Sunday, January 29, 2017

WATCH: Mga benepisyo at dapat mo malaman sa Philhealth

Inpatient Benefits

    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 member’s 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

Outpatient Benefits
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 member’s 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 and duly accomplished PhilHealth Claim Form 1
    Where available: Accredited Ambulatory Surgical Clinics (ASCs)

2. Radiotherapy

    The case rate for radiotherapy using cobalt is P2,000 per session and P3,000 per session for linear accelerator
    Includes radiation treatment delivery using cobalt and linear accelator
    Claims for multiple sessions may be filed using one (1) claim form for both inpatient and outpatient radiation therapy
    May be availed of even as second case rate (full case rate amount)
    45 days benefit limit: One session is equivalent to one day deduction from the 45 allowable days per year
    If procedure is done during confinement, only the total number of confinement days shall be deducted
    Exempted from Single Period of Confinement (SPC) rule (admissions and re-admissions due to same illness or procedure within 90-calendar day period)
    Availment condition: Member must have at least three (3) months’ premium contributions within the immediate six (6) months prior to the month of availment
    Where available: Accredited HCIs including Primary Care Facilities that are accredited for the said service

3. Hemodialysis

    The Case Rate for hemodialysis is P2,600 per session
    Covers both inpatient and outpatient procedures including emergency dialysis procedures for acute renal failure
    Claims for multiple sessions may be filed using one (1) claim form for both inpatient and outpatient hemodialysis
    May be availed of even as second case rate (full case rate amount)
    90 days benefit limit: One session is equivalent to one day deduction from the 90 allowable days per year
    If procedure is done during confinement, only the total number of confinement days shall be deducted
    The procedure is exempted from Single Period of Confinement rule (admissions and re-admissions due to same illness or procedure within 90-calendar day period)
    Availment condition: Member must have at least three (3) months’ premium contributions within the immediate six (6) months prior to the month of availment
    Where available: All Accredited HCIs – this benefit is no longer restricted to hospitals and free standing dialysis centers provided that the service is within their capability as provided for in the DOH license

4. Outpatient Blood Transfusion

    The case rate for outpatient blood transfusion is P3,640 (one or more units)
    Includes Drugs & Medicine, X-ray, Lab & Others, Operating Room
    Covers outpatient blood transfusion only
    One day of transfusion of any blood or blood product, regardless of the number of bags, is equivalent to one session
    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. PCB 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.

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SOURCE: YOUTUBE

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