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.

822 Comments

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  1. I have a thyroid problem,I need to undergo for a biopsy?how much is the coverage of philhealth for that biopsy, and for the surgury of my thyroid?Thanks

  2. hi can I use philhealth one after the other for endoscopy with RBL, if I’ve used it already for endoscopy procedures? and how much po is the deductions for endoscopy with RBL? thanks po

  3. Hi jodelyne, is this the procedure done? coverage for needle biopsy of liver (percutaneous) is 8,020 (2,520 for PF and 5,500 for hospital). If it’s wedge biopsy of liver, coverage is
    18,000 (8,400 for PF and 9,600 for hospital)

  4. Hi Rosalia, if the procedure is Esophagoscopy (rigid or flexible, with band ligation of esophageal varices), coverage is 14,960 (7,560 for PF and 7,400 for hospital). If the same procedure or treatment or the same illness within 90 days, only one treatment/confinement is covered.

  5. Hi Shan, if it’s thyroid biopsy (percutaneous core needle), coverage is 8,260 (3,360 for PF and 4,900 for hospital). Coverage for total thyroidectomy is 31,000 (12,400 for PF and 18,600 for hospital cost).

  6. Good evening!pwde po ba magamit yong phílhealth ng kapatid ko na na stop nila yong contribution for how many yrs and last wednesday june 28 binayaran nila starting april 2016 til sept 2016. Thier son is scheduled for tonsillectomy?

  7. Hi Jessica, yes, they can use their Philhealth any time from July to Dec. I assume their son is less than 21, unmarried and unemployed.

  8. How much will be the Philhealth Coverage on Ultrasound Liver Biopsy if to be done In-patient. and also the room coverage of philhealth per day? If the patient will be admitted in ST.Lukes for Liver Biopsy procedure how much is the estimated cost of philhealth coverage. Thanks

  9. how much will be philhealth coverage on MRI and biopsy for soft tissue neoplasm on her left arm. I need info for this . we need help we don’t have enough money for this procedures. I’m the one shoulder this… my younger brother need to undergo this in Vicente Sotto memorial medical center in cebu.

  10. hi. ask ko po kung cover b ng philhealth ang MRi and biopsy for soft tissue neoplasm. MRI is worth 16thou. what should we do we don’t have enough money for that. after MRI the require next test biopsy. Vicente sotto memorial medical center

  11. Hi retchel, sorry, ang alam ko hindi covered ang outpatient MRI and biopsy as diagnostic procedures. Included lang ang mga ito pag confined for treatment, but usually, dahil ang Philhealth coverage ay maliit compared sa total hospital bill, parang hindi rin covered ang mga diagnostic tests like MRI. Ask the hospital. And ask for assistance from your city hall (offices ng councillors). Show doctor’s MRI prescription.

  12. hi po. ask ko LNG po.wat if kukuha nlng kmi ng room.kc out patient po bro. ko need niya mag undergo ng Ct scan, MRI at needle biopsy for soft tissue neoplasm in left arm. malayo kc sa anim ang hospital 4hrs. po biyahe. Pag ganyan po b covered n b ng Phil Heath. ct scan 3600 .. biopsy is 1700 MRI scan is 16000. thanks po wait for your reply. god bless u

  13. Hi retchel, room sa hospital? Sorry pero most likely hindi puede. Kelangang merong doctor na willing mag-admit sa brother mo, either yong consulting doctor or ER doctor, at dapat meron reason bakit ma-admit. Sa Philhealth naman, covered kapag confined at least 24 hours and then merong diagnosis at merong ginawang treatment. Kung diagnostic procedures lang ang ginawa, hindi ma-cover. So hospitalization na talaga na merong name of illness at treatment na maco-cover, at hindi na lang 1 day or 2 days, mas costly na, at hindi naman lahat covered ng Philhealth. Meron lang fixed na coverage sa specific illness o treatment. For your brother’s MRI, biopsy and CT scan, meron naman palagay ko social services dept ang VSMMC para puede mong kausapin to get a discount. God bless you din.

  14. Hi gud day.. ask ko lang if nacocover ng PHILHEALTH ang PET SCAN sa National Kidney and transplant Institute? How about MRI nd CT scan? thnx alot..

  15. mgkano ba ang maibabawas s hospital bills pag naopeahan ng removal of ovary?philhealth member po ako

  16. Hi joan, sorry wala akong makitang ovary lang ang inaalis. Merong abdominal hysterectomy which is to remove uterus, tubes and ovaries. Coverage is 30k (12k for Pf and 18k for hospital costs). Pag vaginal hysterectomy, coverage is 30,300 (16,800 for pf and 13,500 for hospital costs). Coverage for removal of part of ovary (Wedge resection or bisection of ovary, unilateral or bilateral) is 18,000 (8,400 for pf and 9,600 for hospital costs). Ask na lang your OB or surgeon so you can prepare.

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