PhilHealth Claims Filing

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PhilHealth Claims Filing

• Reducing Mistakes,
• Increasing Reimbursements

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Know the Rules!

• PhilHealth does not pay for all your health care
  costs.
• PhilHealth pays only for covered items and
  services when its rules are met.
• Members usually give a co-payment for the portion
  of the actual cost that is not covered by
  PhilHealth

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PhilHealth

• Govt owned and controlled corporation
• Created by Republic Act 7875
• National Health Insurance Program (NHIP)
• Amended by Republic Act 9241
• Access to health care is a basic right of
  citizens
• Universal coverage

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Members andDependents
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Our Members

• 1. Employees (govt and private)
• monthly payment (3 salary)
• 2. Individually Paying Program (voluntary)
• - quarterly payment (1,200/year)
• 3. Overseas Workers Program
• - Annual payment (900/year)

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Our Members

• 4. Non-paying (pensioner)
• - no payment for life
• 60 years old
• With total 120 monthly contributions
• 5. Sponsored (thru partnership with LGUs)
• - annual payment, eligibility for 1 year

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Your Dependents

• Spouse
• Children lt 21 years old
• Parents gt 60 years old
• Step parents
• Adoptive parents

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Benefits
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45 Days Annual Allowance

• 45 days allowance per year for the principal
  (member)
• Another 45 days shared among dependents

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Your benefits

• Illness requiring hospitalisation
• Outpatient
• Surgical procedures
• Cataract surgery
• BTL
• Vasectomy
• Endoscopy
• Excision
• Suturing

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Drugs and Medicines

• Only drugs used during confinement will be paid
• Drugs must be written in generic name
• Closed formulary only drugs listed in the
  preferred list will be covered by PhilHealth
• 6th edition of the Philippine National Drug
  Formulary (PNDF)

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Anti-convulsants / Epileptics

• CARBAMAZEPINE
• CLONAZEPAM
• DIAZEPAM
• LORAZEPAM
• MAGNESIUM SULFATE
• PHENOBARBITAL
• PHENYTOIN
• VALPROIC DISODIUM

• Gabapentin
• Midazolam
• Thiopental sodium
• Topimarate

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Anti-Parkinsonism

• Pirebidil
• 50 mg
• Selegiline
• 5 mg

• LEVODOPA BENSERAZIDE
• 100 mg/25 mg
• 200 mg/50 mg
• LEVODOPA CARBIDOPA
• 100 mg/25 mg
• 250 mg/25 mg

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Case 65 years old Diagnosis Parkinsons
Disease Drugs Levodopa Benserazide
60 Nifedipine 30 mg 60 (PNDF) Telmisartan
tab 60 (non-PNDF) Admission September 17 - 20
?
?
?
What drugs will be paid?
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Case Diagnosis Parkinsons Disease, HPN Drugs
Levodopa Benserazide 60 Nifedipine 30 mg
60 Telmisartan tab 60 Admission September
17 - 20
?
?
?
?
?
?
How many will be paid?
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Drugs and Medicines

• Only drugs, supplies, and lab used on confinement
  shall be paid
• Must be supported by official receipts

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Fee for Service Scheme

• physician charges separately for each patient
  encounter or service rendered
• expenditures increase if more services are
  provided or a more expensive service is
  substituted for a less expensive one
• Needs itemization

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Computation of Benefits

• Case type of illness
• Category of Facility

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Casetypes

• Casetype A Ordinary
• Casetype B Intensive
• Casetype C Catastrophic
• Casetype D Super Catastrophic

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Level 3 4 Hospitals (Tertiary) Level 3 4 Hospitals (Tertiary) Level 3 4 Hospitals (Tertiary) Level 3 4 Hospitals (Tertiary) Level 3 4 Hospitals (Tertiary)
Case-type A B C D
Room Board P400/day P400/day P400/day P1,035/day
Drugs and Medicines P3,000 P9,000 P16,000 P35,635
X-ray, Lab Others P1,700 P4,000 P14,000 P29,430
Operating Room RVU 30 and below P1,060 RVU 31 to 80 P1,350 RVU 81 up to 200 P3,490 RVU 201 up to 500 P3,490 RVU gt 500 P10,470
Level 2 Hospital (Secondary) Level 2 Hospital (Secondary) Level 2 Hospital (Secondary) Level 2 Hospital (Secondary) Level 2 Hospital (Secondary)
Room Board P300/day P300/day P300/day P660/day
Drugs and Medicines P1,700 P4,000 P8,000 P19,725
X-ray, Lab Others P850 P2,000 P4,000 P10,215
Operating Room RVU 30 and below 670 RVU 31 to 80 P1,140 RVU 81 up to 200 P2,160 RVU 201 up to 500 P2,160 RVU gt 500 P6,480
Level 1 Hospital (Primary) Level 1 Hospital (Primary) Level 1 Hospital (Primary) Level 1 Hospital (Primary) Level 1 Hospital (Primary)
Room Board P200/day P200/day N/A N/A
Drugs and Medicines P1,500 P2,500 N/A N/A
X-ray, Lab Others P350 P700 N/A N/A
Operating Room RVU 30 and below P385 N/A N/A N/A
Not exceeding 45 days for each member another 45 days to be shared by his/her dependents Per single period of confinement Not exceeding 45 days for each member another 45 days to be shared by his/her dependents Per single period of confinement Not exceeding 45 days for each member another 45 days to be shared by his/her dependents Per single period of confinement Not exceeding 45 days for each member another 45 days to be shared by his/her dependents Per single period of confinement Not exceeding 45 days for each member another 45 days to be shared by his/her dependents Per single period of confinement
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Benefit Periods

• PhilHealth benefits are divided into benefit
  periods
• A benefit period is essentially a single hospital
  stay, including re-hospitalisation of up to 90
  days
• In each benefit period, PhilHealth will only pay
  1 benefit

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Single Period of Confinement

• Example
• a 3 week chemotherapy cycle, where a patient has
  treatment on the 1st and 8th days, but nothing on
  days 2 - 7 and days 9 - 21
• Medicine per session is 5,000

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Benefit Unused Payment
16,000
January 1 16,000 5,000
January 8 11,000 5,000
January 22 6,000 5,000
January 29 1,000 1,000
February 12, 19, 0 0
90 days after January 1 New 16,000 March 1
March 5 16,000 5,000
March 12 11,000 5,000
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Single Period of Confinement

• You may only avail of the unused benefits
  except
• for room and board fees
• Professional fees
• until the 45 day allowance is fully exhausted.

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ProfessionalFee
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Professional Fees Professional Fees Professional Fees Professional Fees Professional Fees
Case-type A B C D
General Practitioner P150/day not exceeding P600 P150/day not exceeding P900 P150/day not exceeding P900 P315/day not exceeding P2,430
Specialist P250/day not exceeding P1,000 P250/day not exceeding P1,500 P250/day not exceeding P2,500 P450/day not exceeding P4,050
Surgeon (P40/RVU) not exceeding P16,000 (P40/RVU) not exceeding P16,000 (P40/RVU) not exceeding P16,000 (P120 /RVU for consultation) but not exceeding P47,790
Anesthesiologist 30 Surgeons fee not exceeding P5,000 30 Surgeons fee not exceeding P5,000 30 Surgeons fee not exceeding P5,000 30 Surgeons fee not exceeding P14,355
Per single period of confinement Per single period of confinement Per single period of confinement Per single period of confinement Per single period of confinement
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Professional Fee

• based on the Relative Value Units (RVU)
• The RVU must be multiplied by a Peso Conversion
  Factor (PCF) to become a payment schedule
• Surgeons RVU x P 40
• Covers preoperative visits, intraoperative
  services, postoperative services for 90 days
• Anesthesiologist (RVU x P 40) x 30

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Professional Fee
Example 66270 Spinal
puncture 12 12 RVU x
40 PCF Php 480
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Professional Fee
Example 61793 Stereotactic
radiosurgery 200 200 RVU x
40 PCF Php 8,000
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Professional Fee
Example 61500 Craniectomy w/
excision of tumor 400 400
RVU x 40 PCF Php 16,000
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Policies on PF

• gt 2 procedures, single opening
  
  
  pay highest value
• gt 2 procedures, different incision site
• pay all unit values
• Procedures done on different dates
• pay all unit values

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Policies on PF

• Example
• 49000 - Explor Lap - 150
• 44950 - Appendectomy - 100
• 150 RVU x 40 PCF P6,000

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Policies on PF

• Example
• 49000 - Explor Lap - 150
• 58943 - Oophorectomy for
• ovarian CA - 200
• 200 RVU x 40 PCF P8,000

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Policies on PF

• PF of multiple procedures
• performed on different dates/sites
• Payment within cap
• Payment preference based on RVU

Service Rendered Computed Benefit PHIC
Benefit ORIF Radius Ulna(180 RVU) 7,200 4,000 O
RIF Femur( 300 RVU) 12,000 12,000
Total 16,000
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Policies on PF

• Example Bilateral Cataract Extraction
• 69887 - ECCE phacoemulsification - 200
• 200 x 2 400 RVU
• 400 RVU x 40 PCF P16,000

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Policies on PF

• Repeat Procedures
• Payment within cap
• Covered by rule on single period of confinement

Service Rendered Computed Benefit PHIC
Benefit Ligation, varices esophagus 10,000 10,00
0 Ligation, varices esophagus 10,000 6,000
Total 16,000
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Professional Fee
Example 66270 Spinal
puncture 12 12 RVU x
40 PCF Php 480
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Professional Data Charges
?
Daily visit
RVU
Anesth
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Professional Data Charges
With deduction
Lumbar tap
520
1000
480
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Professional Data Charges
With no deduction
Lumbar tap
1000
1000
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Professional Data Charges
Complimentary PF PhilHealth only
Lumbar tap
480
480
Actual PF PhilHealth benefit
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Professional Data Charges
Government hospital Private Patient
Private hospital Service Patient
Dialysis
400
400
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Private Patient, Government Hospital
PAY TO DOCTOR
NO Stamp PF is made to the Chief
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Service Patient, Pay Hospital
Name of Surgeon
PAY TO CHIEF
NO Stamp PF is made to the MD who signed Form 2
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Reason for Denial

1. Late filing
2. gt 45 days confinement
3. Non-compliance to RTH
4. Not accredited hospital
5. No ICD-10 code
6. Inconsistent data
7. Case not compensable
8. Same illness w/in 90 days
9. No qualifying contribution

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Eligibility Rules
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Are you eligible?

• For employed and IPP, at least 3 monthly
  contributions within the immediate 6 months prior
  to admission
• the 45-days allowance for room and board has not
  been consumed yet
• confinement in an accredited hospital of not less
  than 24 hours

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Case

• Employed member since January 2006
• Admitted for Myelography for tumor (?)
• Paid premium up to January to March 2007
• Is the claim compensable?

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr
x Admit

?
?
?
6 5 4 3 2
1
No !
X start of membership
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Case
Yes !

• IPP applied membership March 2007
• Premium paid
• Admitted April 2007 for TIA

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr
x Admit

?
?
?
6 5 4
3 2 1
3 2 1
3 2 1
X start of membership
1st quarter
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300
06/08/2007
2007 P 300
300

• What if a member enroll today, when can he start
  availing PhilHealth benefits?

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Adverse selection

• Phenomenon whereby a disproportionate share
  unhealthy individuals (high risk) enroll in a
  health plan
• Hidden information member moral hazard
• Influenced by benefit design and individual
  decision
• In contrast to guiding principles of social
  solidarity
• Example CS, Cataract

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Circular 36 s. 2006

• For IPP, at least 9 monthly contributions within
  the immediate 12 months prior to admission for
  the following
• Hemodialysis and Peritoneal Dialysis
• Chemotherapy
• Radiation oncology
• Selected surgeries
• CS
• D C
• Cataract
• Endoscopy effective April 1, 2007

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Supplier induced demand

• Demand created by doctors beyond what would have
  occurred in a market
• Influenced by benefit design and individual
  decision
• Hidden action
• Doctor moral hazard

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PhilHealth Payment 2004

• Cataract (69887 66984)
• Total Payment 590 million
• Total Number Claimed 28,997
• AVPC 20,368.83
• Average PF 7,700

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Adverts

• False adverts tends to deceive or mislead the
  public which makes an untruthful assertion
• E.g., Free cataract surgery for PhilHealth
  members
• No out of pocket payments for PhilHealth members

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Adverts

• Cataract surgery announced as free should not be
  filed to PhilHealth and be offered to all
  regardless of PhilHealth membership status
• Why not offer it to all?
• Not free PhilHealth as third party payor

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Solicitation of patients

• Solicitation of patients, directly or indirectly,
  through solicitors or agents, is unethical
• Example
• NGO sponsorship of medical mission
• Doctors paying for patients premium
• 300 pesos versus 49,000 pesos (bilateral ECCE)

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RVS 2001

• Historically-abused procedures
• Utilization trend data
• Institutional memories
• Blepharoplasty
• Removal of FB, eye
• Pterygium
• Excision (20) Conjunctivoplasty (60)

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RVS 2001

• Upcoding or Creeping
• In claims submission, using a higher level
  procedure code than the level of service actually
  provided
• E.g., appendectomy (100 RVU) to
• AP ruptured (150 RVU)

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Most Common Reasons of RTH
1. No ICD-10 code 2. Operative Record
required 3. Fully accomplished PhilHealth Claim
Form 3 required 4. Item no. 13 of PhilHealth
Claim Form 2 deficient 5. Proof of payment
(MI-5) required
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ICD-10
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ICD-10

• An international classification designed to
  enable CONSISTENCY of coding THROUGHOUT the
  world.

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STRUCTURE OF ICD-10 CODE

• The structure of the 4-character category is

A37.1
Lastly Another digit
First character A to Z (Except U)
Followed by 2 digits
then a point
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MAIN ELEMENTS TO THE STRUCTURE OF ICD-10

• There are three (3) volumes

• There are twenty one (21) chapters

• The structure of the code is alphanumeric

VOLUMES OF THE ICD-10

• Volume 1 (Tabular List) alphanumeric listing of
  diseases and disease groups

• Volume 2 - contains instructions and guidelines
  for Mortality and Morbidity coding

• Volume 3 (Alphabetical Index) comprehensive
  listing of all the conditions in the Tabular List

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Basic Coding Guidelines

• Follow carefully any cross-references found in
  the index.
• Refer to the Tabular List (Vol. 1)
• Be guided by any inclusion and exclusion terms
  under the selected code, chapter, block or
  category heading.
• Finally, ASSIGN THE CODE.

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Example
Assign the ICD-10 code for
Chronic viral hepatitis C
Answer
Lead term
Hepatitis
-viral
--chronic
---type
?
----C
B18.2
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PhilHealth Circular Number 27 series of 2003

• All claims with no ICD-10 codes, incorrect
  codes/and or ambiguous ICD-10 codes shall NO
  LONGER BE DENIED but shall be returned to the
  accredited health care provider (RTH) on the
  ground of non-compliance with the correct ICD-10
  codes

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Nervous System

• Categories ranged from G00-G99

• 67 of the 100 available categories have been used

• There are 11 blocks within this Chapter.

• There are 16 asterisk categories. Most of them
  are result of infectious conditions, as well as
  neurological conditions resulting from other
  diseases and conditions

• G00-G09 block classifies diseases where the
  nerve tissue
• is attacked by various organisms

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Nervous System

• Meningitis is usually due to infection and is
  classified by a combination of a dagger code for
  Chapter 1 and an asterisk code from G01 or G02 to
  provide more information

• G09(Sequelae of inflammatory diseases of central
  nervous system) would be listed as a secondary
  code with the sequelae itself being listed as the
  main condition

• It should be noted that seizures and convulsions
  NOS are
• coded R56.8 and are not considered epilepsy
  unless the
• term epilepsy is specifically used

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ICD-10

• G45.9 TIA (O)
• G45.0 vertebrobasilar insufficiency (O)
• I67.9 CVA, unspecified (C)
• I66.9 CVA, cardioembolic (D)
• I61.9 CVA, hemorrhagic (D)
• I63.9 CVA, thrombotic infarct (D)

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MORPHOLOGY OF NEOPLASMS

• The classification of morphology of neoplasms
• (pp. 1177-1204) is used as an additional code
  to classify the morphological type for neoplasms

S
Site
C00 - D48
M
M8000 M9989
Morphology
B
Behavior
/0, /1, /2, /3, /6
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ICD-10

• C71.9, M9400/3

• Neoplasm of brain
• Astrocytoma
• Malignant

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ICD-10

• D32.1, M9530/0

• Neoplasm of spinal meninges
• Meningioma NOS
• Benign

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ICD-10

• C50.9, M8010/3
• C71.2, M8010/6

1. Breast carcinoma, primary
2. Metastatic carcinoma, temporal lobe

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Additional Tips for Better Payment

1. Eliminate down coding by providing complete
   descriptions
2. Rank procedures by order of importance
3. Dont send documents not required
4. Submit claims promptly and frequently
5. Complete forms ASAP
6. Fill in all blanks. Type NA
7. Make it a practice to follow up with Claims Dept.

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ICD-10

• G96.1 Disorders of meninges, unspecified (B)
• G00.9 Bacterial meningitis (C)
• G04.2 bacterial meningo-encephalitis (D)

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Updates
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Circular 11, 2007
Code Descriptive Terms RVU
99256 Inpatient consultation for a new or established patient which requires an expanded focused history, examination and medical decision making. It is requested by another physician or appropriate source the consultant advises the requesting physician about the management of a specific problem including follow up care for 90 days after the procedure 40
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Circular 11, 2007

• Preoperative medical evaluation is a service
  provided by a physician whose opinion or advice
  is requested by another physician regarding
  evaluation and/or management of a specific
  medical problem which might affect the patients
  ability to undergo a procedure or might influence
  the outcome of the procedure

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Circular 11, 2007

• Qualified physicians who can claim for this
  service
• Family medicine
• Internal Medicine
• Neurology
• Pediatrics

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Circular 11, 2007

• Applicable only while the patient is admitted
• Preoperative medical evaluation given on an
  outpatient basis will not be compensated

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Circular 11, 2007

• Service is applicable only if surgery is
  accomplished within the same admission period.
• If surgery is deferred ? no payment
• But may claim PF based on daily visits subject to
  allowable amount per hospital admission

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Circular 11, 2007

• In filing for claims, a copy of the
  consultation/clearance form with the
  corresponding assessment and recommendation must
  be attached

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Contact Us
www.philhealth.gov.ph
qarp_at_philhealth.gov.ph
0918-9001618