PhilHealth Claims Filing

1. PhilHealth Claims Filing Reducing Mistakes, Increasing Reimbursements

2. 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

3. PhilHealth • 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”

4. Members andDependents

5. Our 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)

6. Our Members 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

7. Your Dependents • Spouse • Children < 21 years old • Parents > 60 years old • Step parents • Adoptive parents

8. Benefits

9. 45 Days Annual Allowance • 45 days allowance per year for the principal (member) • Another 45 days shared among dependents

10. Your benefits • Illness requiring hospitalisation • Outpatient: • Surgical procedures • Cataract surgery • BTL • Vasectomy • Endoscopy • Excision • Suturing

15. Drugs 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)

16. Anti-convulsants / Epileptics • CARBAMAZEPINE • CLONAZEPAM • DIAZEPAM • LORAZEPAM • MAGNESIUM SULFATE • PHENOBARBITAL • PHENYTOIN • VALPROIC DISODIUM • Gabapentin • Midazolam • Thiopental sodium • Topimarate

17. Anti-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

18. 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?

19. 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?

20. Only drugs, supplies, and lab used on confinement shall be paid Must be supported by official receipts Drugs and Medicines

21. Fee for Service Scheme: • 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

22. Computation of Benefits • Case type of illness • Category of Facility

24. Casetypes • Casetype A – Ordinary • Casetype B – Intensive • Casetype C – Catastrophic • Casetype D – Super Catastrophic

26. 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

27. 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

29. 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.

30. ProfessionalFee

32. Professional Fee • 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%

33. Professional Fee Example: 66270 Spinal puncture 12 12 RVU x 40 PCF = Php 480

34. Professional Fee Example: 61793Stereotactic radiosurgery 200 200 RVU x 40 PCF = Php 8,000

35. Professional Fee Example: 61500Craniectomy w/ excision of tumor 400 400 RVU x 40 PCF = Php 16,000

36. Policies on PF • > 2 procedures, single opening = pay highest value • > 2 procedures, different incision site = pay allunit values • Procedures done on different dates = pay allunit values

37. Policies on PF Example: 49000 - Explor Lap - 150 44950 - Appendectomy - 100 150 RVU x 40 PCF = P6,000

38. Policies on PF Example: 49000 - Explor Lap - 150 58943 - Oophorectomy for ovarian CA - 200 200 RVU x 40 PCF = P8,000

39. Policies on PF Example: Bilateral Cataract Extraction 69887 - ECCE phacoemulsification - 200 200 x 2 = 400 RVU 400 RVU x 40 PCF = P16,000

40. Policies on PF Repeat Procedures: • Payment within cap • Covered by rule on single period of confinement Service Rendered Computed Benefit PHIC Benefit Ligation, varices esophagus 10,000 10,000 Ligation, varices esophagus 10,000 6,000 Total = 16,000

41. Professional Fee Example: 66270 Spinal puncture 12 12 RVU x 40 PCF = Php 480

42. Professional Data & Charges  Daily visit RVU Anesth

43. Professional Data & Charges With deduction Lumbar tap 520 1000 480

44. Professional Data & Charges With no deduction Lumbar tap 1000 1000

45. Professional Data & Charges Complimentary PF; PhilHealth only Lumbar tap 480 480 Actual PF = PhilHealth benefit

46. Professional Data & Charges Government hospital; Private Patient Private hospital; Service Patient Dialysis 400 400

47. Private Patient, Government Hospital PAY TO DOCTOR NO Stamp: PF is made to the Chief

48. Service Patient, Pay Hospital Name of Surgeon PAY TO CHIEF NO Stamp: PF is made to the MD who signed Form 2