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.

416 Comments

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  1. Hello po. Pasenxa n if naitanong n ito at d lng aq nkpg backtrack sa comments pero po mgkno po ba ang rate for excision ng phyllodes tumor sa breast? Kc po i recently underwent operation s east ave med ctr..18k+ ung bill pero 8k lng po cngot ng philhealth.ask q lng po if tama po ba un?slmat po.

  2. Hi sylvia, yes, you can both avail. File 2 sets of claim forms. The member has an allocation of 45 days. All the member’s dependents share a separate allocation of 45 days

  3. Good day! Last april 2014 was my last philhealth payment, when i was employed. Since end of contract, I haven’t paid. If I pay for 4th quarter, before Oct.13,2014 can I avail of benefits? that’s my schedule for my child’s follow-up checkup at the hospital?

  4. Hi Emily, sad to say, if you pay Oct to Dec, you can start using it in Jan 2015. Requirement is payment of 3 months within 6 months BEFORE confinement. Philhealth cannot be used for outpatient checkups. Ask others too.

  5. Hi zoila, you present your Philhealth ng masa ID to the clinic/hospital and they will deduct your benefit. You’ll pay the balance if the Philhealth benefit is not enough. No more direct filing by member with Philhealth

  6. my last payment was may to june 2014. that was before when i am ofw. now i stay in the phil. when can i pay again?

  7. Hi jennifer, you can pay asap as individual payor for Oct to Dec, so you can be eligible Jan to Apr 2015. Update your record at a Philhealth branch (bring your ID) so you can get your MDR and your Philhealth card.

  8. Hi, My wife is undergoing CS and I have PHILHealth for my dependent. Can I avail all 3 packages that covers under maternity?
    1. Newborn care package (NCP) 1,750
    2. Delivery by caesarian section (CS) 19,000
    3. Maternity care package (MCP) 8,000
    Please clarify. Thanks. Regards, Raju

  9. Hi Raju, you can avail of Nos. 1 and 2. The 3rd is for those delivering normally. The hospital and doctors should be Philhealth-accredited.

  10. Hello po…my baby is 6month old and got confined in hospital for 3days because of viral infection , how much does philhealth will deduct on our final bill in hospital? how many percent?
    appreciate your immediate response…

  11. Hi Jay-Jay, the deduction is fixed now, not percent of total bill. If the diagnosis is more specific, then I can check the Case Rate list.

  12. hi.. can my dependent still avail PHIC package of pneumonia even if he was diagnosed and admitted in the hospital in the same month?

  13. Hi elvie, yes, if different illness. If it’s pneumonia for the 2 confinements, the 2nd will not be covered if first was already covered. This is 90-day single period of confinement rule. Ask others too

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