Question & AnswerQ&A (PHILHEALTH CIRCULAR NO. 0034, S. 2013)
The main objective is to provide guidelines on the provision of special privileges to those affected by fortuitous events, ensuring responsive health care benefits to all affected members and communities, including displaced and environmentally endangered ones, during such events.
The Circular covers PhilHealth and non-PhilHealth members including dependents; PhilHealth accredited or non-accredited health care institutions (both private and government-owned); and health care professionals licensed by PRC; claims related to treatment as inpatient or outpatient relative to the effects of the fortuitous event.
A declaration of state of calamity or state of emergency and analogous certifications depending on the fortuitous event are required. In the absence of these, justification letters from authorized government agencies may be submitted and are subject to validation by the PhilHealth Regional Office.
The affected health care institution must send a letter request signed by an authorized representative to the PhilHealth Regional Office, including description or photos of the event's effects and information on claim destruction if applicable. The PRO organizes a validation team to validate the request and recommends to the President and CEO for approval.
Existing membership rules apply, with premium contributions required unless exemptions are provided. Members with no qualifying contributions but with ability to pay must settle dues. Indigents and critical poor are enrolled and their premiums should be shouldered by the government or sponsoring facilities. Non-members must pay premiums to access benefits or be enrolled as sponsored members if indigent.
Existing inpatient, outpatient, and other packages apply with priority given to emergency cases. Elective procedures performed during the event are not covered by special privileges except for the claims filing extension. No Balance Billing policy is in effect and reimbursement follows the provider payment mechanism at admission.
Claims submission deadline is extended to 120 calendar days from discharge, including claims for up to 60 days before the event. There is exemption from the 45-day benefit limit and Single Period of Confinement rule for admissions related to the event. Reimbursement covers both referring and receiving health care institutions and extensions on submitting mandatory reports and accreditation validity are allowed.
Health care institutions with destroyed claims may choose to either recover/reconstruct claims for submission or receive payment based on the average reimbursement per day multiplied by the number of days from last submission to a specified date. Once the option is approved, it cannot be changed.
Yes, there is an extension of the deadline for payment of premium contributions and/or extension of existing coverage dates as prescribed by PhilHealth. Members without qualifying contributions but with ability to pay must settle premiums; indigents may have premiums shouldered by government or sponsors.
The separability clause states that if any part of the Circular is declared invalid or unauthorized, the other unaffected provisions shall remain valid and effective.