Question & AnswerQ&A (Republic Act No. 10167)
Claims for benefit items such as drugs, medicines, x-ray, laboratory, operating room, and professional fees shall be paid accordingly. However, reimbursement for room and board charges is limited only to the actual confinement period when the accreditation is still in effect.
Claims for benefit items are paid accordingly, but reimbursement for room and board is limited to the actual confinement period during which membership is effective.
No, upon the principal member's death, membership privileges end and declared dependents cannot use the deceased's membership eligibility.
When the patient is referred to another facility for procedures not available in the admitting hospital, returns to the referring institution within the day, and is not admitted in the referred facility.
The out-on-pass order date is considered the date of discharge for reimbursement purposes.
If the stay is less than 24 hours, no coverage except if transferred to another facility, the case is an emergency, or if the patient dies. If over 24 hours, reimbursement may be filed based on hospital category and case type but requires justification for over bed capacity.
Non-submission of requirements will cause denial of claims.
It aligns with and is without prejudice to the Revised Implementing Rules and Regulations of R.A. 7875 as amended by R.A. 9241 and repeals or modifies inconsistent issuances.
This Circular applies to all claims with admission dates effective January 1, 2011.
Yes, there is a prohibition against unjustified admissions beyond an accredited health care provider's licensed/accredited bed capacity according to R.A. 7875 as amended by R.A. 9241.