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Rationale• DOH Administrative Order No. 2012-0012

Rules and Regulations Governing the NewClassifation o! Hos"itals and Other Health#ailities in the $hili""ines

• $er %ureau o! Health #ailities and &ervies' DOH( “..any hospital can perform

procedures with any RVU provided that thehospitals are capable of handling such cases

by having the following:1. Competent, uali!ed sta" and e#pert to

perform such procedure and$

%. &ecessary euipment and adeuate space

or facility for clinical and ancillary'

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General Guidelines PhilHealth Circular No. 010, s-2014

continuation! Consideration on the training o! the attending

"hsiian or surgeon shall /e the /asis o! the"er!ormane o! the "roedures vis-a-vis thetehnial reuirements in the "er!ormane o!the "roedure.

$er!ormane o! "roedures or

management /eond servie a"a/ilito! the HC+ shall /e monitored and shall/e onsidered a violation o! the"er!ormane ommitment o! the HC+

and the "ro!essional.

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"peci#c Guidelines$or %e&els 1, 2 and ' Hospitals

A.$roedure Case Rates

1. he Cor"oration shall reim/urse anom"ensa/le "roedure "er!ormed / 3evels 12 and 4 hos"itals /ased on the HC+5s a"a/ilitand redentialing and "rivileging o!"ro!essionals as "rovided in $C No. 010 s-2016

2. he Cor"oration shall onl reim/urse laims !orthe !ollowing "roedures i! "er!ormed in anaredited health are institution dul liensed/ DOH !or suh servie7s(

a. Radiation hera" *R8& 99601,/. Hemodialsis *R8& :0:4;,

. Dialsis other than hemodialsis *R8& :0:6;,d. +ntensit modulated radiation thera" *R8&

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"peci#c Guidelines$or %e&els 1, 2 and ' Hospitals

%.Condition *=edial, Case Rates he Cor"oration shall reim/urse laims !or&tro>e ' Hemorrhagi managed / 3evels 1 2and 4 hos"itals .

()*ulatory "ur+ical Clinics ("C!• he Cor"oration shall reim/urse an om"ensa/le

da surgeries and out"atient "roedures"er!ormed / A&Cs /ased on the HC+5s a"a/ilit

and redentialing and "rivileging o! "ro!essionalsas "er $C No. 010 s-2016

)ay surgeries * also +nown as ambulatory or outpatientsurgeries, are services that include elective non*emergency- surgical procedures ranging from minor to

maor operations whether reuiring local, regional or generalanesthesia where atients are safel sent home within the

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Procedureedical

Condition

%e&elype of Health Care

/nstitutionPRC3R

1$roedures with R8? 200 and/elow %e&els 1, 2 and ' hospitals

accordin+ to facilitycapa*ility!

2 $roedures with R8? 201-;00

4$roedures with R8? ;01 and

a/ove

6Da surgeries and out"atient"roedures regardless o! R8?

(ccredited a)*ulatorysur+ical clinics ("C!accordin+ to facilitycapa*ility!

;

Radiation hera" *R8&

99601, and +ntensit=odulated Radiation hera"*R8& 9961e - Hemorrhagi %e&els 1, 2 and ' hospitals

a*le 1. Re&ised %ist of Procedures and edicalConditions Co)pensa*le in ierent ypes ofHealth Care /nstitutions

Note: This table shall amend Table 3. of PhilHealth Circular No. 35, s- 2013

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/ntensity odulated Radiationherapy

R5"C

"CR/P/N

$/R" C(" R(

CaseRate

Professional$ee

HealthCare

/nstitution $ee

66417

+ntensit modulatedtreatment deliversingle or multi"lefelds7ars vianarrow s"atiall andtem"orallmodulated /eams/inar dnami=3C "er session

;@

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a. +=R shall /e eem"ted !rom the ;0B rule onseond ase rate and shall /e "aid the !ull aserate amount even as seond ase rate. he HC+!ee and $# shall !ollow the frst ase ratedistri/ution !or the "roedure.

/. Claims o! multi"le sessions o! +=R shall /ereim/ursed even i! laimed as seond ase ratesu/et to other reim/ursement rules *eg. 6;das limit,.

. &ingle $eriod o! Confnement

+=R shall /e eem"ted !rom the rule on single"eriod o! onfnement and ma /e availed o! atan time su/et to other reim/ursement rules.

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d. #ort-#ive Das %eneft 3imit

i. One +=R session is euivalent to one dadedution !rom the 6; das allowa/le /eneft"er ear.

ii. +! the "roedure is done during a onfnementwhether in the same HC+ or not onl the totalnum/er o! onfnement das shall /ededuted !rom the 6; das total allowa/le/eneft !or the /enefiar.

e. +! an admitted "atient is sent to another HC+!or +=R a se"arate laim shall /e fled / theHC+ that "er!ormed the +=R. he HC+ shall /ereim/ursed the !ull +=R ase rate amount.

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!. Aredited HC+s dul liensed / DOH to "er!orm+=R shall /e reim/ursed 100B o! the +=R aserate.

g. #illing Out o! Claim #orm 2 !or +=R

i. he HC+ ma laim !or +=R sessions done in amonth in a single Claim #orm 2.

ii. #illing out o! +tem No. 9. DishargeDiagnosis7es

+n laiming !or +=R the HC+ shall "lae thediagnosis a""lia/le +CD 10 ode7s related"roedure as +ntensit =odulated Radiation

hera"E or +=RE R8& Code 9961

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$illin+-out of PhilHealth Clai) $or) 28 Part 6

/R

/R

/R/R

/R

/R

/R

C91ali+nant

neoplas) of

prostate

66417

66417

66117

66417

66417

66417

66417

12-01-2014

12-02-2014

12-0'-2014

12-04-2014

12-0:-2014

12-09-2014

12-06-2014

Fam"le ( +! a !ailit is laiming !or +=R sessions !or =alignantneo"lasm o! "rostate done on Deem/er 1 - 9 2016 then +tem No. 9

o! $hilHealth Claim #orm 2 should /e flled out as !ollows.

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iii. #illing out o! +tem No. :. $hilHealth %enefts

R8& ode !or +=R should /e written as *a.,#irst Case Rate or */., &eond Case Ratewhihever is a""lia/le to the laima""liation.

66417

$illin+-out of PhilHealth Clai) $or) 2 8 Part;

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h. +=R and radiation thera" *Co/alt or 3inearAelerator, "er!ormed on the same da as the!ollowing "roedures shall /e reim/ursed the !ullase rate su/et to other reim/ursement rules.

he euivalent dedutions shall /e made to the

6; das /eneft limit o! the /enefiar .i. %lood trans!usion out"atient RV6 Code:

37534-ii. %rahthera" RV6 Codes: 88871, 88887,

88821, 88829-iii. Chemothera" RV6 Code: 97542-iv. Dialsis other than hemodialsis *"eritoneal

dialsis, RV6 Code: 9495-v. Hemodialsis RV6 Code: 9493-

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Clai)s Processin+

Clai)s for ad)issions startin+December 2, 2014

Health are institutions aeted / this

Cirular should dedut a""lia/le$hilHealth /enefts !rom the total atualharges *HC+ and "ro!essional !ees, "riorto disharge o! the "atient7mem/erstarting December 2, 2014. Claims shall/e fled within @0 alendar das !rom thedate o! disharge.

.

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Clai)s Processin+

Clai)s for ad)issions fro) January 1, 2014 up to December 1,

2014

1.$reviousl denied laims due to the HC+

restritions set !orth / $hilHealth Cirular No. 4; s-2014 shall /e "roessed /ased on $C 4; s-2014rules an fle a =otion !or Reonsideration *=R,"rovided the a""lia/le ase rate amount /ased on

the new rules set / this Cirular has /een deduted!rom the total atual harges */oth the HC+ and"ro!essional !ees, u"on disharge.

• $art +++.A. CFR+#+CA+ON O# CON&?=$+ON O#%FNF#+& o! $hilHealth Claim #orm 2 should /e

"ro"erl and om"letel flled out / the

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Clai)s Processin+

Clai)s for ad)issions fro) January 1, 2014 up to December 1,

2014

2.Government health are institutions that did not

fle a laim /ut a""lied the No %alane %illing *N%%,"oli to eligi/le $hilHealth mem/er7"atient ma flea laim until January 31, 2015.

• $art +++.A. CFR+#+CA+ON O# CON&?=$+ON O#

%FNF#+& o! $hilHealth Claim #orm 2 should /e"ro"erl and om"letel flled out / the HC+sand shall reet that the "atient did not inuran out o! "o>et e"ense.

• +t shall /e "roessed and "aid !ollowing the

rules ontained in this Cirular and other

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Clai)s Processin+

irect $ilin+ of Clai)s

1.Claims o! mem/ers !or ases aeted / thisCirular where the HC+ did not dedut an $hilHealth/eneft u"on disharge with ad)ission dates !rom January 1, 2014 u" to December 1, 2014 an /ediretl fled / mem/ers. &u/mission o! laims shall/e allowed until January 31, 2015.

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Clai)s Processin+

irect $ilin+ of Clai)s

2.Diretl fled laims must inlude a waiver issued/ the health are institution that the mem/er "aidthe !ull amount !or the onfnement and no$hilHealth dedutions were made *see Anne 1 o!$hilHealth Cirular No. 020 s. 2016 !or waiver !orm,and other mandator reuirements !or diret flingas s"eifed in +tem +++. Rules on Diret #iling o!

Claims o! $hilHealth Cirular No. 020 s.2016.

4.hese laims shall /e "roessed and "aid !ollowingthe rules ontained in this Cirular and othera""lia/le all ase rates rules.

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onitorin+ and&aluation

•

All aredited health are "roviders shall /esu/eted to monitoring and evaluation o! theCor"oration "ursuant to &etion 1@ o! Re"u/liAt *RA, No. 9e mehanisms suh as !ailit visit andmedial "ost-audit to monitor and assess the"er!ormane o! health are "roviders. hesemehanisms shall ensure that /oth health are

institution and "ro!essional om"l with the

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onitorin+ and&aluation

• Also "roviders shall /e monitored on theirom"liane to this Cirular and violations shall /edealt with in aordane with the "rovisions o! RANo. 9

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ecti&ity

his Cirular shall ta>e eet !or alladmissions starting December 2,2014. +t shall /e "u/lished in an

news"a"er o! general irulation andshall /e de"osited therea!ter withthe National Administrative Register

at the ?niversit o! the $hili""ines3aw Center.

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$or co))ents,su++estions, questions=

)ail us at

actioncenter!hilhealth."o#.!h
mailto:[email protected]:[email protected]

pc 27_acr policy 5

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