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In order to provide an efficient and faster processing of cataract pre-surgery authorization request (previously phrased pre-cataract surgery authorization), PhilHealth Circular No. 59, s-2012 (entitled Requirement of Pre-Cataract Surgery Authorization) is hereby amended to provide an electronic transaction system through the Institutional Health Care Provider (IHCP) Portal. The lHCP Portal is a web-based system where the module on cataract pre-surgery authorization has been incorporated.

II. GENERAL RULES

1. The electronic Cataract Pre-Surgery Authorization (CPSA) shall be incorporated in the Institutional Health Care Provider (IHCPs) Portal. This module shall be used by health care providers to electronically submit their authorization requests for cataract surgeries to their respective PhilHealth Regional Offices (PROs). Using the CPSA module, the health providers shall be able to encode the necessary information required by PROs to process their request, track the status of their request and print approved PCSA request.
2. All authorization requests for cataract surgery shall be transacted electronically through the CPSA module.
3. All health care facilities providing cataract surgery must have the IHCP Portal installed and activated. In addition, these facilities must have CPSA module in their IHCP portal enabled by their respective PROs.
4. For purposes of cataract pre-surgery authorization, a maximum of two (2) user accounts shall be provided to each health care facility. These accounts are ideally installed in computers used by the:
   • PhilHealth Billing Section/Admitting Section
   • Ophthalmology Department/ Eye Center (or its equivalent)
5. Only PhilHealth-accredited professional health care providers shall be granted cataract pre-surgery authorization. Moreover, they must be affiliated with IHCP where the cataract surgery shall be performed. It shall be the responsibility of the professional health care providers to provide PhilHealth an updated list of his/her affiliate facilities accompanied with proof of affiliation (e.g. certification). The IHCP shall likewise provide PhilHealth with an updated list of health care professionals who are affiliated in their facilities, duly authorized by concerned doctor.
6. National Government (NG) or Local Government Unit (LGU)-sponsored mission conducted in any PhilHealth-accredited government facility shall be compensable subject to limitations provided in PhilHealth Circular no. 19 s-2007 (Implementing Guidelines for PC No. 17 s-2007). An endorsement from the Philippine Academy of Ophthalmology (PAO) shall be required for claims/procedures performed in such mission activities to be paid by PhilHealth. The PAO shall issue a reference number for every mission activity that it endorses. This reference number shall be used in the processing of the cataract pre-surgery authorization requests and in the processing of cataract claims.
7. The PROs shall act on the cataract pre-surgery authorization requests within seven (7) working days upon receipt and shall send the decision via the same electronic module. The decision to approve or disapprove shall be based on the clinical and non-clinical parameters.
8. If the request is still on process for more than 7 working days, a follow-up may be done to the appropriate PRO.
9. If granted, the cataract pre-surgery authorization shall be valid for thirty (30) calendar days starting from the date of approval. If the procedure is not done within the validity period, another request must be submitted.
10. In case of disapproval of the request, the IHCP may file a new cataract presurgery authorization request.

III. SPECIFIC RULES

1. The IHCP shall properly fill out the required information prescribed in the cataract pre-surgery authorization request through the module in the IHCP Portal. The required information are as follow: Demographics of patient/member
   1. Name of patient
   2. Birthdate of patient
   3. Address of patient
   4. Name of PhilHealth member
   5. PhilHealth membership category
   Clinical Information
   1. Presence of lens opacity
   2. Complete diagnosis
   3. Planned procedure
   4. Pre-operative uncorrected visual acuity
   5. Pre-operative best-corrected visual acuity
   6. Refraction
   7. Cardio-pulmonary evaluation (if applicable)
   Non-Clinical Information
   1. Date of contemplated operation
   2. Name and address of hospital/ASC
   3. Name of attending eye surgeon
   4. Accreditation number of attending eye surgeon
   5. Name of physician who evaluated the patient before operation
   6. Name of physician who will perform follow-up care
   7. Will the patient be operated in a mission activity?
   8. PAO reference number (when applicable)
2. The approved cataract pre-surgery authorization shall be printed and attached to the Claim Form (CF) during filing of claims. The printed form must be signed by the following:
   1. The patient/member shall sign conforming to all the information supplied by the IHCP. If patient/member cannot sign due to special circumstances, his/her thumb mark is considered.
   2. The attending eye surgeon or the head of Department of Ophthalmology (or its equivalent) shall sign to attest to the veracity of all the information supplied by the IHCP.
3. For filing of claims, the attending eye surgeon who will claim for reimbursement must be PhilHealth-accredited and duly affiliated with the facility where the surgery was performed. For surgeons on training as resident/fellow and are not yet accredited with PhilHealth, any of the following accredited professionals shall sign on their behalf:
   1. Medical Director/Medical Center Chief/Chief of Hospital/Administrator
   2. Chairperson of the Department of Ophthalmology
4. In order to ensure continuity of care, the request for cataract pre-surgery authorization must include the name/s of the physician who will evaluate the patient before the operation (pre-operative care) and perform follow-up care (post-operative). In an ideal set-up, only the attending eye surgeon must provide all these services. However, in training hospitals, where these services may be provided by different doctors, such practice shall be allowed and will be considered in the evaluation.

IV. REQUIREMENTS FOR SUBMISSION OF CLAIMS

In addition to the existing documentary requirements in filing of cataract claims, the approved pre-cataract surgery authorization request and a certified true copy of PAO endorsement shall be attached to facilitate the processing.

1. The IHCP shall print the approved CPSA request and attach a copy when filing a claim.
2. The printed copy must be duly signed by the following:
   1. The patient/member certifying the correctness of the information provided by the IHCP. Under special circumstances, the thumb mark shall be considered.
   2. The attending eye surgeon or the head of the Department of Ophthalmology (or its equivalent) attesting the veracity of the information provided.
3. In case the procedure was conducted by professionals-on-training (i.e., resident) and are not yet accredited with PhilHealth, only the following accredited professionals shall sign the claim form:
   1. Medical Director/Medical Center Chief/Chief of Hospital/Hospital Administrator
   2. Chairperson of the Department of Ophthalmology

V. REPEALING CLAUSE

All other issuances inconsistent herein are hereby revised, modified, or repealed accordingly.

VI. EFFECTIVITY

Requests for cataract pre-surgery authorization shall be accepted immediately for cataract surgeries to be performed starting June 17, 2013. All claims for cataract surgeries filed by accredited IHCPs prior to June 17, 2013 shall be processed with or without approved pre-authorization.

(SGD.) ENRIQUE T. ONA, MD
Secretary of Health/Chairman of the Board and
OIC-President and CEO