Nature of maternity care package
- The new PhilHealth Maternity Care Package for normal spontaneous delivery (NSD) performed in accredited hospitals uses a case payment scheme in claims reimbursement.
- The Relative Value Unit (RVU) assigned for these procedures under Relative Value Scale code number 59409 no longer applies.
- The package is limited only to the first two (2) normal deliveries.
- The circular applies to normal spontaneous delivery (NSD) performed in accredited hospitals.
Case rate and allocation of payments
- A case rate of PHP 4,500 is paid to accredited health care providers regardless of hospital category and length of hospital stay.
- Eligibility includes patients managed for less than 24 hours.
- The PHP 4,500 case rate is divided into PHP 2,000 for the health professional and PHP 2,500 for the health facility.
- The health facility’s PHP 2,500 is intended to cover room and board, drugs and medicines, diagnostics, operating room, and all other medically necessary care except professional fees.
Eligibility for the PhilHealth NSD package
- An individually paying program member (IPP) must comply with the rule on sufficient regularity of premium contributions.
- An IPP must have at least nine (9) months or three (3) quarters of premium payments in the immediate twelve (12) months prior to the NSD.
- IPP enrolled as a group or through the IPP-OWWA program is governed by the eligibility requirements for those types of membership and need not satisfy the sufficient regularity rule.
- All other types of membership are governed by current eligibility requirements.
Claims filing forms and submission rules
- The new PhilHealth Package Claim Form No. 4 must be used to file claims for the new maternity care package.
- Until the new claim form is distributed to providers, providers may use PhilHealth Claim Form No. 2.
- When using Claim Form No. 2, providers shall no longer put itemized charges on Box No. 12 of Part I, Part III and Part IV.
- When using Claim Form No. 2, providers shall indicate in Box No. 12 of Part I the total actual charges and the PHIC benefit claimed.
- Claims must be filed within sixty (60) calendar days from the date of discharge.
What is reimbursable and newborn coverage
- Because reimbursement is case-based, official receipts for drugs, medicines, and supplies bought by the member in the pharmacy or outside the facility and used during the confinement period must be submitted with the PhilHealth claim forms.
- The total amount paid by the member for those items must be deducted from the case rate and made payable to the member.
- When hospital stay continues due to conditions not related to delivery (including hypertensive and diabetes-related conditions), the hospital may seek reimbursement based on the case classification of the condition.
- For deliveries complicated by such medical conditions, the operating room benefit for complicated deliveries is:
- PHP 385 for primary hospitals;
- PHP 1,140 for secondary hospitals; and
- PHP 1,350 for tertiary hospitals.
- Operating room professional fee for anesthesiologist is not paid for NSD.
- Health professionals remain reimbursed PHP 2,000, with additional reimbursements for necessary surgeries and procedures and a daily consultation fee for the co-management of the appropriate health professional.
- For complicated normal deliveries, hospitals shall submit only one (1) claim application.
- With holistic coverage of maternity care under the benefit, all medically necessary care for the newborn, including professional services, medicines, and laboratory examinations, is reimbursable and classified as an ordinary medical case type.
- Room and board charges for the newborn are not covered unless the newborn child was admitted for other indications.
- Infant formula is not reimbursable.
- A separate claim application must be submitted for the newborn child.
ICD-10 compliance and newborn documentation
- All claim applications for the maternity care package are covered by the rules on ICD-10 requirements by the Corporation.
Submission time impact on benefit limits
- Availment of the PhilHealth maternity care package is charged one-day to the annual 45-day limit.
Reimbursable items list requirement
- When seeking reimbursement for continued hospital stay due to non-delivery-related conditions, the hospital must list all reimbursable items so the claims can be processed.
Governance and implementing structure
- The package guidelines govern implementation of the new PhilHealth maternity care package in accredited hospitals for NSD, including case reimbursement and claim requirements.
- The circular adopts the rules for claim processing, including the case rate structure and the professional and facility reimbursement allocation.