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.

491 Comments

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  1. Good day po mam. in what charitable hospital can I have have operation for varicocele and how much will be the cost? im 24 yrs old and member of philhealth. I’m thinking I need 20k to make sure I’ll be able to pay all so I’m saving now. thanks for the answer :) God bless :)

  2. Hi kenneth, Philhealth’s coverage for varicocele excision is 12,900 and for the other type of excision, coverage is 14,960. There are 2 big government hospitals in Metro Manila: PGH and East Avenue. You can try the charity and pay-patient departments. If charity at PGH, you need to go there very early (Padre Faura gate). But if you’re working, sometimes it’s better to have the pay-patient route as the charity route takes a lot of waiting times. Ask the surgeon about costs

  3. Hi simon, Philhealth’s coverage for this: Code 52649, High intensity Focused Ultrasound of the Prostate, including Transurethral Resection of the Prostate (TURP) is 16,800.00 for hospital cost and 21,000.00 for PF. Ask your doctor how much you will pay if you use your Philhealth

  4. maam goodmorning po, ask ko lang po kung magkano ang sagot ng philhealth sa aking acl injury surgery

  5. Hi Emil, if your ACL surgery is this: Code 29888 – Arthroscopically aided anterior cruciate ligament repair/augmentation, Philhealth’s coverage is 37,180 (18,480 for PF and 18,700 for hospital cost). Ask your surgeon how much you will pay if you use Philhealth.

  6. maam, good afternoon po!! ask ko lang po kung sakop pa po ba ng philhealth ang operasyon sa tendon cyst?

  7. maam, gud afternoon po! tanong ko lang po if cover pa po ba ng philhealth ang operation sa tendon cyst?

  8. hello po ask ko lang sana kung cover ang dermoid cyst (ovarian cyst) operation sa philhealth,
    and ano po kaya ang rate cover nito…

    salamat po

  9. Hi po! Ang pinsan ko po may acute glomerulonephritis. Magkanu po ang icocover ng philhealth kung sakali gamitin po. May philhealth po tatay niya. Thanks in advance for the reply.

  10. hello po gud day!!may schedule po ako ng endoscopy magagamit ko po kaya ang philhealth ko? and how much po ang cover kung sakali? thanking you in advance for your reply :)

  11. Hi I gave birth dec 9 2014 at a public hospital here in paranaque. I used my husband’s philhealth then all that were used for my cs were bought by us. how much is philhealth benefit if cs. we had no bill, but we spent for the meds and supplies. we were told we will get a refund. how much? how long before we can get our refund. they said they will text us, but we have not received any text up to now.

  12. Hi,ask ko Lang po kung magkano ang cover Ng lung biopsy sa philhealth kung sa east avenue po senior citizen na po sits pero bagong member pa Lang po.

  13. goodmorning po, maam member po Ako at yung tatay ko ng philhealth, nais ko po sana magpa acl reconstruction, cover din po ba ako ng philhealth nya? Sana po masagot nyo tanong ko maraming salamat po

  14. Good day! My due date is April 27, 2015. I plan to give birth at Amang Rodriquez Medical Center here in Marikina City. My O.B at OPD Section told me her rate for normal delivery package is 25k+ in Semi-Private with Philhealth. Then she mentioned Service Ward. I wish to deliver at the Service Ward as I can’t afford her rate. My husband’s salary is small. How much will I pay if I give birth at the Service Ward? I’ll use my Philhealth. Thank you

  15. Hi lauriz, the benefit for CS is 11,400 for meds and hospital costs and 7,600 for the doctors. So if your hospital cost was, for example, 5,400, and you spent 7k for meds bought outside, your 6k should be refunded to you (11,400 minus 5400 = 6k). If hospital cost was 4k and you spent 5k, you should be refunded 5k (11,400-4k=7400, but only 5k will be refunded). Processing takes 2 to 5 months or more.

  16. Hi Rozaline, ask the people in the service ward if they accept no-balance billing, meaning your Philhealth benefit is enough to cover all expenses, and that you don’t have to pay anything, or you pay only a little amount.

  17. Hi Rozaline, if in a hospital, the deduction is 5k (3k for hospital cost and 2k for OB). If lying-in, the deduction is 6500.

  18. my wife is a member of philhealth. she undergo surgical operation on hemorrhoidectomy yesterday april 11 and will be discharge tomorrow april 13. how much will be covered by philhealth. thank you

  19. Hi may i ask. I’ll give birth this coming may 23,2015. 21,000 is my delivery package at my clinic(philhealth accredited). I’m a member of philhealth. if normal delivery, how much will I get from philhealth? thanks po. last time i gave birth, my bill was 20,000, and only 2000 was deducted as my philhealth benefit

  20. hi…just wanted to know when did philhealth started using fixed rate …the last time i used my philhealth they just deducted it directly from my hosptal bill.i thought they’re still using the old computation..

  21. Hi boss, ask your OB or clinic if that 21k package is already their Philhealth package, so that means you will pay the whole 21k. If not yet, ask if they deduct 6500 (for lying-in clinics) or 3900 (just the clinic portion). The normal delivery benefit at hospitals is 5k (3k for hospital cost and 2k for PF).

  22. hello, philhealth covers only in-patient? my daughter had a minor surgery and ct scan pero out-patient…no coverage for this daw?

  23. hi mam nora:
    my got operated last week (apr 16) for hip replacement. she was admitted in a local hospital (Dr. Yanga Hospital in Bocaue). Our partial billing (frm Apr 9 to Apr 20, 2015 has reached P110,000.00 net of philhealth deduction amounting to P15,000.00. Is this the only amount being deducted in the case of my mother, how about the Z-package benefit, is she not entitle to this. Please note that I first brought my mom at the Phil. Orthopedic Hospital but upon informing the attending doctors there that my mom has polycythemia vera we were informed that my mom shld be brought to a general hospital. Since the hematologist treating my mom with her polycythemia vera is affiliated in Dr. Yanga Hospital, we opted to just bring her to the said hospital.I am just a rank-and file employee of a government agency and raising the amount billed to us is quite difficult.
    hoping for your immediate response.

  24. Hi jennifer, not yet. Philhealth is used only when hospitalized. Can be used only for outpatient services like dialysis and chemotherapy.

  25. Hi, Ms. Nors. how much is the discount for an individually paying member if confined? my sister is in the hospital from April 18 2015 to present due to HYPOCALCEMIA AND LOW POTASSIUM WITH HIGH BLOOD PRESSURE. Our papers are already with the billing department. Upon admission the hospital asked for a deposit of 2500 which I gave. (Bill that day was 4500+ and then after 2 days the bill became 11,800+ and they asked for 5k additional deposit and I complied, giving them 7,500. (TOTAL DEPOSIT is 10,000 as of that day.) Now it’s April 23, and the bill is 33,296.70 without PF. that’s the total running bill as of today without PF and deposit and Philhealth were not yet deducted. this morning, they called my mother to the billing section and they asked again for 10,000 additional deposit. Is this right? We were confined at a Level 3 hospital here in Pampanga. Hope you can help us

  26. Hi Jessy, I can’t find hypocalcemia and low potassium in the Philhealth Case-Rate table. The benefit for hypertension is 9k. Usually, only one illness is covered. Talk with the Philhealth/billing staff, and ask about deduction. Ask about the PF so you can prepare. I hope your sister has already improved and is already well, so she can be discharged.

  27. mam/sir ask ko lang po how much cover ng philhealth ang RAI-131 or Radioactive iodone theraphy.

    thank you very much

  28. Hi Ms. Nora!I would like to ask if cover dn ba ng philhealth ung s radioactive iodine theraphy? I just had my surgery this april because of papillary carcinoma can i still use my philhealth benefit by May w/ the same illness?

  29. Hi Ms. Nora!I would like to ask if cover dn ng phlhealthang RAI-131

    @jovie marasigan how much po quote n dr mu 50k po kc s chnese prang ang mahal

  30. Is this really the policy? That if a patient transfers to another hospital, they cannot use Philhealth at the first hospital?

  31. Hello po. My husband died in 2012 due to hypertension, it was a sudden death. I was shocked so I wasn’t able to think well and use PhilHealth. It’s only now that I read on FB about refund. Can I still avail? Thanks!

  32. Hi nanneth, sorry, but about 3 years have passed. Members are given only 60 days from date of discharge to file a Philhealth claim. Since last year, the rule has changed — it’s now the hospital that files the claim. The patient files with the hospital before discharge.

  33. gud am po. My niece/nephew was admitted at QC Gen Hosp. Had operation on the head. Had titanium plate. We buy meds. How much is the Philhealth package? Patient is Philhealth member.

  34. Hi Agnes, sorry I don’t know the exact procedure done, so I can’t research the list. Ask the hospital’s billing department for your partial billing

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