QuestionsQuestions (PHIC PHILHEALTH CIRCULAR NO. 15, S. 2003)
It is PHIC PhilHealth Circular No. 15, s. 2003, adopted on March 17, 2003; it is effective to all discharges as of May 1, 2003.
The “New PhilHealth Maternity Care Package for Normal Spontaneous Delivery (NSD) Performed in Accredited Hospitals.”
It uses a case payment scheme in claims reimbursement; the assigned RVU (Relative Value Scale code number 59409) shall no longer apply.
Yes. Pursuant to PhilHealth Board Resolution No. 501, the package is limited to the first two (2) normal deliveries.
A case rate of ₱4,500 is paid to accredited health care providers regardless of hospital category and length of hospital stay.
₱2,000 for the health professional and ₱2,500 for the health facility.
Room and board, drugs and medicines, diagnostics, operating room, and all other medically necessary care except for professional fees.
The IPP must comply with the rule on sufficient regularity of premium contributions and must have at least nine (9) months or three (3) quarters of premium payments in the immediate twelve (12) months prior to the NSD.
IPP enrolled as a group or through the IPP-OWWA program, and all other types of membership, which are governed by current eligibility requirements.
PhilHealth Maternity Care Package Claim Form No. 4.
They may still use PhilHealth Claim Form No. 2, but they should no longer put itemized charges on Box No. 12. Only the total actual charges and PHIC benefit claimed should be indicated in Box No. 12.
No payment for an anesthesiologist’s professional fee shall be paid for NSD.
Official receipts for drugs, medicines, and supplies bought by the member in the pharmacy or outside the facility, used during the confinement period, must be submitted together with the PhilHealth claim forms.
The total amount paid by the member for these items shall be deducted from the case rate amount and made payable to the member.
The hospital may seek reimbursement based on the case classification of the condition, and must list down all reimbursable items for claims processing.
Operating room benefit amounts are: ₱385 for primary hospitals, ₱1,140 for secondary hospitals, and ₱1,350 for tertiary hospitals.
Only one (1) claim application must be submitted.
All medically necessary care for the newborn, including professional services, medicines, and laboratory examinations, is reimbursable as an ordinary medical case type; however, room and board charges are not covered unless the newborn was admitted for other indications, infant formula is not reimbursable, and a separate claim application must be filed for the newborn child.
Claims must be filed within sixty (60) calendar days from discharge; claim applications must comply with ICD-10 requirements by the Corporation.
Availment of the maternity care package is charged one-day to the annual 45-day limit.