(NAR) VOL. 24 NO. 4 / OCTOBER - DECEMBER 2013
I. OBJECTIVES:
One of the Guiding Principles and Objectives of R.A. 7875, as
amended by the National Health Insurance Act of 2013 (R.A. 10606),
states that “the Government shall provide public health services for all
groups” this was further explicitly clarified to include “displaced
communities and communities in environmentally endangered areas.”
The recent fortuitous events that visited our country (or
events described as an “act of God” like floods or typhoons; or an “act
of man” such as rebellion, insurgencies, and wars) bear witness to the
inherent powers of the same to effect displacement of communities in
several endangered areas.
Thus, pursuant to PhilHealth Board Resolution No. 1848. s.
2013, the Corporation hereby issues the following guidelines that shall
be applied to all those affected by fortuitous events. This is
consistent with the mandate of the Corporation to provide responsive
health care benefits to its members at all times, more so during a
fortuitous event where help is needed the most.
II. COVERAGE
This Circular shall cover PhilHealth claims of those affected by fortuitous event that covers any of the following conditions:
- PhilHealth and non-PhilHealth members including dependents;
- PhilHealth accredited or non-PhilHealth Accredited Health Care
Institutions (HCls) either privately-owned or government-owned. For
non-PhilHealth accredited HCIs it must be DOH licensed or certified by a
certifying body recognized by PhilHealth;
- PhilHealth accredited or non-PhilHealth accredited health care professionals duly licensed by PRC;
- Claims for treatment done as an outpatient or inpatient relative
to the direct and indirect effects of the fortuitous event within the
HCI or in an improvised/satellite facility.
- Transferred from or managed by health care personnel from
accredited facilities in an evacuation area, or improvised health care
facilities.
III. GENERAL RULES
- Declaration of state of calamity or state of emergency and
analogous certification depending on the fortuitous event are required
for the application of this Circular. In the absence of such documents,
justification letters from the authorized government agencies may be
submitted subject to validation by the concerned PhilHealth Regional
Office (PRO).
- Health care institutions affected by the fortuitous event shall
send a letter request for application of this Circular duly signed by
the Medical Director/Chief of Hospital or any authorized representative
to the concerned PRO. As much as possible include in the letter:
- Description (or photos) of the effects of the fortuitous event.
- Explicitly mention if majority of the claims under the HCls’
custody were totally destroyed and can no longer be recovered or
reconstructed for the same to be able to avail of the reimbursement
option stipulated in Special Privilege No. 8 contained in this circular.
- The PRO shall undertake the following actions upon receipt of the request/s:
- Organize a validation team either composed of staff from
the concerned LHIO or from the PRO or both to validate the basis of such
request. Validation can be through document/news review or survey. The
survey shall be conducted only if the current situation posts no danger
to the PhilHealth personnel.
- Send the written request letter of the HCl along with the
post validation report, with recommendation, duly signed by all members
of the validation team, and the Regional Vice President and Area Vice
President containing the recommendation of the PRO to the President and
CEO for approval. The recommendation shall include the effectivity date
of application of this Circular and special privileges deemed fit for
the situation.
- The PRO and the HCI shall be informed of the decision of the President and CEO through a written communication.
- Should there be no other authority that has established the
specific date of the fortuitous event’s end, the concerned PRO shall
send a written communication to the PCEO, duly signed by the Regional
Vice President and Area Vice President, with regards to the specific end
date of application of special privileges. In turn, the Central Office
shall inform the PRO of the PCEO’s concurrence or denial of their
recommendation.
IV. MEMBERSHIP
- Existing membership rules relative to the qualified principal
member and dependents, amount of premium contribution,
enrolment/updating requirements remain in effect unless exemption is
provided by the Corporation.
- Patients shall be checked whether he/she is an existing PhilHealth member/dependent or not.
a. PhilHealth member/dependent
a.1 |
HCIs shall check for
eligibility to benefit entitlement that is paid premium contribution for
at least three (3) months within the six (6) months prior to first day
of availment, or |
a.2 |
If without qualifying contribution as
stated in a.1. and has the ability to pay for his/her own premium, the
member shall pay in full the required premium contribution for the
calendar year or the missed premium contribution/s plus the other
premiums to complete the calendar year to be paid at the nearest
PhilHealth Office pursuant to Section 39 of the IRR of R.A. 10606 |
a.3 |
Enrolment at Point of Care through
the Medical Social Welfare Officer of government HCIs who shall assess
patients with no capacity to pay the premium contribution. Patients with
no capacity to pay (indigents/critical poor) the premium contribution
shall be shouldered by the government HCI stipulated in the Joint Order
2013-0031: Enrolment of Critical Poor under the Sponsored Program of the
National Health Insurance Program at Point-Of-Care (POC) |
a.4 |
The above provision shall be
applicable to private HCIs who are willing to become an HCI sponsor for
the indigents/critical poor with expired membership validity |
b. Non-PhilHealth members
b.1 |
Non-PhilHealth members
with capacity to pay shall be instructed to pay in full the premium
contribution for the calendar year to the nearest PhilHealth Office. |
b.2 |
Non-PhilHealth members with no capacity to pay the premium contribution shall follow the provisions in item IV.2.(a.3-a.4). |
V. BENEFIT ENTITLEMENT
- Existing inpatient, outpatient and other packages.
- Emergency cases shall be given utmost priority during the period
of the fortuitous event. Elective procedures when performed during the
declared/specified period of a fortuitous event shall not be covered by
any of the special privileges except for the extension period for the
filing of the claim (Special Privilege No. 1)
- No Balance Billing (NBB) policy shall be in effect for all the
applicable cases. Private HCIs are highly encouraged to observe the NBB
policy during the period of the declared/specified period of a
fortuitous event.
- Reimbursement shall be based on the provider payment mechanism at the time of admission.
- Rules on direct filing except the special privileges and other applicable provisions shall still be in effect.
- PhilHealth benefit deduction upon discharge is mandatory. Direct
filing by members shall be allowed if treated in non-accredited HCls
and transfer is impossible/not feasible. The non-accredited HCI should
be duly licensed by DOH or certified by a body approved by PhilHealth.
VI. SPECIAL PRIVILEGES
- Submission of claims 120 calendar days from the date of discharge.
This shall also cover claims due for submission for discharges
covering the period sixty (60) calendar days before and until the day
prior to the actual date of the occurrence of the fortuitous event.
- Exemption from the forty five (45) day benefit limit and Single
Period of Confinement (SPC) for admissions directly or indirectly
related to the Fortuitous Event.
- Reimbursement for both referring and receiving Health Care Institution.
3.1 |
In instances where the
patient necessitates transfer both the referring and receiving HCI shall
file separate claims and shall both be reimbursed subject to the
current limits of the benefit schedule. |
3.2 |
This shall also be applicable to improvised/satellite facilities where patients are brought in for care. |
- Exemption to the less than 24 hour confinement rule.
These cases may be reimbursed based on the current rules of reimbursement.
- Priority in processing of claims
The HCI shall write/stamp on the right upper hand corner of the Claim Form 2 the words “affected by fortuitous event”
to facilitate the appropriate tagging of such claim in the system to
expedite the processing of claims by PRO/Branches within (30) calendar
days or less.
- Extension on the submission of the required/mandatory HCI reports.
- Extension of the accreditation validity and/or submission of application of health care providers.
- Reimbursement for destroyed claims
8.1 HCIs with destroyed claims that are due for submission to
PhilHealth shall have the option to choose the mode of payment of such
claims to be stated in the written request letter. The option could be
any of the following:
- Recovery or reconstruction of claims applications for submission/filing to PhilHealth or
- Payment of claims based on the average reimbursement per day
of the concerned HCI multiplied by the number of days covering the
period from the last submission /filing date up to the date specified by
the Corporation. Claims filed by HCIs on or before the date specified
by the Corporation which were included in the computation for the
payment of claims shall not be processed.
8.2 HCIs shall not be allowed to change the option once it has been approved by the Corporation.
- Extension of deadline of payment of premium contribution and/or
extension of the date of an existing coverage as prescribed by the
Corporation.
VII. MONITORING
The health care providers shall be subjected to the rules on
monitoring and evaluation of performance as provided for in PhilHealth
Circular 54, s.2012: Provider Engagement through Accreditation and
Contracting for Health Services (PEACHeS)
VIII. REPEALING CLAUSE
All provisions of previous issuances that are inconsistent with
any provisions of this Circular are hereby amended/modified/ or
repealed accordingly.
IX. SEPARABILITY CLAUSE
In the event that any part or provision of this Circular is
declared unauthorized or rendered invalid by any Court of Law or
competent authority, those provisions not affected by such declaration
shall remain valid and effective.
X. EFFECTIVITY
This Circular shall take effect for claims brought about by a
fortuitous event. This shall also cover valid claims of victims in areas
affected by Typhoon Maring, last August 2013; Typhoon Santi, last
September 2013; Typhoon Ramil, and the areas in the Visayas Region
affected by the earthquake that occurred on October 2013.
Further, this Circular shall be published in any newspaper of
general circulation and shall be deposited thereafter with the National
Administrative Register at the University of the Philippines Law Center.
(SGD) ALEXANDER A. PADILLA
President and CEO