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In line with efforts to make the National Health Insurance Programs benefits more responsive, the following are additional conditions and guidelines for entitlement to PhilHealth benefits:

A. Effect of Change in Accreditation Status of Facility

In case the hospital’s accreditation is expired, re-accredited or initial accreditation was given anytime within the confinement period, the claim for benefit items such as drugs and medicines, x-ray, laboratory and others, operating room and professional fees shall be paid accordingly. However, reimbursement for room and board charges shall be limited only to the actual confinement period when the accreditation of the facility is still in effect, that is, before its expiration, initialization or after its renewal.

B. Effect of Membership and Dependency

In case a patient has a change in membership status during his/her confinement period such as: 

1. Patient reaches the age of sixty (60) years old and thus qualifies as a dependent;
2. Patient becomes an Overseas Filipino Worker (OFW) member or his membership expires; or
3. Patient’s membership to the Sponsored Program takes effect or ended during his confinement, the claims for benefit items for drugs and medicines, x-ray, laboratory and others, operating room and professional fees shall be paid accordingly. However, reimbursement for room and board charges shall be limited only to the actual confinement period when the membership becomes effective.

In case the principal member expires/dies, his/her membership privileges end. Hence, there shall be no survivorship entitlement to benefit. His/her declared dependents cannot anymore use the deceased membership eligibility.

C. Out-on-Pass

For PhilHealth purposes, out-on-pass shall be considered for payment following all the conditions listed below:

1. When patient is referred to other facility for procedures which are not available in the admitting hospital.
2. Patient returns to the referring/admitting institution within the day.
3. Patient is not admitted in the referred facility.

Other than the abovementioned conditions, out on pass order shall be considered date of discharge; hence, computation of room and board for reimbursement shall only be up to the said date.

D. Non-availability of Room

For patients admitted but must stay in the emergency room (ER) or within the hospital premises pending the availability of rooms, the following shall apply:

1. If the patient stayed in the hospital for less than 24 hours, the patient shall not be covered except when patient is transferred to another facility, the case is considered emergency and if the patient dies. This is in accordance with the Revised Implementing Rules and Regulations of R.A. 7875, as amended by R.A. 9241 and PhilHealth circular No. 7, s-1996.
2. If the patient stayed for more than 24 hours, the patient’s stay may be filed for a reimbursement. The room and board rate shall be compensated based on the benefit allowances according to the hospital category and case type of the disease. This, however shall still require justification for over bed capacity as licensed/accredited prior to payment. Non-submission of requirements shall cause denial of claims.

The preceding guidelines are in accordance and without prejudice to the Revised Implementing Rules and Regulations of R.A. 7875, as amended by R.A. 9241, prohibiting the unjustified admission beyond accredited bed capacity of an accredited health care provider.

All accredited Health Care Providers are hereby enjoined to abide with the abovementioned rules and conditions.

All other issuances inconsistent herewith are hereby repealed or modified accordingly.

This Circular shall apply to all claims with admissions dates effective January 1, 2011.

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