PhilHealth coverage for COVID 19 inpatient care

The PhilHealth Insurance Corporation under the Philhealth Circular No.2020-0009 releases the benefit packages for inpatient care of probable and confirm COVID-19 patients. It was published on Tuesday, April 14, 2020, in Manila Bulletin.

Guidelines for COVID 19 benefits for inpatient care

A. All Filipinos shall be deemed eligible for any of the COVID-19 benefits for inpatient care. Filipinos who are not registered in PhilHealth shall be automatically covered, provided that they complete member registration prior to discharge from the facility;

B. The single period of confinement and 45 days annual benefit limit shall not be applied in this benefit package;

C. All COVID-19 benefits for inpatient care shall have no co-payment from the patient for direct healthcare services, both in private and public healthcare providers. Patients can have co-payments for amenities such as suite room accommodation;

D. Data sharing of suspect, probable, and confirmed cases of COVID-19 shall be done between the DOH and PhilHealth to develop a comprehensive patient registry in accordance with the Data Privacy Act of 2012;

E. All items donated by third parties shall not he charged to the patient.

Philhealth Coverage for Covid-19

The case-based payment of the benefits that shall be available for any Filipino patient with probable or confirmed COVID-19. Refer to the table below.

Package CodePackage amount(PhP)SeverityHCP Category
C19TP143,997Mild pneumonia in the elderly or with comorbiditiesL1 to L3 hospital, private room
C19TP2143,267Moderate pneumoniaL1 to L3 hospital, private room
C19TP3333,519Severe pneumoniaL1 to L3 hospital, private room, ICU
C19TP4786,384Critical pneumoniaL1 to L3 hospital, private room, ICU
(capable of ECMO,RRT)

For critical pneumonia, additional necessary medical services for cases that develop or with impending severe illness, which include, but are not limited to the following, shall be covered by this benefit package:

1. Acute respiratory distress syndrome (ARDS)

2. Septic shock

3. Requiring invasive ventilation

4. Requiring extracorporeal membrane oxygenation (ECMO). HCPS with the necessary equipment for ECMO shall be identified and tagged by PhilHealth.

5. Requiring renal replacement therapy (RRT)

The following are the mandatory services included in these benefit packages, incisive of professional/readers’ fees:

1. Accommodation

2. Management and monitoring of illness

3. Laboratory/diagnostics/imaging

4. Medicines that are included in the guidelines and protocols of the DOH

5. Supplies and equipment (including personal protective equipment.

CLAIMS FILING AND REIMBURSEMENT

The following are the rules for claims filing and reimbursement:

A. All claims shall be filed by the accredited healthcare provider. There shall be no direct filing by the PhilHcalth member

B. Claims for testing for SARS-CoV-2 shall be filed separately;

C. The basis for payment shall be the package code which shall be indicated in item 8b of Claim Form 2 (CF2);

D. For statistical purposes and in accordance with the DOH guidelines, health care providers should indicate the corresponding ICD-10 codes of probable and confirmed COVID-19 patients availing of these benefit packages in item 7 of CF2. Further, ICD-10 codes of all comorbidities shall also be indicated in item 7 of CF2.

E. All procedures done during inpatient case management of probable and confirmed COVID-19 patients shall likewise be indicated in item 7 of CF2;

F. For patients referred and transferred from one facility to another upon confirmation of COVID-19, referring facilities shall be allowed to file claims based on the working diagnosis prior to transfer. Likewise, referral facilities may claim for the appropriate benefits package based on the final diagnosis upon discharge;

G. Claims shall be filed within 60 calendar days upon discharge of the patients. Rules on late filing of claims shall apply;

H. To file a claim for reimbursement, the accredited healthcare provider shall submit the following documents to PhilHealth:

1. Properly accomplished CF2

2. Itemized biling statement, inclhurding professional/readers’ fees. The process flow for submission of itemized billing statements is described in Annex “A”.

3. Properly accomplished PhilHealth Member Registration Form (PMRF) for unregistered PhilHealth members, or updated PMRF, as needed

I. All mandatory deductions as provided by law, such as but not limited to senior citizen discounts, PWD discounts, etc. shall be deducted first from the total hospital bill of the patient. Al other health benefits such as, but not limited to, health maintenance organizations (HMOS), private health insurance (PHIS), and employee discounts shall complement the benefit packages of PhilHealth as stipulated in this circular. All the above deductions and benefits shall be reflected in the itemized billing statement of the patients;

J. Claims wih. incomplete requirements/discrepancy/ies shall be returned to sender (RTS) for compliance within 60 calendar days from receipt of notice;

K. Claims applications shall be processed by PhilHealth within the prescribed filing period provided that all requirements are complied with;

L. If the delay in filing of claims is due to natural calamities, or other fortuitous events, the Accredited healthcare provider be accorded 120 calendar days.

Source: PhilHealth/ Philhealth Circular No.2020-0009