Inpatient Benefits
• These benefits are paid to the accredited Health Care Institution (HCI) through All Case Rates
• The case rate amount shall be deducted by the HCI from the member’s total bill, which shall include professional fees of attending physicians, prior to discharge
• The case rate amount is inclusive of hospital charges and professional fees of attending physician
• Documents needed: copy of Member Data Record or PhilHealth Benefit Eligibility Form (PBEF) and duly accomplished PhilHealth Claim Form 1
• Where available: all accredited HCIs*
*Different case rate amounts for selected medical conditions are being implemented when done in Primary Care facilities (PhilHealth Circular 14, s-2013)
• Only admissible cases shall be reimbursed
Outpatient Benefits
1. Day Surgeries (Ambulatory Or Outpatient Surgeries) Are Services That Include Elective (Non-Emergency) Surgical Procedures Ranging From Minor To Major Operations, Where Patients Are Safely Sent Home Within The Same Day For Post-Operative Care
• Payments for these procedures are made to the accredited facility through All Case Rates
• The case rate amount shall be deducted by the HCI from the member’s total bill, which shall include professional fees of attending physicians, prior to discharge
• The case rate amount is inclusive of hospital charges and professional fees of attending physician
• Documents needed: copy of Member Data Record and duly accomplished PhilHealth Claim Form 1
• Where available: Accredited Ambulatory Surgical Clinics (ASCs)
2. Radiotherapy
• The case rate for radiotherapy using cobalt is P2,000 per session and P3,000 per session for linear accelerator
• Includes radiation treatment delivery using cobalt and linear accelator
• Claims for multiple sessions may be filed using one (1) claim form for both inpatient and outpatient radiation therapy
• May be availed of even as second case rate (full case rate amount)
• 45 days benefit limit: One session is equivalent to one day deduction from the 45 allowable days per year
• If procedure is done during confinement, only the total number of confinement days shall be deducted
• Exempted from Single Period of Confinement (SPC) rule (admissions and re-admissions due to same illness or procedure within 90-calendar day period)
• Where available: Accredited HCIs including Primary Care Facilities that are accredited for the said service
3. Hemodialysis
• The Case Rate for hemodialysis is P2,600 per session
• Covers both inpatient and outpatient procedures including emergency dialysis procedures for acute renal failure
• Claims for multiple sessions may be filed using one (1) claim form for both inpatient and outpatient hemodialysis
• May be availed of even as second case rate (full case rate amount)
• 90 days benefit limit: One session is equivalent to one day deduction from the 90 allowable days per year
• If procedure is done during confinement, only the total number of confinement days shall be deducted
• The procedure is exempted from Single Period of Confinement rule (admissions and re-admissions due to same illness or procedure within 90-calendar day period)
• Where available: All Accredited HCIs – this benefit is no longer restricted to hospitals and free standing dialysis centers provided that the service is within their capability as provided for in the DOH license
4. Outpatient Blood Transfusion
• The case rate for outpatient blood transfusion is P3,640 (one or more units)
• Includes Drugs & Medicine, X-ray, Lab & Others, Operating Room
• Covers outpatient blood transfusion only
• One day of transfusion of any blood or blood product, regardless of the number of bags, is equivalent to one session
• May be availed of as second case rate (full case rate amount)
• 45 days benefit limit: One session for each procedure is equivalent to one day deduction from the 45 allowable days per year Exempted from the SPC rule
• Where to avail: All Accredited HCIs
View Benefits Page here
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