Case Payment Scheme and Coverage Limits
- The package uses a case payment scheme, discontinuing the use of the Relative Value Unit (RVU) code 59409 for claims.
- Coverage is limited to the first two normal deliveries per member.
- A case rate of PHP 4,500 is paid to accredited providers, covering all maternity care services from prenatal to postnatal, including newborn care.
- The payment encompasses room and board, drugs, diagnostics, operating room, professional fees, and all medically necessary care.
- Maternal complication services during delivery are included in the package.
Payment Structure and Claims
- Payments are divided into two parts:
- PHP 3,650 upon delivery for prenatal care and normal delivery.
- PHP 850 after postnatal consultation covering postnatal care and family planning.
- Claims with incomplete service provision will not be reimbursed.
- Availment of the maternity package charges one day against the annual 45-day maternity benefit limit.
Eligibility Requirements
- All NHIP members and qualified dependents who meet eligibility criteria and are not disqualified under exclusion rules may avail of the package.
- Individually paying members must have at least nine months (three quarters) of premium payments in the 12 months before delivery.
- Group-enrolled members and those under IPP-OWWA are exempt from the sufficient regularity rule.
- The first prenatal visit must occur within four months of pregnancy gestation.
Exclusion Criteria
- Claims will be denied for NSD in non-hospital facilities in presence of any of the following:
- Maternal age under 19 or 35 years and older for primiparas.
- Multiple pregnancies.
- Ovarian or uterine abnormalities (e.g., cysts, myoma).
- Placental abnormalities such as placenta previa.
- Abnormal fetal presentations like breech.
- History of up to three miscarriages or one stillbirth.
- Prior major obstetric/gynecologic surgeries (e.g., cesarean section).
- Certain medical conditions (e.g., hypertension, diabetes, heart disease).
- Other risk factors during current pregnancy warranting referral (e.g., premature contractions).
Claims Filing Procedures
- Claims must be filed using Claims Form 4 or, while Form 4 is unavailable, PhilHealth Claim Form No. 2.
- All claims must conform to the ICD-10 coding requirements.
- The prenatal, delivery, and newborn care claims must be filed within 60 calendar days from discharge.
- Postnatal and family planning claims have a 90-day filing period from the discharge date.