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Benefits | PhilHealth 11/09/2017, 11)59 AM

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These benefits are paid to the accredited Health Care Institution (HCI) through All Case Rates

The case rate amount shall be deducted by the HCI from the members total bill, which shall include professional fees of
attending physicians, prior to discharge

The case rate amount is inclusive of hospital charges and professional fees of attending physician

Availment condition: Member must have at least three (3) months premium contributions within the immediate six (6) months
prior to the month of availment

Documents needed: copy of Member Data Record or PhilHealth Benefit Eligibility Form (PBEF) and duly accomplished
PhilHealth Claim Form 1

Where available: all accredited HCIs*


*Different case rate amounts for selected medical conditions are being implemented when done in Primary Care facilities
(PhilHealth Circular 14, s-2013)

Only admissible cases shall be reimbursed

1. Day Surgeries (Ambulatory Or Outpatient Surgeries) Are Services That Include Elective (Non-Emergency) Surgical
Procedures Ranging From Minor To Major Operations, Where Patients Are Safely Sent Home Within The Same Day For
Post-Operative Care

Payments for these procedures are made to the accredited facility through All Case Rates

The case rate amount shall be deducted by the HCI from the members total bill, which shall include professional fees of
attending physicians, prior to discharge

The case rate amount is inclusive of hospital charges and professional fees of attending physician

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May be availed of as second case rate (full case rate amount)

45 days benefit limit: One session for each procedure is equivalent to one day deduction from the 45 allowable days per year
Exempted from the SPC rule

Where to avail: All Accredited HCIs

5. Primary Care Benefits 1


i. Preventive Services

1. Consultation
2. Visual inspection with acetic acid
3. Regular BP measurements
4. Breastfeeding program education
5. Periodic clinical breast examinations
6. Counseling for lifestyle modification
7. Counseling for smoking cessation
8. Body measurements
9. Digital rectal examination

ii. Diagnostic Examinations (as recommended by the doctor)

1. Complete blood count


2. Urinalysis
3. Fecalysis
4. Sputum microscopy
5. Fasting blood sugar
6. Lipid Profile
7. Chest x-ray

iii. Drugs and Medicines

1. Asthma including nebulisation services


2. Acute Gastroenteritis (AGE) with no or mild dehydration
3. Upper Respiratory Tract Infection (URTI)/Pneumonia (minimal and low risk)
4. Urinary Tract Infection (UTI)

Payments for these services are made to the primary care provider through Per Family Payment Rate (PFPR)

Availment condition: Indigent and Sponsored Members, as well as migrant workers and their legal dependents should avail of
these benefits within the effectivity of their coverage as indicated in their PhilHealth ID cards or Member Data Records. iGroup
(Gold) members may avail themselves of these benefits within the validity of their group policy contracts, while DepEd personnel
may avail themselves of the benefits as long as they are still active members of PhilHealth

Documents needed: Copy of Member Data Record or PhilHealth ID

Where available: accredited rural health units, health centers or outpatient departments of selected government hospitals where
members are enlisted

Benefit Package and


Selections criteria Where available
Amount of Benefit

Acute Lymphocytic / Lymphoblastic Leukemia a. Signed Member Empowerment (ME) Form; NCR
(standard risk) Philippine Children's Medical Center

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St. Frances Cabrini Medical Center

Region V
Bicol Medical Center

Bicol Regional Teaching and Training Hospital

Region VI
Corazon Locsin Montelibano Memorial Hospital

Western Visayas Medical Center

Region VII
Vicente Sotto Memorial Medical Center

Region X
Northern Mindanao Medical Center

Region XI
Davao Regional Hospital

Southern Philippines Medical Center

Prostate Cancer a. Signed ME Form; NCR


(low to intermediate risk) Quirino Memorial Hospital
P100,000 b. Male patients age up to 70 years old;
National Kidney and Transplant Institute
c. Clinical stage (T1a-T2c), PSA level 10 to 20
ng/ml, Rizal Medical Center
Tumor Grade (Gleasons score of 2-7)
- Low risk: T1-T2a and Gleason score 2-6, and UP-Philippine General Hospital
PSA 10 ng/ml
- Intermediate risk: T2b to T2c, Gleason score of 7, Region I
and PSA 10-20 ng/ml Ilocos Training and Regional Medical Center

d. Localized prostate cancer; and CAR


Baguio General Hospital and Medical Center
e. No uncontrolled co-morbid conditions
Region III
Dr. Paulino J. Garcia Memorial Research &
Medical Center

Region V
Batangas Medical Center
Bicol Medical Center

Bicol Regional Teaching and Training Hospital

Region VI
Western Visayas Medical Center

Corazon Locsin Montelibano Memorial Regional


Hospital

Region VII
Vicente Sotto Memorial Medical Center

Region X
Northern Mindanao Medical Center

End-state renal disease eligible for requiring a. Signed ME Form; NCR


kidney transplantation (low risk) National Kidney and Transplant Institute
P600,000 b. Age 10 and 70 years;
UP-Philippine General Hospital
c. Single organ transplant;
St. Luke's Medical Center - Global City
d. Patient on chronic dialysis because of end stage
renal disease or patient for pre-emptive kidney Delos Santos Medical Center

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such as coronary angioplasty or stenting Southern Philippines Medical Center


f. ONLINE EUROSCORE II and/or STS scoring
predictive of low mortality risk (5%)

Surgery for Tetralogy of Fallot in Children a. Signed ME Form NCR


P320,000 Philippine Heart Center
b. Age: 1 to 10 years + 364 days
UP - Philippine General Hospital
c. 2D-echocardiogram:
i. Pulmonary artery size Region VII
- McGoons index (Aorta/Pa ratio) 1.5 Vicente Sotto Memorial Medical Center
- Z score Pulmonary Valve Annulus : Acceptable if z
score / BSA : 3 or better Region X
- Z score peripheral PAs : Acceptable if 2 or Northern Mindanao Medical Center
better
ii. Absence of major aortopulmonary collateral Region XI
arteries (MAPCAs) Southern Philippines Medical Center

d. If cardiac catheterization / hemodynamic study


available: PA size: adequate by Z score standards /
BSA

e. No previous cardiac surgery (Blalock Taussig


Shunt)

f. Functional Class I-II

g. No co-morbid factors, such as any of the ff:


i. Preoperative seizures
ii. Brain abscess
iii. Stroke events
iv. Bleeding disorders
v. Infective endocarditis
vi. Other congenital anomalies

Surgery for Ventricular Septal Defect in a. Signed ME Form NCR


Children Philippine Heart Center
P250,000 b. Age: 1 to 5 years + 364 days
UP - Philippine General Hospital
c. 2D-echocardiography
i. Isolated VSD perimembranous, subaortic or Region IV-B
subpulmonic Mary Mediatrix Medical Center
ii. No combined shunts such as atrial septal defect
or patent ductus arteriosus or atrioventricular septal Region VII
defect Vicente Sotto Memorial Medical Center
iii. No other associated CHDs : such as coarctation
of the aorta, or moderate to severe aortic Region X
insufficiency, or moderate to severe pulmonic Northern Mindanao Medical Center
stenosis
iv. Pulmonary artery pressure: 50 mmHg or at least Region XI
2/3 systolic blood pressure Southern Philippines Medical Center
v. QP QS: > 1.5:1

d. No previous cardiac surgery (PA Banding)

e. Functional Class I-II

f. No co-morbid factors, such as any of the ff:


i. Preoperative seizures
ii. Brain abscess
iii. Stroke events
iv. Bleeding disorders
v. Infective endocarditis

g. No chromosomal abnormalities and other


associated congenital defects

Cervical Cancer: a. Signed ME Form; Region VII

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iii. hip fracture with no pre-existing cox-


arthritis; OR
iv. displaced hip fracture
2. Implants for Hip Fixation
- Multiple screw fixation (MSF)*** 6.5mm
cannulated cancellous screws with washer c. Pre-injury status: ambulatory patients
P61,500
d. With no more than two co-morbid illnesses
***59 years and 364 days old and below based on: Physical status classification based on
(both displaced and undisplaced fracture); ASA (low to moderate risk)
60 years old and above (undisplaced
fracture) ASA I normal healthy patient
ASA II Patient with mild systematic disease; no
functional limitation

a. Signed ME Form

b. CHS: stable fracture of the intertrochanteric


area (AO Classification Type A1 fracture)

c. PFLP: unstable/comminuted pertrochanteric


fracture (AO Classification Type A2 and A3
fracture)
3. Implants for Pertrochanteric Fracture
- Compression Hip Screw Set (CHS) d. Pre-injury status: ambulatory patients
P69,000 e. With no more than two co-morbid illnesses
based on: Physical status classification based on
- Proximal Femoral Locked Plate (PFLP) ASA (low to moderate risk)
P71,000
ASA I- normal healthy patient
ASA II Patient with mild systemic disease; no
functional limitation

a. Signed ME Form

b. Femoral shaft fracture


i. without malignant/metastatic pathologic
fracture: AND
ii. with any complete fracture of the femur
4. Implants for Femoral Shaft Fracture Pre-injury status: ambulatory patients
- Intramedullary Nail with Interlocking
Screws
c. Physical status classification based on ASA (low
P48,740
to moderate risk)
- Locked Compression Plate (LCP) Broad
ASA I normal healthy patient
/ Metaphyseal / Distal Femoral LC
ASA II Patient with mild systemic disease: no
P50,740
functional limitation

PD First - for End-Stage Renal Disease a. Signed ME Form (to be submitted annually NCR
Requiring Peritoneal Dialysis together with the pre-authorization) National Kidney Transplant Institute
P270,000 per year
b. Patients must have a permanent Tenckhoff Kidney Solutions, Inc.
peritoneal dialysis catheter properly placed in the
abdominal cavity; Region VI
Corazon Locsin Montelibano Memorial Regional
c. Patients must have completed PD initiation in an Hospital
accredited healthcare institution so that the patient
is no longer uremic, with stable vital signs and St. Paul's Hospital of Iloilo, Inc.
adequately trained (patient himself/herself or a
caregiver) to perform PD at home using manual
exchanges;

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- using cobalt as mode of radiotherapy - (clinically T1-4, N0-2, M0)


P320,000
b. No previous pelvic radiation

c. Pre-operative physical risk protection


ASA I normal health patient OR
ASA II patient with mild systemic disease

d. ECOG Performance Status


e. Mandatory and other services ( procedures,
diagnostics, medicines & others)
See Tables 6, 7, 8 of Circular No. 028-2015

Prevention of Preterm Delivery The following benefits shall be available for


pregnant women who are in their 24 to 36 and 6/7
1.Prevention of preterm delivery with severe weeks of gestation, at risk of preterm delivery. The
pre-eclampsia/eclampsia - 3,000.00 packages for the prevention of preterm delivery are
availed exclusive of each other, with or without the
2.Prevention of preterm delivery, with coordinated referral and transfer package.
preterm pre-labor rupture of membrane
(pPROM) - 1,500.00

3. Prevention of preterm delivery without


pre-eclampsia/eclampsia or rupture of
membranes but with labor or vaginal
bleeding or multifetal pregnancy - 600.00

4. With coordinated referral and transfer


from a lower level of facility - 4,000.00

Preterm and Small Newborns The following benefits shall be available for
(24 to < 32 weeks) pregnant women who are in their 24 to 36 and 6/7
weeks of gestation, at risk of preterm delivery. The
1. Essential interventions for 24 to < 32 packages for the prevention of preterm delivery are
weeks - 35,000.00 availed exclusive of each other, with or without the
coordinated referral and transfer package.
2. Essential intervention with minor ventilator
support and Kangaroo Care for 24 weeks to
< 32 weeks - 85,000.00

3. Essential interventions with major


ventilatory support and Kangaroo Care for 24
weeks to < 32 weeks - 135,000.00

Preterm and Small Newborns The following benefits shall be available for
(32 to < 37 weeks) premature newborns who are visually small or very
small, 24 weeks to < 37 weeks by fetal aging or
1. Essential interventions for 32weeks to < 500g to 2,499g fetal weight
37 weeks - 24,000.00

2. Essential interventions with mechanical


ventilation and Kangaroo Care for 32 weeks
to < 37 weeks - 71,000.00

As of August, 2017

Benefit Package and Where


Services included Conditions
Amount of Benefit available

Outpatient Malaria Package Diagnostic malaria smears and other laboratory Initial providers Patients diagnosed with malaria
P600.00 procedures; drugs and medicines & consultation are the confirmed either through:
services, including patient education & counseling. accredited a. Microscopy-detection of
facilities for the malaria parasites in Giemsa-

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Globulin (HR1G) or
Purified Equine Rubies
Immune Globulin (pERIG)

iii. Local wound care


iv. Tetanus toxoid and anti-
tetanus serum (ATS)
v. Antibiotics
vi. Supplies such as, but not
limited to, syringes, cotton,
alcohol and other antiseptics
b. Dog bites primarily. However,
persons bitten by other
domestic animals (cats) and
livestock (cows, pigs, horses,
goats) as well as wild animals
(bats, monkeys) may be
covered.

c. Category III Rabies exposure


i. Trans dermal bite (puncture
wounds, lacerations, avulsions)
or scratches/abrasions with
spontaneous bleeding
ii. Exposure to a rabies patient
through bites, contamination of
mucous membranes (eyes,
oral/nasal mucosa, genital/anal
Mucous membrane or open skin
lesions with body fluids through
splattering and mouth-to-
mouth Resuscitation
iii. Handling of infected carcass
or ingestion of raw infected
meat iv. Category II Rabies
exposure involving the head
and neck c. Patients with
repeat exposure

Documents needed: copy of Member Data Record and PhilHealth Claim Form 1

2014 Philippine Health Insurance Corporation | Citystate Centre, 709 Shaw Boulevard 1603 Pasig City | Call Center (+632) 441-7442

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