Republic oftire Philippines PHILI PPINEI-lEALTH INSURANCE
CORPORATI ON C itystatc Centre,709 Shaw 13oLIIcvard, Pasig City
HcaiUJiine 637-9999ww1vphilhealth.gov.ph PHILHEALTH CIRCULAR N
o.OJO, s-2011 J,;.1.--TOALL PHILHEALTH MEMBERS, ACCREDITED
PROVIDERS, PHILHEALTH REGIONAL OFFICES (PhROs), AND ALL OTHERS
CONCERNED SUBJECTClarificatory Guidelines No. 2to PhiiHealth
Circular Nos. 11,11-A and 11-Bseries of 2011 PursuanttoP
hilfiealthCircularNos.11 ,11-Aand11 -B,seriesof2011 ,Lhefollowing
additionalguidelinesarebeingissuedforproper implementation. I.NO
BALANCE BILLING POLICY A.Asregani:- toTtemTTT- A.
1onNoBalanceBilling(NBB)P olicyof CircularN o.11s-2011
,itisherebyclarifiedthatNBBpolicyshallonlyappl yto
inpatientcasesofSponsoredProgrammembersanddependentsadmittedin
government hospita ls. Sponsoredmembersandthei
rdependentsshallbegivenutmostpriori tyinservtce (ward)beds.
Whenallthe servicebedsare occupied, sponsored members / dependenrs
foradmissi onshouldbeplacedinanaccommodatio nhigherthantheservi
cebeds; NBBshallstillap plyand no additionalcost shallbe
chargedtothemember.Further, government hospital sare remindednott
or efuse admissionsof Sponsored Members. B.TheNBB Policy shalln
otapplytoany of the following conditions: 1.\Xlhenthesp on
soredmember/dep endentrequestsadmi ssioninoth ertypesof
accommodatio notherthantheservicebed. 2.Whenthe sponsored member/
dependent requestsforapriv ate doctor. 3.Whenamemberini
tiallylldmittedinservi cebedthenrequestedtransfertoa private bed.
4.\"Vhenamemberini tiallyoptedforadmissioninaprivatebedandrequested
transferto a service bed. 5.AnyotheranalogouscasewhenaSpon
soredMemberoptsforabedand/ or private room differen tfr omthewar
dbedbeingoffered. C.TheNBl3poli cyinclairn.ingforreimbursement fo
routpatientsurgeries(e.g. ,cat aract
package),hemodialysis,radiotherapy, TBDOTS, Malaria,HIV-AIDS,
Maternity Care Package,lnclNewb
ornCarePackageinallaccreditedgovernmenthospitalsandall non-
hospnalfaciliti es(government andp rivate)shallstillapp
lyasspecifiedin[terns III.A. 2toIII.A.4
ofPhilHealthCircularNo.11s-2011. D.Allo
theritemsstipulatedinSectionIIIregardingNBB Policyof
PhilHea.lthCircular No.11s-2011shallremainineffect. r \_ ...I -"
II.GENERAL RULES A.For those not covered by the NBB policy,thecase
ratebenefit shall be maximizedto
coverforhospitalservicesandprofessionalfees.If
incasetherateswillnotfully
coverthebill,thentheexcessshallbechargedtothePhilHealthmemberasout
of pocket paymenr. B.Case rates shallcover provisionfor
allservices; hence, alldrugs, supplies, laboratories
anddiagnosticproceduresnecessaryforthemanagement shouldbe
providedbythe h ospital sand not to b ebought/doneoutside by
patients. It isreiteratedthat facilities should purchase necessary
item/s in advance inbehalf of themember. C.AsprovidedforbytheIRRof
RA7875asamendedby9241andtheWarrantiesof
Accreditationbothforfacilitiesandprofessional,automaticdeductionof
Phi lHealth benefits shallbe provided to PhilHealth patients upon
discharge. 1.Directfilingo
fclaimsisnotencouraged.Onlyininstanceswhenthenecessary
(eligibility)documentsforavailmentarenotavailableduringdischarged1athealth
care providersmay not deduct the PhilHealth benefits.
Incaseswheretherearedirectlyfiledclaimsbythepatient,theclaimshouldbe
supportedbyofficial receipts(OR)or waivercoming fromthe pr
oviderstosupport payment tothe claimant. AStatement of Account
(SoA)shallalso be required which
shallincludeboththehospitalandprofessionalchargesattestedbyhospital
representative.ItemizationofPartsTIandIIIof CF2isrequired~ ~ n
shallbe evaluatedprior topayment of claims.The amount
tobepaidshallbebasedonthe actualtotalcost up to the case rate
amount.
2.Ifuponevaluation/monitoringandthereareviolationsornon-adherencewith
issuances,circularsandpoliciesasimplemented,necessarystepsshallbetaken
against the accredited providers asstipulated inthe
aforementionedcircular.
D.AdditionalconditionsforentitlementtoPhilHealthbenefitsasspeci
fiedin PhilHealthCircularNo.31s-201
0shallapplytoallcaserateclaims.Tnsuchcases, the member/patient
isenti tledtothe fullcase rate amount.
E.UntilsuchtimethattheDepartmentof
Health(DOH)shallissueapolicyonhow professionalfeesshouldbe
distributedin governmentfacilitiesforclaimsdesignated forpooling,
check shall be issued asfollows:
1.The30-40%allottedforprofessionalfeeshillbeissuedpayabletotheChief
of Hospital or MedicalDirector. As stated inPbi/IIealthCircular
No.14s-2005 pursuant
toBurea11ofInte1'1JalRevetmcMemorandumCircularNo.21-2005,allPhill-Iealth
reimbursementforprofessionalfeespayabletothe"Chief of
Hospital"forpooling and distributionamong health personnel ina
government hospitalshall no longer be
subjectto10%expandedwithholdingtax.The
accreditedgovernmenthospital,o n theotherhand,"upondistributionof
theirsharefromPhi!Healthtotheirmedical
andnon-medicalpersonnelshallberesponsibleforthewitl1holdingtaxon
compensation,theissuanceof BIRFormNo.2316andsubmissionofAnnual
Information Return". 2.The remaining 60-70%facility fee shallbe
issued under the name of the facility. For private patients in
government hospitals,the check shallbe issu edto thefacilities
following allprovisi ons specified in PhilHealth Circular No.
11s-2011. Page 2of 5 F.T osimplifysubmissiono
fclaimsforcaseratepackages,thefollowingruleshereby
amenditemnos.ITT-2-aandTTT-2-cinpartIII-GeneralRulesof Circular
No.15,s-2011 : 1.InPARTI - PROVIDERINFORMATIONof
Phili-TealthClaimI'orm2(Cf'2), facilitiesonlyneed towritethecase
rate amount under11 e Bmeftt Patkage(Phi/Health Benefit Column).
2.In PARTS II andIII of CF2,faciliti esonlyneedto write the name/
sand quanti tyof thedrugs/meclicinesinPartTT;andsupplies,laboratoq
andancillaryproceduresin Part TTl . III.MEDICAL CASES A.Fo
rPneumoniaIandII(ICD10Codes: )1 2.-
to]18.-),allaccreditedprofessionals
arerequiredtowritethefinaldiagnosisbasedontheClinicalPracticeGuideline
classificationof Pneumoniaforpediatricandadul
tcasesandshallbecodedand reimbursed basedonthefoll owingtable:
1.PEDIA PNEUMONIA DIAGNOSIS (Pedia)ICD-10 COD;E , CASE RATE PACKAGE
PCAPA (Mi nimalRisk)J18. 90 Denied eveninI'FS PCAP B (Low
Risk))18.91 PCAPC(Moderate Risk)]18.92PneumoniaI P CAPD_(High
Risk)J18.9JPneumonia IT 2.ADULT PNEUMONIA DIAGNOSIS
(Adult)ICD-10CODE CASE RATE PACKAGE CAPI(LowRisk)J 18.91Denied even
in FFS CAP II (ModerateRisk)J1 8.92 Pneumonia I CAP III (H igh
Risk)Pneumonia II Accredi
tedprovidersarcremindedtowriteinthefinaldiagnosisthelevelof riskof
pneumonia. Thename of the package should not be written inthefinal
diagnosis. Forpurposesof efficientclaimsprocessing,itisreiterat
edthatallP neumonia(l CD 10Codes: J 12. - to J1 8.-)claimsshallbe
assignedanadditional4'hor characterto be placed in thelast position
of theassigned I CD10codetocliffcrentiatethelevelof
risk.Pneumonia(ICD10Codes:J1 2.- toJ1
8.-)claimswithrmspetifiedriskor110 classification indicated
shallbedeniedpayment. El1xampl e: DIAGNOSISICD-10 CODE CASE RATE
PACKAGE Pneumoniadue to streptococcus J 13.2PneumoniaI pneumoniae
(Moderate Risk) Pneumonia dueto pseudomonas J15.UPneumonia II (High
Risk) Further,N eonatalandobstetriccasescomplicatedbypneumonia(e.g.
,neonatal
aspirationpneumoniaNOS[ICD10Code:P24.9]),diarrhea(e.g.,othermat
ernal
infectiousandparasiticdiseasescomplicatingpregnancy,childbirthandthe
p uerperium[ICD10Code:0.98.81)andotherconditionsclassi
fiedundercaserate shallbeexcludedfromthecaserat
epackage.Itshallbereimbursedv iafee- for -Page3 of5 .,.: ' I,I I
.;
service schemeprovidedthe diagnosisand itsapplicable ICD 10code
are indicated in PhilHeal thClaim Form 2.
B.CVAIPackageshallalsoincludecasesof Stroke,notspeci fi
edashaemorrhageor infarction; Cerebro-vascular accident NOS(164).
C.AcuteGastroenteritis (AGE)Package 1.Unspeci fiedamoebiasis
(A06.9)shallnow be covered under the AGE Package.
2.AllcasescoveredunderAGEPackage(l CD10codes:A09,AOO.-,A03.0,A06.0,
A06. 9, A07.1,K52.9, P78.3) without mentiono flevelo fdehydration
shallbe denied evenunderfee-for-service.However,evenif thementioned
levelof dehydrationis mild, it shall still be denied even under
fee-for-service scheme.
3.Colitis(evenwithoutdehydration)whenendoscopyisperformedshallbepaidvia
fee-for-service scheme. D.Reguirement forPhilHealth Claim Form 3
1.ClaimForm3(CF3)isnolongerrcguiredforreimbursementof Ne::wbomCare
Package (NCP)claims. 2.Asper
PhilT-JcalthCircularNo.15s-2011laboratoryI ancillaryprocedure
resultsare required.SubmissionofCF3isoptionalincaseswhenthercguired
laboratoryI ancillaryprocedureresult ispositive.However, if
thelaboratoryI ancillary procedureresul tisnegative,submissiono
fCF3isstillregu.iredtosupportthe diagnosis.
3.AllclaimsforPneumonia(IandII)andDengue(IandI
I)packages,submissionof CF3 is stillreguired. IV. SURGICAL CASES
A.Level1hospitalsshallnow be
reimbursedforhemodialysisproceduresprovidedtha t hospital
islicensed by the Department of Health(DOH)to perform such
procedure.
B.Forproperpayment,healthcareprovidersareremindedtoindicateapplicableRVS
codesforallproceduresperformedinPhilHeal thClaimForm2(CF2)underItem
Nos.16-c&16-d.Forproceduresperformedincombinationi.e.,CSwith
adhesiolysis, allRVUcodes shouldalso be indicated in CF 2.
Example2: . ,
