Question & AnswerQ&A (PHIC PHILHEALTH CIRCULAR NO. 09, S. 2002)
The circular prescribes the ground rules for the implementation of the Relative Value Scale (RVS) 2001 by the Philippine Health Insurance Corporation (PhilHealth), guiding the computation and payment of professional fees and operating room fees for surgical procedures.
The RVU Oversight Committee is responsible for continuously updating the Relative Value Scale 2001.
Operating room and anesthesia records are mandatory for all surgical procedures being claimed. Claims filed without these or other required documents shall be returned for completion and must be complied within 60 days from receipt.
No, only procedures listed in the Relative Value Scale 2001 manual are compensated. Procedures not listed are not reimbursed unless approved by PhilHealth as an addendum to the scale.
The peso equivalent per Relative Value Unit (RVU) for surgical procedures is 40 pesos.
Yes, any procedure with a unit value above 400 RVU shall have a maximum payment of 16,000 pesos.
Multiple surgical procedures done in one sitting or through a single incision by one or more physicians are compensated using only the procedure with the highest value unit.
The package covers preoperative visits before surgery, intraoperative services, postoperative services within 90 days, and follow-up visits related to surgery recovery. It also includes dressing changes, local incision care, removal of sutures and drains, insertion and removal of catheters, and related routine services.
The anesthesiologist's fee is 30% of the surgeon's fee, with a maximum of 5,000 pesos. Post-surgical pain management is included in this fee.
Operating room fees are based on the Relative Value Unit (RVU) of the procedure and the type of hospital (Primary, Secondary, Tertiary), with specific fixed amounts corresponding to different RVU ranges.
Surgical procedures are classified by case type based on RVU: Ordinary cases (80 RVU and below), Intensive cases (81 to 200 RVU), and Catastrophic cases (above 201 RVU).
Yes, procedures with RVU of 30 and below may be done in an outpatient setting provided they were performed in the emergency room or in the operating room complex of an accredited facility.
Yes, the professional fee covers preoperative, intraoperative, and postoperative services rendered by the physician who performs the surgery.
Yes, separate payment is allowed when co-management is necessary due to complications requiring expertise beyond that of the surgeon.