Last updated on January 3rd, 2017 at 12:29 pm
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||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|
|10. Typhoid fever||14,000|
|11. Newborn care package (NCP)||1,750|
|Surgical Cases||Case Rates in Pesos|
|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|
|7. Dilatation and curettage||11,000|
|Medical or Surgical Case||Fixed Payments||Year Implemented|
|SARS||50 to 100k||2003|
|Avian Influenza||50 to 100k||2006|
|Bilateral Tubal Ligation (BTL)||4,000||2008|
|Normal Spontaneous Delivery|
|(NSD) with BTL||10,500||2009|
|Outpatient HIV/AIDS Treatment||30,000 per year||2010|