Question & AnswerQ&A (PHILHEALTH CIRCULAR NO. 001)
A surgical/medical mission is defined as an outreach program for humanitarian non-profit purposes that provide medical and/or surgical services (including medicines, ancillary procedures, surgical interventions, and professional services) at no cost to people who have limited or no means to pay.
No, claims involving surgical procedures done in private facilities during medical/surgical missions shall not be compensated.
Claims involving surgical procedures done during medical missions sponsored by the National Government or Local Government Unit conducted in any PhilHealth-accredited government facility shall be compensated.
PhilHealth-accredited government facilities include Ambulatory Surgical Care Clinics and Level II, III, and IV hospitals.
Professional fees must be pooled for distribution to all facility personnel and must comply with provisions stipulated in Rule VIII Section 7 of the Implementing Rules and Regulations of RA 7875, as amended by RA 9241.
No, doctors of foreign nationalities who participate or perform surgeries in surgical medical missions should not file claims for reimbursement. Violation will be reported to DOH and PRC for appropriate action.
PhilHealth conducts utilization reviews, validates admissions, evaluates availments of benefits, and monitors quality of care to ensure proper implementation of policies governing missions involving PhilHealth members.
Reimbursement will be withheld pending further validation. Claims confirmed as part of a medical mission will be denied, and previously paid claims will be refunded by the healthcare provider or charged against future claims, along with legal sanctions.
Healthcare providers must refund the Corporation or have the amount charged to their future claims, subject to legal sanctions.
This Circular became effective fifteen (15) days from its publication in the Official Gazette and newspapers of general circulation.