For other information visit these links:

• OFW benefits
• FAQs Benefit Availment related
• Individually Paying Member benefits

What is Sufficient Regularity of Premium Payment?

Sufficient Regularity is defined as "payment of premium contribution of at least nine (9) months within the twelve (12) month period immediately prior to the month of availment" as cited in Section 3-iii of the Revised Implementing Rules and Regulations of PhilHealth. Now what does this mean for us NHIP members particularly since the release of PhilHealth Circular No. 25 s-2010?

• Who are covered by PhilHealth Circular No. 25 s-2010?
NHIP members under the Individually Paying Program and Employed members are covered in this circular. Availment of members belonging to the sponsored program and OFWs will still be based on their effectivity period defined by the date of coverage or payment. OFWs are covered for one year starting with the date of their payment while sponsored members have their corresponding one year NHIP coverage period. Lifetime members no longer have this eligibility criteria as they are no longer considered as paying members of the NHIP.

• What does this have to do with availment of benefits?
This now indicates that before the date of your or your dependent's admission, you should have nine (9) months contribution within a twelve (12) month period. Members covered in this Circular that do not meet this requirement will not be able to avail of PhilHealth benefits.
• How does this relate to our payment of premium contributions?

• Premium payment paid on or during the confinement period will be credited to the succeeding applicable period. Example, if the date of confinement/availment is on March 13, 2011 then payment for the first quarter (1st Qtr) should be made before March 13, 2011 so that the amount shall be credited to the first quarter. If payment was made on March 13 or during the confinement period, the payment will immediately apply to the 2nd Quarter. In short, pay your premium contribution before the date of your or your dependent's admission.

• For payments under the rules of sufficient regularity, payment should be made on the last day prior to confinement or availment of benefits in order to be considered or credited to the quarter being paid. This simply means no retroactive payments on the start, during or after the confinement/availment date will be allowed previously permitted under Section 7 of PhilHealth Circular No. 24 s-2003.

• All benefits shall be covered under this eligibility criteria including treatment or out-patient benefits.

The nine (9) over twelve (12) months contribution eligibility criteria shall take effect starting on July 2011 admission / treatment date. For additional information or clarification you may refer to the PhilHealth Circular No. 25 s-2010 or you may coordinate / inquire with PhilHealth's call center or the nearest PhilHealth office.

Tips in Availing PhilHealth Benefits

These are simple tips to guide and help you in availing PhilHealth benefits:

• Know your PhilHealth Identification Number (PIN) or always have your PhilHealth ID Card (PIC). Most hospitals will ask you to present your PhilHealth ID Card in order for them to acknowledge that you are a PhilHealth member. Those under the sponsored program will be required to present their ID card for the hospital to validate your PhilHealth coverage. If you do not have a PhilHealth Identification Number (PIN) yet, then go to this post;
  


• Make sure that your registration details with PhilHealth is up-to-date. An updated record is usually the cause of problems in availing PhilHealth benefits. Be sure to update PhilHealth about your change in address, civil status and new dependents. If you find that there is a discrepancy in your record, have it corrected immediately. If you are unable to do so, make sure that you attach the required supporting document in the availment/claim document;


• Always have your PhilHealth Official Receipt (POR), PhilHealth Agent Receipt (PAR) or other receipt acknowledged by PhilHealth as proof of payment. Hospitals may require you to present proof of your latest payments especially if you are under the Individually Paying Member category. You should have the receipt/s of your latest nine (9) months payment prior confinement.


For employed members, request your employer to certify the Claim Form 1 (CF1). This will be required by the hospital for automatic deduction of PhilHealth benefits. Ensure that your contributions are being reported and remitted by your employer. As of now PhilHealth does not have an online facility accessible by its members to inquire about their contributions. You may however contact PhilHealth's call center or the Collection Section of PhilHealth Offices to verify your contributions.



For OFWs, your Member Data Record (MDR) will show your recent payments with PhilHealth. Sponsored members' coverage will be visible in their Phil Hea lth ID Card;



• Your or your dependent's confinement should be in a PhilHealth accredited hospital or facility. If you or any of your dependents are confined in an unaccredited hospital or facility then you might not be able to avail of PhilHealth benefits for bills paid to the institution. Accredited hospitals/facilities have a PhilHealth signage at their entrance. You should also know that hospitals and facilities should ha ve a n active accreditation period with PhilHealth in order to avail PhilHealth benefits.

• The doctor, anesthesiologist and other professionals should also be PhilHealth accredited. If your doctor is not accredited, then you will not be able to reimburse the professional fees paid to them. You should also be aware that like the accredited health institutions, there are instances when you may not be paid depending on their accreditation period with PhilHealth;

• Inquire how much is the regular professional fee and how much would be the PhilHealth deduction from your doctor. Some doctors have different rates for a non-PhilHealth and a PhilHealth member. This question should be asked as soon as possible as you might find it a pain if you fully pay the professional fee and then later want to reimburse it directly with PhilHealth only to find out that the doctor will not sign or provide you a disclaimer for full payment. This is usually the cause of conflict between the member and the doctor;

• Inquire whether the hospital allows the senior citizen or government employee discount combined with PhilHealth benefits. Aside from PhilHealth benefits, your hospital bill may still be lessened if the patient is a senior citizen or the member is a government employee. Ask if the hospital/facility is implementing this scheme and if the senior citizen or government employee discount can be combined with the deduction from PhilHealth. As per experience, we have previously availed the senior citizen discount plus the PhilHealth benefit;


• Retain a copy of the hospital and professional receipts, statement of accounts and other documents that will be attached to the PhilHealth claim. This can be used in requesting for adjustments, you may use these as evidence in cases of conflicts and may further be used in ensuring that you have received the right amount of benefits due to you.


• Evaluate the Benefit Payment Notice (BPN) sent by PhilHealth. The Benefit Payment Notice (BPN) is basically a document informing you of how much the hospital, doctor or you as the member received from PhilHealth for your confinement. You may use this document to validate if the amount deducted by the hospital and doctor tallies with the amount they received from PhilHealth. If the amount they received from PhilHealth is greater than the amount they have deducted, then you may request for a refund from the hospital and the doctor. If the balance was returned to PhilHealth you may contact the PhilHealth Office near you. So save your receipts and make sure that the address you have in the PhilHealth record is updated.

Hope this helps you improve your experience in availing benefits under the National Health Insurance Program (NHIP).