1. PhilHealth Claims Filing
Reducing Mistakes,
Increasing Reimbursements

2. Know the Rules!
PhilHealth does not pay for all your health care costs.
PhilHealth pays only for covered items and services when its rules are met.
Members usually give a co-payment for the portion of the actual cost that is not covered by PhilHealth

3. PhilHealth Govt owned and controlled corporation
Created by Republic Act 7875
National Health Insurance Program (NHIP)
Amended by Republic Act 9241
Access to health care is a basic right of citizens
“Universal coverage”

4. Members and Dependents

5. Our Members 1. Employees (govt and private)
– monthly payment (3% salary)
2. Individually Paying Program (voluntary)
- quarterly payment (1,200/year)
3. Overseas Workers Program
- Annual payment (900/year)

6. Our Members 4. Non-paying (pensioner) - no payment for life
60 years old
With total 120 monthly contributions
5. Sponsored (thru partnership with LGUs)
- annual payment, eligibility for 1 year

7. Your Dependents Spouse Children < 21 years old
Parents > 60 years old
Step parents
Adoptive parents

8. Benefits

9. 45 Days Annual Allowance
45 days allowance per year for the principal (member)
Another 45 days shared among dependents

10. Your benefits Illness requiring hospitalisation Outpatient:
Surgical procedures
Cataract surgery
BTL
Vasectomy
Endoscopy
Excision
Suturing

15. Drugs and Medicines Only drugs used during confinement will be paid
Drugs must be written in generic name
Closed formulary – only drugs listed in the preferred list* will be covered by PhilHealth
*6th edition of the Philippine National Drug Formulary (PNDF)

16. Anti-convulsants / Epileptics
CARBAMAZEPINE
CLONAZEPAM
DIAZEPAM
LORAZEPAM
MAGNESIUM SULFATE
PHENOBARBITAL
PHENYTOIN
VALPROIC DISODIUM
Gabapentin
Midazolam
Thiopental sodium
Topimarate

17. Anti-Parkinsonism Pirebidil Selegiline LEVODOPA + BENSERAZIDE 50 mg
100 mg/25 mg
200 mg/50 mg
LEVODOPA + CARBIDOPA
250 mg/25 mg

18. Case: 65 years old    Diagnosis: Parkinson’s Disease
Drugs: Levodopa + Benserazide # 60
Nifedipine 30 mg # 60 (PNDF)
Telmisartan tab # 60 (non-PNDF)
Admission: September   
What drugs will be paid?

19. Case:    Diagnosis: Parkinson’s Disease, HPN
Drugs: Levodopa + Benserazide # 60
Nifedipine 30 mg # 60
Telmisartan tab # 60
Admission: September      
How many will be paid?

20. Drugs and Medicines
Only drugs, supplies, and lab used on confinement shall be paid
Must be supported by official receipts

21. Fee for Service Scheme:
physician charges separately for each patient encounter or service rendered
expenditures increase if more services are provided or a more expensive service is substituted for a less expensive one
Needs itemization
Fee for Service Scheme:
utilized by PHIC in reimbursement
physician charges separately for each patient encounter or service rendered
expenditures increase if more services are provided or a more expensive service is substituted for a less expensive one

22. Computation of Benefits
Case type of illness
Category of Facility

24. Casetypes Casetype A – Ordinary Casetype B – Intensive
Casetype C – Catastrophic
Casetype D – Super Catastrophic

25. P1,035/day P35,635 P29,430 RVU > 500 = P10,470 P660/day P19,725
Level 3 & 4 Hospitals (Tertiary)
Case-type A B C D
Room & Board*
P400/day
P1,035/day
Drugs and Medicines**
P3,000
P9,000
P16,000
P35,635
X-ray, Lab & Others**
P1,700
P4,000
P14,000
P29,430
Operating Room**
RVU 30 and below = P1,060
RVU 31 to 80 = P1,350
RVU 81 up to 200 = P3,490
RVU 201 up to 500 = P3,490
RVU > 500 = P10,470
Level 2 Hospital (Secondary)
P300/day
P660/day
P8,000
P19,725
P850
P2,000
P10,215
RVU 30 and below = 670
RVU 31 to 80 = P1,140
RVU 81 up to 200 = P2,160
RVU 201 up to 500 = P2,160
RVU > 500 = P6,480
Level 1 Hospital (Primary)
P200/day
N/A
P1,500
P2,500
P350
P700
RVU 30 and below = P385
* Not exceeding 45 days for each member & another 45 days to be shared by his/her dependents
** Per single period of confinement

26. Benefit Periods PhilHealth benefits are divided into benefit periods
A benefit period is essentially a single hospital stay, including re-hospitalisation of up to 90 days
In each benefit period, PhilHealth will only pay 1 benefit

27. Single Period of Confinement
Example
a 3 week chemotherapy cycle, where a patient has treatment on the 1st and 8th days, but nothing on days and days
Medicine per session is 5,000

28. Benefit Unused Payment 16,000 January 1 5,000 January 8 11,000
February 12, 19,
90 days after January 1
New 16,000
March 1
March 5
March 12

29. Single Period of Confinement
You may only avail of the unused benefits except:
for room and board fees
Professional fees
until the 45 day allowance is fully exhausted.

30. Professional Fee

31. P315/day not exceeding P2,430 P450/day not exceeding P4,050
Professional Fees**
Case-type A B C D
General Practitioner
P150/day not exceeding P600
P150/day not exceeding P900
P315/day not exceeding P2,430
Specialist
P250/day not exceeding P1,000
P250/day not exceeding P1,500
P250/day not exceeding P2,500
P450/day not exceeding P4,050
Surgeon
(P40/RVU) not exceeding P16,000
(P120 /RVU for consultation) but not exceeding P47,790
Anesthesiologist
30% Surgeon’s fee not exceeding P5,000
30% Surgeon’s fee not exceeding P14,355
** Per single period of confinement

32. Professional Fee based on the Relative Value Units (RVU)
The RVU must be multiplied by a Peso Conversion Factor (PCF) to become a payment schedule
Surgeons: RVU x P 40
Covers preoperative visits, intraoperative services, postoperative services for 90 days
Anesthesiologist: (RVU x P 40) x 30%
Fee Schedule:
Surgical
based on the Relative Value Units (RVU)
The RVU must be multiplied by a Peso Conversion Factor (PCF) to become a payment schedule
Surgeons: RVU x P 420
Anesthesiologists: 30% of surgeons’ fee

33. Professional Fee Example: 66270 Spinal puncture 12
12 RVU x 40 PCF = Php 480

34. Professional Fee Example: 61793 Stereotactic radiosurgery 200
200 RVU x 40 PCF = Php 8,000

35. Professional Fee Example: 61500 Craniectomy w/ excision of tumor 400
400 RVU x 40 PCF = Php 16,000

36. Policies on PF > 2 procedures, single opening = pay highest value
> 2 procedures, different incision site
= pay all unit values
Procedures done on different dates
Fee Schedule:
Surgical
> 2 procedures, single opening = pay highest value
> 2 procedures, different incision site
= pay all unit values
Procedures done on different dates

37. Policies on PF Example: 49000 - Explor Lap - 150
Appendectomy - 100
150 RVU x 40 PCF = P6,000

38. Policies on PF Example: 49000 - Explor Lap - 150
Oophorectomy for
ovarian CA
200 RVU x 40 PCF = P8,000

39. Policies on PF performed on different dates/sites: Payment within cap
PF of multiple procedures
performed on different dates/sites:
Payment within cap
Payment preference based on RVU
Service Rendered Computed Benefit PHIC Benefit
ORIF Radius & Ulna(180 RVU) 7,200 4,000
ORIF Femur( 300 RVU) 12, ,000
Total = 16,000

40. Policies on PF Example: Bilateral Cataract Extraction
ECCE phacoemulsification - 200
200 x 2 = 400 RVU
400 RVU x 40 PCF = P16,000

41. Policies on PF Payment within cap
Repeat Procedures:
Payment within cap
Covered by rule on single period of confinement
Service Rendered Computed Benefit PHIC Benefit
Ligation, varices esophagus 10, ,000 Ligation, varices esophagus 10,000 6,000
Total = 16,000

42. Professional Fee Example: 66270 Spinal puncture 12
12 RVU x 40 PCF = Php 480

43. Professional Data & Charges
Daily visit
RVU
Anesth

44. Professional Data & Charges
With deduction
Lumbar tap
1000
480
520

45. Professional Data & Charges
With no deduction
Lumbar tap
1000
1000

46. Professional Data & Charges
Complimentary PF; PhilHealth only
Lumbar tap
480
480
Actual PF = PhilHealth benefit

47. Professional Data & Charges
Government hospital; Private Patient
Private hospital; Service Patient
Dialysis
400
400

48. Private Patient, Government Hospital NO Stamp: PF is made to the Chief
PAY TO DOCTOR
NO Stamp: PF is made to the Chief

49. Service Patient, Pay Hospital
Name of Surgeon
PAY TO CHIEF
NO Stamp: PF is made to the MD who signed Form 2

52. Reason for Denial Late filing > 45 days confinement
Non-compliance to RTH
Not accredited hospital
No ICD-10 code
Inconsistent data
Case not compensable
Same illness w/in 90 days
No qualifying contribution

53. Eligibility Rules

54. Are you eligible?
For employed and IPP, at least 3 monthly contributions within the immediate 6 months prior to admission
the 45-days allowance for room and board has not been consumed yet
confinement in an accredited hospital of not less than 24 hours

55. Case x    No ! Employed member since January 2006
Admitted for Myelography for tumor (?)
Paid premium up to January to March 2007
Is the claim compensable?
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr x
Admit   
No !
X – start of membership

56. Case x Yes !    IPP applied membership March 2007 Premium paid
Admitted April 2007 for TIA
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr x
Admit   
X – start of membership
1st quarter

57. 06/08/2007
300
2007 P 300
300
What if a member enroll today, when can he start availing PhilHealth benefits?

58. Adverse selection
Phenomenon whereby a disproportionate share unhealthy individuals (high risk) enroll in a health plan
Hidden information; member moral hazard
Influenced by benefit design and individual decision
In contrast to guiding principles of social solidarity
Example: CS, Cataract

59. Circular 36 s. 2006
For IPP, at least 9 monthly contributions within the immediate 12 months prior to admission for the following:
Hemodialysis and Peritoneal Dialysis
Chemotherapy
Radiation oncology
Selected surgeries: CS
D & C
Cataract
Endoscopy effective April 1, 2007

60. Supplier induced demand
Demand created by doctors beyond what would have occurred in a market
Influenced by benefit design and individual decision
Hidden action
Doctor moral hazard

61. PhilHealth Payment 2004 Cataract (69887 & 66984)
Total Payment: million
Total Number Claimed: 28,997
AVPC: ,368.83
Average PF: 7,700

62. Adverts
False adverts tends to deceive or mislead the public which makes an untruthful assertion
E.g., “Free cataract surgery for PhilHealth members “
“No out of pocket payments for PhilHealth members”

63. Adverts
Cataract surgery announced as free should not be filed to PhilHealth and be offered to all regardless of PhilHealth membership status
Why not offer it to all?
Not free; PhilHealth as third party payor

64. Solicitation of patients
Solicitation of patients, directly or indirectly, through solicitors or agents, is unethical
Example:
NGO sponsorship of medical mission
Doctors paying for patients premium
300 pesos versus 49,000 pesos (bilateral ECCE)

65. RVS 2001 Historically-abused procedures Utilization trend data
Institutional memories
Blepharoplasty
Removal of FB, eye
Pterygium
Excision (20) Conjunctivoplasty (60)

66. RVS 2001 Upcoding or Creeping:
In claims submission, using a higher level procedure code than the level of service actually provided
E.g., appendectomy (100 RVU) to
AP ruptured (150 RVU)

67. Most Common Reasons of RTH
1. No ICD-10 code
2. Operative Record required
3. Fully accomplished PhilHealth Claim Form 3 required
4. Item no. 13 of PhilHealth
Claim Form 2 deficient
5. Proof of payment
(MI-5) required

68. ICD-10

69. ICD-10
An international classification designed to enable CONSISTENCY of coding THROUGHOUT the world.

70. STRUCTURE OF ICD-10 CODE:
The structure of the 4-character category is:
A37.1
Lastly
Another
digit
First character
A to Z
(Except U)
Followed by
2 digits
then
a point

71. MAIN ELEMENTS TO THE STRUCTURE OF ICD-10 VOLUMES OF THE ICD-10:
There are three (3) volumes
There are twenty one (21) chapters
The structure of the code is alphanumeric
VOLUMES OF THE ICD-10:
Volume 1 (Tabular List) – alphanumeric listing of diseases and disease groups
Volume 2 - contains instructions and guidelines for Mortality and Morbidity coding
Volume 3 (Alphabetical Index) – comprehensive listing of all the conditions in the Tabular List

72. Basic Coding Guidelines
Follow carefully any cross-references found in the index.
Refer to the Tabular List (Vol. 1)
Be guided by any inclusion and exclusion terms under the selected code, chapter, block or category heading.
Finally, ASSIGN THE CODE.

73.  Example: Answer: Lead term: Hepatitis -viral --chronic ---type ----C
Assign the ICD-10 code for
Chronic viral hepatitis C
Answer:
Lead term:
Hepatitis
-viral
--chronic
---type 
----C
B18.2

74. PhilHealth Circular Number 27 series of 2003
“ All claims with no ICD-10 codes, incorrect codes/and or ambiguous ICD-10 codes shall NO LONGER BE DENIED but shall be returned to the accredited health care provider (RTH) on the ground of non-compliance with the correct ICD-10 codes ”

75. Nervous System Categories ranged from G00-G99
67 of the 100 available categories have been used
There are 11 blocks within this Chapter.
There are 16 asterisk categories. Most of them are result of infectious conditions, as well as neurological conditions resulting from other diseases and conditions
G00-G09 block classifies diseases where the nerve tissue
is attacked by various organisms

76. Nervous System
Meningitis is usually due to infection and is classified by a combination of a dagger code for Chapter 1 and an asterisk code from G01 or G02 to provide more information
G09(Sequelae of inflammatory diseases of central nervous system) would be listed as a secondary code with the sequelae itself being listed as the main condition
It should be noted that seizures and convulsions NOS are
coded R56.8 and are not considered epilepsy unless the
term “epilepsy” is specifically used

77. ICD-10 G45.9 : TIA (O) G45.0 : vertebrobasilar insufficiency (O)
I67.9 : CVA, unspecified (C)
I66.9 : CVA, cardioembolic (D)
I61.9 : CVA, hemorrhagic (D)
I63.9 : CVA, thrombotic infarct (D)

78. S Site C00 - D48 M Morphology B Behavior /0, /1, /2, /3, /6
MORPHOLOGY OF NEOPLASMS:
The classification of morphology of neoplasms
(pp ) is used as an additional code to classify the morphological type for neoplasms S
Site
C00 - D48 M
Morphology
M8000 – M9989 B
Behavior
/0, /1, /2, /3, /6

79. ICD-10
C71.9, M9400/3
Neoplasm of brain
Astrocytoma
Malignant

80. ICD-10 D32.1, M9530/0 Neoplasm of spinal meninges Meningioma NOS
Benign

81. ICD-10 C50.9, M8010/3 C71.2, M8010/6 Breast carcinoma, primary
Metastatic carcinoma, temporal lobe

82. Additional Tips for Better Payment
Eliminate down coding by providing complete descriptions
Rank procedures by order of importance
Don’t send documents not required
Submit claims promptly and frequently
Complete forms ASAP
Fill in all blanks. Type NA
Make it a practice to follow up with Claims Dept.

83. ICD-10 G96.1 : Disorders of meninges, unspecified (B)
G00.9 : Bacterial meningitis (C)
G04.2 : bacterial meningo-encephalitis (D)

84. Updates

85. Circular 11, 2007 Code Descriptive Terms RVU 99256 40
Inpatient consultation for a new or established patient which requires: an expanded focused history, examination and medical decision making. It is requested by another physician or appropriate source; the consultant advises the requesting physician about the management of a specific problem including follow up care for 90 days after the procedure 40

86. Circular 11, 2007
Preoperative medical evaluation is a service provided by a physician whose opinion or advice is requested by another physician regarding evaluation and/or management of a specific medical problem which might affect the patient’s ability to undergo a procedure or might influence the outcome of the procedure

87. Circular 11, 2007 Qualified physicians who can claim for this service:
Family medicine
Internal Medicine
Neurology
Pediatrics

88. Circular 11, 2007 Applicable only while the patient is admitted
Preoperative medical evaluation given on an outpatient basis will not be compensated

89. Circular 11, 2007
Service is applicable only if surgery is accomplished within the same admission period.
If surgery is deferred  no payment
But may claim PF based on daily visits subject to allowable amount per hospital admission

90. Circular 11, 2007
In filing for claims, a copy of the consultation/clearance form with the corresponding assessment and recommendation must be attached

91. Contact Us: