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In compliance to PhilHealth’s objective of providing its members with a responsive benefit, the Corporation shall implement benefit for members/dependents with illness that require blood transfusion in an outpatient basis.

I. General Rules:

1. This benefit shall cover blood transfusion (BT) procedures in cases that do not require confinement.
   
   
2. Only PhilHealth accredited hospitals (Levels 1, 2, 3 and 4) shall be the qualified facilities for this outpatient benefit.
   
   
3. Blood transfusion shall be paid through “fee-for-service scheme” (FFS) and benefit shall be based on case type B as specified in PhilHealth Circular #18 s. 2009.

II.    Benefits:

1. The Relative Value Unit (RVU) for outpatient BT procedure shall be based on its analogous procedure (therapeutic aphaeresis). Claims for blood transfusion shall be coded as follows:
   
   

   ______________________________________________________________________________________
   RVS	PROCEDURE	RVU
   ______________________________________________________________________________________
   36430	Outpatient transfusion of blood or blood products; one or more units	10
   ______________________________________________________________________________________

   
   
   
2. The maximum amount of benefit shall be as follows:
   
   

   ______________________________________________________________________________________
   BENEFIT ITEM	LEVEL 1 HOSPITALS	LEVEL 2 HOSPITALS	LEVEL 3 & 4 HOSPITALS
   ______________________________________________________________________________________
   Drugs & Medicine	9,000	11,200	14,000
   X-ray, Lab & Others	5,000	7,350	10,500
   Operating Room	500	750	1,200
   ______________________________________________________________________________________

   
   
   
3. Rule of single period of confinement (SPC) shall be implemented in this benefit where patients with repeat procedures with interval of less than 90 days within a calendar year shall not be given a new benefit allowance and can only avail of the unused benefit. This rule applies to drugs & medicine, laboratory and supplies.
   
   
4. All medically-necessary drugs and medicines used during blood transfusion shall be reimbursed, example: folic acid, iron, epoetin.
   
   
5. Blood donor screening tests and other serologic/hematologic procedures such as ABO/ Rh blood typing and cross matching shall be compensable under x-ray, laboratory and others.
   
   
6. Professional fee shall be paid to the attending physician who rendered BT procedure based on RVU 10.
   
   
7. Room and board charges are not covered by this benefit. However, one (1) day of the 45-day allowance per year shall be deducted for each day of benefit availment.
   
   
8. There shall be no additional PF payment for blood transfusion done during confinement or other PhilHealth-covered procedures and services such as during hemodialysis.

III. Claims Filing:

1. The following documents must be submitted:
   
   
1. PhilHealth Claim Form 1 to be filled out by the member and/or employer
2. PhilHealth Claim Form 2 to be filled out by providers
3. Official receipts and statement of account (SoA)
4. Other documents required by PhilHealth such as Member Data Record (MDR), proof of premium payment (MI-5), PhilHealth ID.
   
   
2. All claims must be filed within 60 days from the day of outpatient BT procedure.

IV. Eligibility Rules for Members and Dependents:

1. Employed and Individually Paying Program (IPP) members including KASAPI must have at least three (3) months of contribution within the immediate six (6) months prior to the month of availment.
   
   
2. Sponsored and Overseas Workers Program members are entitled to this benefit if the date of availment falls within the validity period of their membership as stated in the ID card.
   
   
3. Lifetime members shall be entitled to avail of the benefit upon presentation of PhilHealth ID.

This Circular shall take effect for outpatient procedures performed starting February 1, 2010.

All other rules and guidelines not contrary hereto shall remain in full force and effect.

Adopted: 21 Dec. 2009

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