Question & AnswerQ&A (PHIC PHILHEALTH CIRCULAR NO. 18, S. 2009)
The purpose of PhilHealth Circular No. 18, s. 2009 is to update and rationalize the current case type classification to make benefits more responsive to the needs of the members.
Case type is classified on a 4-scale system from A to D, where A is the least complex and D is the most severe.
Case type for medical claims is based on the ICD-10 code of the primary illness or main condition identified at discharge.
PhilHealth may return the claim to the hospital for proper documentation and require the submission of properly accomplished Claim Form 3 and other relevant medical documents for evaluation.
Case type for surgical claims is based on the Relative Value Unit (RVU) assigned to the procedure. The highest RVU among multiple procedures determines the case type.
The higher case type between medical diagnosis and surgical procedure prevails in classification.
Yes, case types can be automatically upgraded for conditions such as illnesses requiring blood transfusion, community-acquired pneumonia (various risk levels), malignant neoplasm with metastasis, chemotherapy, radiotherapy, dialysis sessions, and in the event of death.
PhilHealth shall reimburse the member within the remaining benefit amount, provided there is an official receipt and statement of account issued by the hospital.
Claims classified as case type D require submission of PhilHealth Claim Form 3 or Clinical Abstract for proper evaluation; otherwise, the claim is returned to the hospital for completion.
No, benefits for case type D are only payable for patients admitted in Level 3 and 4 (tertiary) hospitals. In Level 1 and 2 hospitals, case type D is paid as case type B and C respectively.
Only the procedure with RVU above 501 uses the Peso Conversion Factor (PCF) for case type D; professional fees for other procedures below 501 are computed using baseline PCF depending on the physician's tier category.
For Level 1 (primary) hospitals, claims for case type C and D require submission of Claim Form 3 or Clinical Abstract, except for claims paid through case payment scheme.