Case rates presentation gen rules

Shirley B. Domingo, MD, MPHVice President

PRO NCR & Rizal

MONTH No. of RTHNo. of received

claims % of RTH

Jan-12 14,669 78,347 18.72

Feb-12 15,763 86,083 18.31

Mar-12 13,889 84,585 16.42

Apr-12

Source: Monthly operations report

HOSPITAL CLAIMSJOSE R. REYES MEMORIAL MEDICAL CENTER 330

UNIVERSITY OF STO. TOMAS HOSPITAL 305

CHINESE GENERAL HOSPITAL & MEDICAL CENTER 274

UNIVERSITY OF STO. TOMAS HOSPITAL 136

METROPOLITAN MEDICAL CENTER 130

GAT ANDRES BONIFACIO MEMORIAL MEDICAL CENTER 129

MCU-FDT MEDICAL FOUNDATION HOSPITAL 86

CARDINAL SANTOS MEDICAL CENTER 80

PERPETUAL HELP HOSPITAL 78

F.Y. MANALO MEDICAL FOUNDATION - NEW ERA GENERAL HOSPITAL 76

MAKATI MEDICAL CENTER 489UNIVERSITY OF PERPETUAL HELP RIZAL MEDICAL CENTER, INC. 322FORT BONIFACIO GENERAL HOSPITAL 257UNIVERSITY OF PERPETUAL HELP RIZAL MEDICAL CENTER, INC. 221TAGUIG-PATEROS DISTRICT HOSPITAL 122MPI-MEDICAL CENTER MUNTINLUPA 121RIZAL MEDICAL CENTER 118ST. LUKE'S MEDICAL CENTER - GLOBAL CITY 110THE MEDICAL CITY 104MPI-MEDICAL CENTER MUNTINLUPA 103

1. Original Philhealth Claim Form 2 not properly accomplished2. Required medical documents3. Required claim form (s)4. Other documents required 5. No proof of contribution.6. Original Philhealth Claim Form 3 not properly accomplished7. No proof of Professional fee billing/payment8. Discrepancies9. No proof of hospital billing/payment10. No proof of dependency

1. Filed beyond 60 days2. Exhausted 45 compensable days 3. Case not compensable4. Benefit exhausted5. Denied due to non-compliance6. Inconsistent data7. Patient not a qualified dependent8. Confinement not within the hospital accreditation period9. Less than 24 hours confinement, case not emergency10. Lack of/no qualifying contribution

PhilHealth does not pay for all your health care costs.PhilHealth pays only for covered items and services when requirements are metMembers are balance billed for the portion of the actual cost that is not covered by PhilHealth

Claims Filing

ENHANCED ENHANCED CLAIMS CLAIMS FORMS FORMS Circular 12, s-2010Circular 12, s-2010

CF1 (PART CF1 (PART I)I)

2 0 1 2 3 4 5 6 7 8 9 1 331-1234

ABC MANUFACTURING COMPANY

UNIT 1 ABC BLDG., 456 MAPAGMAHAL ST., BGY. MABILIS

QUEZON CITY 1100

MARIO A. CRUZ MANAGER 0 9 0 4 2010

The employer or his/her authorized representative shall affix his/her signature certifying that all monthly premium contributions for and in behalf of the member, while employed in their company, including the applicable three (3) monthly premium contributions have been deducted/collected and remitted to PhilHealth during the past six (6) month period prior to the first day of confinement and the information supplied by the member or his/her representative are consistent with their available records

CLAIM FORM 2CLAIM FORM 2

Beginning September 01, 2010Beginning September 01, 2010

PART I – HEALTH CARE PROVIDER INFORMATION

5,000.00

For benefit packages not requiring itemization PHIC benefit should be indicated in 11e

5,000.00

DR. PEDRO A. GOMEZ

1 502 1 2 3 4 5 6 1 09/05/10

PART I – PATIENT’S CLINICAL RECORD

This claim form will support the information supplied in the Claim Form 2 and shall be used in the evaluation of proper case type determination especially TYPE D CASES, EMERGENCY CASES and LESS THAN 24 HOURS ADMISSIONS

This is mandatory in:

Level 1 Facilities;

Case type D;

Maternity Care Package;

Emergency / Transferred cases; and

Less than 24 hours confinement

PART II – MATERNITY CARE PACKAGE

CF3 shall be accomplished for MCP claims (lying-in clinics) and must be submitted together with CF1 and CF2

ELIGIBILITY ELIGIBILITY REQUIREMENTSREQUIREMENTS

Eligibility Requirements

9 months premium within 12 months prior to admission (on selected surgical

cases)

Qualifying Contributions / Eligibility Qualifying Contributions / Eligibility Requirements:Requirements:

Employed / KASAPI

3 months within the immediate 6 months prior to

availment

Properly accomplished Part II of CLAIM FORM

1


IPP and Organized Grp*

At least 9 within the immediate 12 months

of contribution = Official Receipt / MI-5

or proof of payment for MCP

At least 3 within the immediate 6 months

(for NCP)

At least 9 months of premium contribution within the immediate 12 months prior to availment (MCP)

4TH QTR 1ST QTR 2ND QTR 3RD QTR OCT NOV DEC

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AVAILMENT AVAILMENT

illustration of IPMs qualifying illustration of IPMs qualifying contributioncontribution

112233445566778899101011111212

112233445566778899101011111212


OFW

MDR

(eligibility / coverage is reflected)


Sponsored

PhilHealth Sponsored ID

(eligibility / coverage is reflected)

OCT 13, 2010 – OCT 12, 2011OCT 13, 2010 – OCT 12, 2011

19-123456789-119-123456789-1

JUAN A. DELA CRUZJUAN A. DELA CRUZ


NPM

PhilHealth Non-Paying ID or

Lifetime Member ID

Guide to Reimbursement

Single Period of ConfinementRe-admissions due to same illness within a 90-day period shall only be compensated

within one (1) maximum benefit:Availment for the same illness or condition which is not separated from each other by

more than 90 days will not be provided with a new benefit

Only the remaining benefit from the previous confinements may be availed

Benefit for Drugs Tertiary Hospital

Systemic Viral InfectionOrdinary

Remaining Benefit

4,200

Admission January 15

2,000 2,200

Admission February 15

2,000 200

Admission March 15

1800

Single Period of Confinement

Case TypesCase Types

MedicalSurgica

l

A Simple80 and below

B Moderate 81- 200

C Severe 201- 500

D Extremely severe

501 and above

Case-type A B C DLevel 3 & 4 Hospitals (Tertiary)

Room & Board* P500/day P500/day P800/day P1,100/day

Drugs and Medicines** P4,200 P14,000 P28,000 P40,000

X-ray, Lab & Others P3,200 P10,500 P21,000 P30,000

Level 2 Hospital (Secondary)

Room & Board* P400/day P400/day P600/day N/A

Drugs and Medicines** P3,360 P11,200 P22,400 N/A

X-ray, Lab & Others P2,240 P7,350 P14,000 N/A

Level 1 Hospital (Primary)

Room & Board* P300/day P300/day N/A N/A

Drugs and Medicines** P2,700 P9,000 N/A N/A

X-ray, Lab & Others P1,600 P5,000 N/A N/A

Case type A: Acid peptic diseaseBenefit Item Makati

medical Center

Fort Bonifacio General Hospital

Taguig Doctors Hospital

Room/Board P500/day P400/day P300/day

Drugs P4,200 P3,360 P2,700

Lab/Supplies P3,200 P2,240 P1,600

Benefit Item Makati medical Center

Fort Bonifacio General Hospital

Taguig Doctors Hospital

Room/Board P500/day P400/day x

Drugs P14,000 P11,200 x

Lab/Supplies P10,500 P7,350 x

Benefit depends on:Hospital categoryCase type of illness (A, B, C or D)

Covered by rule on single period of confinement Benefit also depend on other claims processing guidelines:

Compliance to PNDF, generics law and Rational drug use– must be in accordance to dosage, preparation and use specified in PNDF Only drugs used during confinement are paid (with exception) Drugs bought by members may be reimbursed

Benefits per Single Period of Confinement

Primary Secondary Tertiary

2,700 – 9,000 3,360 – 22,400 4,200 – 40,000

Drugs and Medicines

All drugs, supplies, and lab used

on the day of the operations shall

be paid

Must be supported by official

receipts

Official receipts dated 30 days

prior to claimed session is allowed

Drugs and Medicines

Drugs must be written in generic namePNDF is main reference for payment

To be disallowed payment:No generic name indicated*Non-PNDF drugs

*except patients’ claims for medicines bought outside the hospital

Supplies, X-ray, Lab & Ancillary

Benefits per Single Period of Confinement

Primary Secondary Tertiary

1,600 – 5,000 2,240 – 14,700 3,200 – 30,000

Benefit depends on:Hospital categoryCase type of illness (A, B, C or D)

Covered by rule on single period of confinement Benefit also depend on:

Medical necessity supplies, x-ray, laboratory and ancillary procedures used during confinement are paid

Benefits per Use of Operating RoomPrimary Hospital

500 pesos

Secondary Hospital

RVU 30 and below 750 pesos

RVU 31 - 80 1,200 pesosRVU 81 – 600 (RVU x 15 PCF)

Minimum: 2,200 pesos Maximum: 7,500 pesos

RVU 81 – 146 2,200 pesos

RVU 147 – 500 2,205 – 7,500 pesos

RVU 501 - 600 7,500 pesos

Benefits per Use of Operating Room

Tertiary Hospital

RVU 30 and below 1,200 pesos

RVU 31 - 80 1,500 pesosRVU 81 – 600 (RVU x 20 PCF)

Minimum: 3,500 pesos

RVU 81 – 175 3,500 pesos

RVU 176 – 600 3,520 – 12,000 pesos

Professional FeeProfessional Fee

Daily Visit

Primary Hospital

A B

GP per day 300 400

Maximum per confinement

1,200 2,400

SP 500 600

Maximum per confinement

2,000 3,600

Secondary Hospital

A B C

GP per day 300 400 500Maximum per confinement 1,200 2,400 4,000

SP 500 600 700Maximum per confinement 2,000 3,600 5,600

Tertiary Hospital

A B C D

GP per day 300 400 500 600Maximum per confinement 1,200 2,400 4,000 6,000

SP 800Maximum per confinement 8,000

Maximum days per

confinement

A B C D

4 days 6 days 8 days 10 days

Surgeons’ fee depends on: RVU of the procedure

PCF depending doctor category (3 tier)

GP (40 pesos)Doctor with training (48pesos)Diplomates and Fellows of Specialty

Societies 56 pesos for RVU 500 and < 80 pesos for RVU 501 and >Doctors classified as GP shall be

compensated up to RVU 80 (3,200 pesos).

GPMD WITH TRAINING

DIPLOMATES AND FELLOWS

Type B, C Type D

PCF 40 48 56 80

Pyelotomy w/ exploration(100 RVU)

(4,000) 3,200*

4,800 5,600 -

Myomectomy; Open (150

RVU)

(6,000) 3,200*

7,200 8,400

Intracranial Surgery

(600 RVU)

(24,000)3,200*

28,800 - 48,000

* GP allowed only to do up to 80 RVU

2 or more procedures Payment of

surgeon

Done in one site or incision (whether by same or different surgeon)

Pay only thehighest RVU

Done in separate site or incision (whether done in 1 operative session)

Pay all RVUs

Done on different dates (within or separate confinement)

Pay all RVUs

Anesthesiologist – 40% 0F BASELINE X PCF OF TIER OF ANESTHESIOLOGIST

Anesthesiologist’ fee depends on: RVU of the procedure PCF depending doctor category (3 tier)

GP (40% of the baseline surgeon’s fee)MD with training (48% baseline)Fellows/diplomates (56 % baseline for RVU 500 and <)

Doctors classified as GP shall only be compensated up to RVU 80 (1,280 pesos).

Payment of anesthesiologist is independent of surgeons’ specialty.

Table 1: List of Procedures and Services that are Limited to Specific Categories of Doctors

Procedures and ServicesClaims

Code GroupDiplomate or Fellow

Preoperative inpatient

consultation (Code 99256 – 99360)

1201Philippine Academy of Family Physicians

1202 Philippine College of Physicians

1203 Philippine Pediatric Society

1210 Philippine Neurological Association

Pathology services(Code 88174 – 88332)

1206 Philippine Society of Pathologist

Radiology services(Code 70010 – 77789

except 75757)1207 Philippine College of Radiology

Fluorescein angiography (Code 75757)

1304Philippine Academy of Ophthalmology

CURRENT YEAR’S GROSS INCOME

PFPHILHEAL

TH PAYMENT

EXPANDED WITHOLDIN

G TAX (EWT)

PERCENTAGE TAX (PT)(GROSS/

1.12 X 5%)

TOTAL TAX (EWT + PT)

PF NET OF TAX

BELOW 720,000 WITH SWORN

16,000

(GROSS /1.12 X 10%)

1,428.57

714.29 2,142.86 13,857.14

ABOVE 720,000 OR NO SWORN

16,000

(GROSS/1.12 X 15%)

2,142.86

714.29 2,857.14 13,142.86

CURRENT YEAR’S GROSS INCOME

PFPHILHEAL

TH PAYMENT

EXPANDED WITHOLDIN

G TAX (EWT)

PERCENTAGE TAX (PT)(GROSS X

3%)

TOTAL TAX (EWT + PT)

PF NET OF TAX

BELOW 720,000 WITH SWORN

16,000(GROSS X

10%)1,600.00

480.00 2,080.00 13,920.00

ABOVE 720,000 OR NO SWORN

16,000(GROSS X

15%)2,400.00

480.00 2,880.00 13,120.00

Issuance of OR for received PhilHealth payments:

Circular 24, s-2005Doctors should issue OR to PhilHealth upon

receipt of reimbursement

DKTM

Case Rates – Surgical ProceduresCases Rates

1 Radiotherapy 3,000

2 Hemodialysis 4,000

3

Maternity Care Package (MCP) 8,000

NSD Package in Level 1 Hospitals 8,000

NSD Package in Levels 2 to 4 Hospitals 6,500

4 Cesarean Section 19,000

5 Appendectomy 24,000

6 Cholecystectomy 31,000

7 Dilatation & Curettage 11,000

8 Thyroidectomy 31,000

9 Herniorrhapy 21,000

10 Mastectomy 22,000

11 Hysterectomy 30,000

12 Cataract Surgery 16,000

Case Rates – Medical CasesCases Rates

1 Dengue I (Dengue Fever and DHF Grades I & II) 8,000

2 Dengue II (DHF Grades III & IV) 16,000

3 Pneumonia I (Moderate Risk) 15,000

4 Pneumonia II (High Risk) 32,000

5 Essential Hypertension 9,000

6 Cerebral Infarction (CVA I) 28,000

7 Cerebral Hemorrhage (CVA II) 38,000

8 Acute Gastroenteritis (AGE) 6,000

9 Asthma 9,000

10 Typhoid Fever 14,000

11Newborn Care Package in

Hospitals and Lying-in Clinics1,750

Pursuant to Board Resolution No.1441 s.2011Case payment mechanism for the most common

medical and surgical conditions (49% of total claims)

“No Balance Billing Policy” (NBB)

Improve turn-around time for claims processing and payment

Case payment shall be the new reimbursement for all the specified cases

Applies to all claims by eligible PhilHealth members and dependents

Reimbursed directly to the facility

Rates are inclusive of payment to all doctors

Computation of doctors’ PF: Medical : 30% of rate Surgical : 40% of rate

Hospitals shall act as the withholding tax agent for PF

Government hospitals PF governed by the existing rules on pooling (Sec 35 of RA 7875 as amended and its IRR and PC No. 27 s-2009)

1. Provide correct RVS and/or ICD-10 codes in Claim Form 2

2. Reimbursement shall be based on main condition (PC No. 04, s-2002)

3. Rule on 45-day limit per calendar year applies• For hemodialysis and radiotherapy, one (1) day shall be

deducted• Outpatient Malaria and HIV-AIDS packages, apply rule on 45-

day limit• TB-DOTS excluded from the 45-day limit

4. Shall follow the rule on single period of confinement

• Except for hemodialysis and radiotherapy per session

“No Balance Billing” Policy shall

mean that no other fees or

expenses shall be charged or paid

for by the patient-member above

and beyond the packaged rates.

Shall be applied to ALL SPONSORED Program members and/or their dependents for the specified cases under the following conditions:

1. When admitted in government facilities/ hospitals.

2. When claiming reimbursement for outpatient surgeries, hemodialysis and radiotherapy performed in accredited government hospitals and all non-hospital facilities (e.g. FDCs, ASCs)

3. Claims for reimbursement of Sponsored members and/or their dependents availing of the following

existing outpatient packages:a) TB DOTS (Php 4,000)b) Malaria (Php 600)c) HIV-AIDS (Php 7,500 /qtr or Php 30,000/yr)

All other existing policies/guidelines covering these packages shall remain in effect.

4. In support of Millennium Development Goals (MDG)

NBB policy shall apply to ALL PhilHealth members and their dependents regardless of

membership type in ALL Accredited MCP (non-hospital) providers

This shall cover claims for MCP and NCP

Facility should purchase necessary items/services in advance on behalf of the member if drugs, supplies, or diagnostic procedures are not available.

Out-of-pocket payment (OOP) made by members shall automatically be deducted against claims of the hospitals (charged to case rates) with corresponding sanctions or penalties the Corporation may charge.

Require attachment of official receipt/s (ORs) for any OOP made by member (for hospital and/or professional fee)

If case rate was already paid in full to the facility; but the official receipts were not attached to the claim application,

the member may request for re-adjustment within 6 months from date of discharge

This may be paid to the member provided necessary evidence of payment is submitted

It shall be charged to future claims of the health facility with corresponding sanctions or penalties

For Claims Not Covered by NBB and Case Rate

For Claims of PhilHealth members not covered by NBB Policy

The benefit shall be deducted from the total actual charges, with the remaining amount to be charged to the member as out-of-pocket payment.

Example: Acute Gastroenteritis = Php 6,000

Total Actual Charges

PhilHealth Benefit Co-Payment of member

Php 9,000 Php 6,000 Php 3,000

For all other claims:

Fee-for-Service Scheme

Based on Benefit Table

Filed within 60 days from date of discharge

Still requires ALL existing documents and information

Properly accomplished Claim Form 2

Correct RVS/ICD 10 code appropriate for the package

Claims with incomplete documents shall be returned for completion

May be re-filed within 60 days from receipt of notice otherwise it shall be denied

Hospitals to segregate claims with separate transmittals as follows:

1. Case Payment claims

2. Fee-for-service claims

Specific Rules Per Package

AUGUST 2011

Case rate directly paid to the facility40% of rate is for PF except for hemodialysis

Allowed only in L2 to L4 facilities, but some may allowed in other facilities:

Completion curettage : L1Fractional curettage : L1, ASC

Herniorrhapy : ASCLaparoscopic chole : ASCCataract : ASCHemodialysis : FDC

Radiotherapy : L3 to L4 only

Emergency procedures in L1 hospitals:Pay as RVU 30 under FFS

Non-emergency cases shall be deniedClaim Form 3 required for all claims

Lateral procedures within same confinement or different confinement

within 90 days pay as 1

2 or more surgical case rates in 1 confinement:

1 session pay higher package

Separate session pay all packages

Transferred patients:

Pay referral facility

Deny payment of referring facilityExcept for MCP in accredited birthing

facilities

Payment for the package shall be 8,000 divided as follows:

SERVICES COVERED AMOUNTa. Facility fee (including PF) 6,500b. Member’s prenatal care fee 1,500 TOTAL 8,000

The enhanced MCP shall be availed by members in non-hospital facilities accredited as providers of MCP.

NBB policy shall apply to all beds in accredited MCP providers.

Maternity Care Package59401

Prenatal care fee directly payable to memberNormal deliveries performed requiring

emergency and subsequent referral to higher facility is allowed

Referring facility (MCP provider) reimbursed fully

Referral facility reimbursed based on services rendered

No deliveries were completed by MCP facility due to complications:

MCP facility pay Php 650 (10% of facility fee) as reimbursement for services

provided

Payment for NSD shall be as follows:

HospitalsCost

Prenatal Care

Facility Fee (with PF)

TOTAL

L1 1,500 6,500 8,000

L2 to L4 1,500 5,000 6,500

Prenatal care fee directly payable to member

Payment for NSD shall be as follows:

Features: @19,000Not allowed in L1 hospitalsElective CS (per request) including repeat CS w/o indication non-reimbursiblePackage covers also (no add’l pay):

CS w/ BTL,

CS w/ appendectomy,

CS with adhesiolysis.

Features: @11,000This package is for:

L1 to L4 hospitals (58120, 58100, 59812, 59814)

ASC (58100, 58120)Excluded: evacuation of H-mole

Features: @30,000 This package also covers CS with

hysterectomy Not allowed in L1 and ASC Exclusions:

vaginal hysterectomy

hysterectomy for malignancy

Features: @22,000This package applies to surgery done in 1 or both breastL2 to L4 hospitals onlyRadical mastectomy (19200, 19220, 19240) is excluded from this package

Features: @31,000This package includes all procedures that removes a portion or the whole gland L2 to L4 hospitals onlyExclusion:

Removal of thyroglossal duct cyst

Removal of sinus

Removal of parathyroid

Features: @24,000This package applies to all appendectomy procedures including laparoscopic appendectomyL2 to L4 onlyElective appendectomy is non-reimbursible (also denied under FFS)Appendectomy following exploratory laparotomy is paid as exploratory laparotomy (FFS)

Features: @31,000This package applies to all cholecystectomy procedures, including laparoscopic cholecystectomyL2 to L4 only, laparoscopic cholecystectomy allowed in ASCs

Features: @21,000This package covers unilateral or bilateral proceduresAlso includes repair of abdominal and femoral herniaNot allowed in L1Allowed in ASC for repair of reducible, non-incarcerated or non-strangulated hernia

Features: @4,000 per session

Outpatient hemodialysis

Includes payment for PF (Php500), dialyzer and epoetin

Not allowed in L1 and ASC

Excluded (pay under FFS):Hemodialysis during confinements

Peritoneal dialysisTreatment of acute renal failure

Creation of fistula

Features: @3,000 per sessionOutpatient radiotherapy onlyThis package cost is per session onlyAllowed in L3 and L4 onlyExclusions:

Treatment planning

Brachytherapy

Stereotactic surgery

Features: @16,000Covers cataract extraction proceduresAllowed in ASC, L2 - L4 onlyDone in an outpatient or inpatient set-up regardless of number of days of confinementCharge 1 day from 45-days limitCovered by single period of confinement

Case rate directly paid to the facility30% of rate is for PF

Reimbursement will be based on main conditionIll defined diagnoses (T/C, R/O, probable, suspected) in the final diagnoses shall be denied even under FFSClaim Form 3 required

Provide correct ICD 10 codes up to the last character requirement

Transferred patients:

Pay referral facility

Deny payment of referring facilityoExcept for MCP in accredited birthing

facilities

The package shall be increased to 1,750 pesos It shall include the following services:

1. Essential newborn care (Immediate drying of the newborn, early skin-to-skin contact, cord clamping, non-separation of mother/baby for early breastfeeding initiation, eye prophylaxis, Vit. K administration)

Newborn Care Package99432

BCG vaccination,Hepatitis B immunization (1st dose), Professional fee (including breastfeeding advise and physical examination of the baby, among others)

2. Newborn screening test (NBS)

3. Newborn hearing screening test


If services were not provided completely or if member was asked to purchase medicines or access services outside the facility It shall be reimbursed to the member based

on the OR attached and deducted from the payment to the facility


If package was paid in full to the facility but upon post-audit services were not completely given, these shall be charged to future claims of the health facility with corresponding sanctions or penalties the Corporation may charge.

All NCP claims are covered by NBB


Features: @8,000 This package covers Dengue Fever and Dengue Hemorrhagic Fever Grades I and IIFor L1 to L4 hospitals

Denied (even on fee-for-service):

Undifferentiated fever

Asymptomatic dengueRequired tests: platelet count, Hgb & Hct

Features: @16,000This package covers Dengue Hemorrhagic Fever Grades III and IV

Presence of shockFor L2 to L4 hospitals

Dengue II managed in L1 TO BE paid as Dengue I

Required tests: platelet count, Hgb & Hct

Dengue IIA91.2, A91.3

I. PEDIA PNEUMONIA

DIAGNOSIS(Pedia) ICD-10 CODE Case rate Package

PCAP A (minimal risk J18.90 Denied even in

PCAP B (lLow risk) J18.91 FFS

PCAP C ( Moderate Risk) J18.92 Pneumonia I

PCAP D(High Risk) J18.93 Pneumonia II

II. ADULT PNEUMONIA

DIAGNOSIS(Adult) ICD-10 CODE Case rate Package

CAP I(Low Risk) J18.91 Denied even in FFS

CAP II(Moderate Risk) J18.92 Pneumonia I

CAP III(High Risk) J18.93 Pneumonia II

Features: @15,000This package covers adult and pediatric cases with unstable vital signs and presence of co-morbid conditionFor L1 to L4 hospitalsDenied:

Low risk pneumonia (no payment even on FFS)

Required tests: chest X-ray

Features: @32,000 This package covers adult and pediatric

cases with unstable vital signs and presence of co-morbid condition PLUS shock or signs of

hypoperfusion: Hypotension I95.9

Hypercapnea R06.4Hypoxia I24.8

Pneumonia II claims without additional codes for signs of shock or hyperperfusion shall be

reimbursed as Pneumonia I for L2 to L4 hospitals; L1 to be paid as Pneumonia I

Required tests: chest X-ray

Features: @9,000 This package covers hypertensive emergency cases requiring admissionExclusion (to be paid under FFS):

Hypertension involving vessels of the brain, eye

Cases of secondary hypertension

CVA I (Infarct)Features: @28,000 This package covers

infarct I63.-, I64.- L1 to L4 Requirements:

1. neuro exam

CVA II (Bleed)Features: @38,000 This package covers

hemorrhage I60.- I61.-, I62.-

L2 to L4 CVA II in L1 hospitals to be

paid as CVA I Requirements:

1. neuro exam, 2. CT Scan

Exclusions:1.CVA requiring neurosurgery2.TIA (G45.9), occlusion stenosis not resulting to infarction I65 – I69

Features: @9,000This package covers persistent and severe cases of asthma requiring admission in adult and pedia Excluded (pay as FFS): status asthmaticus (J46) as well as ICD 10 Codes: J82, J60-J70 Denied (even on FFS): asthma not in acute exacerbation

Features: @14,000 This package covers:

Typhoid and paratyphoid fever Other salmonella infection Typhoid (infective) psychosis

L1 to L4 Exclusion (pay as FFS): typhoid ileitis

requiring surgery Requirement: result of typhidot or Widal

test

Features: @6,000This package covers (infectious/non-infectious) diarrhea with

moderate or severe dehydration; &, patients who remain dehydrated despite initial treatmentChildren with bloody diarrhea and severe

malnutrition Denied:

AGE with NO or SOME signs of dehydration (no pay even on FFS)

Features:Required additional codes:

E86.1 - moderate dehydrationE86.2 - severe dehydration

Absence of additional codes - DENIEDRequired diagnostic: fecalysis or culture

Top 20 illnesses ranked by Number of Claims Paid

September 2011-April 2012

SOURCE: PHILHEALTH N CLAIMS DATABASE Extracted date: May 8, 2012

RANK Description NO OF CLAIMS AMOUNT PAID

1 HEMODIALYSIS 111,270 432,013,770.42

2 ACUTE GASTROENTERITIS (AGE) 32,994 197,321,923.28

3 PNEUMONIA I 28,320 423,129,327.56

4 NSD 16,233 83,112,660.24

5 NCP 14,860 23,974,558.32

6 CAESARIAN SECTION 14,265 269,885,467.04

7 RADIOTHERAPHY 13,285 36,223,168.98

8 ESSENTIAL HYPERTENSION 13,174 117,985,361.80

9 CATARACT 10,777 172,220,658.67

10 ASTHMA 7,855 70,389,360.49

11 DENGUE I 7,451 59,260,427.58

12 DILATION AND CURETAGE 6,003 65,340,127.88

13 TYPHOID FEVER 4,908 68,509,585.70

14 MCP 4,388 33,090,617.23

15 CHOLECYSTECTOMY 3,064 94,404,975.77

16 CVA I (INFARCTION) 2,958 81,652,434.91

17 APPENDECTOMY 2,748 65,675,149.63

18 HYSTERECTOMY 1,602 47,828,863.30

19 HERNIORRHAPY 1,054 22,022,076.95

20 THYROIDECTOMY 770 23,717,528.11

Late filing = 17% Inconsistent data on forms

submitted = 4.37%

Documents must be submitted within 60 days from discharge:

PhilHealth Form 1 (member & employer) PhilHealth Form 2 (doctor & hospital) PhilHealth Form 3 (doctor & hospital as

required in primary hospitals)

Not accredited hospital = 11% < 24 hours confinement, non “E”

= 1.2%

confinement in an accredited hospital of not less than 24 hours

> 45 days allowance, benefit exhausted = 10.21%

Lack of qualifying contribution = 1.10%

the 45-days allowance for room and board has not been consumed yet

at least 3 consecutive monthly contributions within the immediate 6 months prior to admission

Non-compliance to RTH request = 5.25%

Claims with incomplete requirements shall be returned to the facility and must be complied within 60 days

Non-compliance shall cause denial of claim

Most Common Reasons of RTH

OB Record/OR Record/Surgical Record/Anesthesia Record 10,945 31.18

Not properly accomplished PhilHealth Forms 1, 2 & 3 6,493 18.5

Submit PhilHealth Form 3/Clinical Chart 2,860 8.14

Birth Certificate of Member 2,081 5.93

Submit affidavit (dependents) 1,606 4.57

Hospital waiver/Official Receipts 1,529 4.35

Duly validated MI-5 (applicable qtr.) 1,498 4.26

PhilHealth ID Card (Sponsored and NPM) 1,460 4.16

Birth Certificate of patient (No MDR) 1,203 3.43

13013011-9805998-7-9805998-7 13013011-0200190-3-0200190-3

Dr. Edgardo R. Cortez◦ MD◦ Cutting Specialist◦ PCS

Dr. Genevieve P-Evangelista◦ MD◦ Cutting Specialist◦ PCS

12121010-9501093-8-9501093-8

• Dr. Joven R. Cuanang– MD– Non-Cutting Specialist– PNA

12012077-9804494-1-9804494-1

• Dr. Angelito Tingcungco– MD– Non-Cutting Specialist– PCR

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Compliance MonitoringPhilHealth shall regularly monitor compliance with implementing

guidelines to be issued Penalties and Sanctions

Violators shall be meted the appropriate sanctions and penalties available to the Corporation

Violators shall be included in the Provider Assessment Monitoring System (PAMS) and will be subjected to warranties of accreditation

Shall be reported to DOH and/or PRC for appropriate action, when necessary

Periodic Review, Evaluation and AdjustmentsCase rates, processes and the No Balance Billing policy shall be

subjected to regular evaluation and adjustments, as necessary

To be done 6 months after effectivity, then yearly thereafter

Health & Medicine

Case rates presentation gen rules