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.

529 Comments

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  1. hi Ms Nora naoperahan po ako sa thyroid 2weeks ago umabot po ng 41k hospital bill gusto ko lang po malaman sana kung pwede pa rin po ba ko makapag refund para sa mga ibang expenses ko yung mga gamut po na nabili namin sa labas kahit nagamit ko na po yung 31k for thyroidectomy?maraming salamat po ms nora ….

  2. Hi po, how can I avail of benefits? My child was diagnosed with TB on June 2, 2015. He/she has been taking meds for a month as outpatient. What do to avail of benefits? Thank you very much. Kind Regards, Paul

  3. Hi Paul, under the TB-DOTS program, you can avail of 4k worth of meds and other services. Write where you live, so I can give a list of TB-DOTS facilities. P.S. I’ve emailed you the list.

  4. Hello po, cover po ba ng philhealth ang laser treatment ng kidney stones? I yon po ang Sabi ng doctor at malaki ang mga bato. Kung pababayaan ay magiging grabe ang kalagayan. Ano PO ba ang dapat gawin? Salamat PO.

  5. Mam Nora..kakatayo Lang po ng infirmary clinic namin..Hingi naman po ako ng sample computation para sa reimbursement..although I went through an orientation hindi ko po alam paano simulan..please help po

  6. Hi Leo, sad to say, CT scan is not covered if it’s done as outpatient. Even if done while hospitalized, it’s likely that the benefit for the illness will be used up by treatments or procedures other than the CT scan.

  7. Hello po Mrs Nora, how much po is the coverage for ear surgery Tympanoplasty with Mastoidectomy middle ear, operation this coming July 15,2015. I’m OFW, just left Pinas last Dec 2014 and got back home to have my ear treated, so I don’t have much for the operation. What should I file? Thank you po and hoping for your immediate response. God bless.

  8. Hi Merlyn, you should talk with your surgeon about using Philhealth because there are surgeons who are not Philhealth-accredited. The hospital should also be accredited. The coverage ranges from 23,300 to 49,000, depending on the specific surgery. Your doctor should be able to tell you about how much you need to prepare, after deducting Philhealth coverage. Your surgery date should be within the validity dates in your Philhealth receipt. Bring your MDR (from Philhealth), premium receipt and any ID. God bless too

  9. hello po. would like to inquire if removal of small cyst outside at the back particularly in is covered to philhealth?

  10. Hi Ana, yes. Find a surgeon willing to accept Philhealth coverage. Ask how much you will add to the Philhealth coverage.

  11. Just given birth. What should I do to reimburse my expenses at the hospital. Wasn’t able to have my employer sign my cf1 form. Thank you

  12. Hi Sheila, bring your signed claim form 1 to the hospital, with your cert of premium payment and ask the hospital to file for you. If they refuse because you’re already late, request the other claim forms, and file your claim at Philhealth yourself. Philhealth will accept your filing if they see a valid reason why you were not able to have your claim form 1 signed.

  13. Hi, can you help me address my question. My father is in ICU for almost three months now because of kidney failure. On top of that, his lungs are failing, so he has to have the ventilator. Our hospital bill is already 800,0000. How much do you think Philhealth is going to cover?

  14. Hi Dissa, to get an accurate amount, go to the hospital’s Billing section and ask them. They should be able to answer because they know you need to pay, and the amount has escalated to a big amount.

  15. Thank you, Nora. The doctor said my dad needs trach. We cannot afford to pay it nore because they want 100,000 upfront payment. Do you think it’s against the law not to give that procedure if its highly needed by the patient, just because we cannot pay right now?

  16. Hi po. My brother is confined. findings is amoebiasis po. philhealth dependent of my father. how much is the coverage of philhealth? indigent type of philhealth. thank you!

  17. Hi Dissa, there’s the hospital deposit law, but I’m not sure if it covers a procedure after the patient has been hospitalized for weeks already. I pray for your continued strength.

  18. Good Day. My daughter is currently confined because of Dengue. I want to apply for philhealth membership today. Can I use it immediately if I apply as member today and pay for 1 year contribution? thank you so much po.

  19. Hi Joanna, sad to say, Philhealth’s rule is to pay the premium before the start of confinement. Besides, for July confinement, a member should have paid for Apr to June. But ask others too.

  20. Hi pearl, the coverage for hepatic amoebiasis is 10,000; for the other types, coverage is 6,000 pesos.

  21. Hi ms Nora. My ninang was diagnosed with squamous cell carcinoma of the tongue. And she will undergo chemotherapy. Just want to know much is the coverage of Philhealth for this procedure/medication. Hoping for your answer. Thank you and God bless.

  22. Hi Ms. Nora, my son was hospitalized and diagnosed with dengue fever, i am an ofw i want to know po if how much will be deducted from my bill for dengue fever. Thank u po.

  23. My wife had miscarriage. How much is philhealth deduction from our bill so I would know how much to prepare. thanks po

  24. Hi can I use philhealth if I had no payment from January to June? Now my child has been admitted, can I pay and avail? Thanks

  25. Hi sheila, sad to say, no. If you pay today for July to Sep, you can use it only in Sep or Oct or Nov. But I could be wrong, so ask the hospital.

  26. Hi melody, the coverage for chemotherapy administration is 7,280. The coverage amounts for other types of chemo are lower. One chemo equals 2 days. Every member is allotted 45 days per year.

  27. Hi Maam Nora, is endoscopy and gastroscopy covered by the philhealth? if so, how much is the philhealth deduction? thanks

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