Coverage of NSD providers and accreditation
- The NSD package applies to non-hospital health facilities that PhilHealth accredits before they can provide the NSD package.
- Accredited non-hospital facilities must be any of the following: Lying-in Clinics, Midwife-managed Clinics, Birthing Homes, or any other analogous health facilities.
- Currently accredited Rural Health Unit (RHU) and Ambulatory Surgical Clinics (ASC) are allowed to provide the NSD package.
- RHU and ASC must comply with requirements under PhilHealth Circular Nos. 15, s. 2001 and 09, s. 2003.
- No additional accreditation fee shall be imposed on currently accredited RHU and ASC for accreditation as NSD package providers.
Payment scheme and covered services
- The NSD package uses a case payment scheme in claims reimbursement.
- The Relative Value Unit (RVU) assigned for these procedures using Relative Value Scale code number 59409 no longer applies.
- The case rate is limited to the first two (2) normal deliveries, consistent with PhilHealth Board Resolution No. 501.
- The case rate is PHP 4,500 to accredited health care providers.
- For the PHP 4,500 case rate, accredited providers must provide all the services the member or dependent requires, including:
- Prenatal care
- Delivery
- Newborn care
- Postnatal services
- The payment for the health facility is expected to cover:
- Room and board
- Drugs and medicines
- Diagnostics
- Operating room
- Professional fees
- All other medically necessary care
- Services rendered for maternal complications during delivery are integrated in the package.
Claims payments schedule and split
- Case rate payment for non-hospital facilities is divided into two claim payments:
- First payment: Prenatal care & Normal delivery (after delivery) in the amount of PHP 3,650.00
- Second payment: Postnatal care & Family planning services (after postnatal consultation) in the amount of PHP 850.00
- The total case rate is PHP 4,500.
Reimbursement conditions and benefit limit
- PhilHealth shall not reimburse claims with incomplete provision of services.
- Availment of the PhilHealth Maternity Care Package for NSD is charged one-day to the annual 45-day benefit limit.
Eligibility rules for members and dependents
- The NSD benefit package is available to all members and qualified dependents of the National Health Insurance Program (NHIP) who satisfy eligibility criteria and are not disqualified by exclusion criteria.
- Individually paying members must comply with:
- Sufficient regularity of premium contributions, and
- At least nine (9) months or three (3) quarters of premium payments in the immediate twelve (12) months prior to delivery.
- Individually paying members enrolled as a group or through the IPP-OWWA program, and all other types of membership, are governed by current eligibility requirements and need not satisfy the sufficient regularity rule.
- The first prenatal visit must not exceed four (4) months age of gestation (AOG) of the current pregnancy.
Exclusion criteria for non-hospital NSD
- Claims for the NSD package in non-hospital facilities shall be denied payment when claimed if any exclusion criteria apply, including:
- Maternal age under 19 years old
- Elderly primies with maternal age 35 years and older
- Multiple pregnancy
- Ovarian abnormalities (e.g., ovarian cyst)
- Uterine abnormalities (e.g., myoma uteri)
- Placental abnormalities (e.g., placenta previa)
- Abnormal fetal presentation (e.g., breech)
- History of at most three (3) miscarriages or one (1) stillbirth
- History of previous major obstetric/gynecologic operative intervention (e.g., cesarean section, uterine myomectomy)
- History of medical conditions (e.g., hypertension, heart disease, pre-eclampsia, eclampsia, diabetes, thyroid disorders, obesity, moderate to severe asthma, epilepsy, renal disease, bleeding disorders)
- Other risk factors arising during the present pregnancy (e.g., premature contractions, vaginal bleeding) that warrants a referral for further management
Claims filing requirements and deadlines
- Reimbursement requires submission of a Duly accomplished Claims Form 4.
- Until the new claim form is distributed to providers, providers may still use PhilHealth Claim Form No. 2.
- All claim applications for the Maternity Care Package are covered by ICD-10 requirements by PhilHealth Corporation.
- Claims for prenatal, delivery and newborn care must be filed within sixty (60) calendar days from the date of discharge.
- The second claim covering postnatal and family planning services must be filed within ninety (90) days from the date of discharge.