Law Summary
Benefit Structure and Relative Value Unit (RVU)
- RVU for outpatient BT is set by analogy with therapeutic aphaeresis.
- Claims coding: RVS Procedure Code 36430 for outpatient transfusion of one or more units of blood or blood products, with an RVU of 10.
Maximum Benefit and Allowances by Hospital Level
- Drugs & Medicine allowance:
- Level 1: PHP 9,000
- Level 2: PHP 11,200
- Levels 3 & 4: PHP 14,000
- X-ray, Laboratory, and Others:
- Level 1: PHP 5,000
- Level 2: PHP 7,350
- Levels 3 & 4: PHP 10,500
- Operating Room:
- Level 1: PHP 500
- Level 2: PHP 750
- Levels 3 & 4: PHP 1,200
Single Period of Confinement (SPC) Rule
- Applies to repeat procedures within less than 90 days in a calendar year.
- No new benefit allowance for repeat procedures; members can use only the unused portion of the previous benefit.
- Applies to drugs, medicines, laboratory, and supplies.
Reimbursable Items and Exclusions
- All medically necessary drugs and medicines during BT are reimbursable (e.g., folic acid, iron, epoetin).
- Blood donor screening tests and serologic/hematologic tests (ABO/Rh typing, cross matching) are compensable under X-ray, Laboratory and Others.
- Professional fee (PF) is paid based on RVU 10 to the attending physician performing the BT procedure.
- Room and board charges are not covered; from the annual 45-day confinement allowance, one day is deducted per day of outpatient BT.
- No additional PF is paid for BT done during hospital confinement or concurrently with other PhilHealth-covered services like hemodialysis.
Claims Filing Requirements
- Submission of the following is required:
- PhilHealth Claim Form 1 (from member/employer)
- PhilHealth Claim Form 2 (from providers)
- Official receipts and statement of account
- Other documents: Member Data Record (MDR), proof of premium payment (MI-5), PhilHealth ID
- Claims must be filed within 60 days from the date of outpatient BT procedure.
Eligibility Criteria for Members and Dependents
- Employed and Individually Paying Program (IPP) members, including KASAPI, require at least 3 months of contributions within the prior 6 months before availment.
- Sponsored and Overseas Workers Program members must avail benefits within the validity period indicated on their PhilHealth ID.
- Lifetime members are entitled to benefits upon presenting their PhilHealth ID.
Implementing Provisions
- The Circular took effect on February 1, 2010, for outpatient procedures performed from that date onward.
- Existing rules and guidelines not inconsistent with this Circular remain in full force and effect.