%eu

M8p H r L I p p I N r r rorflf i{;;{ffi^!;{{tt o np o not o N

PhilHealth Regional Office VlGaisano City Capital - Iloilo, Luna St., La Paz, Itoilo City

(033) 501-9190 to 62www.philhealth. gov.ph

ALL PHILH ENGAGED HEAITH CARE INSTITUTIONS

LOURDESRegional Vic

BERN ETTE L.HCD Chief

TO:

FROM:

THRU: REYNES,V

DATE: January 30,201,5

SUBJECT: INCLUSION OF THE OF DATE OF LMP (Last Menstrual Period) TOTHE CI.AIM FORM 2

The Corporation, through the National Health Insurance Program, commits towards achieving

Millennium Development Goal for maternal and child health. This is to ensure survival and well

being of all mothers and their newborns by providing them financial tisk protection. Along with

this is the enhancement of system features to increase efficiency of claims processing.

PhilHealth Circular No. 22, s. 2014, ANNEX B - (INSTRUCTION ON HOW TOACCOMPLISH CLAIM FORM 2) instructs that under Special Considetation for ALLdeliveries, the date of last menstrual period (LMP) should be written in Claim Forrn 2 atpaft II, item 8-c. A11 deliveries include and not [mited to MCP, NSD, Cesarean Section &Breech extraction.

For sample claim fotm please see Annex B of PC 22, s.2014.

For yout information and guidance

I C teampnllneartn W www.facebook. com/PhilHealth Yol@ yyla,ly.yeutube.com/teamphilhealth W actioncenter@philhealth.gov.ph

;I

rrated b e

PhllHcalth lOffca ol thc PCEO

ANNEXB-INSTRUCTIONSOCI.AIM FORM 2

Note: Claim Form 2 shall be acconboxes. All items should Ifilled out in MM-DD.YYY

N HOW TO ACCOMPLISH CI-AIM FORM 2 and. SAMPI,I/

/rplished using capital letters and by checking the agXlroprire marked legibly by using ballpen only. AI datey'shouldformat. /

C F 2 P apaft/Item

Description Instructions //

Part I PhilHealth AccreditedNumberName of Health CareInstitutionAddress

!7RITE the PhitHeaLth Accreditation Numbet, name of HCI and theaddtess on the space provided

Patt II,item 1

Name of Patient WRITE the complete name of the patient in this format:Last Name. First Name. Name Extension 6f any). Middle Name

Part II,item 2

Referred bv anothet HCI Tick appropriate boxIF yes, write the name and address of refernng institution

*In NSD Package, write the name of the facility thatorovided the antenatal cate (as applicable)

Patt II,t , - - - _ 4

Confinement petiod

\+-. s , . 1

-_-_!$ l

V EEii H Eg E-,1

)ate Admited WRITE the date of admissron

For Antenatal Care Packaee wtite the date of t't p1e-natal visitlime Admitted $7rite the time of admission

Blank for Antenatal Cate Packaee)ate Discharged !?RITE the date of dischatge

For Antenatal Cate Packase write the date of last pre-natal visit

8lC)

lime Discharged WRITE the time of dischatge

Blank for Antenatal Care PackaseI)^ar TT lPatient Disposition TICK the appropriate boxitem 4Part IIitem 4f

Transfetred/refetred TICK the appropriate box

If patient is refered to anothet facility, write the name,and address ofthe facility and reasons fot tefetal

*Claims for Antenatal Cate Package (ANC01) and Referral Fee(59403) should have the name of the facility wherethe patient is teferted to for delivery/furthermanagement

Patt II,tem 5

Tlpe of Accommodation TICK appropdate boxBlank fot Antenatal Care.Packase

Part II,item 6

Admission Diagnosis/es $flRITE the admitting diagnosis

Part II,item 7

Discharge Diagrrosis '{TRITE the diagnosis on dischatge

ICD 10 Code/s IVRITE the appropriate ICD 10 Code/sCodes for method and outcome of delivery must be included

ffi teamphilhealth ffi www.facebook.com/PhilHealth W actioncenter@philhcalttr. gov.ph

at

,/

, l

I CF 2Pap^tt/Item Desctiption InstructiorsRelated Procedures Leave blankRVS Code VflRITE the applicable Package/RVS Code:

Matemity Care Package: MCP01NSD Package NSD01Cesarean Section; 59513 ot 59514 ot 59620Breech extraction: 5941 1Vaginal delivery aftet CS: 59612NSD 'ffith BTL:59402Antenatal Care Package: ANCO1Intrapartnm monitoring (wlo delivery) : 59403Antenatal Care Package with Inttapartuo monitoring: ANC02Newborn Care Package:99 432

Date of procedures WRITE the coresponding date/s for the ptocedure,/s*for claims for delivery (i.e. MCP, NSD, etc.) write the date

of delivewPart II,item 8 c

Special considetationMCP Package

Fot AII delivedes:$7RITE the date of last menstrual period (Lt\4P)Fot Claims fot MCP and Antenatal Care Package:WRITE the dates of at least 4 pte-natal visits on the spaces provided,Leave blank for other claims.

Patt IIitem 8 d

Newbom Care Package TICI( the services that are providedATTACH the Filtet Caid Sticker for Newbom Scteening Test in thesoace otovided

Part II,item 9

PhilHealth BeneEts V7RITIE the co*esponding package/RVS Codes for the benefits thatvdll be claimedr

Maternity Care Package: MCP01NSD Package: NSDO1Cesarean Section: 59513 or 59514 ot 59620Breech extraction; 59411Vaginal delivery aftet CS: 59612Antenatal Cate Package; ANC01Irtrapartum monitoring (w/o deliverl) : 59 403Antenatal Cate P ackzgewith InftaPartum monitodng: ANC02Newbom Care Package:99432

Part II,item 10

Professional Fees WRITE th. a.*.ditation number and the name of Physician/midwifeon the sPaces Provided

AFFD{ the signature of the Physician/midwife over his/her narnethen write the date of the space ptovided

Part IIISection A

Certification ofConsumption of Benefits

frcf fust box philHealth benefit is enough to cover HCI and PFcharges) ifthe patient did not have any out ofpocketexDen6e

frcf second box the benefit was consumed but there is additionalcost to the patient then accomptth t^blqqg

"gdlgl!Pan III

Section BCorrsent to Access PatientRecord,/s

PRINT the name of the patient and AFFD( his/het signatute overthe narne

WRITE the date when this was sigredShould the patient was unable to sign, tick the apptopriate boxes

Certificarion of Health CateInstitution

ffi authorized person to fill-up the claim andhis/het designation' AFFD( his/her signature abovethe name.

Ttris person rnust revierr and ved$r all the entries before affixinghis/her signahre.

;=EIse\ffi teamphilheatth ffi www.facebook.comr?hilHealth @ actioncentef@philhealth'gov'phl?rstkath lOlBr( thc FCEO

2-

'Itb hm bleds ym$ otF apgortir{ doqrFd! du,rd be frld {idtn 5ffiY (50) @h.dEr davs fton dcb of dldEgeNl hfomu;, 6es3 ad ti* bre: rcquid h E!: fom m xassuy. dain ftrbt Htltr lToosLb hbfffiUon dsfl Dt bc

{NEX C-SAMPLECLAIM

rA[5E

t, Pht8lth AaEdttau{ ri@$$ (PA$) of Haaldr crE tnrtitutis:

a Nanre ot Hal$ car.lneubjtld:

3. AddE: 14

t. l{m. of Patletrtl

q. fv Ottpadat flfU/ADS na'dard hdtgc libot to.y tlsmbai

9. Philx.alth BcncfttrfCD lO of

Tftis fom mcy tt rcprcdqqd andl5$gf r0r

cF2(clalm Fom 2l

revissd ltovember 2013Mes#

ROMERO

(!,ari,-"''g PnilHealthHI

tbur P'dnil hr ,t.a!th

ITIPORTil{T ITIITIIDER5:NEASE WRITE IN CA'TTAL LEITENS A}ID CIIECX THE A9PROPRIATE @IEs'

tGNACIO

Fhlftloefilr lOmca aUo PCeo

IF yes, wnte the name andad&ess of referring instinrtion*In NSD Package, whenantnatal care is provided byother facility write the name ofthat facility

Write the date & time ofadmission and discharge*For Aote-oatal Care Packagewrite the date of 1tc aod lastpre-aatal visit Spacesprovided for time shall be leftblank

-t2'0 ' 1' 4t d'TtfrlDladBrlEdlcm$ggg$q:&l

4 ?otcn1 Ditpotitiqn: {id.