QuestionsQuestions (PHILHEALTH CIRCULAR NO. 2018-0008)
The Circular implements the GAA 2018 special provision on the attainment of universal coverage under PhilHealth (Title XXXVI). It provides a Point of Service (POS) mechanism to cover Filipino citizens, especially those financially incapable, and to include unregistered/inactive members so that the poor can be fully covered under NHIP.
A POS Patient is the patient (or parent/guardian if the patient is a minor) classified as financially incapable based on the DOH classification on indigence, assessed by the DOH-trained MSWO/SWDO using the DOH assessment tool.
They must: (1) be assessed as financially incapable by the MSWO/SWDO; (2) be Filipino citizens (patient and parent/guardian if minor); and (3) be assessed and admitted in a ward type of accommodation in a government facility, or referred to a private HCI after assessment by a government facility.
Financially capable individuals are assessed at the point of service and enrolled as regular contributing members based on their financial capability, included in the membership database, and billed annually; their entitlement depends on existing rules on qualifying contribution and entitlement.
All NGFs, LGU facilities, and other government hospitals/facilities may participate if they: submit POAF and NDA to the nearest PhilHealth office; have dedicated desktop and reliable internet for IHCP/POS; assign IT personnel; assign trained membership/eligibility/enrollment staff; ensure availability of licensed MSWO/SWDO (or submit training certificate/certification of accountable signatory); and ensure compliance by existing ORE-POC/POS users for item 5.
They conduct the assessment to determine financial incapacity using the DOH means test tool and handle assessment documentation (e.g., signing the certificate of assessment) and registration activities for POS patients.
For ward-type admissions, patients are verified through the IHCP Portal to determine membership/dependency/eligibility. Unregistered or inactive members are interviewed and assessed by the MSWO/SWDO using the DOH tool; financially incapable patients may immediately avail benefits after assessment.
Unregistered POS patients must accomplish and sign the PMRF. The MSWO/SWDO or designated personnel must register POS patients through the POS System within 72 hours from admission or prior to discharge.
In lieu of the MSS intake form, the facility issues a pro-forma “Certificate of Assessment” signed by the MSWO/SWDO to financially incapable (and capable) POS patients (Annex C).
Within 72 hours of admission, duly accomplished PMRF is sent to PhilHealth for PIN assignment via email scan, fax, or other agreed means with the PRO/LHIO. Once PIN is secured, it is indicated in the original PMRF to be attached to claim documents.
The POS patient must secure a CEI (Certification/Eligibility indicator as used in the Circular) from the nearest PhilHealth Office or a PhilHealth CARES Form (PCF) from the PCARES personnel in the health facility.
Availment in private facilities is allowed if there is: (1) an appropriate referral from a government facility (with a referral copy/certification attached to claims); (2) dengue cases immunized under DOH School/Community Based Immunization (with proof/certificate of immunization with Dengvaxia); (3) emergency cases with resuscitation package; or (4) financially incapable patients affected by fortuitous events in declared calamity areas, subject to the cited PhilHealth Circular 0034 (2013).
Only claims for POS patients registered in POS/PhilHealth with PIN are submitted (PIN indicated in Claims Form 1). For the first claim, the PMRF (duly accomplished and signed), Registration Slip, and MSWO/SWDO certificate of assessment are required. Manual filing may apply for government HCIs not yet enrolled in eClaims; otherwise, the MSWO/SWDO certificate must be scanned/uploaded with electronic claims.
They are entitled immediately within the validity period, subject to compliance with other requirements to benefit availment, including All Case Rates (ACR) (e.g., preauthorization surgery requirement), Z benefits (e.g., dialysis database registration), and No Balance Billing (NBB).
PhilHealth endorses to DSWD quarterly the list of POS financially incapable registered patients for assessment. Those assessed as poor are included in Listahanan for coverage as indigent members in succeeding years.
POC Enrollment Program (Revision 1) under PhilHealth Circular No. 033-2015 is fully transitioned to POS effective July 1, 2018; the POC-ORE system is deactivated. Patients enrolled under POC on or prior to June 30, 2018 are reimbursed under existing rules and remain entitled until December 31, 2018. Inconsistent previous issuances are amended/modified/repealed accordingly.
It has retroactive effect starting January 1, 2018, and it must be deposited with the National Administrative Register at the University of the Philippines Law Center.