Benefit Packages and Amounts
- Standard members and dependents are entitled to a maximum benefit of PHP 50,000 per SARS case.
- Benefits cover professional health services, medications, radiographic services, laboratory exams, medical supplies, patient transfer services, use of operating room, and all medically necessary care.
- No specific benefit limits except for room rate and professional fees.
- A 45-day room and board allowance period applies.
Special Benefits for Health Workers
- Health workers contracting SARS from patient care in DOH-designated hospitals receive a maximum benefit of PHP 100,000 per case.
- Similar coverage conditions apply as for standard members, with no specific benefit limits aside from room and professional fees caps and the 45-day room and board allowance.
- This recognizes the higher health risk faced by health workers in controlling SARS.
Eligibility Requirements
- Members must meet current PhilHealth eligibility rules.
- This includes having paid at least three months of premiums within the last six months before availing of the benefit.
Claims Processing Procedures
- SARS benefits are paid directly to DOH-designated SARS hospitals; members cannot file claims directly.
- The ICD 10 codes for probable SARS cases are J12.8 and B97.2.
- Required documentation includes PhilHealth Claim Forms 1 and 2 (itemization for parts III and IV is not required).
- Hospital documentation from DOH confirming SARS hospital designation and probable SARS case status of the patient is mandatory.
- For health worker claims, certification by hospital chief/administrator confirming the patient's health worker status and infection during duty in a designated hospital must be submitted.
Effective Date and Implementation
- SARS benefits cover eligible cases discharged from designated SARS hospitals starting May 8, 2003.
- The policy became effective upon adoption on August 1, 2003, as provided by PhilHealth Circular No. 26, Series of 2003.