Supreme Court E-Library
Information At Your Fingertips

Please be guided by the following clarifications for outpatient dialysis procedures performed in PhilHealth accredited facilities:

I. General Rules:

1. Based on the Manual of Surgical and other Procedures, it is reiterated that PhilHealth covers the following procedures in accredited hospitals and freestanding dialysis centers (FDCs):

                                                 

CODE	DESCRIPTIVE TERMS	RVU
90935	Hemodialysis procedure	10
90945	Dialysis procedure other than hemodialysis	10
	(e.g. peritoneal, hemofiltration)

2. The maximum amount of benefits for the abovementioned procedures shall be based on the following table:

                                                                                                         

BENEFIT*	SECONDARY	TERTIARY
	HOSPITALS/FDCS	HOSPITAL
Drugs and Medicines	8,000 pesos*	16,000 pesos*
X-ray, Lab and Supplies	4,000 pesos*	14,000 pesos*
Dialysis Room Fee	670 pesos/sessions	1,060/session;
	2,160 pesos*	3,490 pesos*
Professional Fee	40 pesos/RVU; maximum of 16,000 pesos*
*Per single period of confinement

3. The rule on 45-day allowance per year applies to dialysis benefits, and for this reason, benefits availment including dialysis for each member/patient shall not exceed forty-five (45) days in a year.

4. Dialysis benefits are also covered by the rule on single period of confinement (SPC) where patients with repeat procedures with interval of less than ninety (90) days within a calendar year shall not be given a new benefit allowance and can only avail of the unused benefit.

5. Patient shall only be given a new benefit after a 90-day period from initial dialysis.

Sample Applications of SPC on Dialysis Room benefit in FDC; 2 dialysis sessions/

                                                                                                         

BENEFIT FDCS	UNUSED BENEFIT	PHILHEALTH PAYMENT
Dialysis Room Fee	2,160 pesos per single period of confinement
Session 1	2,160 pesos	670 pesos
Session 2	1,490 pesos	670 pesos
Session 3	820 pesos	670 pesos
Session 4	150 pesos	150 pesos
Session 5 to session 26	0	0
90 days after Session 1	new 2,160 pesos per single period of confinement
Session 27	2,160 pesos	670 pesos
Session 28	1,490 pesos	670 pesos

II. Benefit Items:

1. Room and board charges are not covered in outpatient dialysis procedures performed in hospitals and FDCs
2. Only dialysis solutions included in the latest edition of the Philippine National Drug Formulary (PNDF) shall be reimbursed by PhilHealth and will be charged against the benefit for drugs and medicines.
3. Claims for drugs and medicines used that are considered medically necessary (e.g. anti-hypertensive, anti-diabetics, and erythropoietin) may be reimbursed.
4. Only laboratory procedures and supplies considered necessary shall be covered.
5. Claims for drugs, supplies and laboratory procedures bought by members shall be reimbursed if there are still unused benefits provided they are used on the day of dialysis session and is supported by official receipts.
6. All official receipts for drugs, supplies and laboratory procedures dated thirty (30) days prior to date of claimed sessions shall be reimbursed within the allowable benefit limit.
7. The use of dialysis room shall be paid as Dialysis Room/Operating Room Fee based on Relative Value Unit (RVU) of the procedure. Benefits for dialysis room fee are subject to the rule on single period of confinement.

A. Hemodialysis

1. Each session of hemodialysis shall be charged 1 day against the 45-day room and board allowance.
2. Payment for professional fee shall be 400 pesos/session based on the RVU of the procedure (90935) and is also subject to the rule on single period confinement.
3. Payment for dialysis room fee is Php 670 per session for secondary hospitals/FDC and Php 1,060 per session for tertiary hospitals.

B. Peritoneal Dialysis

1. Any modalities of peritoneal dialysis e.g. automated or continuous ambulatory peritoneal dialysis (CAPD) may be claimed from PhilHealth by patients registered at accredited peritoneal dialysis centers and hospitals.
2. All PD exchanges performed per day shall be charged only 1 day against 45-day allowance.
3. Claims for peritoneal dialysis include payment for dialysis solutions, sup- plies, laboratory, use of dialysis facility and professional fee subject to benefit limits of one-day admission and the rule on single period of confinement.
4. A maximum of twenty (20) liters of PD solution is allowed per day subject to the rule on single period of confinement.
5. Payment for dialysis room fee is Php 670/day for secondary hospitals/ FDCs and Php 1,060/day for tertiary hospitals regardless on the number of exchanges.
6. Payment for dialysis room fee covers use of facility for training of patients and relatives, nutritional advice, dressing changes, flushing of catheter and use of cycler machine.
7. Payment for professional fee shall be 400 pesos/day based on the RVU of the procedure (90945) and this fee covers kidney disease-related management. Professional fee for CAPD shall be paid to the attending physician.

These modifications shall be applied to all hemodialysis and peritoneal dialysis sessions starting April 1, 2006.

III. Claims Filing

1. The following documents must be submitted for claims for dialysis:

a. PhilHealth Claim Form 1 to be filled out by member and employer
b. PhilHealth Claim Form 2 to be filled out by providers of dialysis
c. Proof of membership/contribution as prescribed by the Corporation
d. Other supporting documents as may be required by the Corporation

2. Claims for multiple sessions in one Form 2 may be filed.
3. All claims for dialysis must be filed within 60 days from dates of dialysis service.

IV. Accreditation

1. All currently accredited secondary and tertiary hospitals are not required to have a separate accreditation for providing dialysis services.
2. Freestanding dialysis clinics (FDCs) are required to comply with all accreditation requirements set by PhilHealth Circular No. 20 of 2005.
3. However, FDCs that offer only PD modality shall only be required to comply with the modified requirements attached in this Circular (see Annex A^* – Requirements for FDCs Performing Peritoneal Dialysis)

V. Reporting

1. All accredited facilities (hospital-based dialysis clinics and FDCs) are required to participate in the Philippine Renal Disease Registry (PRDR).
2. All new patients on chronic dialysis therapy should be registered by all accredited dialysis clinics to the PRDR.
3. All PhilHealth-accredited dialysis clinics are required to regularly submit to PRDR the following forms monthly:

a. Registry forms
b. PD prescription for PD patients

4. Noncompliance to reporting with PRDR shall be appropriately dealt with during renewal of accreditation.

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

Adopted: 22 Feb. 2006

(SGD.) LORNA O. FAJARDO
Officer-in-Charge
Office of the President and CEO

^*Text Available at Office of the National Administrative Register, U.P. Law Complex, Diliman, Quezon City