PhilHealth Benefit Entitlement Conditions

Changes in membership status during confinement affect the reimbursement of benefits.
If the patient turns 60 and qualifies as a dependent, or if the patient becomes/remains an OFW member or experiences membership changes in the Sponsored Program during confinement, claims for drugs, medicines, x-ray, laboratory, operating room, and professional fees are paid accordingly.
Room and board reimbursement is limited to the confinement period during which membership is effective.
Death of the principal member ends membership privileges immediately; dependents lose eligibility to use the deceased member's benefits.

Out-on-pass for PhilHealth payment is recognized only if:
1. Patient is referred to another facility for unavailable procedures in the admitting hospital.
2. Patient returns to the admitting/referring hospital the same day.
3. Patient is not admitted in the referred facility.
Otherwise, the out-on-pass order date is considered the discharge date, limiting room and board reimbursement up to that date.

If a patient stays less than 24 hours in the emergency room (ER) or hospital premises waiting for room availability, coverage is excluded, except when the patient is transferred to another facility, the case is an emergency, or the patient dies.
If the stay exceeds 24 hours, reimbursement may be filed for room and board, calculated based on hospital category and case type.
Justification for exceeding bed capacity is required prior to payment; failure to submit requirements results in claim denial.

The guidelines align with the Revised Implementing Rules and Regulations of R.A. 7875, as amended by R.A. 9241, and PhilHealth Circular No. 7, s-1996.
Unjustified admission beyond accredited bed capacity is prohibited.
Accredited Health Care Providers must comply with these rules and conditions.
Any inconsistent prior issuances are repealed or modified.
The Circular applies to claims with admission dates starting January 1, 2011.