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.

672 Comments

Add a Comment
  1. Hi Glendz, your Philhealth deduction should have been 15,000. After you receive your benefit payment notice from Philhealth and you see that Philhealth paid 15k to the hospital, go back to the hospital with this notice and your hospital bill and OR and request for your refund of 10,000.

  2. Hi Nora, my mother is a senior citizen and admitted in a private hospital because of her kidney/diabetes. How much discount she can get in philhealth?

  3. Hi Grace, it depends on the actual diagnosis. Diabetes coverage ranges from 10,100 to 15,800. The same with kidney, from 8k to 15k. The coverage for most kidney illnesses on the list is 10k. She will get one coverage only (the higher coverage) plus dialysis if she needs it. Ask the hospital’s billing/accounting dept.

  4. Hi.am going to have radiatìon for a plasmacystoma(tumor) of a bone marrow cancer called multiple myeloma. How much bebefit can I get from philhealth? Thank you

  5. Hi maribel, the coverage for radiotherapy (radiation Treatment Delivery by Linear accelerator) per session is 3,000. Coverage for multiple myeloma is 13,900 (4170 for PF, 9730 for hospital costs). Ask the hospital about costs.

  6. Hi, I want to ask how much could be deducted from the doctor’s quote of almost 100k for a TURP surgery in a private hospital?

  7. Hi,i just want to ask about the bone that my husbnd need a surgical how will i need to pay for a doctor in phil.general hospital

  8. Good pm!magkano po madidiskwento ko kapag ako ay maooperahan sa ovary at maliligate na rin po.sa private hospital po.salamat.

  9. Hi glenda, the PF of doctors at the pay department of PGH vary. Consult with a doctor and then ask about the things that you need to pay.

  10. Hi Russell, coverage for TURP stage 1 is 21,940 (9,240 for PF and 12,700 for hospital costs); TURP stage 2 is 21,940 (9,240 for PF and 12,700 for hospital costs). I don’t know if the coverage for 2 stages can both be applied to a one-time complete TURP procedure. Doctor and hospital should both be Philhealth-accredited. Ask your doctor how much will you pay if you use Philhealth.

  11. Hi Tizzia, there’s no “paracardiac” in Philhealth’s list, but there are lots of types of high-risk pneumonia — coverage is 32,000 (9,600 for PF; 22,400 for hospital costs)

  12. Hi Charmaine, there are two renal biopsies in the coverage lists:
    1. percutaneous renal biopsy by trocar or needle — 8,020 (2,520 for PF and 5,500 for hospital costs)
    2. renal biopsy by surgical exposure of kidney — 18,000 (8,400 for PF and 9,600 for hospital costs)
    Ask your doctor because I don’t know if it can be availed as outpatient. Doctor and hospital must be Philhealth-accredited

  13. Gud pm my husband will undergo operation for galstone removal nxt week at government hospital and he is my dependent in my philhealth i am now a senior and my philhealth now is lifetime is he also covered to the package of 31k and we will no longer pay anything in the hospital? Thanks

  14. Hi Filomena, do you mean your husband is not yet qualified for Philhealth’s senior Philhealth program? If not yet, then request a new MDR from Philhealth that includes your husband as your dependent. Bring your ID and marriage certificate. If qualified, his operation should be covered fully since it will be done at a government hospital. But ask the surgeon if the Philhealth coverage is enough. Some pay-department doctors at government hospitals ask for additional PFs.

  15. Gud morning my mom confined she has pneumonia and its already 8 days now. Our bill already cost 85k. How much will be cover it by philhealth?tnx

  16. Hi Ivy, sad to say, Philhealth’s coverage for severe pneumonia is only 32k (22,400 for hospital costs and 9,600 for PF). If you like, you can ask the hospital’s collection department to help you with documents needed to ask help from PCSO.

  17. Gud afternoon, how much is coverage for cataract removal? I am the member but my father is my dependent. My father want to be operated in cataract, can we avail the discount in Philhealth. How much would be deducted if in case he ll be operated. thanks.

  18. Hi Amy, the coverage is 16k per eye. Both eyes can be covered in 2 separate operations. The first step is to find a Philhealth-accredited eye surgeon whose clinic or hospital is accredited with Philhealth. If you’re okay with a generic lens (not branded) and if your father does not require high-blood-pressure monitoring, usually you pay only for the check-ups and tests. I have a post here: http://www.workingpinoy.com/2014/08/affordable-cataract-surgery-philhealth/

  19. thanks Nora for your entlightment. Can you recommend hospital in Albay or province or Legazpi City . Im from Bicol.. My father is senior and his not high blood but low blood.
    God bless po

Leave a Reply

Your email address will not be published. Required fields are marked *

Working Pinoy © 2008-2014 Frontier Theme