PhilHealth Claims Filing Reducing Mistakes, Increasing Reimbursements Reducing Mistakes, Increasing...

PhilHealth Claims FilingPhilHealth Claims Filing

Reducing Mistakes,

Increasing Reimbursements

Reducing Mistakes,

Increasing Reimbursements

Know the Rules!Know the Rules!• PhilHealth does not pay for all your

health care costs.

• PhilHealth pays only for covered items and services when its rules are met.

• Members usually give a co-payment for the portion of the actual cost that is not covered by PhilHealth

• PhilHealth does not pay for all your health care costs.

• PhilHealth pays only for covered items and services when its rules are met.

• Members usually give a co-payment for the portion of the actual cost that is not covered by PhilHealth

PhilHealthPhilHealth• Govt owned and controlled corporation

• Created by Republic Act 7875

• National Health Insurance Program (NHIP)

• Amended by Republic Act 9241

• Access to health care is a basic right of citizens – “Universal coverage”

• Govt owned and controlled corporation

• Created by Republic Act 7875

• National Health Insurance Program (NHIP)

• Amended by Republic Act 9241

• Access to health care is a basic right of citizens – “Universal coverage”

Members andDependents

Members andDependents

Our MembersOur Members

1. Employees (govt and private)

– monthly payment (3% salary)

2. Individually Paying Program (voluntary)

- quarterly payment (1,200/year)

3. Overseas Workers Program

- Annual payment (900/year)

1. Employees (govt and private)

– monthly payment (3% salary)

2. Individually Paying Program (voluntary)

- quarterly payment (1,200/year)

3. Overseas Workers Program

- Annual payment (900/year)

Our MembersOur Members4. Non-paying (pensioner)

- no payment for life

• 60 years old

• With total 120 monthly contributions

5. Sponsored (thru partnership with LGUs)

- annual payment, eligibility for 1 year

4. Non-paying (pensioner)

- no payment for life

• 60 years old

• With total 120 monthly contributions

5. Sponsored (thru partnership with LGUs)

- annual payment, eligibility for 1 year

Your DependentsYour Dependents

• Spouse

• Children < 21 years old

• Parents > 60 years old

–Step parents

–Adoptive parents

• Spouse

• Children < 21 years old

• Parents > 60 years old

–Step parents

–Adoptive parents

BenefitsBenefits

45 Days Annual Allowance45 Days Annual Allowance

• 45 days allowance per year for the principal (member)

• Another 45 days shared among dependents

• 45 days allowance per year for the principal (member)

• Another 45 days shared among dependents

Your benefitsYour benefits• Illness requiring hospitalisation• Outpatient:

– Surgical procedures• Cataract surgery• BTL• Vasectomy• Endoscopy• Excision• Suturing

• Illness requiring hospitalisation• Outpatient:

– Surgical procedures• Cataract surgery• BTL• Vasectomy• Endoscopy• Excision• Suturing

Drugs and MedicinesDrugs and Medicines

• Only drugs used during confinement will be paid

• Drugs must be written in generic name

• Closed formulary – only drugs listed in the preferred list* will be covered by PhilHealth

*6th edition of the Philippine National Drug Formulary (PNDF)

• Only drugs used during confinement will be paid

• Drugs must be written in generic name

• Closed formulary – only drugs listed in the preferred list* will be covered by PhilHealth

*6th edition of the Philippine National Drug Formulary (PNDF)

Anti-convulsants / Epileptics

Anti-convulsants / Epileptics

– CARBAMAZEPINE– CLONAZEPAM– DIAZEPAM– LORAZEPAM– MAGNESIUM

SULFATE– PHENOBARBITAL– PHENYTOIN– VALPROIC DISODIUM

–Gabapentin

–Midazolam

–Thiopental sodium

–Topimarate

Anti-ParkinsonismAnti-Parkinsonism–Pirebidil

• 50 mg

–Selegiline• 5 mg

– LEVODOPA + BENSERAZIDE

• 100 mg/25 mg

• 200 mg/50 mg

– LEVODOPA + CARBIDOPA

• 100 mg/25 mg

• 250 mg/25 mg

Case: 65 years old

Diagnosis: Parkinson’s Disease

Drugs: Levodopa + Benserazide # 60

Nifedipine 30 mg # 60 (PNDF)

Telmisartan tab # 60 (non-PNDF)

Admission: September 17 - 20

What drugs will be paid?

Case:

Diagnosis: Parkinson’s Disease, HPN

Drugs: Levodopa + Benserazide # 60

Nifedipine 30 mg # 60

Telmisartan tab # 60

Admission: September 17 - 20

How many will be paid?

Drugs and MedicinesDrugs and Medicines

• Only drugs, supplies, and lab

used on confinement shall be

paid

– Must be supported by official

receipts

• Only drugs, supplies, and lab

used on confinement shall be

paid

– Must be supported by official

receipts

• physician charges separately for each patient encounter or service rendered

• expenditures increase if more services are provided or a more expensive service is substituted for a less expensive one

• Needs itemization

• physician charges separately for each patient encounter or service rendered

• expenditures increase if more services are provided or a more expensive service is substituted for a less expensive one

• Needs itemization

Fee for Service Scheme:Fee for Service Scheme:

Computation of BenefitsComputation of Benefits

• Case type of illness

• Category of Facility

• Case type of illness

• Category of Facility

CasetypesCasetypes

• Casetype A – Ordinary

• Casetype B – Intensive

• Casetype C – Catastrophic

• Casetype D – Super Catastrophic

• Casetype A – Ordinary

• Casetype B – Intensive

• Casetype C – Catastrophic

• Casetype D – Super Catastrophic

Level 3 & 4 Hospitals (Tertiary)

Case-type A B C D

Room & Board* P400/day P400/day P400/day P1,035/day

Drugs and Medicines** P3,000 P9,000 P16,000 P35,635

X-ray, Lab & Others** P1,700 P4,000 P14,000 P29,430

Operating Room** RVU 30 and below = P1,060

RVU 31 to 80 = P1,350

RVU 81 up to 200 = P3,490

RVU 201 up to 500 = P3,490

RVU > 500 = P10,470

Level 2 Hospital (Secondary)

Room & Board* P300/day P300/day P300/day P660/day

Drugs and Medicines** P1,700 P4,000 P8,000 P19,725

X-ray, Lab & Others** P850 P2,000 P4,000 P10,215

Operating Room** RVU 30 and below = 670

RVU 31 to 80 = P1,140

RVU 81 up to 200 = P2,160

RVU 201 up to 500 = P2,160

RVU > 500 = P6,480

Level 1 Hospital (Primary)

Room & Board* P200/day P200/day N/A N/A

Drugs and Medicines** P1,500 P2,500 N/A N/A

X-ray, Lab & Others** P350 P700 N/A N/A

Operating Room** RVU 30 and below = P385

N/A N/A N/A

* Not exceeding 45 days for each member & another 45 days to be shared by his/her dependents** Per single period of confinement

Benefit Periods

• PhilHealth benefits are divided into benefit

periods

• A benefit period is essentially a single

hospital stay, including re-hospitalisation of

up to 90 days

• In each benefit period, PhilHealth will only

pay 1 benefit

• PhilHealth benefits are divided into benefit

periods

• A benefit period is essentially a single

hospital stay, including re-hospitalisation of

up to 90 days

• In each benefit period, PhilHealth will only

pay 1 benefit

Single Period of Confinement

• Example

– a 3 week chemotherapy cycle,

where a patient has treatment on

the 1st and 8th days, but nothing

on days 2 - 7 and days 9 - 21

– Medicine per session is 5,000

• Example

– a 3 week chemotherapy cycle,

where a patient has treatment on

the 1st and 8th days, but nothing

on days 2 - 7 and days 9 - 21

– Medicine per session is 5,000

Benefit Unused Payment

16,000

January 1 16,000 5,000

January 8 11,000 5,000

January 22 6,000 5,000

January 29 1,000 1,000

February 12, 19, 0 0

90 days after January 1

New 16,000March 1

March 5 16,000 5,000

March 12 11,000 5,000

Single Period of Confinement

• You may only avail of the unused

benefits except:

– for room and board fees

– Professional fees

until the 45 day allowance is fully

exhausted.

• You may only avail of the unused

benefits except:

– for room and board fees

– Professional fees

until the 45 day allowance is fully

exhausted.

ProfessionalFeeProfessionalFee

Professional Fees**

Case-type A B C D

General Practitioner P150/day not exceeding P600

P150/day not exceeding P900

P150/day not exceeding P900

P315/day not P315/day not exceeding exceeding P2,430P2,430

Specialist

P250/day not exceeding P1,000

P250/day not exceeding P1,500

P250/day not exceeding P2,500

P450/day not P450/day not exceeding exceeding P4,050P4,050

Surgeon (P40/RVU) not exceeding P16,000

(P120 /RVU for consultation) but not exceeding P47,790

Anesthesiologist 30% Surgeon’s fee not exceeding P5,000

30% Surgeon’s fee not exceeding P14,355

** Per single period of confinement

• based on the Relative Value Units (RVU)

• The RVU must be multiplied by a Peso Conversion Factor (PCF) to become a payment schedule

• Surgeons: RVU x P 40

• Covers preoperative visits, intraoperative services, postoperative services for 90 days

• Anesthesiologist: (RVU x P 40) x 30%

• based on the Relative Value Units (RVU)

• The RVU must be multiplied by a Peso Conversion Factor (PCF) to become a payment schedule

• Surgeons: RVU x P 40

• Covers preoperative visits, intraoperative services, postoperative services for 90 days

• Anesthesiologist: (RVU x P 40) x 30%

Professional Fee

Example:

66270 Spinal puncture

12

12 RVU x 40 PCF = Php 480

Professional Fee

Example:

61793 Stereotactic radiosurgery 200

200 RVU x 40 PCF = Php 8,000

Professional Fee

Example:

61500 Craniectomy w/ excision of tumor 400

400 RVU x 40 PCF = Php 16,000

Professional Fee

Policies on PF Policies on PF

• > 2 procedures, single opening = pay highest value

• > 2 procedures, different incision site

= pay all unit values

• Procedures done on different dates

= pay all unit values

• > 2 procedures, single opening = pay highest value

• > 2 procedures, different incision site

= pay all unit values

• Procedures done on different dates

= pay all unit values

Example:

49000 - Explor Lap - 150

44950 - Appendectomy - 100

150 RVU x 40 PCF = P6,000

Example:

49000 - Explor Lap - 150

44950 - Appendectomy - 100

150 RVU x 40 PCF = P6,000

Policies on PF Policies on PF

Example:

49000 - Explor Lap - 150

58943 - Oophorectomy for

ovarian CA - 200

200 RVU x 40 PCF = P8,000

Example:

49000 - Explor Lap - 150

58943 - Oophorectomy for

ovarian CA - 200

200 RVU x 40 PCF = P8,000

Policies on PF Policies on PF

Example: Bilateral Cataract Extraction

69887 - ECCE phacoemulsification - 200

200 x 2 = 400 RVU400 RVU x 40 PCF = P16,000

Example: Bilateral Cataract Extraction

69887 - ECCE phacoemulsification - 200

200 x 2 = 400 RVU400 RVU x 40 PCF = P16,000

Policies on PF Policies on PF

Repeat Procedures:• Payment within cap• Covered by rule on single period

of confinement

Repeat Procedures:• Payment within cap• Covered by rule on single period

of confinement

Service Rendered Computed Benefit PHIC BenefitLigation, varices esophagus 10,000 10,000 Ligation, varices esophagus 10,000 6,000

Policies on PF Policies on PF

Total = 16,000

Example:

66270 Spinal puncture

12

12 RVU x 40 PCF = Php 480

Professional Fee

Professional Data & Charges

21. Name of Surgeon Signature & Date Signed Reduction Code

22.PHIC Accreditation No. 23. BIR/TIN No. - -24. Services Performed 25. Actual

P P PDate of Operation

SurgeonBenefit Claim

PatientProfessional Charges

14. Complete Final Diagnosis

Relative Unit Value

15. Case Type Ordinary Intensive Catastrophic

16. Name of Attending Physician Signature & Date Signed Illness Code

18. BIR/TIN No. - - Reduction Code

19. Services Performed 20. Actual

P P P

17.PHIC Accreditation No.

PatientPhysicianProfessional Charges

FOR PHILHEALTH USE

Benefit Claim

PART II - PROFESSIONAL DATA AND CHARGES ( Doctor/s to Fill in Respective Portions )

26. Name of Anesthesiologist Signature & Date Signed Reduction Code

27.PHIC Accreditation No. 28. BIR/TIN No. - -29. Services Performed 30. Actual

P P P

Benefit ClaimProfessional Charges Physician Patient

Daily visit

RVU

Anesth

21. Name of Surgeon Signature & Date Signed Reduction Code

22.PHIC Accreditation No. 23. BIR/TIN No. - -24. Services Performed 25. Actual

P P PDate of Operation

SurgeonBenefit Claim

PatientProfessional Charges

Professional Data & Charges

Lumbar tap1000 480

With deduction

520

21. Name of Surgeon Signature & Date Signed Reduction Code

22.PHIC Accreditation No. 23. BIR/TIN No. - -24. Services Performed 25. Actual

P P PDate of Operation

SurgeonBenefit Claim

PatientProfessional Charges

Professional Data & Charges

Lumbar tap1000 1000

With no deduction

21. Name of Surgeon Signature & Date Signed Reduction Code

22.PHIC Accreditation No. 23. BIR/TIN No. - -24. Services Performed 25. Actual

P P PDate of Operation

SurgeonBenefit Claim

PatientProfessional Charges

Professional Data & Charges

Lumbar tap480 480

Complimentary PF; PhilHealth only

Actual PF = PhilHealth benefit

21. Name of Surgeon Signature & Date Signed Reduction Code

22.PHIC Accreditation No. 23. BIR/TIN No. - -24. Services Performed 25. Actual

P P PDate of Operation

SurgeonBenefit Claim

PatientProfessional Charges

Professional Data & Charges

Dialysis400 400

Government hospital; Private Patient

Private hospital; Service Patient

PAY TO DOCTOR

Private Patient, Government Hospital

NO Stamp: PF is made to the Chief

PAY TO CHIEF

Service Patient, Pay Hospital

Name of Surgeon

NO Stamp: PF is made to the MD who signed Form 2

Eligibility RulesEligibility Rules

• For employed and IPP, at least 3 monthly contributions within the immediate 6 months prior to admission

• the 45-days allowance for room and board has not been consumed yet

• confinement in an accredited hospital of not less than 24 hours

• For employed and IPP, at least 3 monthly contributions within the immediate 6 months prior to admission

• the 45-days allowance for room and board has not been consumed yet

• confinement in an accredited hospital of not less than 24 hours

Are you eligible?Are you eligible?

CaseCase• Employed member since January 2006Employed member since January 2006

• Admitted for Myelography for tumor (?)Admitted for Myelography for tumor (?)

• Paid premium up to January to March Paid premium up to January to March 20072007

• Is the claim compensable?

• Employed member since January 2006Employed member since January 2006

• Admitted for Myelography for tumor (?)Admitted for Myelography for tumor (?)

• Paid premium up to January to March Paid premium up to January to March 20072007

• Is the claim compensable?Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

x Admit

X – start of membership

No !

6 5 4 3 2 1

CaseCase

• IPP applied membership March 2007

• Premium paid

• Admitted April 2007 for TIA

• IPP applied membership March 2007

• Premium paid

• Admitted April 2007 for TIAJul Aug Sep Oct Nov Dec Jan Feb Mar Apr

x Admit

1st quarterX – start of membership

Yes !

6 5 4

3 2 1 3 2 1 3 2 1

2007 P 300300

300

• What if a member enroll today, when can he start availing PhilHealth benefits?

06/08/2007

Adverse selectionAdverse selection• Phenomenon whereby a disproportionate

share unhealthy individuals (high risk) enroll in a health plan

• Hidden information; member moral hazard• Influenced by benefit design and individual

decision• In contrast to guiding principles of social

solidarity• Example: CS, Cataract

• Phenomenon whereby a disproportionate share unhealthy individuals (high risk) enroll in a health plan

• Hidden information; member moral hazard• Influenced by benefit design and individual

decision• In contrast to guiding principles of social

solidarity• Example: CS, Cataract

For IPP, at least 9 monthly contributions within the immediate 12 months prior to admission for the following:

1. Hemodialysis and Peritoneal Dialysis

2. Chemotherapy

3. Radiation oncology

4. Selected surgeries:• CS• D & C• Cataract• Endoscopy effective April 1, 2007

For IPP, at least 9 monthly contributions within the immediate 12 months prior to admission for the following:

1. Hemodialysis and Peritoneal Dialysis

2. Chemotherapy

3. Radiation oncology

4. Selected surgeries:• CS• D & C• Cataract• Endoscopy effective April 1, 2007

Circular 36 s. 2006Circular 36 s. 2006

Supplier induced demandSupplier induced demand

• Demand created by doctors beyond what would have occurred in a market

• Influenced by benefit design and individual decision

• Hidden action

• Doctor moral hazard

• Demand created by doctors beyond what would have occurred in a market

• Influenced by benefit design and individual decision

• Hidden action

• Doctor moral hazard

PhilHealth Payment 2004PhilHealth Payment 2004

Cataract (69887 & 66984)

• Total Payment: 590 million

• Total Number Claimed: 28,997

• AVPC: 20,368.83

• Average PF: 7,700

Cataract (69887 & 66984)

• Total Payment: 590 million

• Total Number Claimed: 28,997

• AVPC: 20,368.83

• Average PF: 7,700

AdvertsAdverts• False adverts tends to deceive or

mislead the public which makes an untruthful assertion

– E.g., “Free cataract surgery for PhilHealth members “

– “No out of pocket payments for PhilHealth members”

• False adverts tends to deceive or mislead the public which makes an untruthful assertion

– E.g., “Free cataract surgery for PhilHealth members “

– “No out of pocket payments for PhilHealth members”

AdvertsAdverts

• Cataract surgery announced as free should not be filed to PhilHealth and be offered to all regardless of PhilHealth membership status

– Why not offer it to all?

– Not free; PhilHealth as third party payor

• Cataract surgery announced as free should not be filed to PhilHealth and be offered to all regardless of PhilHealth membership status

– Why not offer it to all?

– Not free; PhilHealth as third party payor

Solicitation of patientsSolicitation of patients

• Solicitation of patients, directly or indirectly, through solicitors or agents, is unethical

– Example: • NGO sponsorship of medical mission• Doctors paying for patients premium

– 300 pesos versus 49,000 pesos (bilateral ECCE)

• Solicitation of patients, directly or indirectly, through solicitors or agents, is unethical

– Example: • NGO sponsorship of medical mission• Doctors paying for patients premium

– 300 pesos versus 49,000 pesos (bilateral ECCE)

RVS 2001RVS 2001

• Historically-abused procedures

– Utilization trend data– Institutional memories

• Blepharoplasty• Removal of FB, eye• Pterygium

–Excision (20) Conjunctivoplasty (60)

• Historically-abused procedures

– Utilization trend data– Institutional memories

• Blepharoplasty• Removal of FB, eye• Pterygium

–Excision (20) Conjunctivoplasty (60)

RVS 2001RVS 2001

Upcoding or Creeping:

• In claims submission, using a higher level procedure code than the level of service actually provided

• E.g., appendectomy (100 RVU) to

AP ruptured (150 RVU)

Upcoding or Creeping:

• In claims submission, using a higher level procedure code than the level of service actually provided

• E.g., appendectomy (100 RVU) to

AP ruptured (150 RVU)

ICD-10ICD-10

ICD-10ICD-10

• An international classification designed to enable CONSISTENCY of coding THROUGHOUT the world.

• An international classification designed to enable CONSISTENCY of coding THROUGHOUT the world.

The structure of the 4-character category is:

STRUCTURE OF ICD-10 CODE:

First character A to Z (Except U)

Followed by2 digits

thena point

Lastly Another digit

There are three (3) volumes

MAIN ELEMENTS TO THE STRUCTURE OF ICD-10

There are twenty one (21) chapters

The structure of the code is alphanumeric

VOLUMES OF THE ICD-10:

Volume 1 (Tabular List) – alphanumeric listing of diseases and disease groups

Volume 2 - contains instructions and guidelines for Mortality and Morbidity coding

Volume 3 (Alphabetical Index) – comprehensive listing of all the conditions in the Tabular List

Basic Coding GuidelinesBasic Coding Guidelines

Follow carefully any cross-references found in the index.

Refer to the Tabular List (Vol. 1)

Be guided by any inclusion and exclusion terms under the selected code, chapter, block or category heading.

Finally, ASSIGN THE CODE.

Follow carefully any cross-references found in the index.

Refer to the Tabular List (Vol. 1)

Be guided by any inclusion and exclusion terms under the selected code, chapter, block or category heading.

Finally, ASSIGN THE CODE.

Assign the ICD-10 code for Chronic viral hepatitis C

Example:

Answer: Lead term: Hepatitis

-viral--chronic

---type

----C B18.2

PhilHealth Circular Number 27 series of 2003

PhilHealth Circular Number 27 series of 2003

“ All claims with no ICD-10 codes, incorrect codes/and or ambiguous ICD-10 codes shall NO LONGER BE DENIED but shall be returned to the accredited health care provider (RTH) on the ground of non-compliance with the correct ICD-10 codes ”

“ All claims with no ICD-10 codes, incorrect codes/and or ambiguous ICD-10 codes shall NO LONGER BE DENIED but shall be returned to the accredited health care provider (RTH) on the ground of non-compliance with the correct ICD-10 codes ”

Categories ranged from G00-G99

67 of the 100 available categories have been used

There are 11 blocks within this Chapter.

There are 16 asterisk categories. Most of them are result of infectious conditions, as well as neurological conditions resulting from other diseases and conditions

G00-G09 block classifies diseases where the nerve tissue is attacked by various organisms

Nervous SystemNervous System

Meningitis is usually due to infection and is classified by a combination of a dagger code for Chapter 1 and an asterisk code from G01 or G02 to provide more information

G09(Sequelae of inflammatory diseases of central nervous system) would be listed as a secondary code with the sequelae itself being listed as the main condition

It should be noted that seizures and convulsions NOS are coded R56.8 and are not considered epilepsy unless the term “epilepsy” is specifically used

Nervous SystemNervous System

ICD-10ICD-10G45.9 : TIA (O)G45.0 : vertebrobasilar insufficiency (O)

I67.9 : CVA, unspecified (C)

I66.9 : CVA, cardioembolic (D)I61.9 : CVA, hemorrhagic (D)I63.9 : CVA, thrombotic infarct (D)

G45.9 : TIA (O)G45.0 : vertebrobasilar insufficiency (O)

I67.9 : CVA, unspecified (C)

I66.9 : CVA, cardioembolic (D)I61.9 : CVA, hemorrhagic (D)I63.9 : CVA, thrombotic infarct (D)

MORPHOLOGY OF NEOPLASMS:

The classification of morphology of neoplasms (pp. 1177-1204) is used as an additional code to

classify the morphological type for neoplasms

S

M

B

Site

Morphology

Behavior

C00 - D48

M8000 – M9989

/0, /1, /2, /3, /6

ICD-10ICD-10

C71.9, M9400/3C71.9, M9400/3

• Neoplasm of brain

• Astrocytoma

• Malignant

• Neoplasm of brain

• Astrocytoma

• Malignant

ICD-10ICD-10

D32.1, M9530/0D32.1, M9530/0

• Neoplasm of spinal meninges

• Meningioma NOS

• Benign

• Neoplasm of spinal meninges

• Meningioma NOS

• Benign

ICD-10ICD-10

C50.9, M8010/3

C71.2, M8010/6

C50.9, M8010/3

C71.2, M8010/6

1. Breast carcinoma, primary

2. Metastatic carcinoma, temporal lobe

1. Breast carcinoma, primary

2. Metastatic carcinoma, temporal lobe

Additional Tips for Better Payment

1. Eliminate down coding by providing complete descriptions

2. Rank procedures by order of importance

3. Don’t send documents not required

4. Submit claims promptly and frequently

5. Complete forms ASAP

6. Fill in all blanks. Type NA

7. Make it a practice to follow up with Claims Dept.

ICD-10ICD-10

G96.1 : Disorders of meninges, unspecified (B)

G00.9 : Bacterial meningitis (C)

G04.2 : bacterial meningo-encephalitis (D)

G96.1 : Disorders of meninges, unspecified (B)

G00.9 : Bacterial meningitis (C)

G04.2 : bacterial meningo-encephalitis (D)

UpdatesUpdates

Circular 11, 2007Circular 11, 2007

Code Descriptive Terms RVU

99256 Inpatient consultation for a new or established patient which requires: an expanded focused history, examination and medical decision making. It is requested by another physician or appropriate source; the consultant advises the requesting physician about the management of a specific problem including follow up care for 90 days after the procedure

40

Circular 11, 2007Circular 11, 2007– Preoperative medical evaluation is a

service provided by a physician whose opinion or advice is requested by another physician regarding evaluation and/or management of a specific medical problem which might affect the patient’s ability to undergo a procedure or might influence the outcome of the procedure

– Preoperative medical evaluation is a service provided by a physician whose opinion or advice is requested by another physician regarding evaluation and/or management of a specific medical problem which might affect the patient’s ability to undergo a procedure or might influence the outcome of the procedure

Circular 11, 2007Circular 11, 2007

• Qualified physicians who can claim for this service:– Family medicine

– Internal Medicine

– Neurology

– Pediatrics

• Qualified physicians who can claim for this service:– Family medicine

– Internal Medicine

– Neurology

– Pediatrics

Circular 11, 2007Circular 11, 2007

• Applicable only while the patient is admitted

• Preoperative medical evaluation given on an outpatient basis will not be compensated

• Applicable only while the patient is admitted

• Preoperative medical evaluation given on an outpatient basis will not be compensated

Circular 11, 2007Circular 11, 2007

• Service is applicable only if surgery is accomplished within the same admission period.– If surgery is deferred no payment

• But may claim PF based on daily visits subject to allowable amount per hospital admission

• Service is applicable only if surgery is accomplished within the same admission period.– If surgery is deferred no payment

• But may claim PF based on daily visits subject to allowable amount per hospital admission

Circular 11, 2007Circular 11, 2007

• In filing for claims, a copy of the consultation/clearance form with the corresponding assessment and recommendation must be attached

• In filing for claims, a copy of the consultation/clearance form with the corresponding assessment and recommendation must be attached

www.philhealth.gov.ph

Contact Us:

qarp@philhealth.gov.ph

0918-9001618