1. PHILHEALTH Updates

2. Outline Benefits Accreditation Standards- policy statements
Z benefit updates
Policy updates:
SOA (PhilHealth Circular )
Dialysis database (PhilHealth Circular )
Annex 2 – List of procedure case rates (Revision
3.0) and supplementary guidelines for all case
rates (PhilHealth Circular No – 0014)

3. Spectrum of PhilHealth Benefits
Outpatient
(PCB & MDG)
Inpatient
(Case Rates)
Catastrophic
(Z benefits)
Acute Lymphocytic Leukemia
Early Breast Cancer
Prostate Cancer
Kidney Transplantation
Coronary Artery Bypass Graft
Primary Care Benefit
Maternity Care/NSD Package
Prenatal care
Newborn Care Package
TB-DOTS Package
Animal Bite Package
Malaria Package
Outpatient HIV-AIDS Package
Inpatient cases
Day surgeries
Chemotherapy
Radiotherapy
Hemodialysis
Total Correction of TOF
Closure of VSD
Cervical Cancer
Z Morph
Peritoneal Dialysis
Colon and rectum cancers

4. Comparative Benefit Expense vs. Premium Income (CY 2010 – 2015)
Ben. Exp. Over Prem. Ratio
88.4% % % % % %

5. 56% OOP 92% Three Dimensions to Consider in Moving Toward UHC
PhilHealth has Expanded the Breadth of the UHC Cube, but Height and Depth are Lacking
Three Dimensions to Consider in Moving Toward UHC
56% OOP
No/little assurance of financial risk protection
No ceiling for out-of-pocket expenditures except those covered by the NBB
Fragmented
Lack of outpatient benefits esp. drugs
92%
High level of population coverage
But last 8% is difficult to target
Adapted from a slide courtesy of John Wong, 2016

6. 2015 TAT on Good Claims OFC TAT TOTAL CLAIMS TOTAL PROCESSING DAYS31
6,901,699
215,481,549

7. Accreditation Statistics

8. PhilHealth-accredited Health Care Institutions, 2001-2015
Source: Accreditation Department, PhilHealth

9. Source: Accreditation Department, PhilHealth

10. PhilHealth Policy Statements on the Management and Diagnosis of Diseases
Appraised and adopted:
ECOPD
Dyslipidemia (circular being routed)
Pneumonia in adults (updated)
UTI in adults (updated)
Pneumonia in children (to translate to policy statements)
Cataract

11. What are Policy Statements?
These are recommendations based on best available evidence (published evidence) or treatment protocols
Expert opinion
Not all recommendations are translated to policy statements

12. Purpose of Policy Statements?
Education
Quality assurance
Policy formulation and monitoring

13. Legal Basis
Revised IRR of the RA under Title V (Quality Assurance and Accreditation) Rule 1 (Quality Assurance) Section 51 provides: ”implementation of quality assurance standards as reference for ensuring quality of care services”

14. Conditions covered by policy statements
1. Acute Gastroenteritis 2. Urinary Tract Infection in Adults 3. Community-acquired Pneumonia (CAP) 4. Cataract 5. Chronic obstructive pulmonary disease 6. Asthma in adults

15. Z Benefit for Colon and Rectum CA

16. Expansion of Contracting for the Z Benefits
Now includes private HCI’s
Recent Contract Signing:
St. Paul Hospital (Ioilo City)
St. Luke’s Hospital Global City
Lorma Medical Center (San Fernando, La Union)
Angeles University Foundation Hospital (Angeles City)
Mary Mediatrix Medical Center (Lipa City)

17. Private HCIs CONTRACTED for Z Benefits as of June 2016
PRO
Name of HCI
Address
Z Benefit Package
NCR
UNIVERSITY OF THE EAST – RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER
Sta. Mesa, Manila
Z MORPH
ST. LUKES MEDICAL CENTER – GLOBAL CITY
Global City, Taguig City
KIDNEY TRANSPLANTATION (KT) I
LORMA MEDICAL CENTER
San Fernando City, La Union
III
ANGELES UNIVERSITY FOUNDATION MEDICAL CENTER
Angeles City, Pampanga
CORONARY ARTERY BY PASS GRAFT (CABG )
IV-B
MARY MEDIATRIX MEDICAL CENTER
Lipa City, Batangas
CORONARY ARTERY BY PASS GRAFT (CABG)
ST. FRANCES CABRINI MEDICAL CENTER
Sto. Tomas, Batangas
KIDNEY TRANSPLANTATION (KT
BREAST CANCER VI
ST PAUL HOSPITAL OF ILOILO
Iloilo City, Iloilo

18. PhilHealth Circular No. 2016 - 005
Submission of Statement of Account (SOA) for All Case Rate Claims Reimbursement

19. Rationale
As part of the review of All Case Rates (ACR) in the context of policy research, the statement of account (SOA) or billing statement shall be required as attachment to PhilHealth claims application for ACR

20. Scope and Coverage
This policy shall cover all case rate claims of eligible PhilHealth members and their qualified dependents in all PhilHealth accredited health care institutions.

21. Statement of Account (SOA)
For the purpose of standard implementation, the SOA must contain the following minimum requirements:
The SOA shall reflect the actual total hospital charges minus the PhilHealth benefit for the Health Care Institution (HCI) fee.
Part III item A of Claim Form 2 Certification of Consumption of Benefits and Consent to Access Patient Record/s must be consistent with that of the SOA of the patient;

22. Statement of Account (SOA)
For the purpose of proper implementation, the SOA must contain the following elements:
The SOA should be duly signed by the member or his/her authorized representative (with printed name, relationship to member and contact number) confirming or concurring with the Statements therein relative to PhilHealth deductions;

23. Statement of Account (SOA)
For the purpose of proper implementation, the SOA must contain the following elements: (continued)
The signatory in SOA must be the same person as the signatory in PhilHealth Claim Form 1 under Part III. Member Certification. In case the signatory in Claim Form 1 is different from the signatory in the SOA, information for authorized representative (name, relationship to member, contact number) should be indicated in the SOA;
The SOA should have the signature over printed name and position of the accountant or billing clerk.

24. Implementing Guidelines
The original or a certified true copy of the SOA shall be submitted together with the PhilHealth claim forms for claims application for ACR.
Part III- Certification of consumption of benefits and consent to access patient record/s of PhilHealth Claim Form 2 should be completely filled out together with the SOA as supporting document
The accredited health care institution shall be obliged to provide assistance to facilitate member requests and concerns, consistent with PC No. 11 – 2008, page 2

25. Implementing Guidelines (continued)
The SOA shall not be required for claims application for the following:
- TB DOTS
- Maternity Care Package
- Peritoneal Dialysis
- Outpatient Malaria Package
- Outpatient HIV/AIDS Treatment Package
- Animal Bite Treatment Package
- Newborn Care Package (in non-hospital facilities)

26. Claims Filing
Claims with incomplete documents shall be returned to sender. Existing RTS rules shall apply.
Claims with incomplete entries shall also be returned to sender for completion.

27. PHILHEALTH DIALYSIS DATABASE (PDD) PhilHealth Circular No. 2016-007

28. OBJECTIVE
To establish the standard registration process of members and dependents who are prescribed with dialysis or other renal replacement therapy under the PDD,

29. DEFINITION
Chronic kidney disease (CKD) stage 5 has end stage renal disease (ESRD) with a GFR of 15 ml/min or less. At this advanced stage of kidney disease the kidneys have lost nearly all their ability to do their job effectively, and eventually dialysis or a kidney transplant is needed to live. This kind of kidney failure is permanent and is usually caused by diabetes  or high blood pressure. 
ICD -10 code
Description
N18.5
CKD stage 5
ESRD
End stage kidney disease
Source: Philippine ICD 10 Modifications. Second edition. May 2014

30. RENAL REPLACEMENT THERAPY (RRT) - is a term used to encompass life-supporting treatments for renal failure. It includes hemodialysis, peritoneal dialysis, hemofiltration and renal transplantation.
Hemodialysis (HD) – blood is removed from the body and filtered through a man-made membrane called a dialyzer, or artificial kidney, and then the filtered blood is returned to the body.
Peritoneal dialysis (PD) -A dialysis technique that uses the patient's own body tissues inside the abdominal cavity as a filter. A plastic tube called a dialysis catheter is surgically placed through the abdominal wall, into the abdominal cavity. A special fluid is then flushed into the abdominal cavity and washed around the intestines. The intestinal walls act as a filter between this fluid and the bloodstream. By using different types of solutions, waste products and excess water can be removed from the body. This form of dialysis can be done either manually or by machine at home, thereby avoiding hospitalization or receiving dialysis treatment at a dialysis center.

31. DEFINITION…..CONT.
C. Philippine Renal Disease Registry (PRDR) –
is being administered by the National Kidney and Transplant Institute – Renal Disease Control Program (NKTI- REDCOP) and includes the following: the End Stage Renal Disease (ESRD) Registry composed of the Hemodialysis, Peritoneal Dialysis & Transplant Registries, and the Chronic Kidney Disease Registry composed of Biopsy.

32. GUIDELINES A. Requirements for Registration of Dialysis Patients
1. PhilHealth Identification Number (PIN)
2. Certification of Diagnosis and Management – CKD:
Members or dependents diagnosed of chronic kidney disease stage 5 who are prescribed with hemodialysis, peritoneal dialysis or other renal replacement therapy shall secure this certification from a PhilHealth -accredited nephrologist (Diplomate or Fellow of Philippine Society of Nephrology or Pediatric Nephrology Society of the Philippines) or an internist with completed training in nephrology (Diplomate of Philippine College of Physicians with completed training in nephrology).

33. The certification shall include the following:
a. estimated Glomerular Filtration Rate: _ ml/min/1.73 m2
b. Creatinine level: ____ mg/Dl
c. Other findings:
d. Doctor’s recommendation: diagnosis and type of dialysis
PDD Registration Form: completely and correctly filled out
The PDD Registration Forms shall be available in all accredited health care institutions (HCIs) with dialysis services, LHIOs, PROs and at the PhilHealth website.

34. 1.The registration and submission shall start on May 1, 2016.
Guidelines…..cont.
B. Registration and Submission
1.The registration and submission shall start on May 1, 2016.
2.Members and dependents diagnosed of CKD stage 5 (previously known as ESRD) who are prescribed with hemodialysis, peritoneal dialysis or other renal replacement therapy shall register under the PDD.

35. Registration and Submission
To register, they shall be required to submit the following to an accredited health care institution with dialysis services with PDD module (see attached Annex):
PDD Registration Form  that is completely and correctly filled out
Certification of Diagnosis and Management – CKD
Registration and Submission

36. Registration and Submission
4. They only need to register under the PDD once unless
their registration has been deactivated .
Registration of members or dependents who availed of kidney transplantation or who underwent kidney transplantation or other related cases  under the Z benefits or All Case Rates packages shall be deactivated under the PDD. If hemodialysis or peritoneal dialysis is prescribed once more for such cases, reactivation of the registration shall be required.
Updating of registration under the PDD shall warrant the same requirements (item IV. A).
Registered members or dependents who are tagged as expired in the membership and claims databases shall be deactivated under the PDD.
The PDD Registration Forms and the Certification of Diagnosis and Management – CKD shall be made available in all accredited HCIs with dialysis services, LHIOs, PROs and at the PhilHealth website.

37. Registration and Submission
The HCIs shall assist their CKD patients in filling out the PDD Registration Forms. The completely and correctly filled out PDD Registration Forms shall be encoded by the HCIs using the PDD module through the HCI Portal.
6. After encoding, the HCIs shall ensure the submission of the PDD Registration Forms and other requirements (original copies) to the LHIOs or PROs within 60 calendar days from date of approval of registration. 

38. Registration and Submission
7. No fees shall be collected by the HCIs for the registration of members or dependents under the PDD.

39. PhilHealth Dialysis Database
The PDD module shall be developed and integrated in the HCI Portal. It shall provide real time information to all authorized users. The PDD shall be operational starting May 1, 2016.
HCIs with dialysis services shall submit a letter of intent to access the PDD.  HCIs with dialysis services with no installed and functional HCI Portal shall be required to apply and be connected before May 1, PhilHealth Circular No. 2 s (item II. B and C)   enumerated the requirements on how to participate in the HCI Portal.

40. PhilHealth Dialysis Database, cont.
3. The Corporation and the HCIs shall ensure the security, confidentiality, and integrity of patients’ information at all times.
4. A regular process of monitoring and evaluation of the PDD shall be conducted. Any identified issues and concerns shall be referred to the concerned offices  for resolution.
5. The Corporation shall be the owner of the PDD data. The information shall be available and accessible to all authorized users as may be determined by the Corporation.

41. PDD and Claims Processing
Registration in the PDD shall be a requirement for reimbursement of claims for dialysis of patients diagnosed of CKD stage 5. Non -registration under the PDD shall mean denial of reimbursement.
To give ample time for PhilHealth members and dependents on chronic dialysis to register, PhilHealth shall only require PDD registration for reimbursement of dialysis claims for admissions or procedures performed starting July 1, 2016.
Registration on the same day as filing of claims for dialysis shall be acceptable provided the regular 45 days benefit limit is not yet exhausted.

42. MONITORING AND EVALUATION
The health care providers shall be subjected to the rules on monitoring and evaluation of performance as provided for in PhilHealth Circular No. 54, s-2012: Provider Engagement through Accreditation and Contracting for Health Services (PEACHeS) and PhilHealth Circular No re: Health Care Provider Performance Assessment System (HCP PAS).
The HCIs shall accept members or dependents seeking dialysis services based on their license and facility’s capability.
The current clinical practice guidelines for the management of chronic kidney disease shall be the basis for the standard of care.

43. The PDD Registration Form and
IX. ANNEX
The PDD Registration Form and
Certification of Diagnosis and Management - CKD
shall also be made available as downloadable document at the PhilHealth website:

45. PC No
ANNEX 2 - LIST OF PROCEDURE CASE RATES (REVISION 3.0) AND SUPPLEMENTARY GUIDELINES FOR ALL CASE RATES

46. RATIONALE
As per Rule I, Sections 35 (objective) and 36 (functions) of the revised IRR of RA 7875 as amended by RA 9241 and 10606, “the National Health Insurance Program aims to provide its members with responsive benefit packages. In view of this, the Corporation shall continuously endeavor to improve its benefit package to meet the needs of its members.”
In setting certain provisions in the policy, the concerned specialty societies and other stakeholders have been consulted. This and future enhancements of All Case Rates policies reflect the diversified scopes of professional practice and prevailing clinical setting.

47. Delisting of RVS codes/procedures
SCOPE
This Circular shall cover the following revisions for selected procedures listed in Annex 2 – List of Procedure Case Rates (Revision 2.0):
Relative Value Scale (RVS) codes/ procedures with changes in case rate amount and /or conditions for claiming.
Delisting of RVS codes/procedures
RVS codes/ procedures that shall be claimed only once in a lifetime per eye
Reimbursement policy for RVS codes and 66821
RVS codes/procedures exempted from the 90 day single period of confinement rule
Other supplementary guidelines
1. Reimbursement of ophthalmic surgical and laser procedures
2. Intraocular lens (IOL)
3. Cataract Pre-surgery Authorization (CPSA) limit

48. Health Care Institution fee
GUIDELINES
The selected procedures listed herein shall now be used for reference by accredited health care providers and PhilHealth members/dependents in claiming for PhilHealth reimbursements.
A. Rvs CODES/ PROCEDURES WITH CHANGES IN CASE RATE AMOUNT AND/ OR CONDITIONS FOR CLAIMING
RVS code
Description
(New)
First
Case Rate
Health Care Institution fee
Professional fee
17000
Destruction by any method, including laser, w/ or w/o surgical curettement, a benign facial lesions or premalignant lesions in any location, or benign lesions other than vascular proliferative lesions, including local anesthesia; any number of lesions
6,000
3,800
2,200
17106
Destruction of cutaneous vascular proliferative lesions (e.g. laser technique)

49. Health Care Institution fee
Rvs CODES/ PROCEDURES WITH CHANGES IN CASE RATE AMOUNT AND/ OR CONDITIONS FOR CLAIMING
RVS code
Description
(New)
First
Case Rate
Health Care Institution fee
Professional fee
65205
Removal of foreign body, external eye; conjunctival, superficial
500
300
200
65772
Corneal relaxing incision for correction of surgically induced astigmatism
10,000
6,000
4,000

50. Maximum Number of sessions per patient
1. RVS code shall only be claimed relative to these conditions:
ICD 10
Code
Description/
Diagnosis
Maximum Number of sessions per patient
Interval
in between
procedures
Can only
be performed by
B07
Verruca vulgaris (located on the palms and soles and periungual areas) 6
30 days
Diplomate/Fellow/
Consultant of Philippine
Dermatological Society (PDS)
D22.0
D22.1
Nevus of Ota
90 days

51. Maximum Number of sessions per patient
2. RVS code shall only be claimed relative to THE FOLLOWING conditions:
ICD 10
Code
Description/
Diagnosis
Maximum Number of sessions per patient
Interval
in between
procedures
Can only
be performed by
B07
Verruca vulgaris (plantar or periungual) 6
30 days
Diplomate/
Fellow/ Consultant of Philippine Dermatological Society (PDS)
L71.9
Rosacea (severe)
D18.0
Hemangioma, any site
Venous malformation
Angioma NOS
except Cherry angioma
Q82.5
Congenital non-neoplastic naevus (portwine)

52. 3. RVS code 65205 (Removal of foreign body, external eye; conjunctival, superficial)
can be performed by all accredited physicians.
The operative record (with OR technique) shall be attached to the clinical chart for monitoring purposes.

53. Further, RVS codes 67400, 67405, 67412, 67413, 67414, 67415, 67420, 67430, and (exploration, excision and decompression of orbit)
shall be reimbursed
if performed by accredited specialists for trauma and maxillofacial surgery.

54. B. Delisting of RVS codes
The following procedures are temporarily delisted until further notice as recommended by the medical specialty societies concerned. Hence, claims for these procedures shall be denied.
RVS Code
Description
17100
Destruction by any method including laser of benign skin lesions other than cutaneous vascular proliferative lesions on any area other than the face, including local anesthesia; any number of lesions
17200
Electrosurgical destruction of multiple fibrocutaneous tags; All lesions
11050
Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o chemical cauterization (such as verrucae or clavi) not extending through the stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; single lesion
11051
Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o chemical cauterization (such as verrucae or clavi) not extending through the stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; two to four lesions
11052
Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o chemical cauterization (such as verrucae or clavi) not extending through the stratum corneum (e.g., callus or wart) w/ or w/o local anesthesia; more than four lesions

55. DELISTING....CONTINUATION 50205
RVS Code
Description
50205
Renal biopsy; by surgical exposure of kidney
65420
Excision or transposition of pterygium; without graft
65771
Radial keratotomy
67042
Vitrectomy, mechanical, pars plana approach; with radial optic nerve neurotomy (RON)
67043
Vitrectomy, mechanical, pars plana approach; with sheathotomy for branch retinal vein occlusion
67044
Vitrectomy, mechanical, pars plana approach; with macular translocation (limited by retinotomy and/or scleral imbrication)
67045
Vitrectomy, mechanical, pars plana approach; with macular translocation (total)

56. C. RVS codes/ procedures that shall be claimed only once in a lifetime per eye
1. The following procedures shall only be reimbursed once in a lifetime per eye.
RVS Code
Description
Removal of Eye
65091
Evisceration of ocular contents; w/o implant
65093
Evisceration of ocular contents; w/ implant
65101
Enucleation of eye; w/o implant
65103
Enucleation of eye; w/ implant, muscles not attached to implant
65105
Enucleation of eye; w/ implant, muscles attached to implant
65110
Exenteration of orbit without skin graft, removal of orbital contents; only
65112
Exenteration of orbit without skin graft, removal of orbital contents; w/ therapeutic removal of bone
65114
Exenteration of orbit without skin graft, removal of orbital contents; w/ muscle or myocutaneous flap

57. 2. To reiterate, the following RVS code 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984, and under “Removal Cataract” shall be claimed only once in a lifetime per eye as listed in Annex 2 – List of Procedure Case Rates (Revision 1.0) of PhilHealth Circular No. 008 – It shall also include RVS code
To illustrate:
Patient A
RVS code
Laterality
Date performed
Remarks
66983
Right eye
June 1, 2015
Pay
Left eye
June 3, 2015
66840
September 5, 2015
Denied, under the same group of “Removal Cataract”

58. D. Reimbursement policy for RVS codes 66820 and 66821
Description
66820
Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); stab incision technique (Ziegler or Wheeler knife)
66821
Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (e.g., YAG laser) (one or more stages)

59. PREVIOUS CATARACT SURGERIES Procedure/Date performed
Claims for RVS codes and shall not be compensable if done less than 90 days after cataract surgery on the same eye. Both procedures can only be done once in a lifetime per eye.
To illustrate:
Claim
PREVIOUS CATARACT SURGERIES
Procedure/Date performed
CLAIM
Procedure/
Date performed
REMARKS 1
RVS code 66987
Right eye
November 1, 2014
RVS code 66820
February 15, 2015
Pay 2
June 15, 2015 3
Left eye
April 1, 2016
July 1, 2016 4
April 5, 2016
Deny claim

60. PREVIOUS CATARACT SURGERIES Procedure/Date performed
2. RVS and shall be exempted from the laterality rule. For bilateral discission procedures (either RVS or 66821) done in one operative session or with less than one day interval (within same or different confinements), the second discission procedure shall be paid at 50% of the case rate. However, if there is at least one day interval between procedures (within same or different confinements), the second discission procedure shall be paid the full case rate.
To illustrate:
Claim
PREVIOUS CATARACT SURGERIES
Procedure/Date performed
CLAIM
Procedure/
Date performed 1
First Case Rate: RVS code 66821
Right eye
June 15, 2015
Second Case Rate: RVS code 66821
Left eye
Pay first case rate full and 50% for second case rate 2
First Case Rate: RVS code 66821
July 1, 2016
July 3, 2016
Pay full case rate for both claims

61. Can only be performed by
3. Both RVS codes and shall automatically be subjected to post-audit.
E. RVS codes/procedures exempted from the 90-day
single period of confinement rule
RVS code
Description
Condition/Rules
Can only be performed by
67036
Vitrectomy, mechanical,
pars plana approach
Exempted from the 90 day Single Period of Confinement rule for the following medical indications only:
H43.1 (Vitreous haemorrhage)
H44.0 (Purulent endophthalmitis)
2. A justification to support the performance of the procedure shall be submitted in filing of claims for cases done by the same surgeon who performed the ocular surgery that led to its complication.
Otherwise, the claim shall be denied.
3. Subject to Automatic Post-Audit
Medical Specialist
a. Philippine
Academy
of Ophthalmology
(PAO)
b. trained in EENT or
General Practitioner with completed residency training in Ophthalmology

62. Can only be performed by
....CONTINUATION
E. RVS codes/procedures exempted from the 90-day
single period of confinement rule
RVS code
Description
Condition/Rules
Can only be performed by
67049
Vitrectomy, mechanical pars plana approach, with removal of dropped IOL
1. If vitrectomy is done in one confinement with cataract extraction, PhilHealth shall reimburse vitrectomy only. If vitrectomy and cataract extraction are performed in separate confinements , both procedures shall be reimbursed.
2. Subject to Automatic Post-Audit
Medical Specialist
a. Philippine
Academy of
Ophthalmology
(PAO)
b. trained in EENT
67050
Vitrectomy, mechanical pars plana approach; with phacofragmentation for dropped lens nucleus

63. F. Other Supplementary Guidelines
Ophthalmic surgical (includes cataract surgeries) and ophthalmic laser procedures shall be reimbursed when performed by an accredited General Practitioner with Completed Residency Training in Ophthalmology (PhilHealth Accreditation Number starting with 1501 and 1503) or by a Medical Specialist of PAO or a Medical Specialist trained in Eye, Ear, Nose, Throat (EENT) (PhilHealth Accreditation Number starting with 1304 and 1314, respectively) unless otherwise specified.
A General Practitioner with completed residency training shall submit the certified true copy of the certificate of completed residency training in Ophthalmology to the concerned PRO for evaluation and tagging in the accreditation database.

64. 3. The removal of corneal, corneo-scleral and conjunctival sutures cannot be claimed using the following RVS codes:
RVS code
Description
65205
Removal of foreign body, external eye; conjunctival, superficial
65210
Removal of foreign body, external eye; subconjunctival or scleral, with slit lamp
65222
Removal of foreign body, external eye; cornea, with slit lamp

65. 4. The Food and Drug Administration Philippines - registered intraocular lens (IOL) sticker or box used in the cataract surgery shall be attached to Claim Form 2 for claiming the following procedures:
RVS code
Description
66982
Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g. iris expansion device, suture support for intraocular lens, or primary posterior capsullorhexis) or performed on patients in the amblyogenic developmental stage
66983
Intracapsular cataract extraction w/ insertion of intraocular lens prosthesis (one stage procedure)
66984
Extracapsular cataract removal w/ insertion of intraocular lens prosthesis (one stage procedure), (e.g., irrigation and aspiration)
66985
Insertion of intraocular lens prosthesis, not associated with cataract removal
66986
Exchange of intraocular lens
66987
Extracapsular cataract removal w/ insertion of intraocular lens prosthesis (one stage procedure), (e.g., phacoemulsification)

66. In transition, the IOL sticker or box should be labeled with but not limited to: 1) product or brand name; 2) model or reference code; 3) manufacturer; and serial number until August 31, 2016 (1 out of 3 labels should be present and serial number). Thereafter, all three (3) labels and serial number should be present. Otherwise, the claim shall be denied.
As is, one (1) IOL sticker shall be placed on the operative record and shall be part of the chart. This shall be checked during monitoring.

67. 5. To reiterate, for cataract surgeries covered by the Cataract Pre-surgery Authorization (CPSA), PhilHealth shall authorize only up to a maximum of fifty (50) approved requests for pre-surgery authorization per PhilHealth-accredited eye surgeon per month not exceeding ten (10) scheduled surgeries per day per PhilHealth-accredited eye surgeon except for those performed by residents-in- training under the eye surgeon’s supervision in accredited government or private HCI with a Philippine Board of Ophthalmology accredited residency training program. The patients of residents- in -training not subject to limit shall only include non-private, service and NBB eligible patients.

68. To illustrate:
Dr. Juan Dela Cruz, an accredited health care professional has the following requests for Cataract Pre-Surgery Authorization:
Date of contemplated surgery
Classification of HCI
Category of patient
Number of approved CPSA
Included in the limit per health care professional? Yes or No
August 5, 2015
Private hospital
Private 9
Yes
August 6, 2015
Government hospital 10
August 9, 2015
Private ASC 5
August 11, 2015
August 15, 2015
Government hospital with no accredited residency training in Ophthalmology
Non-private
August 17, 2015
Sponsored member of PhilHealth 2
August 19, 2015

69. Total No. of Approved CPSA: 66
....CONTINUATION
Date of contemplated surgery
Classification of HCI
Category of patient
Number of approved CPSA
Included in the limit per health care professional? Yes or No
August 20, 2015
Private hospital with accredited residency training in Ophthalmology
Service patient as part of training program, with consultant signing for
patients of
residents 5 No
August 22, 2015
Government hospital with accredited residency training in Ophthalmology
Sponsored member of PhilHealth as part of training program, with consultant signing for patients of 11
August 23, 2015
Private hospital
Private 8
Yes
August 25, 2015
Private ASC 1
Request is denied because Dr. Dela Cruz already exceeded the limit of 50 CPSAs per month that are subject to the limit.
Total No. of Approved CPSA: 66
Total No. of CPSA not subject to limit: 16
Total No. of Surgeries for August: 66

70. 6. To reiterate, CPSA shall no longer be required in cases of childhood and secondary (e.g. traumatic, glaucomatous) cataracts. The clinical abstract (original or certified true copy) or a completely and properly filled out Claim Form 3 (page 1) shall be attached to CF2 for monitoring and evaluation. Otherwise, the claim shall be returned to sender.

71. TRANSITORY PROVISION
Claims for ophthalmic surgical and ophthalmic laser procedures by EENT specialists performed starting July 15, 2015 onwards shall be reimbursed subject to existing rules and regulations.

72. MONITORING AND EVALUATION
The health care provider shall be subjected to the rules on monitoring and evaluation of performance as provided for in PhilHealth Circular No. 54, s-2012: Provider Engagement through Accreditation and Contracting for Health Services (PEACHeS) and PhilHealth Circular No re: Health Care Provider Performance Assessment System (HCP PAS).
This Circular shall be reviewed periodically and as necessary.

73. REPEALING CLAUSE
All provisions of previous issuances, circulars, and directives that are inconsistent with any of the provisions of this Circular for this particular circumstance wherein the same is exclusively applicable, are hereby amended, modified or repealed accordingly.
SEPARABILITY CLAUSE
In the event that a part or provision of this Circular is declared unauthorized or rendered invalid by any Court of Law or competent authority, those provisions not affected by such declaration shall remain valid and effective.
EFFECTIVITY
The new provisions of this Circular shall take effect for claims with admission dates starting July 1, 2016 unless otherwise specified. It shall be published in any newspaper of general circulation and shall be deposited thereafter with the National Administrative Register at the University of the Philippines Law Center.

74. EFFECTIVITY
The new provisions of this Circular shall take effect for claims with admission dates starting July 1, 2016 unless otherwise specified. It shall be published in any newspaper of general circulation and shall be deposited thereafter with the National Administrative Register at the University of the Philippines Law Center.
ANNEX
New case rate amount for selected procedures listed in Annex 2 – List of Procedure Case Rates (Revision 3.0) pdf file and online inquiry “Search Case Rates” utility shall be available at

75. For comments, suggestions, questions:
us at

76. Thank You!