PhilHealth SARS Benefits Guidelines

The circular is issued pursuant to PhilHealth Board Resolutions No. 563 and 564.
The circular establishes specific SARS benefit guidelines for PhilHealth claims and payments.
The circular is implemented through PhilHealth’s payment and claims processing rules for SARS cases and qualifying health workers.

The PhilHealth SARS benefits may be availed by qualified PhilHealth members and their dependents.
Coverage applies when the case is a DOH-identified probable SARS case.
Covered cases must be admitted in a Department of Health (DOH)-designated hospital for SARS cases.
The benefit includes members and their qualified dependents, subject to the eligibility and exclusions stated in the benefit rules.

For members and their qualified dependents, the benefit provides payment of the maximum amount of P50,000 per case.
Payment applies to professional health services.
Payment applies to drugs and medicines.
Payment applies to radiographics services, laboratory examination, supplies, and transfer services from referring hospital to DOH-designated hospital for SARS.
Payment applies to use of the operating room complex.
Payment applies to all other medically necessary care.

The circular provides no specific benefit limits except for room rate and professional fees benefit limits.
The 45 day room and board allowance applies for covered cases under the member/dependent benefit rules.
The circular also applies the same general “no specific benefit limits” approach (subject to room rate and professional fees benefit limits) to the health worker benefit rules.

Health workers who are at the forefront and are at a peculiarly high health risk in national efforts to control SARS receive the maximum amount of P100,000 per case.
The health worker maximum applies when the health worker has contacted the SARS-causing organism as a result of having cared for a patient suspected of having SARS in a DOH-designated SARS hospital.
Health workers receive payment under the same framework where there are no specific benefit limits except for room rate and professional fees benefit limits.
The 45 day room and board allowance applies for the health worker benefit rules.

Current eligibility requirements apply for the availment of the SARS benefit.
Members must have at least paid three months of premium in the last six months prior to availment.

The SARS benefit is paid as a special benefit directly to the DOH-designated hospital for SARS cases.
No direct filing of members is allowed.
The ICD 10 Code for Probable SARS is J12.8, B97.2.

SARS benefit claims require PhilHealth Claim Form 1.
SARS benefit claims require PhilHealth Claim Form 2, and itemization of parts III and IV is not required.
SARS benefit claims require hospital documentation from DOH confirming that:
- the hospital is a designated SARS hospital; and
- the patient is a DOH-identified probable SARS case.
For claims by health workers, the circular requires a certification signed by the Hospital Chief/Administrator stating that the patient is a health care worker who contacted the disease:
- in the course of the performance of duties; and
- in a DOH-designated hospital for SARS.
Health worker claims may be supported by any other document attesting to that fact, signed by an authorized officer of the DOH.

The benefit amount of P50,000 per case applies to members and their qualified dependents, except health workers for DOH-identified probable SARS cases in DOH-designated SARS health care institutions.
Health workers are covered under the separate P100,000 per case rule when the health worker has contacted the SARS-causing organism through caring for a suspected SARS patient in a DOH-designated SARS hospital.