Philhealth Benefits — Case Rates Payments for Certain Medical and Surgical Cases

Updated June 2, 2014:

Since January 2014, all hospitalizations and outpatient treatments eligible for Philhealth coverage are already being covered under the Philhealth Case Rate system.  Each medical or surgical case is covered by a fixed amount.

For medical cases, 30% of the fixed amount is for Doctors’ Professional Fees  (PF) and 70% is for hospital costs.

For surgical cases, it’s 40% for PF and 60% for hospital costs.

You can no longer file your Philhealth claims directly with Philhealth.

Submit your Philhealth documents to the hospital BEFORE DISCHARGE, so the hospital will deduct the Philhealth coverage from your bill.  It will be to the hospital that Philhealth will send the check.

If the hospital asks you to sign a waiver, READ the waiver.

You can see the coverage amounts here: Procedure Case Rates and Medical Case Rates.

The coverage amounts listed in the charts below, posted in August 2011, are still correct, but the list below includes only the first procedures and conditions covered under the Case Rate program.

 

Article below was posted on August 2011:

Last September 1, 2011, Philhealth started implementing its policy of paying fixed rates or fixed amounts to accredited hospitals and clinics for 11 medical cases and 11 surgical cases under its reimbursement scheme called Case Rates Payment.

If we count 9 case rates payment packages implemented since 2003, there are now 31 medical and surgical cases paid by Philhealth under its Case Rates Payment scheme. Other cases are paid under the regular Fee-for-Service scheme.

The fixed Philhealth payments are made directly to the hospitals or clinics. The fixed Philhealth payment is deducted from the total hospital bill and the balance will be paid by the patient.

Philhealth said that the Case Rates basis of payments for SURGICAL CASES  is applied to cases managed at Levels 2 to 4 hospitals (bigger hospitals), with certain exceptions.

For sponsored members and their dependents, the No Balance Billing Policy will apply when they are confined in government hospitals or clinics. It means the Philhealth payments will be adequate to cover their expenses for these 22 medical and surgical cases and they don’t need to pay anything. In cases where patients are asked to buy certain drugs or supplies, they will be reimbursed.

These are the selected medical and surgical cases and the fixed amounts that Philhealth is going to pay to hospitals or clinics, implemented for patients admitted starting September 1, 2011:

MEDICAL CASES

Medical cases Case Rates in Pesos
1.  Dengue 1
Dengue Fever and DHF Grades 1 and 2 8,000
2.  Dengue 2
DHF Grades 3 and 4 16,000
3.  Pneumonia 1 – Moderate Risk 15,000
4.  Pneumonia 2 – High Risk 32,000
5.  Essential hypertension 9,000
6.  Cerebral infarction (CVA I) 28,000
7.  Cerebro-vascular accident
hemorrhage (CVA II) 38,000
8.  Acute gastroenteritis (AGE) 6,000
9.  Asthma 9,000
10.  Typhoid fever 14,000
11.  Newborn care package (NCP) 1,750
SURGICAL CASES

Surgical Cases Case Rates in Pesos
1.  Radiotherapy 3,000
2.  Hemodialysis 4,000
3.  Maternity care package (MCP) 8,000
Normal spontaneous delivery (NSD)
in Level 1 Hospitals 8,000
NSD in Levels 2 to 4 Hospitals 6,500
4.  Delivery by caesarian section (CS) 19,000
5.  Appendectomy 24,000
6.  Cholecystectomy 31,000
7.  Dilatation and curettage 11,000
8.  Thyroidectomy 31,000
9.  Herniorrhapy 21,000
10.  Mastectomy 22,000
11.  Hysterectomy 30,000
PHILHEALTH PACKAGES launched from 1993 to 2010

Medical or Surgical Case Fixed Payments Year Implemented
TB-DOTS 6,500 2003
SARS 50 to 100k 2003
Avian Influenza 50 to 100k 2006
Bilateral Tubal Ligation (BTL) 4,000 2008
Vasectomy 4,000 2008
Cataract 16,000 2008
Malaria 600 2008
Normal Spontaneous Delivery
(NSD) with BTL 10,500 2009
Outpatient HIV/AIDS Treatment 30,000 per year 2010
Note:
Treatment for influenza A (H1N1) is now paid as Case Type A under the Fee-for-Service scheme. It was previously paid at a package rate of from 75k to 100k since 2009.

398 Comments

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  1. Hi Levie, there are many types of biopsy listed in the Philhealth Case Rate for Medical Procedures. Ask your hospital to be sure. He can use your Philhealth as your dependent if he doesn’t have yet his Lifetime Member ID

  2. My grandson will be undergo orthopedic procedure called closed reduction or wire fixation,how much do you think will be the deductions by philhealth for all the total bills for example 15 thousands

  3. Hello po, nadischarge na po mother ko from hospital last saturday. Pneumonia po un sakit, then ang nakita ko lang na kaltas for philhealth is 10,500.00 should be 15,000.00 po di ba? Can I file for reinbursement if ever?

    Thanks!

  4. for other medical illnesses like electrolyte imbalance . cardiac dysrrhythmia where can we find the other rates thanks

  5. Hi Jing, 10,500 is for hospital costs and 4,500 is for PF. After receiving your benefit payment notice (BPN) from Philhealth, xerox it and then ask your hospital for a refund of your 4,500. Bring your hospital bill and OR. While waiting for your BPN, you can also ask the hospital why the 4,500 for PF was not deducted from your bill.

  6. Hi sammy, sorry for the delayed response. If the procedure is:
    Code 31630 — Bronchoscopy; with tracheal or bronchial dilation or closed reduction of fracture, the coverage is this:
    9,600 hospital costs
    8,400 PF
    18,000 total coverage

  7. Tanong ko lang inoperahan kapatid ko dahil may early stage breast cancer sya, magkano po ang babayaran ng philhealth?

  8. Hi Evangeline, depends on the kind of surgery performed, and if 2 coverages can be claimed (1 for surgery and 1 for malignancy condition). The surgeries on the list range from about 8k (cyst excision) to 22k (mastectomy). Ask your hospital.

  9. Hi Ms. Nora ask ko lang po if nadischarge na sa hospital at hndi ngamit ang philhealth hindi naba pwede makapagfile ng reimbursement sa philhealth? nanganak kasi ako cs delivery sa isang public hospital ndischarge aq july 3,2014. Nong ngfile aq ng reimbursement sa hospital after 2 days dala mga receipts ng mga nbiling gamot sinabihan lang ako ng philhealth personnel ng hospital wala na daw refund ang philhealth.

  10. Hi kristine, it’s true that there’s no more direct filing with Philhealth by members. You should have submitted your Philhealth papers before discharge.
    But just to comfort you, I’ll say that if you didn’t pay the doctors and paid not much to the hospital, sometimes in a public hospital, that’s better than using Philhealth — there are cases when Philhealth is used, you pay a big amount to the doctor and the anesthesiologist because you’re a paying patient.

  11. Hi Ms.Nora…if its a hip replacement surgery how much will be covered by Philhealth.
    hoping for your immediate response.

  12. may discount b kapag ngpacheck up ako sa specialist? how much ang discount kapag nag-undergo ako MRI?

  13. Hi vench, sad to say, outpatient consultations are not covered. Outpatient MRI and other lab tests are also not covered. Lab tests are partly covered when they’re used during covered hospitalization or surgery. Ask others too.

  14. Hi Maritess, coverage for Codes 44950 and 44960 Appendectomy is 24,000 (9,600 for PF and 14,400 for hospital cost)

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  16. I was confined at the medical city from Aug. 2-6, 2014.
    They did not deduct any philhealth benefit because according to
    them, my diagnosis was not included in the case rate. I got a
    leaflet from philhealth that if the confinement is not one of
    the case rate, I can still claim benefits(room and board/medicine/
    laboratories/PF according to hospital level.
    Can you please clear this?
    Thanks.

  17. Good day, is eye surgery called phakic intraocular lens implant covered by Philhealth? How much will be the deduction? thanks and Godbless…

  18. Hi mark, in the Procedure Case list, there’s a Code 66985 — Insertion of intraocular lens prosthesis, not associated with cataract removal, and the coverage is 16k. If you’re in QC, and if you like, you can visit Nova Eye Center at SM Fairview and look for Dra. Capinpin, or text 0919 991 1111 for Dra. Capinpin’s sked at SM Fairview.

  19. naadmit po anak ko sa ospital na di accreditedalth ng philhealth pwede ko pa po bang mareimburse ang bayad ko sa hospital.two days lang po naadmit.tonsilopharyngitis at dehydration. thank you

  20. Hi marilou, sorry the hospital should be accredited. Also, direct filing with Philhealth is no longer allowed.
    You can file only if the hospital is DOH-licensed and if you can prove it’s emergency and it’s impossible to reach the nearest Philhealth-accredited facility.

  21. Hi maam nor, my friend gave birth last august 23,2014 and was discharged august 25, but her baby remained at the hospital for infection treatment for 1 week. Can my friend use her philheath for her baby? The hospital said she can no longer use her Philhealth because she has already used it for her delivery

  22. How much is less at philhealth for mayoma operation if its in public or private I need to know ASAP thnks.

  23. Hi emy, is your friend the Philhealth member? If yes, she can use her Philhealth for her baby’s confinement, even if she has used it already for her delivery. She fills up another claim form 1 and uses the birth certificate issued by the hospital (Philhealth allows this, but if she can already get a birth cert from the local civil registrar, then it’s better). The father of the baby, if Philhealth member, can also cover the baby’s confinement. Can be father’s or mother’s Philhealth.

  24. Good pm po.i have just gave birth last saturday and have used the maternity package if philhealth and have an 8k discount. However becaude of my pregnancy,benign masses on my breasts started to grow again and i may need to undergo a mastectomy or excision of breast mass (still not sure since i will know nxt wk) my question is could i still use my philhealth since i have used it in my delivery? And do you know what are the requirements of East Ave med Center (philhealth req) for us to be able to prepare it before my surgery. Thank you and God Bless!

  25. Hi jingelbells, you can use your Philhealth again because childbirth and breast mass excision are different conditions. You’ll submit the same Philhealth papers at East Ave upon admission, but since that’s a public hospital, you might be required to buy meds/supplies outside, then later on be refunded by the hospital. Find a Philhealth-accredited surgeon there, and ask about how much you will pay if you use Philhealth.

  26. Hello,

    Ask lng po. Tama po ba ang deduction ng Philhealth if two cases ang diagnose (1) TB spondylitis / Pott’s Disease Php 9,800.00 and (2) Pneunmonia (moderate risk)Php 15,000.00.

    Ang both case ba is subject for hospital bill deduction?

    Thanks po.

  27. Hi Lanie, 2 cases can be claimed if the 2nd illness is on Philhealth’s list of conditions that can be covered as a 2nd case (100% coverage for 1st illness and 50% for 2nd illness or procedure). In the cases you mentioned, pneumonia might be the case covered since it has higher coverage. Sorry I don’t know if the 2nd diagnosis can be covered, as both illnesses are not in the list of 2nd case conditions. Ask your doctor.

  28. Hello po,

    Last wk naadmit po ako ung diagnosis po ai pneumonia (moderate risk) while i’m at my 14wks pregnant…tanong ko po magkano po ba yong package ng pnuemonia pagbuntis? Sabi ng hospital di daw 15k ang covered para s buntis kundi 6,800 lang…tnx!

  29. Hi Fel mar, the coverage for moderate pneumonia is 15k, and what I know is it should be 15k regardless if the patient is pregnant or not. Is pneumonia the diagnosis written in your discharge papers? Maybe it’s a maternity-related diagnosis with 6,800 coverage. You can see later on when you receive the benefit payment notice from Philhealth how much Philhealth paid the hospital.

  30. hi.. may i ask… my son was admitted due to pneumonia and thyphoid fever. Is it possible that I can avail of 2 packages from philhealth? for pnuemonia and thypoid fever? thanks

  31. Hi I had severE stomach pain sometime in June and consulted a doctor who advised me to have laboratory test and ultra sound. The blood tests came out all negative except the ultra sound with enlarge prostate. I was prescribed medicines for acidic stomach and referred to another doctor for the enlarge prostate. The new doctor wanted me to have a biopsy of colon which I differed meanwhile my pain was persistently getting worst that leads me to go to another internest doctor who diagnosed me with ulcer. I was prescribed WITH some more medicine for ulcer, until the pain had traverst to my back that prompt me to go to another doctor a ‘diplomate for rehabilitation medicine’, who directed me to have an MRI and I was luckily rehabilitated from the pain but found out that I need to undergo further MRI, COLONOSCOPHY, & ENDOSCOPHY to further check the ‘cloudy portion at my THORACIC SPINE. ALL OF THE ABOVE PROCEDURES THAT ENTAILED HUGH AMOUNT OF EXPENSES WERE PAID BY ME BECAUSE ANYWHERE I GO I WAS ADVISED THAT THOSE WERE NOT COVERED BY PHILHEALTH. I AM SCHEDULED TO HAVE ANOTHER MRI, ENDOSCOPHY & COLONOSCOPHY AND ALREADY SHORT OF FUNDS TO COVER THESE FORTHCOMING EXPENSES, CAN I EXPECT PHILHEALTH TO DEFRAY THESE EXPENSES AND WHAT IS THE EASIEST WAY TO DO IT. THANK YOU AND I HOPE TO HAVE FAVORABLE RESPONSE AT THE SOONEST POSSIBLE TIME. REGARDS.

  32. Hi Ernesto, these are all diagnostic procedures, and I commiserate with you because these are really expensive. Sadly, outpatient diagnostic procedures are not covered. In Philhealth’s list of Case-Rate procedures covered, endoscopy and colonoscopy are listed, and they have coverage amounts. MRI is covered only if it’s used during certain treatment procedures. So I think one diagnostic procedure can be covered if you’re confined and treated, meaning there’s diagnosis and there’s treatment. What I understand about Philhealth’s coverage, based on comments on our blogs and on rules I’ve read, is that there should be a diagnosis and treatment. If there’s no treatment done, even if confined, the confinement is not covered. But you need to ask your doctor or your hospital. They should know by now the conditions and procedures that can be covered when confined. Take care. I hope the doctors will finally make the right diagnosis and the right treatment. We emailed you the relevant case rate list.

  33. Hi jenny, only one of these diagnosis will be covered. Most likely, it would be pneumonia. Ask your hospital, to be sure.

  34. Talaga po bang ide-deduct ng ospital sa claim na 11k yung VAT daw amounting to 2,800? 25 po yung total bill namin. Miscarriage po yung case.

  35. nora gud pm.

    6mos pregnant ako. may philhealth as voluntary. yung father ng baby ko ay philhealth member din under NHTS-pr . sponsored. We were asked to buy the hepa B vaccine since sa maternity clinic ako manganganak, gagamitin ko philhealth ko para mareimburse ko ycung 1750.00 NEW BORN PACKAGE, ano yung pwedeng gawin ng partner ko para magamit namin philhealth mya at makatulong sa gastos since my hepa B ako. o kaya dun nlng sa baby namin

  36. Hi Cesar, I’m puzzled that they used the word “VAT”. Why didn’t they just say that it’s for additional doctor’s fee or hospital charge? What I know is there’s no VAT for regular medical bills. It’s the doctors and the hospital that pay VAT for payments received from Philhealth and from patients. You can ask if that’s really your VAT or their VAT (and you’re paying for them) or additional charge. They should just be honest.

  37. Hi shania, are you updated with your Philhealth payments? If you are updated, your Philhealth will be enough for your maternity and newborn care needs. You’ll file 2 claim form 1, one for you and one for your baby. You can also submit prenatal ORs worth 1500 or more so Philhealth can mail you your 1500 refund.

  38. Hi Ms. Nora! Yung father ko po need magpa’endoscopy s PGH next week, pwede ko po bang gamitin philhealth ko for the procedure?

  39. Hi rom, endoscopy is listed in the Case Rate list, but I’m not sure if it’s covered if it’s done as outpatient. Ask PGH

  40. I believe it’s their VAT that we pay for. Is that really how it goes, as per Philhealth guidelines? Do they have to have the patients pay for it?

  41. Hi Ms. Nora..I would like to ask how much will be covered by Philhealth in Inguinal Surgery for my son?

  42. hi maam nora, magkano po ba covered ng philhealt sa stroke, confine kasi mother ko sa s.l.u baguio. at yong bang gamot na nabibili sa labas pwede po ba ererefund ng philhealth. thank you po.

  43. Hi evangeline, the coverage for stroke is 38k (11,400 PF and 26,600 hospital costs). Keep the ORs (should be in patient’s name, with dates and OR nos.) and give the hospital xerox copies before discharge. You might be able to refund them later on if the 26,600 is not fully consumed by hospital costs. Get deductions before discharge; patient’s filing with Philhealth is no longer allowed.

  44. madam,
    ask ko lang po na confine anak ko for dengue panu po ba ang computation na pwede e deduct sa aming billing.salamat! godbless

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