Tutorials

II. Requirement for submission of claims for reimbursement

A. When claiming for reimbursement: Tranche 1

Checklist of Mandatory Services and other services (Annex C1)

B. When claiming for reimbursement: Tranche 2

Checklist of Mandatory Services and other services (Annex C2)

C. When claiming for reimbursement: Tranche 3

Tranche Requirements Checklist (Annex E3)

Checklist of Mandatory Services and other services (Annex C3)

Annex H: Transmittal Form

Breast Cancer

I. Requirements when filing claims for Diagnostic Tests and Prognostication of Breast Cancer

Annex A.1: Checklist of Eligibility Criteria for Diagnostic Tests and Prognostication – Breast Cancer

Annex C.1. Checklist of Mandatory and Other Services for Diagnostics and Prognostication

Annex E.1. Checklist of Requirements for Reimbursement – Diagnostic Tests and Prognostication

II. Requirements for Pre-authorization

Annex A.2: Pre-authorization Checklist and Request Form

Annex B: Member Empowerment (ME) Form

III. Requirements for submission of claims for reimbursement

A. When filing claims for surgical procedure of breast cancer

Annex H: Transmittal Form

Annex C.2. Checklist of Mandatory and Other Services for Surgery

C. When filing claims for chemotherapy of breast cancer

Annex C.3. Checklist of Mandatory and Other Services for Chemotherapy

Annex E.3. Checklist of Requirements for Reimbursement – Chemotherapy

D. Hormonotherapy
D.1. When filing claims for Hormonotherapy: Tranche 1

Annex C.4.1. Checklist of Mandatory and Other Services for Hormonotherapy Tranche 1

Annex E.4.1. Checklist of Requirements for Reimbursement – Hormonotherapy Tranche 1

D.2. When filing claims for Hormonotherapy: Tranche 2

Annex C.4.2.Checklist of Mandatory and Other Services for Hormonotherapy Tranche 2

Annex E.4.2.Checklist of Requirements for Reimbursement – Hormonotherapy Tranche 2

E. Targeted Therapy
E.1. When filing claims for Targeted Therapy: Tranche 1

Annex C.5.1. Checklist of Mandatory and Other Services for Targeted Therapy - Tranche 1

Annex E.5.1. Checklist of Requirements for Reimbursement – Targeted Therapy Tranche 1

E.2. When filing claims for Targeted Therapy: Tranche 2

Annex C.5.2. Checklist of Mandatory and Other Services for Targeted Therapy - Tranche 2

Annex E.5.2.Checklist of Requirements for Reimbursement – Targeted Therapy Tranche 2

E.3. When filing claims for Targeted Therapy: Tranche 3

Annex C.5.3. Checklist of Mandatory and Other Services for Targeted Therapy - Tranche 3

Annex E.5.3. Checklist of Requirements for Reimbursement – Targeted Therapy Tranche 3

F. When filing claims for surveillance of breast cancer

Annex C.6. Checklist of Mandatory and Other Services for Surveillance

Annex E.6. Checklist of Requirements for Reimbursement – Surveillance

G. Patient transfer

Annex G: Checklist for Patient Transfer

Annex I: Letter of Intent for Transfer to a Contracted Health Facility

H. Sample Claim Form (CF) 2

Annex J.1. Diagnostic Tests or Prognostication

Annex J.2. Surgery

Annex J.3. Cytotoxic Chemotherapy

Annex J.4.1. Hormonotherapy Tranche 1

Annex J.4.2. Hormonotherapy Tranche 2

Annex J.5.1. Targeted Therapy Tranche 1

Annex J.5.2. Targeted Therapy Tranche 2

Annex J.5.3. Targeted Therapy Tranche 3

Annex J.6. Surveillance

I. Other Documents

Annex K: Pathway of the Benefits Availment of Z Benefits for Breast Cancer

Annex L: Breast Cancer Treatment Protocols

Annex M: Breast Cancer Medical Records Summary Form

Annex N: Outcome Indicators

Annex O: Guide on Co-payment Proposal of the Z Benefits Package for Breast Cancer

Coronary Artery Bypass Graft Surgery

I. Requirements for Pre-authorization

A. Pre-authorization Checklist and Request (Annex A)

II. Requirement for submission of claims for reimbursement

A. When claiming for reimbursement: Tranche 1

Checklist of Mandatory Services and other services (Annex C1)

B. When claiming for reimbursement: Tranche 2

Pre-authorization Checklist and Request Form (Annex A)

Cervical Cancer

I. Prior to availment of benefits

II. When filing claims for the surgery for cervical cancer stage IA1, IA2-IIA1

Checklist of Requirements for Reimbursement (Annex E1.1 – Cervical CA)

Checklist of mandatory and other services (Annex C1.1 – Cervical CA)

III. When filing claims for chemoradiation with cobalt and brachytherapy (low dose) for cervical cancer

Checklist of Requirements for Reimbursement (Annex E1.2 – Cervical CA)

Checklist of mandatory and other services (Annex C1.2 – Cervical CA)

IV. When filing claims for chemoradiation with linear accelerator and brachytherapy (low/high dose) for cervical cancer

Checklist of Requirements for Reimbursement (Annex E1.3 – Cervical CA)

Checklist of mandatory and other services (Annex C1.3 – Cervical CA)

A. Pre-authorization Checklist and Request (Annex A)

Colon Cancer

I. Requirements for Pre-authorization

II. Requirement for submission of claims for reimbursement

A. Stage I-II (low risk):

When claiming for reimbursement: Post-surgery Stage I-II (low risk) - (Single tranche)

Tranche Requirements Checklist (Annex E1.1)

Checklist of Mandatory Services and other services (Annex C1.1)

B. Stage II (high risk)- III

1. When claiming for Tranche , Post-surgery Stage II (high risk)- III

Tranche Requirements Checklist (Annex E1.2)

Checklist of Mandatory Services and other services (Annex C1.2)

2. When claiming for Tranche 2, Stage II (high risk)-III

Tranche Requirements Checklist (Annex E2.2)

Checklist of Mandatory Services and other services (Annex C2.2)

A. Pre-authorization Checklist and Request (Annex A)

Kidney Transplantation

I. Requirements for Pre-authorization

II. Requirement for submission of claims for reimbursement

A. When claiming for reimbursement: Tranche 1

Checklist of Mandatory Services and other services (Annex C1)

B. When claiming for reimbursement: Tranche 2

Laboratory Monitoring for Recipient and Donor Form (Annex C2)

A. Pre-authorization Checklist and Request (Annex A)

Peritoneal Dialysis (PD) First

I. Requirements for Pre-authorization

II. Requirement for submission of claims for reimbursement

A. When claiming for reimbursement: Tranche 1

Checklist of Services Provided (Annex C)

Photocopy of approved Pre-authorization and ME-Form

B. When claiming for reimbursement of succeeding tranche

Checklist of Services Provided (Annex C)

C. When claiming reimbursement of the last tranche

Checklist of Services Provided (Annex C)

Letter of Intent for Transfer to PD Center (Annex G)

PD Passport (Annex F)

Home Visit Questionnaire (Annex L)

PD Referral (Annex M)

Selected Orthopedic Implants

I. Requirements for Pre-authorization

Pre-authorization Checklist and Request for Hip Arthoplasty (Annex A1)

Pre-authorization Checklist and Request for Hip Fixation (Annex A2)

Pre-authorization Checklist and Request for Pertrochanteric Fractures (Annex A3)

Pre-authorization Checklist and Request for Femoral and Tibial Shaft Fractures (Annex A4)

Pre-authorization Checklist and Request for Total Knee Replacement (Annex A5)

Pre-authorization Checklist and Request for Upper Extremities (Annex A6)

Discharge Checklist for the Z Benefits - Tranche 1 (Annex C1)

II. Requirements for submission of claims for reimbursement (Tranche 1)

Checklist of Requirements for Reimbursement - Orthopedic Implants - Tranche 1 (Annex E1)

Transmittal Form of Claims for the Z Benefits (Annex H)

III. Requirements for submission of claims for reimbursement (Tranche 2)

Discharge Checklist - Orthopedic Implants - Tranche 2 (Annex C2)

Checklist of Requirements for Reimbursement - Tranche 2 (Annex E2)

Transmittal Form of Claims for the Z Benefits (Annex H)

Other Annexes

Outcome Indicator (Annex F)

Algorithm for Orthopedic Patient Surgical Pathway (Annex G)

Prostate Cancer

I. Requirements for Pre-authorization

A. Pre-authorization Checklist and Request (Annex A)

II. Requirement for submission of claims for reimbursement

A. When claiming for reimbursement: Tranche 1

Checklist of Mandatory Services and other services (Annex C)

A. Pre-authorization Checklist and Request (Annex A)

Rectal Cancer

I. Requirements for Pre-authorization

II. Requirement for submission of claims for reimbursement

A. Rectum Cancer Stage I (clinical and pathologic stage):

When claiming for reimbursement: Rectum Cancer Stage I (clinical and pathologic stage) - (Single tranche)

Tranche Requirements Checklist (Annex E1.1)

Checklist of Mandatory Services and other services (Annex C1.1)

B. Rectum cancer pre-operative clinical stage I with post-operative pathologic stage II - III

1. When claiming for Tranche 1, Rectum cancer pre-operative clinical stage I with post-operative pathologic stage II - III

Tranche Requirements Checklist (Annex E1.2)

Checklist of Mandatory Services and other services (Annex C1.2)

Satisfaction Questionnaire (Annex D)

2. When claiming for Tranche 2, Rectum cancer pre-operative clinical stage I with post-operative pathologic stage II - III

Tranche Requirements Checklist (Annex E2.2)

Checklist of Mandatory Services and other services (Annex C2.2)

Satisfaction Questionnaire (Annex D)

3. When claiming for Tranche 3, Rectum cancer pre-operative clinical stage I with post-operative pathologic stage II - III

Tranche Requirements Checklist (Annex E3.2)

Checklist of Mandatory Services and other services (Annex C3.2)

Satisfaction Questionnaire (Annex D)

C. Rectum cancer pre-treatment clinical stage II - III

1. When claiming for Tranche 1, Rectum cancer pre-treatment clinical stage II - III

Tranche Requirements Checklist (Annex E1.3)

Checklist of Mandatory Services and other services (Annex C1.3)

2. When claiming for Tranche 2, Rectum cancer pre-treatment clinical stage II - III

Tranche Requirements Checklist (Annex E2.3)

Checklist of Mandatory Services and other services (Annex C2.3)

3. When claiming for Tranche 3, Rectum cancer pre-treatment clinical stage II - III

Tranche Requirements Checklist (Annex E3.3)

Checklist of Mandatory Services and other services (Annex C3.3)

A. Pre-authorization Checklist and Request (Annex A)

Tetralogy of Fallot

I. Requirements for Pre-authorization

II. Requirement for submission of claims for reimbursement

A. When claiming for reimbursement: Tranche 1

Checklist of Mandatory Services and other services (Annex C1)

B. When claiming for reimbursement: Tranche 2

A. Pre-authorization Checklist and Request for VSD Closure (Annex A1) or

Ventricular Septal Defect Surgery

I. Requirements for Pre-authorization

Pre-authorization Checklist for VSD Closure with Associated Special Clinical Conditions (Annex A2)

II. Requirement for submission of claims for reimbursement

A. When claiming for reimbursement: Tranche 1

Checklist of Mandatory Services and other services (Annex C1)

B. When claiming for reimbursement: Tranche 2

Pre-Authorization checklist for Expanded ZMORPH for Upper and Lower Limb Prosthesis (Annex A)

ZMORPH

I. Prior to availment of the Benefit

II. Requirements for submission of claims for reimbursement

Tranche Requirements Checklist Discharge checklist of services (Annex C)

Checklist of Requirements for Reimbursement (Annex E)

Pre-Authorization checklist for Expanded ZMORPH for Upper and Lower Limb Prosthesis (Annex A1)

Expanded ZMORPH

I. Prior to availment of the Benefit

II. When filing for Tranche 1

Checklist of requirements for reimbursement (Annex E1-EMORPH)

Discharge Checklist for Expanded ZMORPH Tranche 1 for Lower Limb Prosthesis (Annex C1.1 - EMORPH)

Discharge Checklist for Expanded ZMORPH Tranche 1 for Upper Limb Prosthesis (Annex C1.2 - EMORPH)

III. When filing for Tranche 2

Checklist of requirements for reimbursement (Annex E2 - EMORPH)

Discharge Checklist for Expanded ZMORPH Tranche 2 (Annex C2-EMORPH)

Pre-Authorization Checklist for Expanded ZMORPH for Lower Limb Orthosis (Annex A2)

For Expanded ZMORPH for Lower Limb Orthosis

I. Prior to availment of the Benefit

ME Form (Annex B)

II. When filing for Tranche 1

Checklist of requirements for reimbursement (Annex E1-EMORPH)

Discharge Checklist for Expanded ZMORPH Tranche 1 for Lower Limb Orthosis (Annex C1.3 - EMORPH)

III. When filing for Tranche 2

Checklist of requirements for reimbursement (Annex E2 - EMORPH)

Discharge Checklist for Expanded ZMORPH Tranche 2 (Annex C2-EMORPH)

Pre-Authorization chcklist for Expanded ZMORPH for Spinal Orthosis (Annex A3)

For Expanded ZMORPH for Spinal Orthosis

I. Prior to availment of the Benefit

ME Form (Annex B)

II. When filing for Tranche 1

Checklist of requirements for reimbursement (Annex E1-EMORPH)

Discharge Checklist for Expanded ZMORPH Tranche 1 for Spinal Orthosis (Annex C1.4 - EMORPH)

III. When filing for Tranche 2

Checklist of requirements for reimbursement (Annex E2 - EMORPH)

Discharge Checklist for Expanded ZMORPH Tranche 2 (Annex C2-EMORPH)

Checklist of Eligibility Criteria (Annex A)

Premature or Small Newborns

I. Prevention of Complications of Preterm Delivery

Patient Registry Matrix (Annex B)

Checklist of Mandatory and Other Services for Prevention of Pre-term Delivery (Annex C1)

Checklist of Requirements for Reimbursement (Annex E1)

Coordinated Referral and Transfer Form (Annex G)

Other High Risks Conditions (Annex P)

WHO Partograph (Annex I)

II. Premature or Small Baby

Checklist of Eligibility Criteria (Annex A)

Patient Registry Matrix (Annex B)

Checklist of Mandatory and Other Services for Premature and Small Baby (Annex C2)

Checklist of Requirements for Reimbursement (Annex E2)

Coordinated Referral and Transfer Form (Annex G)

Essential Intrapartum and Newborns care (EINC) (Annex J)

WHO Partograph (Annex I)

Kangaroo Care Protocol Checklist (Annex K)

Field Survey Tool (Annex L)

Pre-Discharge Checklist (Annex M)

Pre-Discharge Counselling Services Checklist (Annex M1)

Post Mortem Care, Bereavement Support and Counselling Services Checklist (Annex M2)

Certificate of Medical Futility (Annex N)

Indicators for Medical Futility (Annex O)

Z Benefits for Children with Mobility Impairment

Prior to availment of the Z Benefits

A. Pre-authorization Checklist and Request (Annex A)

II. Assistive Device Provision, Training and Rehabilitation

A. When claiming for assessment, prescription, casting and measurement of the assistive device (1st Tranche)

Checklist of Requirements for Reimbursement (Tranche 1) (Annex E1)

Checklist of Mandatory Services Z Benefits for Children with Mobility Impairment (Tranche 1) (Annex C1)

B. When claiming for assistive device fitting and mobility training (2nd Tranche)

Checklist of Requirements for Reimbursement (Tranche 2) (Annex E2)

Checklist of Mandatory Services Z Benefits for Children with Mobility Impairment (Tranche 2) (Annex C2)

Certificate of Completed Training on the Safe and Functional use of the Device (Annex J)

C. When claiming for rehabilitation services (3rd tranche)

Checklist of Mandatory Services Z Benefits for Children with Mobility Impairment (Tranche 3) (Annex E3)

Certificate of outcomes after rehabilitation session (Annex K)

III. Assistive device repair, replacement and yearly service

Checklist of Requirement for Reimbursement Mobility Impairment Yearly Services and Replacement (Annex E)

Checklist of Mandatory Services Z Benefits for Children with Mobility Impairment Yearly Services and Replacement (Annex C)

A. Pre-authorization Checklist and Request (Annex A)

Z Benefits for Children with Developmental Disabilities

I. Prior to availment of the Z Benefits

II. Initial Assessment

A. When claiming for Initial Assessment from a Medical Specialist (1st Tranche)

Checklist of Requirements for Reimbursement (Tranche 1) (Annex E1)

Checklist of Mandatory Services Z Benefits for Children with Developmental Disabilities (Tranche 1) (Annex C1)

Certificate of Assessment and recommendations(Annex J)

B. When claiming for Initial Assessment from a Rehabilitation Therapist/Allied Health Professional (2nd Tranche, if applicable)

Checklist of Requirements for Reimbursement (Tranche 2) (Annex E2)

Checklist of Mandatory Services Z Benefits for Children with Developmental (Tranche 2) (Annex C2)

Certificate of Assessment and recommendations(Annex J)

III. When claiming for Rehabilitation Tranches (up to 9 claims)

Checklist of Requirements for Reimbursement Z Benefits for Children with Developmental Disabilities Rehabilitation Therapy (Annex E)

Checklist of Mandatory Services Z Benefits for Children with Developmental Disabilities Rehabilitation Therapy (Annex C)

IV. Discharge Assessment

A. When claiming for Discharge Assessment from a Rehabilitation Therapist/Allied Health Professional (1st tranche, if applicable)

Checklist of Requirements for Reimbursement (Tranche 1) (Annex E1)

Checklist of Mandatory Services Z Benefits for Children with Developmental Disabilities (Tranche 1) (Annex C1)

Certificate of Assessment and recommendations(Annex J)

B. When claiming for Discharge Assessment from a Medical Specialist (2nd tranche)

Checklist of Requirements for Reimbursement (Tranche 2) (Annex E2)

Checklist of Mandatory Services Z Benefits for Children with Developmental (Tranche 2) (Annex C2)

Certificate of Assessment and recommendations(Annex J)

Z Benefits for Children with Hearing Impairment

I. Prior to availment of the Z Benefits

A. Pre-authorization Checklist and Request (Annex A)

II. Initial Assessment when claiming for Initial Assessment (1st Tranche)

Checklist of Requirements for Reimbursement Assessment (Tranche 1) (Annex E1)

Checklist of Mandatory Services Z Benefits for Children with Impairment Hearing (Tranche 1) (Annex C1)

Certificate of Completed Hearing Aid Verification (Annex J)

III. When claiming for reimbursement hearing aid provision (Tranche 2)

Checklist of Requirements for Reimbursement Hearing aid provision (Tranche 2) (Annex E2)

Checklist of Mandatory Services Z Benefits for Children with Hearing Impairment (Annex C2)

Certificate of Completed Hearing Aid Verification (Annex J)

IV. When claiming for reimbursement for ear-mold refitting

Checklist of Requirements for Reimbursement for ear-mold refitting (Annex E3)

Checklist of Mandatory Services Z Benefits f or ear-mold refitting (Annex C3)

Checklist of Mandatory Services Z Benefits hearing aid replacement (Annex C)

V. When claiming for hearing aid replacement

Certification of completed speech therapy sessions (Annex K)

Z Benefits for Visual Disabilities

I. Prior to availment of the Z Benefits

A. Pre-authorization Checklist and Request (Annex A)

II. Category 1

A. Initial Assessment and Intervention

1. When claiming for initial assessment and intervention (Tranche 1)

Checklist of Requirements for Reimbursement (Annex E1.1)

Checklist of Mandatory Services (Annex C1.1)

2. When claiming for appropriate assistive device (add-on) (Tranche 2)

Checklist of requirements for reimbursement (Annex E2.1)

Checklist of Mandatory Services (Annex C2.1)

3. When claiming for other services including training and rehabilitation (Tranche 3)

Checklist of requirements for reimbursement (Annex E3.1)

Certificate of Training and Rehabilitation (Annex J)

Checklist of Requirements for Reimbursement (Annex E.4)

B. Yearly Diagnostics

Checklist of Mandatory Services (Annex C.3)

III. Category 2, 3, 4

A. Initial Assessment and Intervention

1. When claiming for initial assessment and intervention (Tranche 1)

Checklist of Requirements for Reimbursement (Annex E1.2)

Checklist of Mandatory Services (Annex C1.2)

2. When claiming for appropriate assistive device (add-on) (Tranche 2)

Checklist of requirements for reimbursement (Annex E2.2)

Checklist of Mandatory Services (Annex C2.2)

3. When claiming for other services including training and rehabilitation (Tranche 3)

Checklist of requirements for reimbursement (Annex E3.2)

Certificate of Training and Rehabilitation (Annex J)

Checklist of Requirements for Reimbursement (Annex E.4)

B. Yearly Diagnostics

Checklist of Mandatory Services (Annex C.3)

Checklist of Mandatory Services (Annex C.4)

C. Electronic assistive device replacement

IV. Category 5

A. Initial Assessment and Intervention

1. When claiming for initial assessment and intervention (Tranche 1)

Checklist of Requirements for Reimbursement (Annex E1.3)

Checklist of Mandatory Services (Annex C1.3)

Checklist of requirements for reimbursement (Annex E2.3)

2. When claiming for appropriate assistive device (add-on) (Tranche 2)

Checklist of Mandatory Services (Annex C2.3)

Checklist of requirements for reimbursement (Annex E3.3) Certificate of Training and Rehabilitation (Annex J)

3. When claiming for other services including training and rehabilitation (Tranche 3)

Checklist of Requirements for Reimbursement (Annex E.4)

B. Yearly Follow up Consultations

Checklist of Mandatory Services (Annex C.3)

Checklist of Mandatory Services (Annex C.4)

C. Electronic assistive device replacement