TS Circ09 2014

PhilHealth Circular No. 009, s.
2014
ACR POLICY NO.3 - ADDITIONAL LIST OF MEDICAL CONDITIONS FOR

HOSPITALS, NEW RATES FOR SELECTED CASE RATES IN PRIMARY CARE
FACILITIES–INFIRMARIES/DISPENSARIES, AND CLARIFICATION OF EXISTING
RULES ON ALL CASE RATES
- TAMANG SAGOT -
1. What is ACR Policy No. 3?
ACR Policy No. 3 contains reiterations/clarifications on the provisions stated in ACR Policy
No. 2 to properly implement All Case Rates and additional benefits/policies under the All Case
Rates (i.e., Resuscitation Package).
2. What are the new case rates for Primary Care Facilities (Infirmaries/Dispensaries)?
Starting January 1, 2014, Annex 5 of PC 35, s-2013 shall be amended by Annex 1 of PC 9, s-

2014. Annex 1 of PC 9, s-2014 shall be the new reference for medical case rates for Primary Care
Facilities.
3. Are there additional medical case rates allowed in hospitals?
Yes, there are additional list of medical conditions which shall be covered by PhilHealth if
admitted in a hospital. Included in the list are acute lymphoblastic leukemia, measles with other
complications, etc. (please see complete list in Table 2. Additional List of Medical Case Rates of
PhilHealth Circular No. 9, s-2014).
4. Hospitals are still adjusting with the new PhilHealth All Case Rate rules, will PhilHealth
extend the deadline for the return to sender claims?
Yes, return to sender (RTS) of claims for correction/revision/completion shall be allowed for
claims with admission dates on or before June 30, 2014 to give health care institutions enough
time to adjust and get used to the new claims processing forms and rules.
5. Are claims for confinements of less than 24 hours wherein the patient expired now
covered by PhilHealth? Will this be allowed in all health care institutions?
Yes, PhilHealth now has a Resuscitation Package which shall cover claims for confinement of
less than 24 hours if the patient expired even if beyond the service capability of the health care
institution (HCI). For this Resuscitation Package, the HCI shall be reimbursed a fixed rate of
4,000 pesos to be distributed as follows:
Page 1 of 3
Particulars Percentage (%) Amount (in Php)
Health Care Institution (HCI) Fee 70 2,800
Professional Fee (PF) 30 1,200
Total Case Rate 100 4,000
This package is available for all HCIs, however along with the usual requirements for filing
claims, HCIs are required to submit a certified true copy of the doctor’s and nurse’s notes as
proof that resuscitative measures were done to the patient.
6. For claims whereby the patient expired, what should be the basis for the time of
discharge of the patient?
The time of death of the patient shall be the basis of the time of discharge in determining the
number of confinement days/hours.
7. How are we going to claim for chemotherapy? Can we claim multiple cycles of
chemotherapy in a single claim form?
In order to facilitate claims for chemotherapy, only one (1) cycle of chemotherapy shall be
claimed in the PhilHealth Claim Form 2. The guidelines on how chemotherapy claims may be
filed are found in Annex 11 of PhilHealth Circular 35, s. 2013.
8. For procedures requiring general and spinal anesthesia, can we submit a photocopy
instead of a certified true copy of the records of anesthesia?
Photocopy of records of anesthesia and surgical or operative techniques shall be accepted in lieu
of the original or certified true copy.
9. Can a member still file claims directly to PhilHealth?
Yes, PhilHealth shall give special consideration for direct filing of claims for selected cases that
were either denied or not filed and with appeals for adjustment of reimbursement.
Members may directly file their claims if their illness is included in the list of allowed medical
conditions and if their confinement falls within the prescribed period of confinement.
The following are the list of cases allowed for direct filing/request for adjustments:
Confinement Period Confinement

Allowed for Direct Period NOT
No. Cases
Filing/Request for Allowed for Direct
Adjustment Filing
1 All medical conditions listed in Admissions starting Admissions starting
Table 2-Additional List of Medical January 1, 2014 until March 21, 2014
Case Rates (Annex 1 of PC 35 s. March 20, 2014 onwards
2013) of PhilHealth Circular No. 9
s-2014 for all hospital admissions
Page 2 of 3
2 Confinements of less than 24 hours Admissions starting Admissions starting
where the patient expired including January 1, 2014 to March March 21, 2014
confinements beyond service 20, 2014 onwards
capability
3 Patients who were admitted in Admissions starting Admissions starting
primary care facilities (PCF) for January 1, 2014 to March March 21, 2014
the following cases since their rates 20, 2014 onwards
were adjusted:
Description From To
Measles
complicated by
otitis media;
1 Otitis media in 2,800 5,460
viral diseases
classified
elsewhere
Measles with
2 intestinal 2,800 6,650
complications
Measles without
3 2,800 5,390
complications
Hyperosmolality
and
hypernatraemia;
4 2,800 5,950
Sodium [Na]
excess; Sodium
[Na] overload
4 The Newborn Care Package (NCP) Admissions starting Admissions starting
being claimed as second case rate. January 1, 2014. March 21, 2014
NCP shall be included in the list of onwards
case rates allowed as second case
rate if admitted in hospitals.
However, all claims for special consideration shall be processed subject to existing rules of the
Corporation. Requirements for filing of adjustment for reimbursement include official receipts
or its equivalent and a completely filled-out adjustment form.
Starting March 21, 2014, health care institutions should properly deduct these
additional/adjusted rates to the claim.
10. Can a newborn sick baby still avail of the Newborn Care Package?
Starting January 1, 2014, a newborn sick baby may now avail of the Newborn Care Package
(NCP) on top of the illness the newborn baby is being managed/treated at the hospital. The
NCP benefit of Php 1,750 (RVS Code: 99432) may be claimed as second case rate.
Page 3 of 3

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PhilHealth Circular No. 009, s.

ACR POLICY NO.3 - ADDITIONAL LIST OF MEDICAL CONDITIONS FOR

1. What is ACR Policy No. 3?

Starting January 1, 2014, Annex 5 of PC 35, s-2013 shall be amended by Annex 1 of PC 9, s-

3. Are there additional medical case rates allowed in hospitals?

9. Can a member still file claims directly to PhilHealth?

Confinement Period Confinement

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