Training Manual

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IN-HOUSE LIAISON
OFFICER
Training Manual
MediCard
In 1987, a group of eminent physicians from the most
distinguished medical centers in the country,
concerned at the ability of working people to pay for
much needed quality health care, consolidated their
resources together to put up MEDICard Philippines,
Inc. MEDICard is a pioneer in the industry. The
owners have been in the health care service for
years.
The country had suffered badly during the waning years of Marcos rule.
Health costs were rising, but incomes were falling. Even middle income
families were finding difficulty in putting money for emergencies. Thus, if
sickness occurred the necessary funds were just not available to receive
treatment and pay for medicines. MEDICard was born out of a desperate
need.
One of the founders, who was to become the first president, Dr. Nicanor D.
Montoya M.D., held a very simple philosophy. It was that if a person could
just put away P3.00 per day, (not a large sum, even then), he could afford
hospitalization.
From this premise, MEDICard was created. An organization was formed,
MEDICard (Philippines) Inc., that would provide quality comprehensive
health care services to a large number of Filipinos, at a cost that they could
afford.
Brief History
MISSION
We are the HMO that
contributes to the well
being of society by
providing the best quality
managed healthcare
services.
VISION
We are the partners of
choice in managed
healthcare with the most
innovative range of
quality programs and
services in the industry.
QUALITY POLICY
As the leading HMO in the
Philippines, MediCard Philippines,
Inc. is committed to improve the
quality of members lives by
providing comprehensive
healthcare services which would
address all their requirements
and exceed their expectations.
To achieve this we will:
. Come up with programs
that will improve relations
with clients and further
expand membership base;
. Give support to our
affiliated medical network
and suppliers by ensuring
a mutually beneficial
business relationship;
QP 1
. Provide fair opportunities for
professional growth and
development and an
environment conductive to
employees and sales forces
productivity, efficiency and work
gratification;
. Seek continuous improvement
by effective handling of
customers feedback and
establishing and maintaining a
quality system consistent to the
requirements of ISO 9001:2000
Standards.

QP2

JOB SUMMARY .Handles all inpatient concern of members confined in
assigned hospitals and facilitate issuance of Letter of Authorization.

DUTIES AND RESPONSIBLITIES
Regularly call hospital to check any confined
member and receive report from hospitals of
confined members.
Verify reported confinements and gather
details accurately to help determine the
coverage.
Responsible for handling confined members
admitted on assigned hospitals including
gathering of necessary information, encoding of
all data in Members Information Management
System and generating Information Sheet.
IN-HOUSE LIAISON OFFICER
Generate members utilization report, validate membership
with URG and billing status with RMG if needed.
Help facilitate prompt issuance of Letter of Authorization
(LOA) and ensure that LOA is properly received by the
hospital.
Inform and explain to confined member and hospital staff
members coverage and limit.
Handles and answer members inquiries promptly and
accurately.
Investigate and answer members complaints before
referring to Manager.
Update members final hospital bill in Daily Confinement
Report.
Report to Team Leader, Asst. Supervisor or Supervisor
difficult cases to facilitate early resolution.
Mediates with the attending physician the concerns of
confined members.
Perform other tasks that maybe assigned from time to time.
KEY ORGANIZATIONAL
RELATIONSHIP
MANAGER
DOC CRIS
SUPERVISOR
MAM COR
AS
MAM TERE
DEPARTMENTS
Manila Operations handles
in-patient within Metro Manila
and areas with Field Liaison
Officer
Customer Management Group
(CMG) handles out-patient
services/approval
Revenue Management
Department (RMD/Billing)
updates status of company
payments
Underwriting (URG) handles
membership status and
renewal updates
Claims Pro processes hospital
bills and doctors PF
Claims/ Reimbursement
Department processes
patients reimbursements
Sales and Business Devt (
SBD)- handles membership
acquisition
DEPARTMENTS
GENERAL PROCEDURE
1. Call hospital to check new
admission.
2. All confinement information
are secured at the hospital
(HMO officer/ Nurse
station/ patient)

Chief complaint
History of present illness
Past Medical History e.g. HTN x 2years etc.
Medications
Laboratory/ Diagnostic exams
3. Encode all gathered details at
MIMS and generate an
Information sheet (INFOSHEET)

4. Check Membership Validation at
Infosheet
If Verify Payment with RMD:
forward Infosheet at RMD

Infosheet attachments
a. Front page Infosheet itself
b. Members details -
c. Company details Summary of benefits
(SOB)
d. Utilization
If Verify Renewal with
Marketing/Sales: forward
Infosheet at URG
5. All completed infosheet is then
forwarded to the approving
officer for evaluation and
issuance of Letter of
Authorization (LOA)

Complete the
admission details !
Chief Complain
History of present Illness
Medications
Laboratories/ diagnostic Test
+ results
Past medical history

TALK to patient /
relative and update
them of their benefits --
IMPORTANT
Sample
INFOSHEET
LETTER OF AUTHORIZATION
GENERAL GUIDELINES
Get DATA needed in INFORMATION SHEET
PATIENT NAME
ACCOUNT NUMBER
COMPANY
AGE Get the date of birth. Check if age in infosheet is
correct. Check for eligibility.
PLAN/ROOM/RATE/CATEGORY - Check if room is in
accordance to plan.
If not, check if with benefits for PLUS
PHILHEALTH ROOM &BOARD, then compute if patient
still needs to pay excess/incremental. If not, check reason.
If PATIENTS CHOICE, charge
EXCESS/INCREMENTAL.
If NOT AVAILBALE, check if with benefit for IN
CASE OF NON-AVAILABILITY OF ROOM PLAN. Take note of
EXCEPT LARGE SUITE ROOM, etc. Ask for
CERTIFICATION of non-availability of room from
admitting section. Check if there is really a reservation
for the patient under his room plan. (If there is no
reservation, this provision will not apply.)
GENERAL GUIDELINES 2
If NO ROOM PLAN in the hospital, computation needs to be done
(e.g. no semi-private rooms: highest ward room rate plus lowest
private room rate divided by two = semi-private rate). Patient
then pays for excess only, no incremental charges. In case of
non-availability provision does not apply here.
LOA No. - For presigned LOAs, make sure the number is
encoded in the
System and the Infosheet has a signed disposition (COVERED) so
it will
be reflected as DCR.
ADMISSION DATE , TIME OF ADMISSION
TYPE OF ADMISSION Direct, ER, Elective
DATE REPORTED - Ask reason why late in reporting, if
ever.
DIAGNOSIS Check if coverable or not. Primary/Admitting
Diagnosis? Is
the diagnosis related to the chief complaint? Always
update diagnosis.
Decisions are based on FINAL DIAGNOSIS.

If NO ROOM PLAN in the hospital, computation needs to be done
(e.g. no semi-private rooms: highest ward room rate plus lowest
private room rate divided by two = semi-private rate). Patient
then pays for excess only, no incremental charges. In case of
non-availability provision does not apply here.
LOA No. - For presigned LOAs, make sure the number is
encoded in the
System and the Infosheet has a signed disposition (COVERED) so
it will
be reflected as DCR.
ADMISSION DATE , TIME OF ADMISSION
TYPE OF ADMISSION Direct, ER, Elective
DATE REPORTED - Ask reason why late in reporting, if
ever.
DIAGNOSIS Check if coverable or not. Primary/Admitting
Diagnosis? Is
the diagnosis related to the chief complaint? Always
update diagnosis.
Decisions are based on FINAL DIAGNOSIS.

ATTENDING PHYSICIAN/SPECIALIZATION/ACCREDITED Make sure
specialty of MDs are appropriate with the diagnosis. If not, please
ask
why patient is being managed by that doctor. Make sure MDs are
accredited. Check if with P.O.S. (Point of Service). If not, ask why
patient has a non-accredited doctor. If reason is not valid, admission
will not be covered. If with valid reason, accomplish special
arrangement (SA) form and have it signed by PRD or Operations
Manager. Please ask if doctor is willing to be accredited or willing to
accept MEDICARD rate and indicate in SA form. Indicate also if PF
will
be care of patient, reimbursable as MRV rate only. Indicate role of
doctor for PF: # of daily visits, procedure, CP clearance?

MEMBERSHIP VALIDATION - Check if status is ACTIVE. If not, have
Underwriting/RMD or Billing validate status of membership (signed).
CHECK EFFECTIVITY DATE & VALIDITY DATE!!!

PRINT OUT THE INFOSHEET, MEMBER DETAILS, HOSPITALIZATION
BENEFITS, PRE-EXISTING CONDITIONS (if PEC < DD & case is PEC),
MATERNITY (if maternity case).

ROUTINE/STANDARD OPERATING PROCEDURES:
Greet (Good morning/afternoon) and introduce yourself to patient.
Inform patient/relative about requirements:
MEDICARD ID
Valid ID with picture. Company ID if possible.
PHILHEALTH Requirements. Explain what documents are needed and that
these should be completed prior to discharge. If patient is not able to submit
requirements, PHIC portion will be paid by the patient.
Member Data Form (MDR) computerized copy; They can get from their
company or Philhealth Office. If none, Birth Certificate with registry number
issued by NSO
Philhealth Forms They can get it from their company or the hospital.
Form 1 Should be the original copy with the HRs
signature
Form 2 They should have the doctor sign it prior to
Discharge.
Certification of Contribution from company
Explain benefits, limitations, exclusions of their plain (incremental cost, excess
in room, computation of disapproved charges for hospitals with blanket
authority, what charges they should pay for, e.g. miscellaneous, etc.).
Other requirements
Get data needed for info sheet.
Visit patients daily.
update diagnosis
progress notes (have them signed by patient or relatives of patient)
take note of attendance of physicians (did they make rounds, etc.)
Make sure LOA is issued and that information in LOA is correct (including
start/end of coverage, list of attending physicians, procedures, limits,
exclusions, etc.)
Fill-up necessary forms and attach to info sheet (special arrangement,
reimbursement, etc.)
Assist patient especially if with inquiries, problems with coverage, etc.
Monitor until patient is discharged. If needed, ask for itemized billing for
segregation of charges, etc. Check if patient will exceed the limit for the
confinement. Take into account PF of doctors* (daily visits, CP clearance,
procedure, etc.).

* Check standard rates for Professional Fees

FEMALE PATIENTS of child-bearing age
Pregnant? Last normal menstrual period (LNMP)?
Case might be maternity

All OB-GYN Cases
Chief complaint
Married? How many years?
Children? How many? Age of youngest child? (esp if case is
infertility related)
Pregnant? LNMP?
Obstetric Score (Gravida _____, Para_____), Mode of delivery (NSD,
CS)
Copy of ultrasound results
Fertility-related?
STD-related?

NO PEC, PEC less than DD
Verify the diagnosis. Make sure that there is no PEC being managed.
Ask for all labs done, meds given, etc. Ask for results if needed. (E.g.
ask for
urinalysis results if diagnosis is UTI, potassium for
Hypokalemia, chest
x-ray for pneumonia, ultrasound for cholelithiasis,
urolithiasis, etc.)
Ask for itemized billing especially when patient is already for
discharge.
There might be PEC-related charges.
For segregation if with PEC diagnosis.
If no PEC coverage, all PEC-related charges c/o patient.
Check utilization from effectivity of membership.
Check PEC coverage, print out.

TRAUMA / ACCIDENTS
History. Narration of events.
Police Report?
Incident Report? Industrial Report?
Any violation of the law or negligence, etc? (Exclusions e.g.
motorcycle
accident not wearing helmet, overloading, etc. Driving
without a license,
expired license, not authorized to drive motorcycles, driving
while
intoxicated, etc.)
Vehicle Registration (photocopy)
Drivers License (take note of classification, code)
Subrogation Form
No waivers signed. No arrangements made with other party.

CONGENITAL (examples of congenital cases)
Indirect Inguinal Hernia less than 45 years old (If 45 and above,
considered
as PEC
). For inguinal hernias, get OR tech and check for presence of
sac to verify if direct or indirect.. Give Congenital limit first
pending
verification from OR tech (for Inguinal Hernia cases below
age 45).
Umbilical Hernia
Polycystic Kidney Disease
Hemangioma
Hemophilia
Thyroglossal Duct Cyst (beware of neck masses, might be congenital)
Umbilical Hernia
Undescended Testis
Hirschsprung
Mitral Valve Prolapse
Arteriovenous Malformation (AV Malformation, AVM)
SEIZURE
EEG Results needed
Check history, maintenance medications, if any
Check if with seizure coverage.
Get itemized bill to segregate charges.

SPINAL
Check if with Spinal Coverage
X-ray result (osteophytes, hypertrophic changes, degenerative
changes equivalent to Spondylosis)
MRI result
Check provision acquired during time of membership? Employees
only?
Slipped disc, scoliosis, spinal stenosis, spondylosis

MATERNITY
Uterine prolapse, cystocoele, rectocoele (for colporrhaphy, A-P repair,
etc.)
maternity-related, NOT COVERED unless patient has never been
pregnant..
Upon report of admission, decide immediately if confinement is
covered or
not. Better to deny coverage initially if patient is pregnant
with no
maternity benefits. We will just reevaluate if patient appeals
later on.
Check provisions reimbursement, outright coverage, etc.

SURGERIES / PROCEDURES
Elective procedures should be pre-approved first.
CP clearance, if needed, should be done as out-patient.
For pre-approvals, please ask if patient is for pre-op clearance and what labs
areneeded for the clearance.
Explain to the patient/caller that the limit is not yet final and we need to
reutilize prior to admission. Limit might change.
Emphasize to the patient/caller that they need to inform us if the patient will
be admitted already.
Some procedures are approved as out-patient only and therefore should not be
admitted.
Check limits for said procedures (e.g. ESWL, hysteroscopic D&C, CDP) If
patient was admitted for the said procedure, limit would include R&B,
PF, incidental expenses, etc. (meaning, the whole confinement). If
patient was not admitted for the procedure but the procedure was
done
during the confinement, the inner limit for the procedure will still hold
but R&B and other charges not related to the procedure will be under
the limit for the confinement.
For standard contracts, limit for
modern therapeutic procedure (laparoscopic, etc.) is P20,000 only,
CDP P5,000 only.
Get OR Tech whenever possible. Get corresponding CPT code & RUV
for the
said procedure (from the Customer Care System or from the
Medical
Administrators).
Surgeons Fee: PHIC RUV x 100 (for OPD, ward)
x 105 (for semi-private
room)
x 110 (for private
room)
x 115 (for Suite)
Anesthesiologist: Surgeons Fee x 40% (Minimum of P1,000)

ADMITTING ORDERS make sure admission is not per patients request

CHIEF COMPLAINT (with qualifiers)
abdominal pain severity (8/10 -> 10 being highest)
- specific location (right lower quadrant, hypogastric, right upper
quadrant, periumbilical, etc.)
- duration, relation to food intake, etc.
fever since when? Temp?
bleeding from where? Duration? Amount?
High BP BP upon admission, Hypertension since when?
Hypoglycemia CBG on admission, diabetic?
Syncope, blackout, etc duration, hx of seizure?
Mass size? Duration? Laterality?

REASON FOR ADMISSION
Why was the patient admitted? Is the case really admissible? Can
the
management be done as out-patient?
The answer here should not be the chief complaint
Patients request? With admitting orders?
What management will be done that needs confinement?
The patient will be given IV antibiotics.
The patients blood sugar will be monitored and will be given
emergency intervention depending on CBGs.
The patient is dehydrated and needs to be hydrated with IV
fluids.
The patient will undergo major operation which cannot be done
as out-patient. If OR can be done at OPD, why should
the patient be admitted? If no valid reason, inform
patient/caller that we will not cover confinement.

HISTORY & NATURE OF PRESENT ILLNESS
Narration of events
Symptoms noted since when? Size of mass? Expound on chief
complaint.
PAST MEDICAL HISTORY
An ordinary illness may be related to a PEC. We will need to watch out if it
will be managed during the confinement. We might need to
segregate
DM? Asthma? Hypertension? PTB? CA? Etc (Since when?)

LAST NORMAL MENSTRUAL PERIOD (LNMP or LMP) for females age 18-48

DIAGNOSIS
Admitting Diagnosis Is this related to chief complaint?
Updated Diagnosis Update diagnosis regularly Especially if not yet
established (e.g. Rule out, To consider, Versus) Check
if labs are
consistent with diagnosis (e.g. Pneumonia Chest X-ray
result is
normal; UTI urinalysis WBC 0-2, Hypokalemia
Potassium level is
normal, etc.).
Final Diagnosis Primary Diagnosis (if with more than one
diagnosis).
Is primary diagnosis related to chief complaint? Verify
diagnosis
especially if not consistent with lab results. Whenever
possible,
doctor should commit to a diagnosis (e.g. To consider
Appendicitis,
Rule out UTI, Rule out Urolithiasis. Does the patient really
have
Appendicitis, UTI, Urolithiasis?). Decisions regarding
coverage are
based on Final DIagnosis.

MANAGEMENT
What management will be done that needs confinement? * SEE
ABOVE
Whenever possible, clarify end-point of admission. Ex. # 1. AGE with
dehydration. Patient was admitted for hydration with IV fluids and given
antibiotics. If end-point is to hydrate patient, patient should then be
discharged when LBM/vomiting is resolved and hydration status is okay. Ex. #
2. Uncontrolled Hypertension. BP on admission was 180/100. End-point is to
control hypertension. Patient was admitted, given IV and oral anti-
hypertensives. On 2nd HD, BP = 160/90, IV meds stopped. On 3rd HD, BP =
120/80, on oral meds. At this point, BP already controlled. Patient should be
discharged soon(Today? Tomorrow?)
On follow-up, ask for reason for continued hospital stay. Reasons such as
waiting for schedule of 2D-echo, ultrasound, especially if not really needed
urgently and may be done as out-patient are not valid for continued hospital
stay.

LABORATORY / DIAGNOSTICS/ PROCEDURES
List down all diagnostics done on the patient. Make sure they are pertinent to
the diagnosis or chief complaint. If not, ask reason why these were
done. We can disapprove labs done if without valid reason
. We might need to update diagnosis if it turns out that the patient has other
illnesses being managed. Segregate bills
Get results of diagnostics pertinent to diagnosis especially if it will establish or
rule out the diagnosis. E.g. Urinalysis result for UTI, Chest x-ray
result
for Pneumonia or PTB, ECG/Troponin/CPK for Myocardial Infarction,
Abdominal ultrasound for cholelithiasis, etc.
Take note of Complex Diagnostic Procedure (CDP) and specific Procedure
Limits. There may be inner limits. Take note of other charges related
to the CDP. E.g. cost of contrast used in CT scan, instrument fees,
professional fees, etc. Total should be within limit. If over the limit,
patient will pay for the excess. If reason for admission is to do the
procedure, the CDP limit (or specific procedure limit) will be the limit
for the whole confinement.

MEDICATIONS
List down all medications given to the patient. Make sure they are pertinent to
the diagnosis or chief complaint. If not, ask reason why these were
given. We can disapprove meds given if without valid reason. We
might need to update diagnosis if it turns out that the patient has
other illnesses being managed. Segregate bills
Specify whether oral or IV if needed. If all meds are oral, can the
management be done as out-patient? Patient might not need to be admitted
or the case may not be admissible. Either we do not cover the confinement or
we ask that the patient be discharged soon.
UTILIZATION
Always check utilization for related illnesses, especially PEC.
If PEC less than DD or no PEC, please check utilization from
effectivity of membership.
STANDARD MEDICARD CONTRACT
Know and understand this by heart, especially the following: Pre-
Existing Conditions, Dreaded Disease, Complex Diagnostic Procedures,
Exclusions, etc.

DO NOT BE AFRAID TO ASK QUESTIONS

MEMBER - An enrollee who has complied with all the requirements of
membership under the MEDICARD HMO program and is hereby entitled
to its medical benefits. Unless otherwise specified, all members are
entitled to all benefits.

MEDICAL BENEFITS - The medical, surgical and dental services
available as out-patient or in-patient benefits at no cost to MEMBERS,
whenever the need for them arises, and when rendered by and in
MEDICARD accredited doctors, hospitals and clinics.

MEDICAL SERVICE UNITS/TEAMS - A group of MEDICARD
physicians and other allied health professionals, who will carry out the
delivery of MEDICARD medical and hospital services to MEDICARD
MEMBERS.

DEFINITION OF TERMS

PRIMARY PHYSICIAN/ACCREDITED
PHYSICIAN/COORDINATOR - The officer-in-charge physician who
acts as the family physician of the MEMBERS in their MEDICARD
accredited hospital. He directs the MEMBERS' medical care, examines,
treats and/or refers members to specialists, orders x-ray and other
laboratory tests, prescribes medicines and arranges for hospitalization,
if needed.

MEDICARD ACCREDITED HOSPITALS/CLINICS - Hospitals
accredited by MEDICARD, where the designated physician assigns
MEDICARD members for hospitalization.

MEDICARD CORPORATE HEALTH PROGRAM
AGREEMENT - Refers to this Agreement. It contains the provisions of
enrollment eligibility and effective date; benefits and coverages; claims
and member satisfaction provisions; exclusions and limitations of
benefits; payment of membership fees; termination of coverages; etc.
MEDICARD IDENTIFICATION CARD - Issued to the MEMBERS for
their identification. It contains the member's name, account number
and validating signature.

IN-PATIENT - A person who has been admitted to a hospital as a
registered bed patient and is receiving services under the direction of
a MEDICARD physician.

OUT-PATIENT - A person receiving medical services under the
direction of a MEDICARD physician, but not as an in-patient.

CONVALESCENT CARE OR REHABILITATION CARE - The
restoration of a person's ability to function as normally as possible
after a disabling illness or injury.

CUSTODIAL OR MAINTENANCE CARE - Care furnished primarily to
provide room and board (which may or may not include nursing care,
training in personal hygiene and other forms of self-care and/or
supervisory care by a physician); or care furnished to a person who is
mentally and physically disabled and:

who is not under specific medical, surgical or psychiatric treatment
so as to reduce the disability to such extent necessary as to enable
them to live outside an institution providing such care; or

when, despite such treatment, there is no reasonable likelihood that
the disability will be so reduced.

DOMICILIARY CARE - Care provided because care in the patient's
home is not available or unsuitable.

COMPLEX DIAGNOSTIC EXAMINATIONS - Procedures which
may or may not be invasive in nature involving use of
nuclear/radionuclide scans, digital imaging, fiberoptic/video
endoscopy, markers/dyes and specific modalities listed in Article IV,
subsection D.1.

HAZARDOUS JOB RELATED ILLNESSES/INJURIES -
Illnesses/injuries suffered on the occasion or as a consequence, of
the performance of a job attended with a high risk of suffering of
physical injury or illness, or those brought about by negligence or
non-use of protective measures in jobs requiring the handling of
biological agents, radioactive substances, toxic chemicals and high
voltage equipment.

DISEASE Any illness, injury or adverse medical condition
characterized by the abnormal functioning of a part, organ or system
of the human body hallmarked by identifiable signs and symptoms,
including all Disease Complications thereof.

DISEASE COMPLICATION Any illness, injury or adverse medical
condition that is caused by or is a consequence of an identifiable
disease process. A disease complication shares the same limit as the
primary disease which caused it.

PRE-EXISTING CONDITIONS
PROVISIONS

Any illness, injury or any
adverse medical condition
shall be considered
pre-existing if during the
entire period prior and within
the first twelve (12) months
from the effectivity date of
this Agreement:

CONT. PEC 1
1. Any professional advise or consultation
and/or treatment was made given as a result
of such illness, injury or adverse medical
condition; or
2. The MEMBER was aware or should
reasonably have been aware of the signs or
symptoms of such illness, injury or adverse
medical condition; or
3. The pathogenesis or onset of such illness,
injury or adverse medical condition has been
started during the contestability period for
membership in this Corporate Health
Program as determined by MEDICARD's
Medical Director or accredited physicians.

CONT. PEC 2.
Without necessarily limiting the following
enumeration, the following are automatically
considered as pre-existing conditions if
consultation or treatment is sought within the
first twelve (12) months of coverage:
Any dreaded diseases as defined in this
Agreement except letters k and l.
Hypertension
Goiter (Hypo/Hyperthyroidism)
Cataracts/Glaucoma
ENT conditions requiring surgery
Bronchial Asthma/Allergy/Urticaria
CONT. PEC 3.
Tuberculosis
Chronic Cholecystitis/cholelithiasis (gall bladder
stones)
Acquired Hernias
Prostate disorders
Hemorrhoids and Anal Fistulae
Benign Tumors
Uterine Myoma, ovarian cyst, Endometriosis
Buergher's Disease
Varicose Veins
Arthritis
Migraine headache
Gastritis/Duodenal or Gastric Ulcer

Dreaded diseases" are potentially
or actually life threatening conditions.
They may also be illnesses that may
require unusually or uncustomary
prolonged or repeated hospitalization
and may likewise require intensive
care management. These are
enumerated but not limited to the
illnesses/conditions listed.

DREADED DISEASES
The following are considered dreaded diseases:
Cerebrovascular Accident (stroke)
Central Nervous System lesions
(Poliomyelitis/Meningitis/Encephalitis
/ neurosurgical conditions)
Cardiovascular
Disease(Coronary/Valvular/Hypertens
ive Heart Disease/ Cardiomyopathy)
Chronic Obstructive Pulmonary
Disease (Chronic
Bronchitis/Emphysema), Restrictive
Lung Disease
Liver Parenchymal Disease (Cirrhosis,
Hepatitis (except Type A), New
Growth)
Chronic Kidney/Urological disease
(Urolithiasis, Obstructive uropathies,
etc.)
Chronic Gastrointestinal Tract Disease
requiring bowel resection and/or
anastomosis
Collagen diseases (Rheumatoid
Arthritis, Systemic Lupus
Erythematosus)
Diabetes Mellitus and its
complications
Malignancies and Blood dyscrasias
(Cancer, Leukemias, Idiopathic
Thrombocytopenic Purpura)
Injuries from accidents or assaults,
frustrated homicide or frustrated
murder; subject to police report
Complications of an apparent
ordinary illness including MODS and
SIRS (e.g. sepsis due to pneumonia,
typhoid ileitis, kawasaki disease,
cerebral malaria, etc.)
Single or multiple organ
dysfunction and failure (MODS and
MOF)
Conditions that may require
dialysis
Chronic pain syndrome (greater
than six weeks)
Any illness other than the above
which would require Intensive
Care Unit confinement

MEDICARD shall pay for the
hospitalization services, as herein
defined, of a member for "dreaded
disease" up to the stated maximum
amount or limit as specified in
Annex A per illness per year.

"Dreaded diseases" which are pre-existing in
accordance with this Agreement are to be
governed by the provisions of Article XI.

HOSPITALIZATION

All confinement shall be upon recommendation of
the corporate health program holder's MEDICARD
accredited Physician, or the MEDICARD Medical
Director or the Emergency Room Resident Physician
of the MEDICARD Accredited Hospital who decides
to admit MEDICARD patient-member in cases of life
threatening emergencies.

Hospital bills for the following hospital services shall
be charged to the account of the MEDICARD
patient-member: services of a private nurse or
doctor, use of extra food and/or bed, T.V., electric
fan, VCD, ID bracelet, thermometer and all other
items not directly related to the medical
management of the patient.

EXCLUSIONS AND
LIMITATIONS
Hospitalization and treatment outside the
Philippines is not covered except during
emergency cases as stated in Article IV Section
E.4 of this Agreement.

MEDICARD is not responsible and will not
recognize any hospital bills incurred by a
corporate health program holder in hospitals not
accredited by MEDICARD, except for emergency
care services under the terms provided in this
Agreement.

Cost of hospitalization, medical services,
medicine and other expenses incurred as a result
of a member's decision to avail of such
hospitalization, medical services, treatment or
procedure, not prescribed or contrary to what
has been prescribed by the attending MEDICARD
provider, or without MEDICARDs express written
report shall not be shouldered by MEDICARD.
1. Services which a member receives from a
non-MEDICARD Physician, non-MEDICARD
Accredited Hospital or other provider of
care, except as described in the
emergency care in non-MEDICARD
hospitals, as provided for in this
Agreement;
2. Hereditary and/or congenital defects of
whatever form;
3. Sensorineural hearing impairments except
those acquired during time of
membership;
4. Plastic and reconstructive surgery for
cosmetic purposes and for physical
congenital deformities and abnormalities;
5. Dermatological care for aesthetic purposes
such as electrocautery or chemical
treatment for skin tags, xanthelasma,
milia, keloids, scars, etc. on any exposed
areas of the body;
6. Guillain-Barre syndrome, multiple sclerosis,
demyelinating disease, Parkinsons disease,
Alzheimers disease, Myasthenia Gravis,
epilepsy, seizure disorder and other
autoimmune neurological disease;
7. Slipped disc, scoliosis, spinal stenosis and
spondylosis;
8. AV malformation and aneurysms which are
considered congenital except only those
unequivocably proven to be acquired
secondarily;
9. Corrective eye surgery for error of refraction
including laser surgery for correction of
myopia and hypermyopia;
10. Psoriasis, vitiligo;
11.Experimental medical procedures,
acupuncture, acupressure, reflexology and
chiropractics;
12.Services to diagnose and/or reverse infertility
or fertility and virility/potency (erectile
dysfunction);
13.Open heart surgeries, angioplasties,
valvulaplasties, permanent pacemaker
insertion, intra coronary thrombolysis, balloon
valvuloplasties, transvenous endocardial
biopsy, percutaneous intraaortic balloon pump
insertion, balloon atrial septostomy, previous
craniotomy sequelae, organ transplantation
and complication and other surgeries related
to the heart;
14.Diagnostics for hypersensitivity and
desensitization treatment;

15.Purchase or lease of durable medical
equipment, oxygen dispensing equipment and
oxygen except during hospital confinement
under the Hospital Confinement Benefit
16. Corrective appliances and artificial aids and
prosthetic devices;
17. Human blood products like platelets, packed
RBC, plasma, gamma globulin, etc. and its
processing;
18. Psychiatric and psychological illnesses including
neurotic and psychotic behavior disorders;
19. Treatment for alcoholic intoxication and drug
addiction or overdose reaction to use of
prohibited drugs including illnesses directly
related to it and other injuries attributed as a
result of it;
20.Rehabilitation treatment, physical, speech,
occupational and hormonal therapies;
21.Developmental disorders, metabolic diseases,
sleep and eating disorders;
22.Sexually transmitted diseases such as AIDS,
Hepatitis B, condyloma, gonorrhea, syphilis,
herpes etc. and their attendant complications;
23.Hazardous job-related illnesses and/or
injuries;
24.Physical examinations required for obtaining
or continuing employment, insurance or
government licensing;
25.Injuries or illnesses resulting from
participation in war-like or combat operations,
riots, insurrection, rebellion, strikes and other
civil disturbances;

26. Treatment of self-inflicted injuries or injuries
attributable to the MEMBER'S own misconduct,
gross negligence, use of alcohol and/or drugs,
vicious or immoral habits, participation in act of
crime, violation of a law or ordinance,
unnecessary exposure to imminent danger or
hazard to health and hazardous sports related
injuries;
26.Maternity care and other conditions as a result
of pregnancy unless specifically provided;
28.Custodial, domiciliary care, convalescent and
intermediate care;
29.Oral surgery for purposes of beautification,
temporomandibular joint disease (TMJ) surgery
done by dental practitioner;
30.Circumcision, except for correction of Phimosis;

31. Treatment of injuries sustained in a motor
vehicle accident if the member or his
guardian fails or refuses to execute the deed
of Subrogation specified in Article VII hereof;
32. Professional fees of medico-legal officers;
33. Diagnosis of unknown etiology or the
absence of any organic dysfunction;
34. Cost of vaccines for active and passive
immunization except as otherwise provided
for in this Agreement;
35. Laboratory examinations for screening
sexually related illnesses and injuries
36. Any condition or illness waived upon
membership except as otherwise provided for
in this Agreement;

It is hereby declared and agreed that
hospitalization benefits due under the
PHILHEALTH program are assigned to
and integrated with the MEDICARD
program such that any of the
MEDICARD benefits due under this
Agreement shall be net of the
member's PHILHEALTH benefits.

PHILHEALTH
PHIC REQUIREMENTS
FORMS

CF1: ACCOMPLISHED AND
ORIGINALLY SIGNED BY
MEMBER AND EMPLOYER .
ATTENDING PHYSICIAN,
SURGEON, ANESTHESIOLOGIST
AND PATIENT OR NEXT OF KIN
IF PATIENT IS UNABLE TO SIGN.
ATTENDING PHYSICIAN FOR
SPONTANEOUS VAGINAL
DELIVERY, MEDICARD CASE
RATES , EXPIRED PATIENTS AND
FOR ADMISSIONS LESS THAN 24
HOURS.
PHIC REQUIREMENTS
A. EMPLOYED MEMBER
COPY OF UPDATED MEMBER DATA
RECORD (MDR) OR PHIC ID
FOR DEPENDENT: COPY OF
UPDATED MDR WITH LIST OF
DEPENDENTS
B. INDIVIDUALLY PAYING
MEMBER OR VOLUNTARY MEMBER
COPY OF UPDATED MEMBER DATA
RECORD (MDR) OR PHIC ID
CLEAR COPY OF MI-5 OR PHIC
OFFICIAL RECEIPT (LATEST
SHOULD BE 9-12 MONTHS PRIOR
TO ADMISSION)
FOR DEPENDENTS: COPY OF
DEPENDENTS
PHIC REQUIREMENTS
C. NON-PAYING MEMBER AND
LIFETIME MEMBER
COPY OF NON-PAYING MEMBER
OR LIFETIME MEMBER ID (FRONT
AND BACK)
FOR DEPENDENT: COPY OF
DEPENDENTS
D. INDIGENT MEMBER
COPY OF VALID FAMILY
HEALTHCARD OR PHIC PARA SA
MASA ID (FRONT AND BACK)
WITH VALIDITY PERIOD
CLEAR COPY OF MI-5 OR PHIC
OFFICIAL RECEIPT (LATEST
SHOULD BE 9-12 MONTHS PRIOR
TO ADMISSION)
FOR DEPENDENTS: COPY OF
DEPENDENTS
PHIC REQUIREMENTS
E. OWWA/ OFW
COPY OF UPDATED MDR WITH PAYMENT
INFORMATION
FOR DEPENDENT: COPY OF UPDATED MDR
WITH LIST OF DEPENDENTS

PHIC CASE RATE
MEDICAL CASES
1. DENGUE FEVER 1
2. DENGUE FEVER 2
3. PNEUMONIA 1
4. PNEUMONIA 2
5. ESSENTIAL HTN
6. CEREBRAL INFARCTION (CVA 1)
7. CVA2
8. AGE
9. ASTHMA
10. TYPHOID FEVER
11. NEW BORN PACKAGE

PHIC REQUIREMENTS
SURGICAL CASES
1. RADIOTHERAPHY (PER SESSION)
2. HEMODIALYSIS (PER SESSION)
3. NSD PACKAGE IN LEVELS 2 TO 4
HOSPITAL
4. CEASARIAN SECTION
5. APPENDECTOMY
6. CHOLECYSTECTOMY
7. DILATATIONANDCURETTAGE
8. THYROIDECTOMY
9. HERNIORRHAPY
10. MASTECTOMY
11. HYSTERECTOMY
12. CATARACT SURGERY

MOTOR VEHICLE
LIABILITY

MEDICARD medical and hospital services
are extended to a member if the
member's bodily injuries and fractures are
claimed to have been caused by any act
or omission of a third party through a
motor vehicle. Provided, however, that
the member executes an agreement to
subrogate to MEDICARD whatever rights
the member may have by reason of such
accident or event that gave rise to such
claim to the extent of the value of the
services so rendered. The agreement to
subrogate form is available at MEDICARD
Head Office.

REQUIREMENTS FOR MVA
POLICE REPORT
OFFICIAL RECEIPT OF VEHICLE (OR)
CERTIFICATE OF REGISTRATION OF
VEHICLE (CR)
DRIVERS LICENSE
SUBROGATION FORM ( IF WITH
THIRD PARTY INVOLVED)

NOTE: MAKE A THOROUGH HISTORY ON THE
ACCIDENT THAT TRANSPIRED .FIRST
HAND INFORMATION IS NECESSARY.
NOI -NATURE OF INCIDENT
DOI- DATE OF INCIDENT
POI- POINT OF INCIDENT
TOI-TIMEOF INCIDENT
**INQUIRE IF MEMBER IS NOT UNDER THE
INFLUENCE OF ALCOHOL DURING THE
ACCIDENT AND IF WEARING PROTECTIVE
GEARS SUCH AS HELMET ETC.

GENERAL PROVISIONS FOR
ROOM ACCOMMODATION

If a member occupies a room higher than
what he/she is entitled to, he/she shall
share in the medical expenses according
to the following formula:

If a member occupies a higher priced
room of the same category, the member
shall pay for the excess on room & board:

Computation:
(Rate of room occupied minus maximum
room and board benefit) multiplied by
(No. of days confined)

If a member occupies a room one category
higher than what he/she is entitled to, the
member shall pay for the incremental cost on
hospital expenses and professional fees and
the excess on room & board.
Incremental cost for hospital expenses:
(Total hospital bills minus total room and
board charges minus disapproved charges)
multiplied by 30%

Incremental cost for professional fees:
Medical case: Actual Charges - MEDICARD
Rate
Surgical case:
Ward to Private Room: Actual
Charges - MEDICARD Relative Value
Private Room to Suite: Actual
Charges - MEDICARD Relative Value

UPGRADING
SMALL ROOM CATEGORY TO A
HIGHER CATEGORY
EXAMPLE: WARD TO SEMI PVT, WARD TO PRIVATE,
PRIVATE TO SUITE ETC.

Y TAG
(WITH INC)
N TAG
(WITHOUT INC)
EXCESS ROOM
AND BOARD
EXCESS ROOM
AND BOARD

INCREMENTAL
IN PF
INCREMENTAL
IN PF

INCREMENTAL
IN TOTAL
HOSPITAL BILL

X
APPLY THE SAID CHARGES
AUTOMATICALLY IF ROOM
UPGRADING IS PATIENTS CHOICE
IN CASES OF ROOM NON-
AVAILABILITY
GIVE PATIENTS BENEFIT FOR
INVOLUNTARY ROOM UPGRADING .
HOWEVER, CHARGES WILL APPLY
AFTER THE WAIVED PERIOD IF
PATIENT FAILED TO TRANSFER FOR
WHATEVER CIRCUMSTANCE.

CLAIMS AND
REIMBURSEMENTS

REIMBURSEMENT PROCEDURE

All claims for reimbursement must
be submitted or forwarded to
MEDICARD Head Office within thirty
(30) calendar days after discharge
from the hospital. Failure to do so
shall invalidate the claim, except if it
can be shown in writing that it was
not reasonably possible to furnish
such documents within thirty (30)
calendar days.

Required documents in availing
reimbursement:

.Duly filled-up claim form
.Clinical Abstract
.Medical Certificate to include
complete final diagnosis
.Original Official Receipt paid to
the hospital and doctor
.Hospital statement of account and
corresponding charge slips
.Police report if due to accident or
medico-legal case
.Incident report or proof that
MEDICARD accredited doctor
was not available during the
time of confinement
ACUTE GASTROENTERITIS (AGE)
HISTORY: CHIEF COMPLAINT?
VOMITING - # of times, amount?
LBM - # of times, quantity, watery? Soft? Bloody stools?
ABDOMINAL PAIN - Location, character
SIGNS OF DEHYDRATION sunken eyeballs, poor skin turgor, dry tongue,
feeling of thirst, dry axillae
Other SYMPTOMS?
History of other DISEASES, maintenance meds for these? (We
might need to
segregate or relate, if ever.)
LMP for females of reproductive age (might be maternity related)

REASON FOR ADMISSION: Is the case really admissible?
Is there DEHYDRATION, needing IV fluids?
Can the management be done as out patient?

AGE 1
LABS: LIST DOWN ALL LABS
FECALYSIS RESULTS check WBC or pus cells, (+) E. hystolitica
trophozoite
(amoebiasis), parasites, bacteria
CBC results take note of WBC and differential count result (proof of
infection: increased WBC and neutrophils)
ELECTROLYTES (esp. Potassium), RBS, Crea, if with dehydration
OTHER LABS REQUESTED check if relevant/appropriate to the
diagnosis
MEDS : list down all meds being given
take note of antibiotics (oral? Intravenous? Appropriate?)
take note of not covered meds such as probiotics (OMX, etc), food
supplements, etc.
take note of meds not related to the management of AGE (there might be
other diseases being managed during this confinement)*

* If patient was given meds not related to management of AGE, please ask the
doctor or patient if patient has OTHER DISEASES or a specific disease (e.g.
May diabetes po ba ang pasyente? Kasi po binibigyan sya ng Metformin?.)

AGE 2
SPECIAL CONSIDERATIONS:

AGE after discharge or following another treatment may be considered as
related to the prior illness depending on the type of illness, medications taken,
etc. Meaning, there are instances that AGE may be related to previous
hospitalizations/illnesses so it is very important to know the history of the
patient, especially recent hospitalizations or illnesses, maintenance meds, etc.
E.g. Patient has DM and is taking Metformin.

AGE may be related to DM since Metformin may cause GI symptoms such as
AGE. So it is important to check the fecalysis result (may not be related if with
pus cells/WBC, bacteria, or parasites

AGE may be related to a congenital disease (e.g. Hirschsprungs).

Always ask about HYDRATION STATUS. If hydration status is okay, patient
should be able to go home and just continue management at home Ask if
patient is already for discharge or when the patient will be discharged

DENGUE FEVER (DF, DFS, DHF)
FEVER? Since when? Temperature?
HEADACHE? MUSCLE/JOINT PAINS?
RASHES? BLEEDING? (hematuria, hematochezia, melena, epistaxis,
etc.)
GI SYMPTOMS (abdominal pain, nausea, vomiting, diarrhea)
Other SYMPTOMS? (Cough, dysuria, etc.)
Hx of CANCER? Other DISEASES? (We might need to segregate or
relate)

REASON FOR ADMISSION:

LABS: List down all labs done
DENGUE TEST should be done if available, especially if patient has other
diseases that may cause low platelet count (e.g. blood
dyscrasia,
post-chemo cancer, etc.)
CBC results take note of PLATELET COUNT, HEMATOCRIT, WBC (&
other
counts; case might not be dengue; check Plt ct &
hematocrit
monitoring (Is plt ct really decreasing? Hct increased, WBC
decreased)

DENGUE FEVER 1
MALARIAL SMEAR, TYPHIDOT, etc.
CHEST X-RAY to check for pleural effusion or pneumonia
ABDOMINAL ULTRASOUND if patient has persistent abdominal pain,
especially on epigastric/RUQ area. There may be
hepatosplenomegaly,
thickening of gallbladder wall, ascitis, etc.
diagnosis

usually Paracetamol, IV fluids
take note of meds not related to the management (there might be other
diseases being managed during this confinement)*

* If patient was given meds not related to the management (esp. if PEC is less
than DD or no PEC) please ask the doctor or patient if patient has OTHER
DISEASES or a specific disease (e.g. May diabetes po ba ang pasyente? Kasi
po binibigyan sya ng Metformin?.)

DENGUE FEVER 2
PROCEDURE:
PLATELET CONCENTRATE TRANSFUSION (check provisions for blood
products).

OTHER SPECIAL CONSIDERATIONS:

Take note of other findings such as pleural effusion, ascites, splenomegaly, etc.
May be complications of dengue (plasma leakage).

If all blood counts (pancytopenia) are down, does patient have Aplastic
Anemia? Leukemia? SLE? Taking steroids?

Care has to be taken as diagnosis of DHF can mask end stage liver disease
and vice versa.

Take note of past medical history. A cancer patient who underwent
chemotherapy might be misdiagnosed to have Dengue when the cause of
thrombocytopenia (low platelet count) is really the chemotherapy.

PNEUMONIA (PNA, CAP, PCAP)
COUGH? Since when? Phlegm? Color?
Other SYMPTOMS?
History of ASTHMA? Other DISEASES? (We might need to segregate,
if ever.)

IV Meds? If only oral meds are being given, patient might not really
need to be admitted
LABS:
CHEST X-RAY RESULTS (If PEC is less than DD or no PEC, please ask
for copy of the results so we have proof that there really is Pneumonia,
especially if patient has asthma or is being given meds for asthma such as
steroids and nebulization)
diagnosis

PNEUMONIA 1
take note of steroids (solucortef, fluticasone, prednisone), nebulization/inhaler
(salbutamol, fluticasone, etc.), other meds for asthma (montelukast, etc.)*
take note of meds not related to the management of pneumonia (there might
be other diseases being managed during this confinement)**

* if patient was given meds for asthma (esp. if PEC is less than DD or no PEC)
please ask the doctor if patient has ASTHMA or HYPERACTIVE AIRWAYS. The
doctor should choose one especially if steroids were given then it should be
reflected in the Final Diagnosis.

** If patient was given meds not related to management of pneumonia (esp. if
PEC is less than DD or no PEC) please ask the doctor or patient if patient has
OTHER DISEASES or a specific disease (e.g. May diabetes po ba ang
pasyente? Kasi po binibigyan sya ng Metformin?.)

PNEUMONIA 2

If patient has metastatic cancer to the lungs and has pneumonia (or other
pulmonary diseases), location of the pneumonia in relation to the metastatic
lesion is important in determining if pneumonia will be considered as related to
the cancer or not.

If patient is bed-ridden (post-stroke, cerebral palsy, etc.), whether there are
chest x-ray findings of aspiration pneumonia will determine if pneumonia will
be considered related to the debilitating illness or not.

Pneumonia after surgery will be considered as related to the surgery
depending on the type of surgery, duration of hospital stay during surgery,
time of development of symptoms in relation to the surgery, etc. Meaning:
case to case basis. Suffice it to say that there are instances that pneumonia
may be related to previous surgeries/hospitalizations so it is very important to
know the history of the patient, especially recent hospitalizations/illnesses.

PNEUMONIA 3
Pneumonia may be related to typhoid. There is such a term as Typhoid
Pneumonia.

If patient has Chronic Kidney Disease/End-Stage Renal Disease or Congestive
Heart Failure and Pneumonia, make sure there is really Pneumonia in Chest x-
ray. Difficulty of breathing or cough may be due to congestion and not
pneumonia

Pleural effusion is not automatically attributed to pneumonia. It may also be
due to PTB, Lung cancer, etc
SYSTEMIC VIRAL INFECTION (SVI )
COUGH?
HEADACHE? MUSCLE/JOINT PAINS?
RASHES? BLEEDING?
WEAKNESS?
Other SYMPTOMS? (Nausea/vomiting, dysuria, etc.)
Hx of CANCER? Other DISEASES? (We might need to segregate or
relate)

REASON FOR ADMISSION: Whenever possible, find out the end-point of
admission.
Is case really admissible?
VARICELLA (Chicken Pox), MEASLES, GERMAN MEASLES, VIRAL
EXANTHEM ARE NOT ADMISSIBLE !!! NOT COVERED
LABS: List down all labs done
CBC results
URINALYSIS results
SVI 1
MALARIAL SMEAR, TYPHIDOT, DENGUE TEST, etc.
CHEST X-RAY to check for pneumonia
diagnosis

check meds if oral or IV. If all oral meds, can the patient be managed as out-
patient? Can the patient be discharged already?
usually symptomatic: Paracetamol for fever, IV fluids for hydration, anti-
emetics (if with vomiting), etc.
if given antibiotics Why? (only for bacterial infection)

* If patient was given meds not related to the management (esp. if PEC is less
than DD or no PEC) please ask the doctor or patient if patient has OTHER
DISEASES or a specific disease (e.g. May diabetes po ba ang pasyente? Kasi
po binibigyan sya ng Metformin?)

SVI 2

Once end-point of admission is reached or fulfilled, patient should be
discharged. E.g. patient was admitted for dehydration and fever. Once patient
is hydrated and fever lyses, patient should be discharged soon

Take note of past medical history. A cancer patient who underwent
chemotherapy might be misdiagnosed to have an ordinary disease (SVI) when
in fact, the patient has febrile neutropenia (which should be related to the
primary cancer with respect to limits).

VARICELLA (Chicken Pox), MEASLES, GERMAN MEASLES, VIRAL EXANTHEM
ARE USUALLYNOT ADMISSIBLE !!! NOT COVERED UNLESS WITH VALID
REASON
ATP
SORE THROAT ?
PAIN on swallowing?
Other SYMPTOMS?
History of other DISEASES, maintenance meds for these? (We might
need to

Will patient undergo tonsillectomy?
For IV antibiotics for exudative tonsillitis?

NECK X-RAY
diagnosis

ATP 2
MEDS : LIST DOWN ALL MEDS BEING GIVEN
other meds: pain reliever, Paracetamol.

* If patient was given meds not related to management, please ask the doctor
or patient if patient has OTHER DISEASES or a specific disease (e.g. May
diabetes po ba ang pasyente? Kasi po binibigyan sya ng Metformin?.)


If patient is for tonsillectomy, ask for indication for doing the procedure.
Absolute indications:
Enlarged tonsils that cause upper airway obstruction, severe dysphagia, sleep
disorders, or cardiopulmonary complications
Peritonsillar abscess that is unresponsive to medical management and
drainage documented by surgeon, unless surgery is performed during acute
stage
ATP 3
Tonsillitis resulting in febrile convulsions
Tonsils requiring biopsy to define tissue pathology
Relative indications
Three or more tonsil infections per year despite adequate medical therapy
Persistent foul taste or breath due to chronic tonsillitis that is not responsive to
medical therapy
Chronic or recurrent tonsillitis in a streptococcal carrier not responding to beta-
lactamase-resistant antibiotics
Unilateral tonsil hypertrophy that is presumed to be neoplastic

Peritonsillar abscess may develop as a complication and even Septicemia

Chronic/Recurrent Tonsillitis - generally defined as seven (7) episodes of
tonsillitis in the preceding year, five (5)episodes in each of the preceding two
years or three (3) episodes in each of the preceding three years.

ATP 4
Hypertrophy of the tonsils can result in snoring, mouth breathing, disturbed
sleep, and obstructive sleep apnea (OSA), during which the patient stops
breathing and experiences a drop in the oxygen content in the bloodstream. A
tonsillectomy can be curative.

If patient is for Sleep Study, check if they have coverage for it.

In very rare cases, diseases like rheumatic fever or glomerulonephritis can
occur.
Bacteria feeding on mucus which accumulates in pits (referred to as "crypts")
in the tonsils may produce whitish-yellow deposits known as tonsilloliths.
These may emit an odour due to the presence of volatile sulfur compounds.
CP clearance, if needed, chould be done as out-patient unless with valid
reason.
Should specify if Acute of Chronic. For classification whether Ordinary or PEC
and limit purposes

RUVs: Get OR tech whenever possible.
UTI
DYSURIA
PAIN - Location, character, severity
HEMATURIA
FEVER Temp?
Other SYMPTOMS?
History of other DISEASES? (We might need to relate or segregate, if
ever. E.g.
urolithiasis, nephrolithiasis, etc.)
LMP for females of reproductive age (case might be maternity)

Can the management be done as out patient? IV meds?

LABS: LiIST DOWN ALL LABS DONE
URINALYSIS RESULTS check WBC or pus cells

UTI 2
URINE GS/CS
GRAM STAIN (Gonorrhea: gram-negative intracellular
diplococci;
Chlamydia:gram-negative coccobacilli) should be
requested/done
especially if case might be STD-related
KUB ULTRASOUND should not be done routinely for UTI
diagnosis

MEDS : LIST DOWN ALL MEDS
take note of not covered meds such as food supplements, etc.
take note of meds not related to the management of UTI (there might be

* If patient was given meds not related to management of UTI, please ask the
doctor or patient if patient has OTHER DISEASES or a specific disease (e.g.

UTI 2


UTI after discharge or following another illness may be considered as related
to the prior illness. Meaning, there are instances that UTI may be related to
previous surgeries/hospitalizations/illnesses so it is very important to know the
history of the patient, especially recent hospitalizations/illnesses. E.g. patient
underwent abdominal surgery one week prior and was catheterized during the
hospitalization. Unless there is proof that patient had no UTI prior to
discharge, present UTI may be related to the previous hospitalization.

UTI in patients with kidney stones (nephrolithiasis, urolithiasis, etc.), BPH are
related.

BEWARE of UTI IN CHILDREN, MALES. Males are not really prone to UTI.
Usually, it is either STD-related or there is a structural or organic cause. In
children, cause may be congenital. In adults, please ask if with penile
discharge, most probably STD-related.

APPENDICITIS
ABDOMINAL PAIN Location (classic: RLQ), character (SEVERITY)
FEVER, NAUSEA/VOMITING
Other SYMPTOMS?
need to
Reproductive females: Pregnant? LMP? Case might be maternity-
related
(ectopic pregnancy, etc.)


PREGNANCY TEST, URINALYSIS
ABDOMINAL ULTRASOUND is NOT routinely done
diagnosis

APPENDICITIS 1
usually: pain-reliever, anti-pyretics, anti-emetics
take note of meds not related to the management of appendicitis (there might
be other diseases being managed during this confinement)*

* If patient was given meds not related to management of appendicitis, please
ask the doctor or patient if patient has OTHER DISEASES or a specific disease
(e.g. May diabetes po ba ang pasyente? Kasi po binibigyan sya ng
Metformin?.)


Take note of CDP limits for procedures such as ultrasound, etc.

Verify diagnosis: Ruptured or not? (versus Suppurative or Congestive)


ASTHMA
DIFFICULTY OF BREATHING Qualify
COUGH? Since when? Phlegm? Color?
Other SYMPTOMS?
History of ASTHMA? Maintenance meds? Other DISEASES? (We
might need
to segregate, if ever.)

Requiring oxygen? IV Meds? Nebulization? If only oral meds are
being given, patient might not really need to be admitted

LABS: LIST DOWN ALL LABS DONE
CHEST X-RAY RESULTS (If PEC is less than DD or no PEC, please ask
for copy of the results

ASTHMA 2
PFTs? ABGs?
diagnosis

take note of steroids (solucortef, fluticasone, prednisone), nebulization/inhaler
(salbutamol, fluticasone, etc.), other meds for asthma (montelukast, etc.)*
take note of meds not related to the management of asthma (there might be
other diseases being managed during this confinement)**

* if patient was given meds for asthma (esp. if PEC is less than DD or no PEC)
please ask the doctor if patient has ASTHMA or HYPERACTIVE AIRWAYS. The
doctor should choose one especially if steroids were given then it should be
reflected in the Final Diagnosis.

** If patient was given meds not related to management of asthma (esp. if
OTHER DISEASES or a specific disease (e.g. May diabetes po ba ang
pasyente? Kasi po binibigyan sya ng Metformin?.)

ASTHMA 3

the cancer or not.



Pneumonia.

pneumonia

ASTHMA 4

the cancer or not.



ASTHMA 5
Pneumonia.

pneumonia

CHOLECYSTITIS
ABDOMINAL PAIN - Location, character (SEVERITY)
JAUNDICE
Other SYMPTOMS?
need to

Will patient undergo cholecystectomy? ERCP?

ULTRASOUND RESULTS
diagnosis

CHOLECYSTITIS 2
take note of meds not related to the management of cholecystitis (there might
be other diseases being managed during this confinement)*

* If patient was given meds not related to management of cholecystitis, please
ask the doctor or patient if patient has OTHER DISEASES or a specific disease
(e.g. May diabetes po ba ang pasyente? Kasi po binibigyan sya ng
Metformin?.)


If ERCP is done and there is an inner limit for CDP, this includes OR charges,
PF of gastroenterologist, instrument fee, radiocontrast, etc.). Same for other
procedures (CT scan, etc.)

Pancreatitis is related to cholelithiasis. There is such a term as BILIARY
PANCREATITIS.

CHOLECYSTITIS 3
If PEC less than DD or no PEC, check utilization from effectivity of
membership. Coverage will depend on when symptoms started or diagnosis
made or size of mass (growth rate of gall stones: 0.4mm/yr to 1.33 mm/yr).

OPEN vs. LAPAROSCOPIC CHOLE (check inner limit for laparoscopic).

If LAPAROSCOPIC, please check if the laparoscopic machine to be used is
owned by the hospital or a private individual. If not owned by the hospital,
ask for mode of payment and terms (cash basis, amount). Check if asking
price is reasonable. If not, maybe we can haggle on the price Ask for PRDs
help. They already have a list of instrument fees.

RUVs: Get OR Tech whenever possible.

DIABETES MELLITUS
HYPOGLYCEMIA?
UNCONTROLLED SUGAR? CBG or bld sugar on admission? DM since
when?
DIZZINESS?
WEAKNESS?
Other SYMPTOMS?
History of Hypertension? Other DISEASES? (We might need to relate
or
segregate)

IV Meds/Fluids? Insulin drip?If only oral meds are being given,
patient might not really need to be admitted Not all DM cases need to be
admitted.

LABS: - list down all labs
- FBS, crea, electrolytes, HbA1c
check if relevant/appropriate to the diagnosis

DIABETES MELLITUS 2
oral? Intravenous? Insulin?
take note of meds not related to the management of diabetes (there might be
ask for maintenance meds (being taken at home prior to admission)

* If patient was given meds not related to management of diabetes (esp. if
OTHER DISEASES or a specific disease (e.g. May TB po ba ang pasyente?
Kasi po binibigyan sya ng Rifampicin?.)


Hypertension is always related to dyslipidemia, gout (hyperuricemia), stroke,
HASCVD, ischemic heart disease, coronary artery disease, angina, myocardial
infarction. If DM is related to hypertension , then it follows that all above
diseases are also related to DM.

kidney disease.
DIABETES MELLITUS 3
Hypertension is usually related to diabetes especially if diabetes was diagnosed
prior to hypertension (since it is a complication of DM). If hypertension was
diagnosed prior to DM (depending on history of diagnosis: years, few weeks,
etc.) it may be considered as not related to DM.
Always check maintenance meds as they may cause side effects that are
related to an ordinary illness. E.g. AGE, hypokalemia.
Check if end-point of confinement was already reached or fulfilled. E.g.
Patient was admitted for sugar control. Take note of blood sugar on
admission, blood sugar monitoring, what meds were given (insulin?) and blood
sugar at present. If blood sugar is already stable, the patient should be
discharged soon

Check other related diseases (for computation of limit). E.g. abscess,
retinopathy, kidney problem, neuropathy, etc.

Diabetes may be caused by another disease. E.g. Patient has a disease
needing steroids for treatment. Prolonged steroid use may cause diabetes
later on
Anemia may be related to diabetes if the patient has chronic
GASTRITIS, UGIB
Other Terms: DYSPEPSIA, ACID PEPTIC DISEASE

NAUSEA, VOMITING - # of times, amount?
LBM - # of times, quantity, watery? Soft? Bloody stools?
BLEEDING hematemesis? vs. hematochezia/melena?
Other SYMPTOMS?
need to
LMP for females of reproductive age (might be maternity related)
Hx of prolonged use of anti-inflammatory drugs (aspirin, mefenamic
acid,
ibuprofen, etc.), steroids?
Hx of excessive alcohol intake?

Is there DEHYDRATION, needing IV fluids?

GASTRITIS, UGIB 2
CBC
H. pylori test
Occult blood to check if with GI bleeding
Gastroscopy not routinely done
diagnosis
oral? Intravenous? Appropriate?
Usually: antacids, proton pumps inhibitors (omeprazole, etc.), anti-emetics
(plasil, etc.)
May also give antibiotics for H. pylori infection.
take note of not covered meds such as probiotics (OMX, etc), food
supplements, etc.
take note of meds not related to the management of AGE (there might be
* If patient was given meds not related to management of AGE, please ask
the doctor or patient if patient has OTHER DISEASES or a specific disease (e.g.

GASTRITIS, UGIB 4

Gastritis after discharge or following another treatment may be considered as
related to the prior illness depending on the type of illness, medications taken,
etc. Meaning, there are instances that Gastritis may be related to previous
hospitalizations/illnesses so it is very important to know the history of the
patient, especially recent hospitalizations or illnesses, maintenance meds, etc.
E.g. Patient has Nephritis and is taking prednisone.

The main erosive causes of gastritis are excessive alcohol consumption or
prolonged use of nonsteroidal anti-inflammatory drugs (also known as
NSAIDs) such as aspirin or ibuprofen. Please ask about alcohol consumption
history, intake of pain meds, etc. If UGIB is secondary to liver cirrhosis
secondary to alcohol liver disease, exclusion

Sometimes gastritis develops after major surgery, traumatic injury, burns, or
severe infections. Gastritis may also occur in those who have had weight loss
surgery resulting in the banding or reconstruction of the digestive track.

GASTRITIS, UGIB 3
Non-erosive causes are infection with bacteria, primarily Helicobacter pylori.
Certain diseases, such as pernicious anemia, chronic bile reflux, and certain
autoimmune disorders can cause gastritis as well.

If endoscopy will be done, check if with inner limits for the procedure. This
will include OR charges, instrument fee, professional fee, H. pylori test and
histopath (if done).

Check for other related diseases. E.g. Patient has cholelithiasis. Abdominal
pain may really be secondary to the cholelithiasis

Always ask about PAIN & HYDRATION STATUS (and other symptoms). If
hydration status is okay and pain and other symptoms are already resolved
patient should be able to go home and just continue management at home
Ask if patient is already for discharge or when the patient will be discharged

RUV: Get OR tech or EGD report whenever possible

GOITER
NECK MASS? Since when? Moves with deglutition/when tongue stuck out?
PAIN on swallowing?
TACHYCARDIA?
Other SYMPTOMS?
need to

Will patient undergo thyroidectomy?
For RAI (Radioactive Iodine ) Therapy?

TSH, T4 (Thyroid Function Tests)
Serum Calcium
Ultrasound, FNAB results
diagnosis

GOITER 2
MEDS : LIST DOWN ALL MEDS BEING GIVEN



If patient is for RAI, check # of MCI:

79000-1 RAI therapy 1-20 MCI P 3,000
79000-2 RAI therapy 21-50 MCI P 9,000
79000-3 RAI therapy 51 MCI & above P 13,000

There is such a diagnosis as Thyrotoxic Heart Disease so beware of meds &
labs related to cardiac diagnosis. It may be related to the patients goiter.

GOITER 3
Beware of sublingual, submental, floor of the mouth mass in children or
young patients: may be Thyroglossal Duct Cyst (Congenital).

RUVs: Always get OR tech. Very important to evaluate RUV. If no OR tech,
give lowest RUV:

GYNECOLOGICAL CASES
OTHER CASES: Cervicitis, Pelvic Inflammatory Disease, Salpingitis, Cervical
Polyps,
Uterine prolapse, Dermoid Cyst, etc.

VAGINAL BLEEDING Since when? Profuse?
PAIN - Characterize
PAINFUL MENSTRUATION?
Other SYMPTOMS?
MARRIED? # of years
CHILDREN? How many?
Pregnant? LNMP?
STD-related?
History of OCP (oral contraceptive pills) use, IUD use, hormonal
therapy, etc.
need to

GYNECOLOGICAL CASES 2

ULTRASOUND RESULTS should be submitted upon seeking pre-
approval
PREGNANCY TEST
GRAM STAIN (Gonorrhea: gram-negative intracellular diplococci)
should
be requested/done especially if case may be STD-related
(cervicitis, PID,
salpingitis, etc.)
PAP SMEAR
HISTOPATH RESULTS
diagnosis



Take note of limits for procedures such as ultrasound (CDP), hysteroscopic
D&C/myomectomy, pelvic laparoscopy, etc.


Uterine prolapse, Rectocoele, Cystocoele maternity-related. Get OB score of
patient (Gravida____ Para______) Beware of procedures such as
colporrhaphy, A-P repair, etc. These are procedures for above cases.

Endometriosis usually infertility-related. Important to ask chief complaint, #
of years married, # of children.

Beware of procedures such as Chromotubation, Chromopertubation, etc.
Infertility-related, not covered.

Beware of hysteroscopic procedures Infertility-related?

Dermoid cyst is considered PEC, except for cases wherein patient has other
congenital problems or the doctor says that its congenital. Please ask if
congenital especially if patient is very young.

Hydrosalpinx, hematosalpinx, pyosalpinx may be fertility-related or STD-
related If possible, ask for GS

HTN
HIGH BP? BP at home? BP on admission? Hypertension Since when?
DIZZINESS?
WEAKNESS?
Other SYMPTOMS?
History of DM? Other DISEASES? (We might need to relate or
segregate)

IV Meds (e.g. nitroprusside drip)? If only oral meds are being given,
patient might not really need to be admitted Not all hypertension cases need
to be admitted.

LABS: - list down all labs
check if relevant/appropriate to the diagnosis
check if really needed during confinement (e.g. stress test can it be done as
out-patient? Esp. if schedule is not immediate)

HTN 2
take note of antihypertensives (oral? Intravenous?)
take note of meds not related to the management of hypertension (there
might be other diseases being managed during this confinement)*
ask for maintenance meds (being taken at home prior to admission)

* If patient was given meds not related to management of hypertension (esp.
if PEC is less than DD or no PEC) please ask the doctor or patient if patient has
OTHER DISEASES or a specific disease (e.g. May TB po ba ang pasyente?
Kasi po binibigyan sya ng Rifampicin?.)

Hypertension is always related to dyslipidemia, gout (hyperuricemia), stroke,
HASCVD, ischemic heart disease, coronary artery disease, angina, myocardial
infarction.
Hypertension is usually related to diabetes especially if diabetes was
diagnosed prior to hypertension (since it is a complication of DM). If
hypertension was diagnosed prior to DM (depending on history of diagnosis:
years, few weeks, etc.) it may be considered as not related to DM.

HTN 3
Always check maintenance meds as they may cause side effects that are
related to an ordinary illness. E.g. AGE, hypokalemia.

Check if end-point of confinement was already reached or fulfilled. E.g.
Patient was admitted to control BP. Take note of BP on admission, BP
monitoring, what meds were given (IV?) and BP at present. If BP already
stable, the patient should be discharged soon

Hypertension may be related to other diseases e.g. Polycystic Kidney Disease
(Congenital).
MATERNITY
VAGINAL BLEEDING Since when? Profuse?
PAIN - Characterize
Other SYMPTOMS?
MARRIED? # of years
CHILDREN? How many?
Pregnant? LNMP?
need to


ULTRASOUND RESULTS should be submitted upon seeking pre-
approval
PREGNANCY TEST
diagnosis

MATERNITY 2



Take note of limits for procedures such as ultrasound (CDP), hysteroscopic
D&C, pelvic laparoscopy, etc.

Take note of manner of delivery of previous pregnancies (NSD or cesarean).


MATERNITY 3
Uterine prolapse, Rectocoele, Cystocoele maternity-related. Get OB score of
patient (Gravida____ Para______) Beware of procedures such as
colporrhaphy, A-P repair, etc. These are procedures for above cases.

Endometriosis usually infertility-related. Important to ask chief complaint, #
of years married, # of children.

Beware of procedures such as Chromotubation, Chromopertubation, etc.
Infertility-related, not covered.

Beware of hysteroscopic procedures Infertility-related?

Dermoid cyst is considered PEC, except for cases wherein patient has other
congenital problems or the doctor says that its congenital. Please ask if
congenital especially if patient is very young.

Hydrosalpinx, hematosalpinx, pyosalpinx may be fertility-related or STD-
related If possible, ask for GS

RENAL CA, RENAL CYSTS, POLYCYSTIC KIDNEY DISEASE,
NEPHROLITHIASIS, UROLITHIASIS, OBSTRUCTIVE UROPATHY, BPH,.
DYSURIA
HEMATURIA
URINARY INCONTINENCE
Other SYMPTOMS?
History of other DISEASES? We might need to relate (e.g.
End-stage renal disease or chronic kidney disease, etc.) or
segregate (e.g.
cholelithiasis).
LMP for females of reproductive age (case might be maternity)

Can the management be done as out patient? IV meds?
Admitted for CDP? Limit, including room and board, PF, CP clearance
if done
in-patient, etc. will be under CDP limit. E.g. admitted for CT stonogram or
cysto-RGP (unless with stenting).

NEPHROLITHIASIS, UROLITHIASIS, OBSTRUCTIVE UROPATHY, BPH,2
LABS LIST DOWN ALL LABS
KUB XRAY/ULTRASOUND, CT SCAN, IVP, etc. RESULTS to verify if patient
indeed has stones or diagnosis is correct; If with renal cyst: check if
solitary or multiple. Polycystic kidney disease is congenital.
URINALYSIS RESULTS check WBC or pus cells, RBC
CBC results take note of Hemoglobin, WBC and differential count
URINE GS/CS
diagnosis

take note if meds are oral/intravenous? Appropriate?

* If patient was given meds or labs requested are not related to the
management, please ask the doctor or patient if patient has OTHER DISEASES
or a specific disease (e.g. May diabetes po ba ang pasyente? Kasi po
binibigyan sya ng Metformin?.)

NEPHROLITHIASIS, UROLITHIASIS, OBSTRUCTIVE UROPATHY, BPH,3

If CT scan is done and there is an inner limit for CDP, this includes PF of
reader, radiocontrast, etc.). Same for other procedures.

If PEC less than DD or no PEC, check utilization from effectivity of
membership. Coverage will depend on when symptoms started or diagnosis
made or size of mass (growth rate of renal stones: radius of 4.43mm/yr to
12.03 mm/yr).

PERCUTANEOUS ULTRASONIC NEPHROLITHOTOMY, EXTRACORPOREAL
SHOCKWAVE LITHOTRIPSY (ESWL), etc. Check if with inner limits. This
includes PF, etc.
ESWL is usually done as out-patient. Ask why patient has to be admitted.
Take note of other diseases which may be related.
Take note of CONGENITAL CASES, limits, especially in children.
Polycystic kidney disease is congenital. It is related to Hypertension.

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