A government owned and

corporation created by virtue of

Act
7875,
as
by RA 10606, mandated to
administration of the NHIP.
IEC version 2014.9.9
PUBLIC AFFAIRS UNIT

controlled
Republic
amended
lead the

BAYANIHA
N

The healthy
subsidizes the
sick

The young
subsidizes the old

The rich
subsidizes the
poor

Health Care
Problems
- No access to
medical and
health services
- Inequities in
health care
- Poor Health
Outcomes

A call for a better

program
MEDICARE
1972

PHILHEALTH
1995

Health Care Reforms

Bridged the gap of inequities in access to

health care service

Better health Outcomes

Achieving Universal Health Care for

All
Filipinos or Kalusugan
Pangkalahatan (KP)

Improved
Health Status of
Filipinos

ANY of the following:

Birth

Certificate
Marriage Contract
Baptismal Certificate
Barangay Certification
Any valid ID (as per PC 50, s. 2012)

DEPENDENT
Spouse (not a
member)
for Muslim spouse
Children below 21
yrs old
Mentally or
physically disabled
children who are 21
yrs old and above
Adopted children
below 21 yrs old
Foster Children
below 21 yrs old
Stepchildren below

DOCUMENT
Marriage Certificate/Contract
Affidavit of Marriage issued by
Office of the Muslim Affairs
Birth /Baptismal Certificate
Birth /Baptismal Certificate and
Medical Certificate issued by the
attending physician within the past
6 months
Court
Decree/Resolution
of
Adoption or Birth Certificate with
annotation
Foster Family Care License and
Foster Placement Authority
Marriage Certificate between

PhilHealth ID Card

Effective January 1, 2014

LOCAL HEALTH INSURANCE OFFICES

ACCREDITED COLLECTING BANKS

SINGAPORE
PhilHealth Accredited Bank with Electronic Payment System facility (E-Pay)

 Single Period of Confinement rule

45 days LIMIT RULE

Eligibility Rule
Payment of at least 3 months within 6
months prior to the first day of confinement
Confinement falls within validity

 Facility and attending physician

should be ACCREDITED/
ENGAGED by PhilHealth
Compensability of
conditions/procedures will be
based on the service capability
and DOH classification
Admission due to patients
choice shall NO longer be
reimbursed

 At least 24 hours confinement

Paid via CASE RATE payment mechanism
Based on diagnosis with the most resources
used
List of compensable conditions/procedures
(Annexes)
Pre-operative diagnostics are NOT covered
May claim 2 packages (1st and 2nd case
rates)
For medical conditions, benefit will be 70%
for the facility fee and 30% for the doctors fee

When a patient has multiple conditions

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

Second case rate medical condition, or

procedure with the second most resources used
(not all conditions may be claimed 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.

FIRST
CASE
RATE

(100% of
case rate
amount)

SECOND
CASE
RATE
(50% of
case rate
amount)

TOTAL
REIMBURSE
MENT

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.

REFERRAL PACKAGE
Referring hospital shall be paid Php 4,000
Reimbursement of the full case rate shall be paid to

referral hospital
Allowed if transfer is to a higher facility
Limited to conditions in Annex 8 & duly
accomplished referral form is required
For series of referral, only the FIRST and LAST
facility will be reimbursed

CONFINEMENTS ABROAD

RESUSCITATION PACKAGE
Confinement of less than 24 hours & patient dies
Fixed rate of Php 4,000

ADDITIONAL LIST OF MEDICAL CONDITIONS FOR HOSPITALS

Diabetes Mellitus with/without
complications

Streptococcal tonsillitis

Measles with/without complications

Acute tonsillitis

Varicella (chickenpox)

Acute bronchitis

Rubella

Bronchitis

Viral exanthem

Dyspepsia

Coronavirus infection

Constipation

Viral infection

Epidermal cyst

Schistosomiasis

Urolithiasis

Hypoglycemia

Urinary tract infection in

pregnancy

Moderate/severe dehydration

Superficial injuries

NEW RATES FOR SELECTED CASES IN PRIMARY CARE FACILITIES

DESCRIPTION

FROM

TO

Measles complicated by otitis media, Otitis

media in viral diseases classified elsewhere

2,800

5,460

Measles with intestinal complications

2,800

6,650

Measles without complications

2,800

5,390

Hyperosmolality and hypernatraemia; Sodium

excess; Sodium overload

2,800

5,950

 For Sponsored Program

Members and Kasambahay
availing of benefits in:
accredited government
hospitals;
accredited non-hospital
facilities

MATERNITY CARE PACKAGE

OUTPATIENT HIV/AIDS
TREATMENT PACKAGE
ANIMAL BITE PACKAGE
OUTPATIENT MALARIA PACKAGE
TB-DOTS PACKAGE (All Cases)
NEWBORN CARE PACKAGE

8,000
30,000/yr
3,000
600
4,000
1,750

CASE TYPE Z BENEFITS

Acute Lymphocytic Leukemia (ALL)
(for children 1 to less than 10 years
old)
Breast Cancer (Stage 0 to III-A)

210,000
100,000

Prostate Cancer (Low to

100,000
Intermediate Risk requiring
Prostatectomy)
Kidney Transplant (Age 11 to 69
600,000
years old)
Coronary Artery Bypass Graft) 19
550,000
to 70 y/o)
Total Correction of Tetralogy of
320,000
Fallot
Surgery for Ventricular Septal
250,000
defect

Southern Philippines Medical Center

Cervical
cancer
120,000
Davao Regional Hospital
175,000
Z MORPH (Lower limb prosthesis)
15,000-

CASE TYPE Z BENEFITS

ORTHOPEDIC IMPLANT

RATE

Total Hip Prosthesis, cemented

103,400.00

Total Hip Prosthesis, cementless

169,400.00

Partial Hip Prosthesis, bipolar

73,180.00

Multiple screw fixation

61,500.00

Compression Hip screw set

69,000.00

Proximal Femoral Locked Plate

71,000.00

Intramedullary Nail with Interlocking screws

48,740.00

Locked Compression PlateBroad/Metaphyseal/Distal Femoral

50,740.00

CASE TYPE Z BENEFITS-Peritoneal Dialysis

Package Rate
Php 270,000/year
Mandatory supplies to be provided by contracted HCIs
PD supplies
PD Solutions
PD double bag system 2.0 liters
Dextrose concentrations: 1.5%, 2.25%
and 4.25%
Calcium content: Low
calcium(1.25mmol/L) or regular Calcium
(1.75 mmol/L)
PD accessories
Transfer Set changed every 6 months
Caps (disconnect cap, minicap)

TOTAL ACCREDITED HEALTH

CARE PROVIDERS (AHCP) as of
November 5, 2014
ARE
A

HOSPITAL
S
PRI
V

OUTPATIENT PROVIDERS

GOV PCF
T

DC

16

12

DS

12

28

DN

10

12

CV
DO

TOT
AL

39

64

ASC
2

FDC DOT ABT MCP PCB RHU

S
C
5

1
1

69

12

11

38

11

10

10

123

54

308 ACCREDITED FACILITIES

REQUIREMENTS

1) Philhealth Benefit Eligibility Form (PBEF)

to be generated by the HCI Portal
Or the following:
1) Duly accomplished Claim Form 1
2) Proof of membership
3) Proof of contribution
Sponsored or OFW (within validity as stated
in MDR)
Employed/Self employed 3 months
Lifetime members ID/MDR

Juan Dela Cruz

"Sulit na Benepisyo sa Bawat

Miyembro, Dekalidad na Serbisyo
para sa Lahat"

FOR INQUIRIES
Office Address: Valgosons Bldg.
Bolton Ext., Poblacion, Davao City
Telefax number (082) 295-2133
Healthline: 09229242159
www.facebook.com/philhealthregion11
info.pro11@philhealth.gov.ph
publicaffairs.philhealthxi@gmail.com