case rates presentation gen rules
TRANSCRIPT
Shirley B. Domingo, MD, MPHVice President
PRO NCR & Rizal
MONTH No. of RTHNo. of received
claims % of RTH
Jan-12 14,669 78,347 18.72
Feb-12 15,763 86,083 18.31
Mar-12 13,889 84,585 16.42
Apr-12
Source: Monthly operations report
HOSPITAL CLAIMSJOSE R. REYES MEMORIAL MEDICAL CENTER 330
UNIVERSITY OF STO. TOMAS HOSPITAL 305
CHINESE GENERAL HOSPITAL & MEDICAL CENTER 274
UNIVERSITY OF STO. TOMAS HOSPITAL 136
METROPOLITAN MEDICAL CENTER 130
GAT ANDRES BONIFACIO MEMORIAL MEDICAL CENTER 129
MCU-FDT MEDICAL FOUNDATION HOSPITAL 86
CARDINAL SANTOS MEDICAL CENTER 80
PERPETUAL HELP HOSPITAL 78
F.Y. MANALO MEDICAL FOUNDATION - NEW ERA GENERAL HOSPITAL 76
MAKATI MEDICAL CENTER 489UNIVERSITY OF PERPETUAL HELP RIZAL MEDICAL CENTER, INC. 322FORT BONIFACIO GENERAL HOSPITAL 257UNIVERSITY OF PERPETUAL HELP RIZAL MEDICAL CENTER, INC. 221TAGUIG-PATEROS DISTRICT HOSPITAL 122MPI-MEDICAL CENTER MUNTINLUPA 121RIZAL MEDICAL CENTER 118ST. LUKE'S MEDICAL CENTER - GLOBAL CITY 110THE MEDICAL CITY 104MPI-MEDICAL CENTER MUNTINLUPA 103
1. Original Philhealth Claim Form 2 not properly accomplished2. Required medical documents3. Required claim form (s)4. Other documents required 5. No proof of contribution.6. Original Philhealth Claim Form 3 not properly accomplished7. No proof of Professional fee billing/payment8. Discrepancies9. No proof of hospital billing/payment10. No proof of dependency
1. Filed beyond 60 days2. Exhausted 45 compensable days 3. Case not compensable4. Benefit exhausted5. Denied due to non-compliance6. Inconsistent data7. Patient not a qualified dependent8. Confinement not within the hospital accreditation period9. Less than 24 hours confinement, case not emergency10. Lack of/no qualifying contribution
PhilHealth does not pay for all your health care costs.PhilHealth pays only for covered items and services when requirements are metMembers are balance billed for the portion of the actual cost that is not covered by PhilHealth
Claims Filing
ENHANCED ENHANCED CLAIMS CLAIMS FORMS FORMS Circular 12, s-2010Circular 12, s-2010
CF1 (PART CF1 (PART I)I)
2 0 1 2 3 4 5 6 7 8 9 1 331-1234
ABC MANUFACTURING COMPANY
UNIT 1 ABC BLDG., 456 MAPAGMAHAL ST., BGY. MABILIS
QUEZON CITY 1100
MARIO A. CRUZ MANAGER 0 9 0 4 2010
The employer or his/her authorized representative shall affix his/her signature certifying that all monthly premium contributions for and in behalf of the member, while employed in their company, including the applicable three (3) monthly premium contributions have been deducted/collected and remitted to PhilHealth during the past six (6) month period prior to the first day of confinement and the information supplied by the member or his/her representative are consistent with their available records
CLAIM FORM 2CLAIM FORM 2
Beginning September 01, 2010Beginning September 01, 2010
PART I – HEALTH CARE PROVIDER INFORMATION
5,000.00
For benefit packages not requiring itemization PHIC benefit should be indicated in 11e
5,000.00
DR. PEDRO A. GOMEZ
1 502 1 2 3 4 5 6 1 09/05/10
PART I – PATIENT’S CLINICAL RECORD
This claim form will support the information supplied in the Claim Form 2 and shall be used in the evaluation of proper case type determination especially TYPE D CASES, EMERGENCY CASES and LESS THAN 24 HOURS ADMISSIONS
This is mandatory in:
Level 1 Facilities;
Case type D;
Maternity Care Package;
Emergency / Transferred cases; and
Less than 24 hours confinement
PART II – MATERNITY CARE PACKAGE
CF3 shall be accomplished for MCP claims (lying-in clinics) and must be submitted together with CF1 and CF2
ELIGIBILITY ELIGIBILITY REQUIREMENTSREQUIREMENTS
Eligibility Requirements
9 months premium within 12 months prior to admission (on selected surgical
cases)
Qualifying Contributions / Eligibility Qualifying Contributions / Eligibility Requirements:Requirements:
Employed / KASAPI
3 months within the immediate 6 months prior to
availment
Properly accomplished Part II of CLAIM FORM
1
Qualifying Contributions / Eligibility Qualifying Contributions / Eligibility Requirements:Requirements:
IPP and Organized Grp*
At least 9 within the immediate 12 months
of contribution = Official Receipt / MI-5
or proof of payment for MCP
At least 3 within the immediate 6 months
(for NCP)
At least 9 months of premium contribution within the immediate 12 months prior to availment (MCP)
4TH QTR 1ST QTR 2ND QTR 3RD QTR OCT NOV DEC
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AVAILMENT AVAILMENT
illustration of IPMs qualifying illustration of IPMs qualifying contributioncontribution
112233445566778899101011111212
112233445566778899101011111212
Qualifying Contributions / Eligibility Qualifying Contributions / Eligibility Requirements:Requirements:
OFW
MDR
(eligibility / coverage is reflected)
Qualifying Contributions / Eligibility Qualifying Contributions / Eligibility Requirements:Requirements:
Sponsored
PhilHealth Sponsored ID
(eligibility / coverage is reflected)
OCT 13, 2010 – OCT 12, 2011OCT 13, 2010 – OCT 12, 2011
19-123456789-119-123456789-1
JUAN A. DELA CRUZJUAN A. DELA CRUZ
Qualifying Contributions / Eligibility Qualifying Contributions / Eligibility Requirements:Requirements:
NPM
PhilHealth Non-Paying ID or
Lifetime Member ID
Guide to Reimbursement
Single Period of ConfinementRe-admissions due to same illness within a 90-day period shall only be compensated
within one (1) maximum benefit:Availment for the same illness or condition which is not separated from each other by
more than 90 days will not be provided with a new benefit
Only the remaining benefit from the previous confinements may be availed
Benefit for Drugs Tertiary Hospital
Systemic Viral InfectionOrdinary
Remaining Benefit
4,200
Admission January 15
2,000 2,200
Admission February 15
2,000 200
Admission March 15
1800
Single Period of Confinement
Case TypesCase Types
MedicalSurgica
l
A Simple80 and below
B Moderate 81- 200
C Severe 201- 500
D Extremely severe
501 and above
Case-type A B C DLevel 3 & 4 Hospitals (Tertiary)
Room & Board* P500/day P500/day P800/day P1,100/day
Drugs and Medicines** P4,200 P14,000 P28,000 P40,000
X-ray, Lab & Others P3,200 P10,500 P21,000 P30,000
Level 2 Hospital (Secondary)
Room & Board* P400/day P400/day P600/day N/A
Drugs and Medicines** P3,360 P11,200 P22,400 N/A
X-ray, Lab & Others P2,240 P7,350 P14,000 N/A
Level 1 Hospital (Primary)
Room & Board* P300/day P300/day N/A N/A
Drugs and Medicines** P2,700 P9,000 N/A N/A
X-ray, Lab & Others P1,600 P5,000 N/A N/A
Case type A: Acid peptic diseaseBenefit Item Makati
medical Center
Fort Bonifacio General Hospital
Taguig Doctors Hospital
Room/Board P500/day P400/day P300/day
Drugs P4,200 P3,360 P2,700
Lab/Supplies P3,200 P2,240 P1,600
Benefit Item Makati medical Center
Fort Bonifacio General Hospital
Taguig Doctors Hospital
Room/Board P500/day P400/day x
Drugs P14,000 P11,200 x
Lab/Supplies P10,500 P7,350 x
Benefit depends on:Hospital categoryCase type of illness (A, B, C or D)
Covered by rule on single period of confinement Benefit also depend on other claims processing guidelines:
Compliance to PNDF, generics law and Rational drug use– must be in accordance to dosage, preparation and use specified in PNDF Only drugs used during confinement are paid (with exception) Drugs bought by members may be reimbursed
Benefits per Single Period of Confinement
Primary Secondary Tertiary
2,700 – 9,000 3,360 – 22,400 4,200 – 40,000
Drugs and Medicines
All drugs, supplies, and lab used
on the day of the operations shall
be paid
Must be supported by official
receipts
Official receipts dated 30 days
prior to claimed session is allowed
Drugs and Medicines
Drugs must be written in generic namePNDF is main reference for payment
To be disallowed payment:No generic name indicated*Non-PNDF drugs
*except patients’ claims for medicines bought outside the hospital
Supplies, X-ray, Lab & Ancillary
Benefits per Single Period of Confinement
Primary Secondary Tertiary
1,600 – 5,000 2,240 – 14,700 3,200 – 30,000
Benefit depends on:Hospital categoryCase type of illness (A, B, C or D)
Covered by rule on single period of confinement Benefit also depend on:
Medical necessity supplies, x-ray, laboratory and ancillary procedures used during confinement are paid
Benefits per Use of Operating RoomPrimary Hospital
500 pesos
Secondary Hospital
RVU 30 and below 750 pesos
RVU 31 - 80 1,200 pesosRVU 81 – 600 (RVU x 15 PCF)
Minimum: 2,200 pesos Maximum: 7,500 pesos
RVU 81 – 146 2,200 pesos
RVU 147 – 500 2,205 – 7,500 pesos
RVU 501 - 600 7,500 pesos
Benefits per Use of Operating Room
Tertiary Hospital
RVU 30 and below 1,200 pesos
RVU 31 - 80 1,500 pesosRVU 81 – 600 (RVU x 20 PCF)
Minimum: 3,500 pesos
RVU 81 – 175 3,500 pesos
RVU 176 – 600 3,520 – 12,000 pesos
Professional FeeProfessional Fee
Daily Visit
Primary Hospital
A B
GP per day 300 400
Maximum per confinement
1,200 2,400
SP 500 600
Maximum per confinement
2,000 3,600
Secondary Hospital
A B C
GP per day 300 400 500Maximum per confinement 1,200 2,400 4,000
SP 500 600 700Maximum per confinement 2,000 3,600 5,600
Tertiary Hospital
A B C D
GP per day 300 400 500 600Maximum per confinement 1,200 2,400 4,000 6,000
SP 800Maximum per confinement 8,000
Maximum days per
confinement
A B C D
4 days 6 days 8 days 10 days
Surgeons’ fee depends on: RVU of the procedure
PCF depending doctor category (3 tier)
GP (40 pesos)Doctor with training (48pesos)Diplomates and Fellows of Specialty
Societies 56 pesos for RVU 500 and < 80 pesos for RVU 501 and >Doctors classified as GP shall be
compensated up to RVU 80 (3,200 pesos).
GPMD WITH TRAINING
DIPLOMATES AND FELLOWS
Type B, C Type D
PCF 40 48 56 80
Pyelotomy w/ exploration(100 RVU)
(4,000) 3,200*
4,800 5,600 -
Myomectomy; Open (150
RVU)
(6,000) 3,200*
7,200 8,400
Intracranial Surgery
(600 RVU)
(24,000)3,200*
28,800 - 48,000
* GP allowed only to do up to 80 RVU
2 or more procedures Payment of
surgeon
Done in one site or incision (whether by same or different surgeon)
Pay only thehighest RVU
Done in separate site or incision (whether done in 1 operative session)
Pay all RVUs
Done on different dates (within or separate confinement)
Pay all RVUs
Anesthesiologist – 40% 0F BASELINE X PCF OF TIER OF ANESTHESIOLOGIST
Anesthesiologist’ fee depends on: RVU of the procedure PCF depending doctor category (3 tier)
GP (40% of the baseline surgeon’s fee)MD with training (48% baseline)Fellows/diplomates (56 % baseline for RVU 500 and <)
Doctors classified as GP shall only be compensated up to RVU 80 (1,280 pesos).
Payment of anesthesiologist is independent of surgeons’ specialty.
Table 1: List of Procedures and Services that are Limited to Specific Categories of Doctors
Procedures and ServicesClaims
Code GroupDiplomate or Fellow
Preoperative inpatient
consultation (Code 99256 – 99360)
1201Philippine Academy of Family Physicians
1202 Philippine College of Physicians
1203 Philippine Pediatric Society
1210 Philippine Neurological Association
Pathology services(Code 88174 – 88332)
1206 Philippine Society of Pathologist
Radiology services(Code 70010 – 77789
except 75757)1207 Philippine College of Radiology
Fluorescein angiography (Code 75757)
1304Philippine Academy of Ophthalmology
CURRENT YEAR’S GROSS INCOME
PFPHILHEAL
TH PAYMENT
EXPANDED WITHOLDIN
G TAX (EWT)
PERCENTAGE TAX (PT)(GROSS/
1.12 X 5%)
TOTAL TAX (EWT + PT)
PF NET OF TAX
BELOW 720,000 WITH SWORN
16,000
(GROSS /1.12 X 10%)
1,428.57
714.29 2,142.86 13,857.14
ABOVE 720,000 OR NO SWORN
16,000
(GROSS/1.12 X 15%)
2,142.86
714.29 2,857.14 13,142.86
CURRENT YEAR’S GROSS INCOME
PFPHILHEAL
TH PAYMENT
EXPANDED WITHOLDIN
G TAX (EWT)
PERCENTAGE TAX (PT)(GROSS X
3%)
TOTAL TAX (EWT + PT)
PF NET OF TAX
BELOW 720,000 WITH SWORN
16,000(GROSS X
10%)1,600.00
480.00 2,080.00 13,920.00
ABOVE 720,000 OR NO SWORN
16,000(GROSS X
15%)2,400.00
480.00 2,880.00 13,120.00
Issuance of OR for received PhilHealth payments:
Circular 24, s-2005Doctors should issue OR to PhilHealth upon
receipt of reimbursement
DKTM
Case Rates – Surgical ProceduresCases Rates
1 Radiotherapy 3,000
2 Hemodialysis 4,000
3
Maternity Care Package (MCP) 8,000
NSD Package in Level 1 Hospitals 8,000
NSD Package in Levels 2 to 4 Hospitals 6,500
4 Cesarean Section 19,000
5 Appendectomy 24,000
6 Cholecystectomy 31,000
7 Dilatation & Curettage 11,000
8 Thyroidectomy 31,000
9 Herniorrhapy 21,000
10 Mastectomy 22,000
11 Hysterectomy 30,000
12 Cataract Surgery 16,000
Case Rates – Medical CasesCases Rates
1 Dengue I (Dengue Fever and DHF Grades I & II) 8,000
2 Dengue II (DHF Grades III & IV) 16,000
3 Pneumonia I (Moderate Risk) 15,000
4 Pneumonia II (High Risk) 32,000
5 Essential Hypertension 9,000
6 Cerebral Infarction (CVA I) 28,000
7 Cerebral Hemorrhage (CVA II) 38,000
8 Acute Gastroenteritis (AGE) 6,000
9 Asthma 9,000
10 Typhoid Fever 14,000
11Newborn Care Package in
Hospitals and Lying-in Clinics1,750
Pursuant to Board Resolution No.1441 s.2011Case payment mechanism for the most common
medical and surgical conditions (49% of total claims)
“No Balance Billing Policy” (NBB)
Improve turn-around time for claims processing and payment
Case payment shall be the new reimbursement for all the specified cases
Applies to all claims by eligible PhilHealth members and dependents
Reimbursed directly to the facility
Rates are inclusive of payment to all doctors
Computation of doctors’ PF: Medical : 30% of rate Surgical : 40% of rate
Hospitals shall act as the withholding tax agent for PF
Government hospitals PF governed by the existing rules on pooling (Sec 35 of RA 7875 as amended and its IRR and PC No. 27 s-2009)
1. Provide correct RVS and/or ICD-10 codes in Claim Form 2
2. Reimbursement shall be based on main condition (PC No. 04, s-2002)
3. Rule on 45-day limit per calendar year applies• For hemodialysis and radiotherapy, one (1) day shall be
deducted• Outpatient Malaria and HIV-AIDS packages, apply rule on 45-
day limit• TB-DOTS excluded from the 45-day limit
4. Shall follow the rule on single period of confinement
• Except for hemodialysis and radiotherapy per session
“No Balance Billing” Policy shall
mean that no other fees or
expenses shall be charged or paid
for by the patient-member above
and beyond the packaged rates.
Shall be applied to ALL SPONSORED Program members and/or their dependents for the specified cases under the following conditions:
1. When admitted in government facilities/ hospitals.
2. When claiming reimbursement for outpatient surgeries, hemodialysis and radiotherapy performed in accredited government hospitals and all non-hospital facilities (e.g. FDCs, ASCs)
3. Claims for reimbursement of Sponsored members and/or their dependents availing of the following
existing outpatient packages:a) TB DOTS (Php 4,000)b) Malaria (Php 600)c) HIV-AIDS (Php 7,500 /qtr or Php 30,000/yr)
All other existing policies/guidelines covering these packages shall remain in effect.
4. In support of Millennium Development Goals (MDG)
NBB policy shall apply to ALL PhilHealth members and their dependents regardless of
membership type in ALL Accredited MCP (non-hospital) providers
This shall cover claims for MCP and NCP
Facility should purchase necessary items/services in advance on behalf of the member if drugs, supplies, or diagnostic procedures are not available.
Out-of-pocket payment (OOP) made by members shall automatically be deducted against claims of the hospitals (charged to case rates) with corresponding sanctions or penalties the Corporation may charge.
Require attachment of official receipt/s (ORs) for any OOP made by member (for hospital and/or professional fee)
If case rate was already paid in full to the facility; but the official receipts were not attached to the claim application,
the member may request for re-adjustment within 6 months from date of discharge
This may be paid to the member provided necessary evidence of payment is submitted
It shall be charged to future claims of the health facility with corresponding sanctions or penalties
For Claims Not Covered by NBB and Case Rate
For Claims of PhilHealth members not covered by NBB Policy
The benefit shall be deducted from the total actual charges, with the remaining amount to be charged to the member as out-of-pocket payment.
Example: Acute Gastroenteritis = Php 6,000
Total Actual Charges
PhilHealth Benefit Co-Payment of member
Php 9,000 Php 6,000 Php 3,000
For all other claims:
Fee-for-Service Scheme
Based on Benefit Table
Filed within 60 days from date of discharge
Still requires ALL existing documents and information
Properly accomplished Claim Form 2
Correct RVS/ICD 10 code appropriate for the package
Claims with incomplete documents shall be returned for completion
May be re-filed within 60 days from receipt of notice otherwise it shall be denied
Hospitals to segregate claims with separate transmittals as follows:
1. Case Payment claims
2. Fee-for-service claims
Specific Rules Per Package
AUGUST 2011
Case rate directly paid to the facility40% of rate is for PF except for hemodialysis
Allowed only in L2 to L4 facilities, but some may allowed in other facilities:
Completion curettage : L1Fractional curettage : L1, ASC
Herniorrhapy : ASCLaparoscopic chole : ASCCataract : ASCHemodialysis : FDC
Radiotherapy : L3 to L4 only
Emergency procedures in L1 hospitals:Pay as RVU 30 under FFS
Non-emergency cases shall be deniedClaim Form 3 required for all claims
Lateral procedures within same confinement or different confinement
within 90 days pay as 1
2 or more surgical case rates in 1 confinement:
1 session pay higher package
Separate session pay all packages
Transferred patients:
Pay referral facility
Deny payment of referring facilityExcept for MCP in accredited birthing
facilities
Payment for the package shall be 8,000 divided as follows:
SERVICES COVERED AMOUNTa. Facility fee (including PF) 6,500b. Member’s prenatal care fee 1,500 TOTAL 8,000
The enhanced MCP shall be availed by members in non-hospital facilities accredited as providers of MCP.
NBB policy shall apply to all beds in accredited MCP providers.
Maternity Care Package59401
Prenatal care fee directly payable to memberNormal deliveries performed requiring
emergency and subsequent referral to higher facility is allowed
Referring facility (MCP provider) reimbursed fully
Referral facility reimbursed based on services rendered
No deliveries were completed by MCP facility due to complications:
MCP facility pay Php 650 (10% of facility fee) as reimbursement for services
provided
Payment for NSD shall be as follows:
HospitalsCost
Prenatal Care
Facility Fee (with PF)
TOTAL
L1 1,500 6,500 8,000
L2 to L4 1,500 5,000 6,500
Prenatal care fee directly payable to member
Payment for NSD shall be as follows:
Features: @19,000Not allowed in L1 hospitalsElective CS (per request) including repeat CS w/o indication non-reimbursiblePackage covers also (no add’l pay):
CS w/ BTL,
CS w/ appendectomy,
CS with adhesiolysis.
Features: @11,000This package is for:
L1 to L4 hospitals (58120, 58100, 59812, 59814)
ASC (58100, 58120)Excluded: evacuation of H-mole
Features: @30,000 This package also covers CS with
hysterectomy Not allowed in L1 and ASC Exclusions:
vaginal hysterectomy
hysterectomy for malignancy
Features: @22,000This package applies to surgery done in 1 or both breastL2 to L4 hospitals onlyRadical mastectomy (19200, 19220, 19240) is excluded from this package
Features: @31,000This package includes all procedures that removes a portion or the whole gland L2 to L4 hospitals onlyExclusion:
Removal of thyroglossal duct cyst
Removal of sinus
Removal of parathyroid
Features: @24,000This package applies to all appendectomy procedures including laparoscopic appendectomyL2 to L4 onlyElective appendectomy is non-reimbursible (also denied under FFS)Appendectomy following exploratory laparotomy is paid as exploratory laparotomy (FFS)
Features: @31,000This package applies to all cholecystectomy procedures, including laparoscopic cholecystectomyL2 to L4 only, laparoscopic cholecystectomy allowed in ASCs
Features: @21,000This package covers unilateral or bilateral proceduresAlso includes repair of abdominal and femoral herniaNot allowed in L1Allowed in ASC for repair of reducible, non-incarcerated or non-strangulated hernia
Features: @4,000 per session
Outpatient hemodialysis
Includes payment for PF (Php500), dialyzer and epoetin
Not allowed in L1 and ASC
Excluded (pay under FFS):Hemodialysis during confinements
Peritoneal dialysisTreatment of acute renal failure
Creation of fistula
Features: @3,000 per sessionOutpatient radiotherapy onlyThis package cost is per session onlyAllowed in L3 and L4 onlyExclusions:
Treatment planning
Brachytherapy
Stereotactic surgery
Features: @16,000Covers cataract extraction proceduresAllowed in ASC, L2 - L4 onlyDone in an outpatient or inpatient set-up regardless of number of days of confinementCharge 1 day from 45-days limitCovered by single period of confinement
Case rate directly paid to the facility30% of rate is for PF
Reimbursement will be based on main conditionIll defined diagnoses (T/C, R/O, probable, suspected) in the final diagnoses shall be denied even under FFSClaim Form 3 required
Provide correct ICD 10 codes up to the last character requirement
Transferred patients:
Pay referral facility
Deny payment of referring facilityoExcept for MCP in accredited birthing
facilities
The package shall be increased to 1,750 pesos It shall include the following services:
1. Essential newborn care (Immediate drying of the newborn, early skin-to-skin contact, cord clamping, non-separation of mother/baby for early breastfeeding initiation, eye prophylaxis, Vit. K administration)
Newborn Care Package99432
BCG vaccination,Hepatitis B immunization (1st dose), Professional fee (including breastfeeding advise and physical examination of the baby, among others)
2. Newborn screening test (NBS)
3. Newborn hearing screening test
Newborn Care Package99432
If services were not provided completely or if member was asked to purchase medicines or access services outside the facility It shall be reimbursed to the member based
on the OR attached and deducted from the payment to the facility
Newborn Care Package99432
If package was paid in full to the facility but upon post-audit services were not completely given, these shall be charged to future claims of the health facility with corresponding sanctions or penalties the Corporation may charge.
All NCP claims are covered by NBB
Newborn Care Package99432
Features: @8,000 This package covers Dengue Fever and Dengue Hemorrhagic Fever Grades I and IIFor L1 to L4 hospitals
Denied (even on fee-for-service):
Undifferentiated fever
Asymptomatic dengueRequired tests: platelet count, Hgb & Hct
Features: @16,000This package covers Dengue Hemorrhagic Fever Grades III and IV
Presence of shockFor L2 to L4 hospitals
Dengue II managed in L1 TO BE paid as Dengue I
Required tests: platelet count, Hgb & Hct
Dengue IIA91.2, A91.3
I. PEDIA PNEUMONIA
DIAGNOSIS(Pedia) ICD-10 CODE Case rate Package
PCAP A (minimal risk J18.90 Denied even in
PCAP B (lLow risk) J18.91 FFS
PCAP C ( Moderate Risk) J18.92 Pneumonia I
PCAP D(High Risk) J18.93 Pneumonia II
II. ADULT PNEUMONIA
DIAGNOSIS(Adult) ICD-10 CODE Case rate Package
CAP I(Low Risk) J18.91 Denied even in FFS
CAP II(Moderate Risk) J18.92 Pneumonia I
CAP III(High Risk) J18.93 Pneumonia II
Features: @15,000This package covers adult and pediatric cases with unstable vital signs and presence of co-morbid conditionFor L1 to L4 hospitalsDenied:
Low risk pneumonia (no payment even on FFS)
Required tests: chest X-ray
Features: @32,000 This package covers adult and pediatric
cases with unstable vital signs and presence of co-morbid condition PLUS shock or signs of
hypoperfusion: Hypotension I95.9
Hypercapnea R06.4Hypoxia I24.8
Pneumonia II claims without additional codes for signs of shock or hyperperfusion shall be
reimbursed as Pneumonia I for L2 to L4 hospitals; L1 to be paid as Pneumonia I
Required tests: chest X-ray
Features: @9,000 This package covers hypertensive emergency cases requiring admissionExclusion (to be paid under FFS):
Hypertension involving vessels of the brain, eye
Cases of secondary hypertension
CVA I (Infarct)Features: @28,000 This package covers
infarct I63.-, I64.- L1 to L4 Requirements:
1. neuro exam
CVA II (Bleed)Features: @38,000 This package covers
hemorrhage I60.- I61.-, I62.-
L2 to L4 CVA II in L1 hospitals to be
paid as CVA I Requirements:
1. neuro exam, 2. CT Scan
Exclusions:1.CVA requiring neurosurgery2.TIA (G45.9), occlusion stenosis not resulting to infarction I65 – I69
Features: @9,000This package covers persistent and severe cases of asthma requiring admission in adult and pedia Excluded (pay as FFS): status asthmaticus (J46) as well as ICD 10 Codes: J82, J60-J70 Denied (even on FFS): asthma not in acute exacerbation
Features: @14,000 This package covers:
Typhoid and paratyphoid fever Other salmonella infection Typhoid (infective) psychosis
L1 to L4 Exclusion (pay as FFS): typhoid ileitis
requiring surgery Requirement: result of typhidot or Widal
test
Features: @6,000This package covers (infectious/non-infectious) diarrhea with
moderate or severe dehydration; &, patients who remain dehydrated despite initial treatmentChildren with bloody diarrhea and severe
malnutrition Denied:
AGE with NO or SOME signs of dehydration (no pay even on FFS)
Features:Required additional codes:
E86.1 - moderate dehydrationE86.2 - severe dehydration
Absence of additional codes - DENIEDRequired diagnostic: fecalysis or culture
Top 20 illnesses ranked by Number of Claims Paid
September 2011-April 2012
SOURCE: PHILHEALTH N CLAIMS DATABASE Extracted date: May 8, 2012
RANK Description NO OF CLAIMS AMOUNT PAID
1 HEMODIALYSIS 111,270 432,013,770.42
2 ACUTE GASTROENTERITIS (AGE) 32,994 197,321,923.28
3 PNEUMONIA I 28,320 423,129,327.56
4 NSD 16,233 83,112,660.24
5 NCP 14,860 23,974,558.32
6 CAESARIAN SECTION 14,265 269,885,467.04
7 RADIOTHERAPHY 13,285 36,223,168.98
8 ESSENTIAL HYPERTENSION 13,174 117,985,361.80
9 CATARACT 10,777 172,220,658.67
10 ASTHMA 7,855 70,389,360.49
11 DENGUE I 7,451 59,260,427.58
12 DILATION AND CURETAGE 6,003 65,340,127.88
13 TYPHOID FEVER 4,908 68,509,585.70
14 MCP 4,388 33,090,617.23
15 CHOLECYSTECTOMY 3,064 94,404,975.77
16 CVA I (INFARCTION) 2,958 81,652,434.91
17 APPENDECTOMY 2,748 65,675,149.63
18 HYSTERECTOMY 1,602 47,828,863.30
19 HERNIORRHAPY 1,054 22,022,076.95
20 THYROIDECTOMY 770 23,717,528.11
Late filing = 17% Inconsistent data on forms
submitted = 4.37%
Documents must be submitted within 60 days from discharge:
PhilHealth Form 1 (member & employer) PhilHealth Form 2 (doctor & hospital) PhilHealth Form 3 (doctor & hospital as
required in primary hospitals)
Not accredited hospital = 11% < 24 hours confinement, non “E”
= 1.2%
confinement in an accredited hospital of not less than 24 hours
> 45 days allowance, benefit exhausted = 10.21%
Lack of qualifying contribution = 1.10%
the 45-days allowance for room and board has not been consumed yet
at least 3 consecutive monthly contributions within the immediate 6 months prior to admission
Non-compliance to RTH request = 5.25%
Claims with incomplete requirements shall be returned to the facility and must be complied within 60 days
Non-compliance shall cause denial of claim
Most Common Reasons of RTH
OB Record/OR Record/Surgical Record/Anesthesia Record 10,945 31.18
Not properly accomplished PhilHealth Forms 1, 2 & 3 6,493 18.5
Submit PhilHealth Form 3/Clinical Chart 2,860 8.14
Birth Certificate of Member 2,081 5.93
Submit affidavit (dependents) 1,606 4.57
Hospital waiver/Official Receipts 1,529 4.35
Duly validated MI-5 (applicable qtr.) 1,498 4.26
PhilHealth ID Card (Sponsored and NPM) 1,460 4.16
Birth Certificate of patient (No MDR) 1,203 3.43
13013011-9805998-7-9805998-7 13013011-0200190-3-0200190-3
Dr. Edgardo R. Cortez◦ MD◦ Cutting Specialist◦ PCS
Dr. Genevieve P-Evangelista◦ MD◦ Cutting Specialist◦ PCS
12121010-9501093-8-9501093-8
• Dr. Joven R. Cuanang– MD– Non-Cutting Specialist– PNA
12012077-9804494-1-9804494-1
• Dr. Angelito Tingcungco– MD– Non-Cutting Specialist– PCR
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Compliance MonitoringPhilHealth shall regularly monitor compliance with implementing
guidelines to be issued Penalties and Sanctions
Violators shall be meted the appropriate sanctions and penalties available to the Corporation
Violators shall be included in the Provider Assessment Monitoring System (PAMS) and will be subjected to warranties of accreditation
Shall be reported to DOH and/or PRC for appropriate action, when necessary
Periodic Review, Evaluation and AdjustmentsCase rates, processes and the No Balance Billing policy shall be
subjected to regular evaluation and adjustments, as necessary
To be done 6 months after effectivity, then yearly thereafter