(NAR) VOL. 20 NO.3 / JULY - SEPTEMBER 2009

[ PHIC PHILHEALTH CIRCULAR NO. 27, S. 2009, July 07, 2009 ]

ADDITIONAL RULES ON REIMBURSEMENT OF PROFESSIONAL FEES DESIGNATED FOR POOLING



Date Filed: 21 July 2009

Payment of professional fees (PF) of physicians in government or private training hospitals wherein the payment for professional fees are set aside for pooling with respect to PhilHealth Circular No. 9 s. 2009 shall be:

1) Even for PF designated for pooling, professionals who actually rendered the service should be the signatory in Part II of the Claim Form 2. The phrase “PAY TO DIRECTOR/ADMINISTRATOR/CHIEF” should be indicated in Item Numbers 19, 24 or 29 of Form 2. In such cases, computation of PFs shall be based on the accreditation category of the accredited physicians.

2) However, claims signed by Medical Director, Hospital Administrator (physician) , Chief of Clinic or Department Heads in behalf of salaried physicians in government or private training hospitals wherein the payment for professional fee is set aside for pooling may be compensated.

a. Daily visit shall be based on rate for non-specialists. While PCF of 40 shall be used in the computation of professional fee regardless of the accreditation category of the Medical Director, Administrator (physician), Chief of Clinics or Department Heads.

b. Exception to the above rule is when the Medical Director, Administrator (physician), Chief of Clinics or Department Heads is also the provider of the service as reflected in the attached document (e.g., Operative Record, OB sheet, endoscopy report). In such case, computation of PF shall be based on accreditation category of Medical Director, Administrator (physician), Chief of Clinics or Department Heads.

3) It is reiterated that the following procedures and services are limited to the specified subclass of doctors:


Table 1: List of Procedures and Services that are Limited to Specific Categories of Doctors

Procedures and Services
Claims Code Group
Diplomate or Fellow

1) Preoperative
1201
Philippine Academy of Family Physicians



     inpatient
1202
Philippine College of Physicians



     consultation
1203
Philippine Pediatric Society



(Code 99256 -99360)
1210
Philippine Neurological Association

2) Pathology services



(Code 88174-88332)
1206
Philippine Society of Pathologist

3) Radiology services



(Code 70010-77789 except 75757)
1207
Philippine College of Radiology

4) Fluorescent angiography



(Code 75757)
1304
Philippine Academy of Ophthalmology



a. Claims for PF for the abovementioned services provided by doctors who are not authorized to provide such services (based on Claims Code Group) shall be disallowed.

b. However, claims signed by Medical Director, Administrator (physician), Chief of Clinics or Department Heads in behalf of salaried physicians in government or private training hospitals wherein the payment for professional fee is set aside for pooling may be compensated.

i. PCF 40 shall be used in the computation of PF.

ii. However, PCF 56 shall be used if the Medical Director, Administrator or Chief of Clinics actually rendered the service and is in compliance with Table 1 of this Circular.

For example, the Medical Director is a diplomate of the Philippine College of Physicians (Claims Code Group 1202) and provided Code 99256. In this case, PCF 56 shall be used in the computation of PF.

c. If an accredited doctor other than the Medical Director signed Part II of PhilHealth Claim Form 2, payment shall be in compliance with Table 1 of this Circular.

i. PCF 56 shall be used for the computation of PF for pooling if the doctor is allowed to provide the service listed in Table 1, e.g., Doctor with Claims Code Group 1207 for brachytherapy (77761).

ii. Claims for PF shall be denied if the accreditation category of the doctor who signed Form 2 is not in accordance with Table 1 of this Circular, e.g., Doctor with Claims Code Group 1202 for brachytheraphy (77761).

4) Doctors providing surgery or anesthesia services who are classified as general practitioners (GPs; Group 1) shall only be paid based on maximum of 80 RVU for surgeries and RVU-linked services on secondary (Level 2) and tertiary (Levels 3 & 4) hospitals, i.e., 3,200 pesos for surgeries/RVU services and 1,280 pesos for anesthesia services. Exempted from this rule are:

a. Services provided by salaried physicians;
i. done in government hospitals or private training hospitals; and,

ii. payment for professional fee is allocated for pooling

b. Procedures performed by GPs in PhilHealth-designated shortage areas. In such cases, computation of PF shall be based on PCF for Group 1 doctors.

This Circular shall take effect for all claims with admission dates starting April 5, 2009.

All other provisions of previous issuances remain in full force and effect.

Please be guided accordingly.

Adopted: 07 July 2009

(SGD.) DR. REY B. AQUINO
President and CEO


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