QuestionsQuestions (PHIC PHILHEALTH CIRCULAR NO. 16, S. 2003)
It shall be effective to maternity care services initiated on May 1, 2003.
Lying-in clinics, midwife-managed clinics, birthing homes, and any other analogous health facilities. Currently accredited RHUs and ASCs may also provide the NSD package if they comply with specified requirements.
No additional accreditation fee may be imposed; they are allowed provided they comply with requirements in PhilHealth Circular Nos. 15, s. 2001 and 09, s. 2003.
A case payment scheme in claims reimbursement is used; the Relative Value Unit (RVU) assigned for code 59409 shall no longer apply.
Php 4,500.
All services the member/dependent requires including prenatal care, delivery, newborn care, and postnatal services; the facility payment is expected to cover room and board, drugs/medicines, diagnostics, operating room, professional fees, and all medically necessary care.
Prenatal care & normal delivery (1st payment) after delivery: Php 3,650. Postnatal care & family planning services (2nd payment) after postnatal consultation: Php 850. Total: Php 4,500.
PhilHealth shall not reimburse claims with incomplete provision of services.
It is charged one-day to the annual 45-day benefit limit.
All members and qualified dependents of the NHIP who satisfy eligibility criteria and are not disqualified by exclusion criteria.
The member must comply with sufficient regularity of premium contributions and have at least nine (9) months or three (3) quarters of premium payments in the immediate twelve (12) months prior to delivery.
No. IPP enrolled as a group or through the IPP-OWWA program and other membership types are governed by current eligibility requirements and need not satisfy the sufficient regularity rule.
The first prenatal visit must not exceed four (4) months AOG of the current pregnancy.
Examples include: maternal age under 19; elderly primies age 35 and older; multiple pregnancy; ovarian abnormalities (e.g., ovarian cyst); uterine abnormalities (e.g., myoma uteri); placental abnormalities (e.g., placenta previa); abnormal fetal presentation (e.g., breech); prior major obstetric/gynecologic operative intervention (e.g., cesarean section).
It is limited to the first two (2) normal deliveries.
A duly accomplished Claims Form 4 is required. Until the new claim form is distributed to providers, they may still use PhilHealth Claim Form No. 2.
Prenatal, delivery, and newborn care claims: within sixty (60) calendar days from date of discharge. Second claim for postnatal and family planning services: within ninety (90) days from date of discharge.