QuestionsQuestions (PHILHEALTH CIRCULAR NO. 0003, S. 2014)
The Circular cites Section 43 of the IRR of Republic Act No. 10606 (National Health Insurance Act of 2013), stating that no other fee or expense shall be charged to the indigent patient, subject to guidelines issued by the Corporation.
Covered are: (1) Indigent members identified by DSWD; (2) Sponsored members whose contribution is paid by another person/government agency/private entity; (3) Household Help (as defined under RA 10361, kasambahay law); and (4) Group Gold members with existing Group Policy Contract (GPC) until expiration.
NBB covers all case-based payments, including all case rates (including 23 case rates in PhilHealth Circular No. 11, s-2011), Case Type Z benefits, Leptospirosis Package, TB-DOTS Package, Outpatient Malaria Package, Animal Bite Treatment Package, and Voluntary Surgical Contraception Package; and also selected other packages such as OHAT, SARS, Avian Influenza, and IUD insertion.
For private infirmaries and dispensaries, NBB applies only to claims for Maternity Care Packages (MCP) and Newborn Care Packages (NCP). All other benefits in private infirmaries/dispensaries are not subject to NBB. Government infirmaries are covered for all benefits under NBB.
If the patient opts to avail private accommodation (instead of ward type accommodation), the NBB policy shall not apply. Otherwise, NBB patients should not be charged above the packaged rates for covered benefits.
The provider must make the next higher accommodation available to the NBB patient at no added cost if a ward type accommodation is not available.
They must give NBB patients preferential access to social welfare funds, which may be used to augment the benefit package when necessary to fully cover confinement charges.
It mandates membership verification prior to hospital admission and outpatient services to ensure qualified NBB patients have no out-of-pocket expenditures. Government facilities should have real-time verification capacity.
It is a web-based system for online verification of membership and eligibility. The Circular requires all government facilities to have it in place, and PhilHealth ensures its deployment.
Indigent members may present their MDR, PNC, or PhilHealth Identification Number (PIN). For Pantawid Pamilyang Pilipino Program (4Ps) beneficiaries, hospitals must accept 4Ps ID cards as proof of membership with presumptive validity and in good faith.
It becomes the provider’s responsibility to devise a mechanism to verify eligibility prior to admission—either coordinate with PhilHealth CARES personnel assigned to the facility or call the Local Health Insurance Office (LHIO) to verify eligibility.
Providers must ensure utmost quality of care, using the most cost-effective clinical approach without compromising quality. It also states that PhilHealth will monitor via post-audit and impose sanctions for compromising quality.
Facilities must ensure availability through mechanisms like maintaining a hospital formulary and forecasting; prescribed medications must be dispensed exclusively from the hospital pharmacy. If unavailability occurs, the facility must ensure no-cost availability through consignment (discouraging conflict-of-interest arrangements), consideration of therapeutic alternatives, and strict observance of generic substitutions.
If a test is unavailable and the hospital cannot carry it out, the hospital must refer and endorse the patient to the nearest government hospital or private diagnostic center at no cost to the patient. For non-ambulatory patients, the hospital must arrange patient conduction via ambulance without additional cost.
Salaried physicians must not charge additional professional fees over and above the professional fees provided by the Program for NBB patients admitted to a service bed. Non-salaried physicians (consultants) shall not charge additional professional fees to NBB patients admitted in ward-type accommodation.
Providers must not resort to unnecessary referrals merely due to lack of resources (e.g., lab/diagnostics). If referral is necessary, providers must make arrangements such as endorsement, transportation, and accommodation.
PhilHealth conducts regular monitoring via the Standards and Monitoring Department, including random exit interviews among NBB patients prior to discharge. Violations trigger documentation and escalation. It also requires post-audit of applicable claims and may involve validation through domiciliary visits and submission for appropriate action.
NBB members may report to PhilHealth CARES assigned in the facility, which are included in monthly reports. They can also use an SMS hotline managed by PhilHealth’s Corporate Action Center; validated by PhilHealth Regional Offices and anti-fraud/AQAS units. The Circular also lists direct reporting channels (phone, email, Facebook, Twitter).
Penalties are handled in accordance with the pertinent provisions of RA 7875 (as amended) and its IRR, together with the terms of the signed Performance Commitment and related PhilHealth circulars, office orders, and directives.