Coverage
- Applies to PhilHealth and non-PhilHealth members and dependents.
- Covers treatment conducted in both PhilHealth accredited and non-accredited health care institutions (HCIs), whether private or government owned, provided the latter are duly licensed or certified.
- Includes health care professionals licensed by PRC, whether accredited or not.
- Applies to outpatient and inpatient claims related directly or indirectly to the fortuitous event.
- Encompasses services rendered at HCIs, improvised/satellite facilities, and those managed by accredited personnel in evacuation areas.
General Rules
- Requires official declaration of state of calamity/emergency or equivalent certification; absent these, justification letters from government agencies may be accepted.
- Affected HCIs must submit a formal request for application of the circular to the relevant PhilHealth Regional Office (PRO), including details/photos of the event’s effects and possible destruction of claim records.
- PRO organizes validation teams to assess requests through document review or survey if safe.
- PRO sends recommendations to PhilHealth President and CEO for approval, including effective dates and special privileges.
- The end date of privileges is communicated by the PRO to the President and CEO.
Membership
- Existing rules on membership qualifications, premium contributions, and enrolment remain unless exempted by the Corporation.
- Patients' PhilHealth status must be verified:
- Members must have paid premiums for at least 3 months within 6 months prior to availment.
- Members without qualifying contributions but capable of paying may pay full premium for the year.
- Point of Care enrolment facilitated by Medical Social Welfare Officers for indigents/critical poor.
- Non-members with ability to pay must pay full premium; indigents without capacity to pay are handled similarly as above.
Benefit Entitlement
- Standard inpatient, outpatient, and other benefit packages apply.
- Emergency cases receive priority.
- Elective procedures during fortuitous event periods are not covered by special privileges except filing deadline extensions.
- No Balance Billing (NBB) policy applies to all covered cases; private HCIs are strongly encouraged to comply during the event.
- Reimbursement follows existing payment mechanisms; direct filing is allowed for non-accredited licensed HCIs where necessary.
Special Privileges
- Claims submission extended to 120 days post-discharge, covering admissions 60 days before and until prior to the event.
- Exemption from 45-day benefit period and Single Period of Confinement limits for event-related admissions.
- Separate reimbursement for both referring and receiving HCIs in patient transfers.
- Cases with confinement under 24 hours may be reimbursed.
- Claims affected by fortuitous event are to be prioritized for processing.
- Extensions granted for mandatory reports, accreditation validity, and health care providers’ applications.
- HCIs with destroyed claim records may opt for:
- Claim reconstruction or recovery submission or
- Payment calculated on average daily reimbursement multiplied by uninsured period days.
- Once a payment option is approved, it cannot be reversed.
- Extensions on premium payment deadlines and coverage validity periods may be granted.
Monitoring
- Health care providers remain subject to monitoring and evaluation rules under PhilHealth’s Provider Engagement framework.
Repealing Clause
- Previous inconsistent issuances are amended, modified, or repealed as necessary to conform with this Circular.
Separability Clause
- Invalidity of any provision does not affect the validity of the remaining provisions.
Effectivity
- Applies to claims arising from fortuitous events, including Typhoons Maring, Santi, Ramil, and October 2013 Visayas earthquake.
- Circular is published in general circulation newspapers and registered with the National Administrative Register at the University of the Philippines Law Center.