ALL CASE RATES.

ALL CASE RATES

All Case Rates Policy NO. 1
Governing Policies in the Shift of Provider Payment Mechanism From Fee-For-Service to Case-Based Payment All Case Rates Policy NO. 1

“Universality” “Equity “ “Effectiveness” “Cost Sharing “
BASES IN THE R.A. 7875 “Universality” “Equity “ “Effectiveness” “Cost Sharing “ “Cost Containment” Universality that states that NHIP give the highest priority to achieving coverage for the entire population with at least a basic minimum package of health insurance benefits Equity that emphasizes that ‘the Program shall provide for UNIFORM BASIC BENEFITS Effectiveness that stipulates that ‘the Program shall balance economical use of resources with quality of care... Cost Sharing that mentions that ‘the Program shall continuously evaluate its cost sharing schedule to ensure that costs borne by the members are fair and EQUITABLE and that the charges by health care providers are reasonable, “Cost Containment” that stresses that “the Program shall incorporate features of cost containment in its design and operations and provide a viable means of helping the people pay for health care services.”

WHY REPLACE FEE FOR SERVICE
Inefficient Overutilization of diagnostic procedures Unnecessary health care services Wasteful payments Inequity when comparing payments to private and government health care institutions And because... Why do we NEED to replace our mechanism of reimbursing our Health care providers? The RATIONALE of the circular contains more than adequate reasons why. But one of the most compelling reasons is…

COUNTRIES WORLDWIDE HAVE BEGUN TO SHIFT TO CASE-BASED PAYMENT
Experience from other countries all over the world shows that Case Based Payment is preferred over FFS. SOURCE: “Case-Based Hospital Payment Systems: A Step by Step Guide for Design and Implementation in Low and Middle Income Countries” – Cashin, et. al, USAID from the American People, December 2005

General Objectives To phase out fee-for-service payment mechanism
To simplify reimbursement rates understood by all sectors To improve turnaround time of processing of claims

Scope and Coverage Case rate payments shall be uniformly applied to all medical conditions and procedures, regardless of member category, that are admitted in accredited health care institutions. It shall also apply to all identified day surgeries and select procedures done in accredited health care institutions. It shall also be applied to directly filed claims by members subject to compliance to rules on direct filing.

WHAT WILL THE CIRCULAR CHANGE?
The Fee-for-Service (FFS) system shall be replaced by CASE-BASED payment. FFS 23 Case Rates All Case Rates In essence, this is the Reason for Being of the circular: To shift from FFS to CASE BASED payment.

WHAT WILL BE THE EFFECTS?
PhilHealth members shall have a much reduced out-of-pocket spending as compared to non-PhilHealth members IF Case Rate (CR) reimbursements is NOT construed as an add-on All CR payments shall be paid to the account of the HCI. HCI to pay health care professionals (HCP) not exceeding 30 calendar days Credentialing and Privileging of doctors shall be delegated to the HCI HCI shall withhold the expanded withholding tax, VAT, as per BIR policy These are the expected positive effects of the shift to CASE RATES.

WHAT WILL BE THE EFFECTS?
PhilHealth shall NO longer have tiered payments according to training or specialization of the doctors. Direct filing by members shall only be allowed under certain circumstances. NBB policy shall apply to ALL CASES, no longer confined to the initial 23. Post Audit Monitoring is Institutionalized- replacing Pre-Audited Claims Processing

HOW WERE THE RATES DETERMINED?

Methodology COSTING using 2 sets of codes: GROUPING
ICD 10 for medical conditions RVS for procedures GROUPING condition of similar nature and management were grouped together The case rate developers utilized 2 sets of codes in coming up with case rates similar to the 23 case rates in 2011.

Methodology Condition Case Rates Why AVPC?
AVPC of all ICD 10 codes + 20% of the AVPC Comparison with existing case rates, PF study, actual rates in database For medical conditions, the following process was used: Data from PhilHealth database was used. PhilHealth claims database has the richest information of health care cost. Data comes from all accredited hospitals all over the country. Claims data from September 2009 to August 2011 was used. Only average values per claim from L3 and L4 hospitals were used on the assumption that the new DOH classification will be used by the time the policy is implemented. AVPC of all ICD codes were summarized. Additional 20% is added to the AVPC to come up with the case rates. However, this is subject to actuarial evaluations. Data from other sources – existing case rates, professional fee study by National Institute for Health, were used for comparison. Why AVPC? Source of available data is PHIC dbase No fair costing studies on PF and hospital charges

Professional Fee: RVU-based rates Average hospital fee per RVU +20%
Methodology Procedure Case Rates Professional Fee: RVU-based rates = RVU x 56 x1.5 Facility Fee: Average hospital fee per RVU +20% Why RVU? To make PF rate Commensurate to the level expertise of doctors and receive what they used to get from PHIC For procedure case rates (surgical and diagnostic procedures), a different process was utilized. Majority of the feedback on surgical case rates were on the professional fees. The PF was significantly lower compared to what doctors received in FFS. Hence, professional fees for the new procedure case rates were computed using the formula on the box on the upper right hand corner. The relative value per unit for each procedure was used. We used the peso conversion factor for specialists. We also included the anesthesiologist fee, which is roughly 40% of the surgeon’s fees and included an additional 10% for other consultations that may be needed for the procedure. This is reflected in the formula as x 1.5. For the facility fee component, we used the average value per claim of hospital fees.

Methodology Conditions of similar nature and management were grouped together Review of grouping and rates Objective: to validate the ICD codes within the group and rates of the group; to determine if effect of proposed policies to the grouping and vice versa; Specialty societies were asked to submit a list of their most commonly claimed conditions and procedures Comparison of IPT proposed rates with rates from specialty societies Consultation with societies to verify/validate groups and identify admissions criteria Adjust groups and rates based on consultation Actuarial evaluation and projection on proposed case rates

Support to Universal Health Care
We, the (Name of Society), support the Philippine government thru the Department of Health (DOH) and the Philippine Health Insurance Corporation (PhilHealth) in the pursuit of Universal Health Care (UHC) known as Kalusugan Pangkalahatan (KP). We understand that the achievement of KP is premised on an improved way of provider engagement through a more transparent and efficient provider payment mechanism that is the case rates payment scheme. We understand that case rates promote equity and financial risk protection especially through the implementation of the No Balance Billing (NBB) Policy for the poor under the Sponsored Program. In support of KP, we, the (Name of Society) support the implementation of case rates. Thank stakeholder for participation and ask to sign the document of support for UHC.

Consultations with Specialty Societies, Professional Groups, Hospitals, Non-Government Organizations and Other Experts

Includes PMA, PCP, PCS, PPS, PAFP, POGS, PCR, DOH-retained hospitals

Presentation of the All Case Rates Message, Sample Groups and Rates
Discussion of issues on payment of professional fees, credentialing and privileging and quality care

23 medical specialty societies signed the Support to Universal Health Care (UHC) document including the major societies – PMA, PCP, PCS, PPS, PAFP, PSA

General Policies The FFS is being phased out and the preferred mode shall be case rates. All claims for medical conditions and procedures submitted to PhilHealth shall be paid using case rates. All ICD and RVS codes will be given rates The objective is to reduce the out-of-pocket expenditures of patient-members. In no instance, therefore, shall case rates be added to the expenses. CR payment not an add-on to hospitalization and PF fees

General Policies For certain surgical procedures, in order to promote better efficiency and the most modern interventions, patient admission may not be necessary in the provision of complete quality care. Thus, these surgical case rates shall be paid in full whether done as inpatient or outpatient (i.e., day surgeries). A list of these procedures shall be specified in the implementing guidelines.

General Policies All Case Rate Reimbursement will be paid to HCIs.
HCI shall be accountable to PHIC for all that happens to the patient while under their care HCI to facilitate the payment to health care professionals (HCP) not exceeding 30 calendar days upon receipt of the reimbursement or to a time frame as agreed upon by the specific facility management and their professionals. PhilHealth shall regularly inform the HCPs of payments made to the HCI through a furnished copy of the Notice of Paid Claims and/ or Notice of Denied Claims (through ) HCI as the withholding tax agent for PF fees withhold the expanded withholding tax and the final value added tax (VAT) on Government Money Payment (GMP), if applicable PhilHealth shall withhold the income tax as per BIR policy against the case rate amount to be paid to the HCI

General Policies Credentialing and privileging of doctors (including specialists), and other health care professionals shall be delegated to the concerned HCI. Hospitals will deduct PHIC benefit for eligible patients and file the claims within 60 days except for direct claims No more tiered payments according to training or specialization of the doctors HCIs shall be responsible to file the claims of PhilHealth beneficiaries within the prescribed period of filing (60 days). Direct filing by members shall only be allowed for certain circumstances as prescribed by PhilHealth.

General Policies The No Balance Billing (NBB) policy shall apply to all indigents and sponsored sectors. The Corporation shall set specific case rate guidelines for the following special circumstances: Geographically Isolated and Disadvantaged Areas (GIDA) Health Human Resource Shortage areas Emergency/ acute care - selected emergency department visits that are skilfully evaluated and efficiently managed without need for further admission Other special circumstances as determined by the Corporation

Implementing Guidelines on Medical and Procedure Case Rates
ACR Policy No. 2

IV. General Rules The case rates shall be the only reimbursement rates for all specified cases. These rates shall be the amount to be paid to the health care institutions and shall include the professional fees (PF). Medical conditions and procedures that are not in the list shall no longer be reimbursed Admission due to patient’s choice shall NOT be reimbursed by the Corporation

IV. General Rules Case rate payments shall cover for Professional fees
HCI charges, including but not limited to: room and board diagnostics and laboratories drugs/medicines supplies operating room fees other fees and charges Pre-operative diagnostics done prior to confinement are not covered.

IV. General Rules Computation of Reimbursement Professional Fees
Health Care Institutions Single Period of Confinement Forty-Five Days Benefit Limit Special Reimbursement Rules Additional Conditions for Entitlement Computation of Taxes Quality Standards

IV. D. Computation of Reimbursement
For MEDICAL case rates, the HCI fee and the PF shall be 70% and 30% of the case rate amount respectively

For procedure case rates, the following shall be the basis for computation except for specified cases: PF = RVU x 56 x 1.5 (except for specified procedure case rates) HCI fee = case rate amount - PF

A list of the complete benefit schedule for medical and procedure case rates (including the exemptions) is provided in Annexes 1 and 2, and shall be posted in the PhilHealth website (

When a patient has multiple conditions that are actively being managed during one confinement, the health care provider may claim for two case rates relevant to the conditions of the patient.

When a patient has multiple conditions … The first case rate  medical condition or procedure that used the most resources (drugs and medicines, laboratories and diagnostics, professional fees, etc) in managing the patient The second case rate  medical condition, or procedure with the second most resources used

When a patient has multiple conditions … A case rate group shall not be allowed to be used both as first and second case rate in one claim except for procedures with laterality. Rules on procedures with laterality are found on item IV. G. 4.

When a patient has multiple conditions … Initially, NOT all medical conditions or procedures may be claimed as second case rate. A list of medical conditions, and procedures allowed as second case rate is provided in Annex 3. Medical conditions and procedures not included in Annex 3 shall not be reimbursed as second case rate.

For a claim with a combination of case rates, the provider shall be paid the full case rate amount for the first case rate plus 50% of the second case rate. Combination: medical condition and medical condition; medical condition and procedure; or procedure and procedure

Matrix of Payment for Combination of Case Rates
HCI Fee (70% of Case Rate) MEDICAL CASE RATES If claimed as 1st Case Rate (100% of Case Rate) Professional Fee (30% of Case Rate) (20% of Case Rate) If claimed as 2nd Case Rate (50% of Case Rate) (fixed depending on RVU) PROCEDURE CASE RATES (RVU x 56 x 1.5) (10% of Case Rate) (40% of Case Rate) Matrix of Payment for Combination of Case Rates

Total Professional Fee
1st Case Rate (Medical): Subarachnoid haemorrhage from middle cerebral artery (ICD 10 Code: I60.1) (Case rate: 100% of P 38,000 = P 38,000) 2nd Case Rate (Medical): Acute subendocardial myocardial infarction (ICD 10 Code: I21.4) (Case Rate: 50% of 18,900 = P 9,450) Hospital Fee (70% of P 26,600) Professional Fee (30% of P 11,400) (20% of P 18,900 = P 3,780) (30% of P18,900 = P 5,670) Total Benefit = P 47,450 Total Hospital Fee = P 30,380 Total Professional Fee = P 17,070 SAMPLE CLAIM 1

List of exemptions to the 50% rule on second case rate, which shall be paid in full even as second case rate:

Table 1. List of Exemptions to the 50% Rule on Second Case Rate

1st Case Rate (Medical): CAP III Total Professional Fee =
(ICD 10 Code: J18.92) (Case rate: 100% of P 15,000 = P 15,000) 2nd Case Rate (Procedure): Hemodialysis (RVS Code: 90935) (Case Rate: 100% of 4,000 = P 4,000) Hospital Fee (70% of P15,000 = P 10,500) Professional Fee (30% of P 15,000 = P 4,500) (Fixed P 3,500) (Fixed P 500 = P 500) Total Benefit = P 19,000 Total Hospital Fee = P 14,000 Total Professional Fee = P 5,000 SAMPLE CLAIM 4

Aside from being exempted from the 50% rule, claims of multiple sessions of the following procedures under Procedure List A shall be reimbursed even if claimed as second case rate subject to other reimbursement rules.

Table 2. Procedure List A Procedure RVS Code 1
Blood transfusion, outpatient 36430 2 Brachytherapy 77761 77776 77781 77789 3 Chemotherapy 96408 4 Dialysis other than hemodialysis 90945 5 Hemodialysis 90935 6 Radiotherapy 77401 7 Simple Debridement 11000 11010 11011 11012 11040 11041 11042 11043 11044 11720 11721 16010 21627

Computation of reimbursements based on first & second CR (if applicable) as declared by the HCI in PhilHealth CF 2. The total benefit (sum of the first CR and 50% of the second CR) shall be deducted from the total actual charges (HCI fee + PF). The remaining amount shall be charged as out of pocket to the beneficiary except in cases where the NBB policy applies.

XYZ Medical Center – Patient B
Table 2. Computation of Reimbursement and Multiple Sessions in One Claim XYZ Medical Center – Patient B Diagnosis: Pneumonia, Moderate Risk; Chronic Kidney Disease First Case Rate Pneumonia, Moderate Risk Second Case Rate Hemodialysis x 2 sessions Hospital Charges 25,345.50 Total Professional fees 15,000.00 Total Actual Charges 40,345.50 PhilHealth Reimbursement 8,000.00 Total PhilHealth Deductions 23,000.00 Total Remaining Balance 17,345.50

AAA Provincial Hospital – Patient C
Table 3. Computation of Reimbursement for NBB, Multiple Sessions in One Claim NBB AAA Provincial Hospital – Patient C Diagnosis: Pneumonia, Moderate Risk; Chronic Kidney Disease First Case Rate Pneumonia, Moderate Risk Second Case Rate Hemodialysis x 2 sessions Hospital Charges 25,345.50 Total Professional fees 15,000.00 Total Actual Charges 40,345.50 PhilHealth Reimbursement 8,000.00 Total PhilHealth Deductions 23,000.00 Total Remaining Balance 0.00

IV. E. Professional Fees The entire case rate amount, including the PF, shall be paid directly to the HCI concerned. The HCI shall act as the withholding tax agent for the PF.

IV. E. Professional Fees The PF shall be distributed by the HCI within 30 calendar days from the date of receipt of reimbursement. Policies and procedures on the distribution of PF shall be drafted and enforced by the HCI based on the agreements between the HCI and the professionals.

IV. E. Professional Fees ... Reports of noncompliance to this provision shall be forwarded to the PRO Health Care Delivery Management Division (HCDMD) and shall be included as a violation of the HCI to the Health Care Provider Performance Commitment.

IV. E. Professional Fees The government HCI shall facilitate the payment of the pooled PF share to the health personnel. The payment of the pooled PF shall be subject to existing rules on pooling by the Department of Health (DOH).

IV. E. Professional Fees The claims shall still be reimbursed even if managed by several doctors (accredited and non-accredited) provided the said case is attended by at least one (1) PhilHealth accredited doctor.

IV. E. Professional Fees The HCIs shall inform the concerned professionals of the status of their claim whether the claim was paid, returned to sender (RTS) or denied.

IV. E. Professional Fees To facilitate distribution of the PF within the prescribed/agreed schedule, each printed voucher for reimbursed HCI claims  corresponding Claims Summary Report. Claims Summary Report  contains all information in the voucher + the name/s of doctor/s who attended to the patient. This shall be sent to the hospital along with the voucher.

IV. F. Health Care Institutions
Table 3. List of Procedures and Medical Conditions Allowed in Different Types of Health Care Institutions

Primary Care Facilities – Infirmaries/Dispensaries Claims of PCF shall be limited to the medical conditions and procedures enumerated in PC 14 s and its amendments. The complete list is in Annex 5 and 6.

Primary Care Facilities – Infirmaries/Dispensaries Primary care facilities shall be reimbursed at 70% of the case rate except for the following case rates enumerated in PC 14, s 2013,which are hereby assigned new classifications:

Primary Care Facilities – Infirmaries/Dispensaries Reimbursement for these medical case rates shall be maintained at 100% of case rates until December 31, 2013 after which, the 70% rate shall be implemented

2.c. The HCI fee shall be 70% of the HCI fee for hospitals. Likewise, the PF shall also be 70% of the PF allotted for hospitals. To illustrate:

2.d. The following procedures shall be reimbursed at 100% of case rate when done in accredited PCF :

Primary Care Facilities – Infirmaries/Dispensaries Claims for medical and procedure case rates that are beyond the service capability of the HCI shall be denied.

Single Period of Confinement
1. Admissions and readmissions due to the same illness or procedure within a 90-calendar day period shall only be compensated with one (1) case rate benefit. First and second case rates both evaluated for compliance with the SPC rule PC 35 s 2013 Item IV.G

Table 4. List of Case Rates Exempted from the SPC Rule

Table 4. Single Period of Confinement
First Admission Second Admission Case A 1st Case Rate 2nd Case Rate Decision January 1 - 7, 2014 Pneumonia, HR Hemodialysis Both case rates are paid in full. HD is exempted from 50% rule for 2nd case rate. March 1- 4, 2014 (59 days from previous confinement) Appendectomy Both case rates are paid in full. HD is exempted from SPC.

Table 4. cont’n First Admission Second Admission Case B 1st Case Rate
2nd Case Rate Decision January 1-9, 2014 Stroke - Infarction IHD with MI Stroke - infarction paid in full. IHD with MI paid at 50% of case rate. March 21-26, 2014 (79 days from previous confinement) Pneumonia, HR Pneumonia is paid in full. IHD with MI is denied; covered by SPC.

Identified procedures, when done on the contralateral side, shall also be exempted from the SPC rule (Annex 7). The health care provider shall always indicate the laterality of these procedures in the claim form. PC 35 s 2013 Item IV.G

… When the identified procedures are done on both sides during one confinement, the second procedure shall be considered as the second case rate and shall be reimbursed at 50% of the case rate. PC 35 s 2013 Item IV.G

… Except for cataract package surgeries (RVS 66983, and 66987), which are subject to the provisions in PC 17 s. 2013 These procedures with laterality may not be claimed as second case rate together with other medical conditions/procedures. PC 35 s 2013 Item IV.G

Table 5

45 Days 45 days confinement for members, and 45 days for dependents per calendar year The total number of confinement days shall be deducted from the 45-day benefit limit of the beneficiary except for the following medical/procedure case rates with pre-determined number of days deduction. PC 35 s 2013 Item IV.H

45 Days Dialysis other than hemodialysis e.g., peritoneal dialysis (RVS 90945) Six days of dialysis, regardless of the number of exchanges per day, shall be equivalent to one day deduction from the 45 days allowable benefit per year. If procedure is done during a confinement, whether in the same HCI or not, only the total number of confinement days shall be deducted from the 45 days total allowable benefit for the beneficiary. PC 35 s 2013 Item IV.H

Table 6.1 Forty-Five Days Benefit Limit – Peritoneal Dialysis
Patient A Patient B Hospital Admission Date Discharge Date Total # Days XYZ Medical Center February 8 February 26 18 days (OPD) ABC Hospital February 15 February 18 3 days 1st Case Rate 2nd Case Rate Peritoneal dialysis (PD) (18 days) AGE, moderate dehydration Peritoneal dialysis (4 days) Total deduction from 45 days benefit limit 3 days (Every 6 days of PD is equivalent to one day deduction. 18 days of PD is equivalent to 3 days deduction.) 3 days (Only the number of days of confinement is deducted from the benefit limit. The PD is not added to the deduction.)

45 Days Chemotherapy (RVS 96408)
One cycle of chemotherapy is equivalent to two (2) days deduction from the 45 days allowable benefit per year regardless of the number of days of confinement per cycle. If procedure is done during a confinement, whether in the same HCI or not, only the total number of confinement days shall be deducted from the 45 days total allowable benefit for the beneficiary PC 35 s 2013 Item IV.H

Table 6.2 Forty-Five Days Benefit Limit – Chemotherapy
Patient C Hospital Admission Date Discharge Date Total # Days NOP Hospital January 9 January 13 4 days Diagnosis Procedures Colon Cancer Chemotherapy x 1 cycle Total deduction from 45 days benefit limit 4 days (Only the number of days of confinement is deducted from the benefit limit. The chemotherapy is not added to the deduction.)

45 Days Blood Transfusion, Outpatient (RVS 36430)
One session for each procedure is equivalent to one day deduction from the 45 days allowable benefit per year. PC 35 s 2013 Item IV.H

45 Days Radiotherapy (RVS 77401) and Hemodialyis (RVS 90935)
One session for each procedure above is equivalent to one day deduction from the 45 days allowable benefit per year. If procedure is done during a confinement, whether in the same HCI or not, only the total number of confinement days shall be deducted from the 45 days total allowable benefit for the beneficiary. PC 35 s 2013 Item IV.H

Table 6.3 Forty-Five Days Benefit Limit
Patient D Patient E Hospital Admission Date Discharge Date # Days Confined XYZ Medical Center January 10 January 18 8 days NOP Hospital Diagnosis Procedures Breast Cancer Radiotherapy x 1 session (sent to ABC Hospital*) Radiotherapy x 1 session (done in-hospital) Total deduction from 45 days benefit limit 8 days (claim confinement days + claim 2*- 0 day deduction for the radiotherapy since procedure is done while patient is confined) *ABC Hospital files separate claim for the radiotherapy session. 8 days (Only the number of days of confinement is deducted from the benefit limit. The radiotherapy session is not added to the deduction.)

45 Days For claims with combination of case rates, the single period of confinement rule shall be applied prior to evaluation of deductions from the 45 days benefit limit. In cases when one of the two case rates claimed is denied due to the single period of confinement rule, then the rule for the approved case rate is used to determine the number of days to be deducted from the 45 days benefit limit. PC 35 s 2013 Item IV.H

Table 7.1 Forty-Five Days Benefit Limit and Combination of Case Rates
Patient A First Admission Second Admission Admission Date Discharge Date Total # Days 1st Case Rate 2nd Case Rate January 1, 2014 January 9, 2014 8 days Stroke - Infarction IHD with MI March 21, 2014 March 26, 2014 5 days Pneumonia, HR Decision Total deduction from 45 days benefit limit Pay 1st case rate in full and 2nd case rate 50% 8 days (assuming no benefit availments within previous 90 days) Pay 1st case rate in full. Deny 2nd case rate (covered by SPC). Remaining Benefit 37 days (45 – 8 days) 32 days (37 – 5 days)

Table 7.2 Forty-Five Days Benefit Limit and Combination of Case Rates
Patient B First Admission Second Admission Admission Date Discharge Date Total # Days 1st Case Rate 2nd Case Rate January 1, 2014 January 10, 2014 9 days Stroke - Infarction IHD with MI March 21, 2014 March 26, 2014 5 days Hemodialysis x 2 sessions Decision Total deduction from 45 days benefit limit Pay 1st case rate in full and 2nd case rate 50% 9 days (assuming no benefit availments within previous 90 days) Deny 1st case rate (covered by SPC). Pay 2nd case rate in full (HD exempted from 50% rule for 2nd case rate). 2 days (Use only # sessions of HD since 1st case rate is denied. 1 session of HD is equivalent to 1 day deduction) Remaining Benefit 36 days (45 – 9 days) 34 days (36 – 2 days)

I. Special Reimbursement Rules

1. Referral Package (P00001) Reimbursement of the full case rate package shall be paid to the referral (receiving) hospital. Claims filed by the referring hospital shall be reimbursed a fixed amount of 4,000 pesos The HCI fee and PF shall be 70% and 30% respectively PC 35 s 2013 Item IV.I

1. Referral Package (P00001) Claims for referrals shall only be allowed if the transfer is to a higher level hospital except in Level 3 hospitals where transfer to the same level is allowed: Level 1 to Level 2, Level 1 to Level 3, Level 2 to Level 3 or Level 3 to Level 3 Claims for referrals shall be limited to the conditions listed in ANNEX 8! PC 35 s 2013 Item IV.I

1. Referral Package (P00001) Claims for referrals shall be filed following the same rules as a regular case rate as contained in this circular. Special requirements The referring and referral hospital shall indicate the complete admission and final diagnoses in their respective claim forms. The referring hospital shall indicate the referral package code in the first case rate field in Claim Form 2. The referral hospital indicates the appropriate case rate codes in the first and second (if applicable) case rate field/s in Claim Form 2. PC 35 s 2013 Item IV.I

The referring and referral hospitals must tick the appropriate box provided in Claim Form 2 in order for them to get reimbursement. PC 35 s 2013 Item IV.I

A duly accomplished referral form (Annex 9) is also required for reimbursement.
PC 35 s 2013 Item IV.I

1. Referral Package (P00001) In cases of series of referrals, Hosp A B
Only the first and last hospitals to handle the patient shall be reimbursed. Claims of the facilities in between shall be denied. Hosp A B C D PC 35 s 2013 Item IV.I

1. Referral Package (P00001) Claims for referral from accredited Maternity Care Package (MCP) shall still be reimbursed based existing rules Other claims for referral package from the following HCI shall be denied: Freestanding Dialysis Center Ambulatory Surgical Clinic Rural Health Units/Health Center Primary Care Facilities PC 35 s 2013 Item IV.I

2. Confinement Abroad For confinements abroad, the claim shall be reimbursed the full case rate amount based on the final diagnosis/es. Requirements for filing of claims Claim form 1 Statement of account Certification from the physician English translations PC 35 s 2013 Item IV.I

3. Direct Payment to Member
Full case rate payment shall be directly paid to the member Direct filing of claims shall not be allowed except in the following cases: Claims for confinements abroad Emergency in non-accredited HCIs PC 35 s 2013 Item IV.I

4. Overlapping Claims Overlapping of claims happens when two or more claims of one beneficiary have the same or intersecting confinement periods. In cases of overlapping claims, both (or all) claims shall be evaluated and validated. Only the valid claim/s shall be reimbursed following rules on reimbursement. Invalid claims Legal Services Unit of the PRO PC 35 s 2013 Item IV.I

5. Others If the patient dies…
and a procedure has been done  case rate of the procedure as claimed by the HCI following the rules contained in this circular. but was confined for more than 24 hours  case rate as claimed by the HCI following the rules. PC 35 s 2013 Item IV.I

5. Others Immediate cause of death (disease, injury, or complication that caused death) shall be the basis for the case rate/s that will be claimed. This does not mean the mode of dying, e.g., Cardio-Respiratory Arrest. If a procedure has been done, the procedure and/or the immediate cause of death may be claimed as first and/or second case rate. The rule on first and second case rate applies. PC 35 s 2013 Item IV.I

J. Additional Conditions for Entitlement

Change in Accreditation of HCI
In case of change in STATUS, the claim shall still be paid the full amount of the case rate as long as one day of the confinement falls within the validity of the accreditation of the HCI. In case of UPGRADE, the claim shall be reimbursed based on the category at the date of discharge. In case of DOWNGRADE the claim shall be reimbursed based on the category at the date of admission PC 35 s 2013 Item IV.J

Membership and Dependency
As long as one day of the confinement falls within the validity of either membership or dependency, the beneficiary is entitled to the full PhilHealth benefit. PC 35 s 2013 Item IV.J

Out-on-pass Except for day surgeries and Millennium Development Goal (MDG) packages, as long as the beneficiary is admitted for at least 24 hours, the beneficiary is entitled to the full PhilHealth benefit subject to other rules of reimbursement. PC 35 s 2013 Item IV.J

Non-availability of room
This refers to cases when admitted patients must stay in the emergency room or within the hospital premises pending the availability of rooms. Day surgeries and MDG packages are exempted from this rule. Full payment shall be given if the patient stayed in the hospital for 24 hours or more. However, private HCIs shall submit a letter of justification with the claim. Non-submission of requirements shall result in the denial of the claim. If the patient stayed in the HCI for less than 24 hours, the claim shall be denied PC 35 s 2013 Item IV.J

K. Computation of Taxes PhilHealth adheres to the prescribed computation of taxes issued by the Bureau of Internal Revenue

L. Quality Standards Clinical Practice Guidelines (CPG) adopted by societies, the Department of Health (DOH) or as provided by the World Health Organization (WHO) or if not available, Current accepted standards of care, to support their diagnosis and management. Claims filed shall be subject to post-audit evaluation to check for the quality of care provided to the patient-beneficiary

Upon evaluation and monitoring, all inconsistencies regarding reimbursement policies shall be charged to future claims of the facilities.

The complete list of reimbursable medical case rates, including the specific ICD 10 codes and rates is found in Annex 1 (www. Philhealth.gov.ph) MEDICAL CASE RATES

Only admissible medical conditions shall be reimbursed by PhilHealth
For medical conditions that are managed primarily using interventional or surgical procedures, health care providers shall use the appropriate procedure case rates. Specific diagnostic/laboratory examinations shall no longer be prescribed for all medical case rates. MEDICAL CASE RATES

MEDICAL CASE RATES AGE and non-hepatic amoebiasis
E86.1 – moderate/marked dehydration E86.2 – severe dehydration Asthma in acute exacerbation Additional 5th character ICD 10 code Maternal co-morbidities conditions Admission that do not lead to delivery If the co-morbidity has no case rate available from the list Pneumonia Additional 4th or 5th character ICD 10 code MEDICAL CASE RATES

The complete list of reimbursable procedure case rates is found in Annex 2 (www. Philhealth.gov.ph).

Adhesiolysis (RVS 44005) shall only be reimbursed if performed independent of any other procedure.
Blood transfusion, outpatient (RVS 36430) This package covers outpatient blood transfusion only. Inpatient transfusion of blood or blood products shall be covered by the medical case rate of the patient. One day of transfusion of any blood or blood product, regardless of the number of bags, is equivalent to one session. Multiple sessions may be claimed in one claim form. The dates of each session claimed shall be indicated in the blank provided in Claim Form 2. PROCEDURE CASE RATES

PROCEDURE CASE RATES Cataract Package (RVS 66983, 66984 and 66987)
Cataract extraction and vitrectomy. For claims of cataract extraction that are accompanied by vitrectomy secondary to posterior capsular rupture resulting from cataract surgery, only the cataract extraction shall be paid. Moreover, a claim for postoperative vitrectomy performed within 90 days from cataract surgery shall be denied reimbursement whether done during the same or different confinement. Vitrectomy performed at the time of cataract extraction shall only be paid if an indication specified in the admitting diagnosis supports the performance of the procedure. In such case, payment of professional fee and hospital charges shall be based on vitrectomy and not on the cataract surgery. PROCEDURE CASE RATES

Cesarean section (CS) (RVS 59513, 59514, 59620)
Cesarean section (CS) (RVS 59513, 59514, 59620). Cesarean section per patient request shall not be reimbursed by the Corporation. Chemotherapy (RVS 96408) The case rate amount for chemotherapy is equivalent to one cycle of chemotherapy. One cycle of chemotherapy is equivalent to 2 days deduction from the 45 days benefit allowance. Chemotherapy may be claimed as inpatient or outpatient. If claimed as inpatient and in the same HCI, this package may be claimed as first or second case rate. Multiple cycles may be claimed in one claim form for both inpatient and outpatient chemotherapy. The dates of each cycle claimed shall be indicated in the space provided in Claim Form 2. PROCEDURE CASE RATES

Circumcision (RVS 54150, 54152, 54160, 54161). Circumcision shall only be reimbursed if done secondary to phimosis (ICD 10: N47). Dialysis other than hemodialysis (e.g., peritoneal dialysis) (RVS 90945) The case rate amount for Dialysis other than hemodialysis (e.g., peritoneal dialysis) is equivalent to 6 days of PD exchanges. All PD exchanges done for six days shall be charged one day against the 45-day benefit allowance. Claims of less than 6 days of exchanges shall also be charged one day against the 45-day benefit allowance. Multiple sessions may be claimed in one claim form. The dates of each session claimed shall be indicated in the blank provided in Claim Form 2. PROCEDURE CASE RATES

PROCEDURE CASE RATES Hemodialysis (RVS 90935)
This package covers BOTH inpatient and outpatient hemodialysis procedures including emergency dialysis procedures for acute renal failure. Reimbursement shall include payment for use of the dialysis machine and health care institution, drugs and medicines, supplies and others on per session basis. Creation of fistula shall be reimbursed using a different case rate but in accredited health care institutions only. Multiple sessions may be claimed in one claim form for both inpatient and outpatient hemodialysis. The dates of each session claimed shall be indicated in the space provided in Claim Form 2. If an admitted patient is sent to another HCI for hemodialysis, a separate claim shall be filed by the HCI that performed the dialysis. This shall be reimbursed the full case rate. PROCEDURE CASE RATES

PROCEDURE CASE RATES Radiation therapy (RVS 77401)
This includes radiation treatment delivery using cobalt and linear accelerator. The HCI shall indicate in Claim Form 2 which between cobalt and linear accelerator was done. Multiple sessions may be claimed in one claim form for both inpatient and outpatient radiation therapy. The dates of each session claimed shall be indicated in Claim Form 2. If an admitted patient is sent to another HCI for radiation therapy, a separate claim shall be filed by the HCI that did the radiation therapy. This shall be reimbursed the full case rate. Radiotherapy performed on the same day as brachytherapy (RVS 77761, 77776, and 77789) or chemotherapy (RVS 96408) shall be reimbursed the full case rate subject to other reimbursement rules. The equivalent deductions shall be made to the 45 days benefit limit of the beneficiary. PROCEDURE CASE RATES

Vaginal delivery (RVS 59409)
Vaginal delivery (RVS 59409). This includes deliveries done vaginally for mothers with medical conditions or other indications that exempt them from the normal spontaneous delivery package. The following are the accepted indications: Preterm deliveries O60.1 Multiple deliveries O84.0 Maternal distress during delivery (unstable vital signs) O75.0 Delayed delivery after rupture of membranes O75.6 Abnormality in uterine contraction O62.4 Prolonged labor O63.- Precipitous delivery O62.3 Labor complicated by fetal distress O68.- Labor complicated by cord complication O69.- PROCEDURE CASE RATES

MILLENNIUM DEVELOPMENT GOAL PACKAGES
The following packages shall be paid using case-based payment but will follow the existing rules of reimbursement, payment and claims filing contained in their respective circulars. Maternity Care Package (RVS 59401) Outpatient HIV/AIDS Treatment Package (RVS 99246) Animal Bite Package (RVS 90375) Outpatient Malaria Package (RVS 87207) TB-DOTS (RVS 89221, 89222) Newborn Care Package (RVS 99432)

Z benefit packages Excluded from the all case rates policy and shall be governed by existing circulars.

X. Filling out the Claim Forms

The PhilHealth claim forms must be properly and completely filled out, otherwise, it shall be returned to sender (RTS) The PhilHealth accredited healthcare provider shall also write the complete admitting and final diagnoses in the claim form Incorrect/incomplete/without, ICD 10 or RVS codes shall be RTS.

Claims with discharge diagnoses written in Claim Form 2 as ill-defined and/or suspected diagnoses i.e., “to consider (T/C)”, “versus or vs.”, “rule out (R/O)”, “probable”, or “potential” shall be denied

The Corporation shall only allow (RTS) with admission dates on or before March 31, 2014.
RTS shall no longer be allowed for all claims with date of admission starting April 1, 2014. Instead, these claims shall be denied. All claims that were returned to the sender for correction or completion shall be re-filed within 60 days from receipt of notice

Re-filed claims with non-compliance to deficiencies stated in RTS shall be denied.
A properly and completely filled out Claim Form 3 shall be required for MCP claims and cases managed in PCF. Records of anesthesia and surgical or operative technique are required for all procedure claims except for some procedures listed in ANNEX 10

The No Balance Billing Policy shall be applicable to all case rates.
NBB The No Balance Billing Policy shall be applicable to all case rates.

Monitoring and Evaluation/Post Audit of Case Rate Claims
Providers shall be monitored on their compliance to this circular and violations shall be dealt with in accordance with the provisions of PhilHealth Circular No. 54 s (Provider Engagement through Accreditation and Contracting for Health Services) and other pertinent issuances. The penalties to these violations shall be charged to future claims of the health care institution or as determined by the Corporation.

15 days after publication
EFFECTIVITY 15 days after publication

List of Annexes Annex 1: List of Medical Case Rates Annex 2: List of Procedure Case Rates Annex 3: List of Medical Conditions and Procedures Allowed as Second Case Rate Annex 4: Examples and Scenarios for the All Case Rates Implementing Guidelines Annex 5: List of Medical Case Rates for Primary Care Facilities- Infirmaries/Dispensaries Annex 6: List of Procedure Case Rates for Primary Care Facilities – Infirmaries/Dispensaries Annex 7: List of Procedures with Laterality Annex 8: List of Medical Conditions Allowed for Referral Package Annex 9: Referral Form Annex 10: List of Alternative Documents for Record of Operative or Surgical Technique Annex 11: PhilHealth Claim Forms 1, 2 and 3

FROM FEE-FOR-SERVICE… TO CASE-BASED PAYMENT
FROM CHAOS… TO ORDER

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