Benefit Package and Payment Scheme
- Utilizes a case payment scheme instead of the Relative Value Unit (RVU) system.
- Package limited to the first two normal deliveries per member.
- Fixed case rate payment of PHP 4,500 to health care providers regardless of hospital category or length of stay.
- Case rate is divided as PHP 2,000 for health professionals and PHP 2,500 for the health facility.
- PHP 2,500 covers room and board, drugs, diagnostics, operating room, and other medically necessary care excluding professional fees.
- Patients managed for less than 24 hours are also eligible.
Eligibility Requirements
- Individually Paying Program (IPP) members must comply with premium payment regularity: at least nine months or three quarters within the 12 months preceding delivery.
- IPPs enrolled through groups or IPP-OWWA and other membership types are exempt from the premium regularity rule but must adhere to existing eligibility rules.
Claims Filing Procedures
- Use of PhilHealth Package Claim Form No. 4 is required; until distributed, Claim Form No. 2 may be used with modifications.
- Itemized charges must not be indicated; only total actual charges and PHIC benefit claimed should be stated.
- Anesthesiologist’s professional fee is excluded from reimbursement for NSD.
- Official receipts for drugs and supplies purchased outside the hospital but used during confinement must be submitted; amounts reimbursed to members and deducted from case rate.
- Prolonged hospital stays due to conditions unrelated to delivery must be claimed separately based on the specific medical case.
Provisions for Complicated Deliveries
- Operating room reimbursement varies by hospital level:
- PHP 385 for primary hospitals
- PHP 1,140 for secondary hospitals
- PHP 1,350 for tertiary hospitals
- Health professionals receive PHP 2,000 plus additional fees for necessary surgeries, procedures, and daily consultations.
- Only one claim application is submitted per complicated delivery.
Coverage for Newborn Care
- Includes all medically necessary care for the newborn such as professional services, medicines, and laboratory tests.
- Classified as ordinary medical cases.
- Room and board covered only if newborn is admitted for indications other than delivery.
- Infant formula is not covered.
- Newborn’s claim must be filed separately.
Claims Submission and Administrative Rules
- Claims must be filed within sixty (60) calendar days from discharge.
- ICD-10 coding requirements apply.
- Availment of the maternity care package counts as one day against the annual 45-day hospital confinement limit.