Wednesday, September 23, 2009


When you are age 21 and unexpectedly get hospitalize, you cannot avail of PhilHealth benefits because perhaps you are neither a member nor can be covered under your parents’ PhilHealth.

But still you can take option for the continuance of PhilHealth coverage if you enroll or shift to Individually Paying program.

Most enrollee in the group are newly graduated professionals who are not yet employed, medical, law and graduate students, seminarians, priests, ministers, media practitioners and self-employed professionals.

Premium is at affordable rate of100 pesos per month. After a quarter of membership or in the 4th month thereto, enrollee becomes eligible to avail PhilHealth benefits for some medical related treatment except for maternity care benefits and certain elected surgical cases, that a sufficient regularity of payments that is, payment of 3-quarters prior confinement is observably required.

Upon application, prospect member will just present their birth certificate, an original copy to be authenticated by Philhealth frontline staff. In its absence, presentation of baptismal certificate or any two valid IDs maybe done for registration. Applicant must remit the initial contribution of P300 for the outright issuance of PIN and MDR.

As to the mode and easiness of payment, a member can pay by quarter which has its deadline on the last working day of applicable quarter, or post an advance semi-annual or annual remittance. The member or its representative may opt to pay at any of PhilHealth Service Office, accredited Banks or MLhuiller branches within Region VI, as its authorized collecting agents.

Member contracting marriage, can then register his/her spouse to become a dependent and later with the consequent offspring. Only direct family members can be included as dependents, which include parents who are at least 60 years old, provided such dependent is totally dependent from member for support. (Larry T. Tabsing)

PF of Government Salaried Physicians

Professional fees (PF) paid by PhilHealth for salaried physicians in government or private training hospitals are pooled for hospital personnel. It has been a policy that the services of the accredited medical practitioners are paid even though they are employed by the government. PFs’ total amount are pooled to form as additional remuneration equally shared by every hospital staff so as in return will offer better services towards PhilHealth patients. Disposition of such is left to the discretion of hospital management or the hospital chief.

In claiming PhilHealth benefits, physician who actually rendered the service must be the signatory in the Claim Form 2 declaring therein that PF is payable to the director, administrator or hospital’s chief. However, the medical director, administrator (physician), chief of clinic or department heads can also sign for the government salaried physicians for as long as these are set aside for pooling, hence, maybe compensated.

Computation of benefits like daily visit shall be based on rate for non-specialists according to what is prescribed in the New Benefit Schedule. While the Peso Conversion Factor (PCF) of 40 shall be used in the computation of professional fee regardless of the accreditation category of the medical director, administrator, etc. except when the said medical director is also the provider of the service as reflected in the operative record, OB sheet or endoscopy report. With this, computation of professional fee is based on the accreditation category of the subject physician-signatory.

To this effect, PhilHealth has prescribed the list of procedures and services which are limited to the specified subclass of doctors. Preoperative Inpatient Consultations are either done by physician who is a diplomate or fellow of Philippine Academy of Family Physicians, College of Physicians, Pediatric Society or Neurological Association. Same is required to radiology services that need to be a fellow or diplomate member of Philippine College of Radiology and for procedures of flourescein angiography from the Philippine Academy of Ophthalmology.

Claims for PF of the above services provided by doctors who are not authorized to render such services are disallowed. Doctors providing surgery or anesthesia services who are classified as general practitioners based on maximum of 80 Relative Value Unit (RVU) for surgeries and RVU –linked services on secondary and tertiary classified hospitals, that is, 3,200 pesos for surgeries per RVU services and 1,280 pesos for anesthesia services and exempted from this rule are government salaried physicians and payment for PF is for pooling. (Larry T. Tabsing)

PhilHealth for Senior Citizens

Not all senior citizens are eligible to avail PhilHealth benefits unless one becomes a Philhealth enrollee - a voluntary member, a lifetime member or a dependent of a PhilHealth member.

“There are membership programs which are being provided for our elderly, for them to avail our PhilHealth benefits”, said Regional Vice President Alberto C. Manduriao.

Voluntary members under the Individually Paying program remit the monthly premium contributions while Lifetime members no longer need to pay. And some can be a dependent of their spouse or children.

Eligible members and their dependents avail benefits when confined at any accredited health care facilities for reasons of illness or injury and for undergoing compensable out-patient procedures.

According to Dr. Royce S. Reyes, Chief of Benefit Administration Section of PhRO VI, the commonly filed claims applications for them were illnesses of renal, cardio-vascular and respiratory. Cases like hypertension, diabetes which sometimes resulted to a chronic renal disease and require dialysis sessions.

“Other patients were admitted because of complications like pneumonia and chronic obstructive pulmonary disease”, Reyes noted, “and these are classified under the New PhilHealth Inpatient Benefit Schedule as case Type C”.

When admitted at a Tertiary Hospital under case type C, a member in a single period of confinement may avail a maximum of P28,000 for drugs and medicines; P21,000 for laboratory and supplies. The accredited doctor’s visit is paid at a maximum of P4,000 for General Practitioner and P5,600 when the physician is a Specialist.

Other examples of Case Type C are cerebro vascular disease or stroke, carcinomas with metastasis or even undergoing chemo and radio therapy. The OR fee is pegged at P1,200 per session and Professional Fee for accredited Specialist is at P560 per session.

This ceiling of benefit can also be availed in case of death without a specified caused during confinement. Payment will depend on the actual compensable items incurred by the patient.

However, there are conditions specified by PhilHealth (National Health Insurance) law and this must be construed in relation to other special laws. To become a Lifetime member, one must meet the twin requirements - the age and the contribution factors.(Larry T. Tabsing)


No PhilHealth Identification Number (PIN) - No Claim, a strict policy that will be implemented in CY 2010.

As early as of this time, PhilHealth instituted measures to lead members in complying with this personal and unique requirement. A Regional Advisory was issued to enjoin compliance in advising all Accredited Collecting Banks and Agents like MLhuiller to refer all paying members/employers with No PIN/PEN directly to PhilHealth Office to secure the same.

Subject of this advisory are Employed and OFWs and some Individually Paying Members. An applicant needs only to fill out a request form, submit and wait for the immediate issuance of his/her PIN. While it allows the Employer’s Admin/HR or liaison officers to facilitate on behalf of their employees, personal transaction is encouraged especially when they have to update record of their dependents. Aside from the PIN, PhilHealth also requires Member Data Record (MDR) especially when availing benefits.

PhilHealth observed that among the employed sector, most Private Employers neither have their PhilHealth Employer Number (PEN) nor PIN of their employees. From the government, it is obvious that most of the teachers, military and police personnel have not yet secured their PIN.

As a current policy, PhilHealth allows the use of SSS and GSIS policy number in posting the member’s premium contribution payments as well as in claims filing.

The clean up utility mapping drive by PhilHealth VI Contribution Section revealed that more than 7,000 registered employees have no PIN. Unfortunately, considerable quantity of those requesting for MDR are members with confinement who apply for their PhilHealth Identification Number only during such request.

As to OFWs, those who hastily left the country for work did not have their PIN for only the registration process was complied by them.

Under the Universal Counter System of PhilHealth (all-in-1 system), member may approach any of our Service Offices and all their concerns are set to be acted directly.

A member can invoke his/her rights to PhilHealth but along these rights is an attached responsibility, one of this is applying for Philhealth Identification Number (PIN). (Larry T. Tabsing)

Benefit Packages

A SEPARATE transmittal is now required to Health Care Providers (HCP) in filing PhilHealth Packages apart from the regular claims to hasten the turn around time of processing.

PhilHealth Regional Office (PhRO) VI issued an Advisory effective June 1, 2009. It also directed that Professional Fee (PF) whether actual, deducted or net should be included in the Statement of Account or Billing Statement to ensure that reimbursements are provided to the rightful beneficiary for the PF. This shall be added prior to the signature of the member or the authorized representative confirming or concurring thereto.

PhilHealth Packages are derived from Maternity Care - Normal Spontaneous Delivery (MCP-NSD), Newborn Care (NCP), Voluntary Surgical Contraception Procedures, TB-DOTS, and Cataract claims. Other benefit packages are Outpatient Malaria, Severe Acute Respiratory Syndrome (SARS), Avian Influenza (Bird Flu) and Swine (H1N1) Flu.

Payments under the schemes are generally made to the accredited health care providers, facilities and professionals, for the supposed complete services to PhilHealth beneficiaries.

MCP covers 1st to 4th normal spontaneous deliveries both in hospital and non-hospital maternity facilities for a case rate of P4,500. (Non-hospital facility: P3250 for pre- natal, delivery & newborn care +P850 for post-natal and family planning. For hospital - P2,500 for room and board, drugs and medicines, diagnostic and OR fee; P2,000 for health care professional).

NCP rate is P1,000 which covers the newborn screening (P500), 1st dose of Hepa B (P250) and vaccination, BCG and others (P250).

TB-DOTS Package on the other hand, has a case payment of P4,000. Of which, P2,500 is paid after the intensive phase and P1,500 is given after the maintenance phase under eligibility criteria that the TB case is new or the patient neither had a treatment for TB nor has taken up TB drugs for less than one month; it has smear positive or negative pulmonary TB or extrapulmonary TB; and TB of children. Excluded to the package are cases of failure on previous treatment, relapse or return after default.

Cataract Package case rate is P16,000 - P8,000 for charges on room, drugs, meds, supplies including intraocular lens, x-ray, laboratory & ancillary procedures and use of OR complex and machines while the other P8,000 is paid to the doctor. Pre-operative tests done prior the confinement, consultation and physician standby service, PF for anesthesia service and complex cataract surgery (RVS code 66982) requiring techniques not generally used in routine cataract surgery or performed in amblyogenic developmental stage are excluded.

Voluntary Surgical Contraception Procedures, Bilateral Tubal Ligation (BTL) and Vasectomy has a case payment of P4,000. The component of which is P3,000 for the facility services and P1,000 for physician to cover family planning counseling and client assessment, intraoperative service services including provision of anesthesia and postoperative consultation procedures including management of complications.

Wednesday, September 9, 2009

The Philhealth 60 days

The Philhealth 60 days
The 60day period is considered as quiet to be a long time for those awaiting for PhilHealth refund, however, a number still fails to beat the prescriptive limit. Under the policy, filing for local confinement is within 60 days and 180 days for confinement abroad. Late claims are simply, denied.

This period is prescribed by the national health insurance law. Bonafide member and their dependents can automatically avail benefits from any of the accredited facilities after presenting eligibility standard to avail medical care attention.

Actually, PhilHealth unlike other insurances extends to patient all the Philhealth benefits outrightly. One needs not to wait the 60 day when he can immediately charge to PhilHealth certain in and out-patient hospital supplies and services.

The very essence of hospitals is to provide medical services including drugs, medicines and supplies, diagnostics, laboratory and medical procedures and equipment. It is not pleasing but there are facilities that are claiming for the room & board and doctor’s fee but failed to provide other benefit items required for medication. So, one has to buy items outside and later claim the reimbursement from PhilHealth.

Lack or limited supplies and services aside from delimiting and overpricing of stocks when one has to charge it to Philhealth have been an issue raised against our health care providers. However, we have to note that PhilHealth pay claims of outside bought items and services. The option to what facility or health care professional PhilHealth patient would sought for treatment is on member’s discretion. Member should only remember that he has to file his claim within 60 days.

A member should also determine what items with the corresponding amount deducted from his billing before paying the uncovered amount. The official receipts both from the facility and the attending doctor are need to be asked by the member so that he has the evidenced records of all the actual medical expenses including the benefits availed.

PhilHealth does not pay for all your health care costs. It pays only for covered items and services when its rules are met. Members usually give a co-payment for the portion of the actual cost that is not covered by PhilHealth. As to medicines rules set that they must be generic and/or included in the PNDF. It innovates to give a lee way that drugs, medicines, supplies and necessary laboratory procedures supported by official receipts dated 30 days prior to admission can now be reimbursed like those in hemodialysis, peritoneal dialysis, chemotherapy and other elective surgeries.

Our partner-health care providers from time to time are keep updated of the latest issuances and various activities have been undertaken to promote close coordination. We establish a mechanism feedback for PhilHealth clients to air their grievances against PhilHealth staff and/or any of its stakeholders. (Larry T. Tabsing)

PhilHealth- CSR of ILECO 1

PhilHealth- CSR of ILECO 1

Iloilo Electric Cooperative (ILECO) 1 enrolled their member-consumers to the National Health Insurance program. As such, it will shoulder the yearly premium contributions. Under sponsored program, premium is shared by the Sponsor with the counterpart paid by the government thru PhilHealth.

Initially, ILECO 1 prioritized the head of the family so that all the qualified immediate kin can also benefit the social health program.

15 LGUs under its jurisdiction were tasked and became signatories to the tripartite Memorandum of Agreement forged with ILECO1 and PhilHealth. Their social welfare office identified indigent members screened through the conduct of means test. Part of the requirements was the passage of LGU Resolution adopting the program and every LGU supported the project.

Under the program, members with their dependents can avail PhilHealth benefits during the effectivity of their Philhealth cards. There are 694 PhilHealth ID card turned-over by PhilHealth to ILECO 1 and these will benefit around 4,000 beneficiaries this year.

Aside from the regular hospital benefits, sponsored members and dependents can avail free consultation and diagnostic procedures from Rural Health Units, avail 1st to 4th normal delivery package from accredited Maternity Centers and free tuberculosis treatment from any of the accredited TB-DOTS Center. Above to this, a Capitation Fund will be doled out by PhilHealth to the LGUs - 300 pesos per sponsored member to augment RHU medical finances in catering the needs of indigent PhilHealth patients.

During the MOA signing held last September 4, 2009 LCEs attended were mayors or their representatives. But the following LCEs took effort to be physically present and these include Vic Tabaquirao of Tubungan, 2nd district mayors, Arcadio Gorriceta of Pavia and Greg Villarico of San Miguel and Mayor Ramon Yee of Cabatuan. The rest had their representatives except for Tigbauan and Oton, while Mayor Ninfa Garin who earlier sent VM Aquiles Alcalde and their SBs, Cristine Garin of Guimbal and Juliet Flores of Miagao joined later.

MOA assignatories were ILECO 1 President Atty. Salvador P. Cabaluna III, RVP Alberto C. Manduriao for PhilHealth and the respective Local Chief Executives (LCE).

Witnessing the event were the members of the electric cooperative board together with its employees, and Engr. Raynaldo Sobusa who consistently made coordination for its realization.

“There is no politics here”, emphasized by Engr. Wilfred Billena, ILECO 1 General Manager, “we are just doing our Corporate Social Responsibility (CSR) to help our stakeholders”, he added. He pledged to continue this endeavor and assured to increase their beneficiaries next year.

“It’s the 1st in Region VI and we are very happy that this program is recognized as vehicle for Corporate Social Responsibility, a new trend in management, especially by ILECO 1 institution”, Lourdes F. Diocson, PhilHealth Field Operation Chief explained. (Larry T. Tabsing)