PhilHealth


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individually payingfrequently asked questions

Benefits and availment concerns

1. I am a new member. When will I become eligible to avail of PhilHealth benefits?

For one to become eligible for the benefits, payment of at least three (3) months within the immediate six (6) months prior to the month of confinement shall be required. However, payment of at least nine months within the last 12 months shall be asked of Individually Paying Members availing of the following procedures/packages:

However, beginning July 2011 (as per PhilHealth Circular #25, s-2010), Individually Paying Members and Employed Members will now be required to have at least nine (9) months contributions within twelve (12) months prior to the month of availment for all confinements including availment of outpatient benefits.

2. In case my qualified dependent is not included in the Member Data Record (MDR) and he/she gets sick, what applicable document should I submit?

If your dependent gets hospitalized and he/she is not listed in your MDR yet, you may submit a clear copy of the following:

3. Will PhilHealth reimburse my hospitalization in a foreign country even if the hospital is not accredited by PhilHealth?

Overseas confinements of PhilHealth members, regardless of their membership category, and their dependents are still covered and shall be paid based on Level 3 Hospital benefit rates.

4. What is a "single period of confinement"?

It refers to a confinement or series of confinements for the same illness with intervals of not more than 90 days. In such cases, members are not entitled to another set of benefits/allowances until after 90 days. They can only avail of the unused portion of their benefits and their room and board allowance until their 45-day allowance in a year is exhausted. Each member is entitled to a maximum of 45 days for room and board allowance per calendar year and another 45 days to be shared by all of the dependents.

However, members can avail themselves of a new set of benefits if succeeding confinements are of different illnesses or conditions.

5. What if I am not readily available to sign the PhilHealth Claim Form 1?

The following are allowed to sign the said form on your behalf:

Member Status Authorized person (in order of priority)
Member is married Legal spouse
Child 18 years old and above in the absence of spouse.
Parent (mother or father) in the absence
of spouse and child.
Member is single Parent (mother or father)
Member is orphaned Brother/sister/guardian
Other individuals as duly Authorized Representative

Clearly state in the form the reason for signing on behalf of the member, or a certification (on a separate sheet of paper) may also may be issued to this effect, with the full name, complete address and contact number/s of the authorized signatory also indicated.

Provide a photocopy of the authorized signatory's identification card (ID) and/or proof establishing his/her relationship to the member.

6. Are emergency cases covered?

Emergency cases as defined by PhilHealth shall be paid.

7. What if the hospital is not accredited? Will I still get paid?

Claims of members confined in non-accredited hospitals shall not be compensated unless all of the following conditions are met:

8. How will I know if I was deducted the correct amount of benefits?

Members are sent a benefit payment notice or BPN to report the actual payments made by PhilHealth relative to their confinement/availment. The BPN is sent to the address indicated by the member in their claim form.

Should there be discrepancies in the payments and the actual benefits deducted from your hospital and doctors' bills, you may present your BPN, your copy of the hospital's Statement of Account/Billing Statement, and Official Receipts to your health care provider.

9. How long does it take to process a PhilHealth claim?

All claims with complete and properly accomplished documents except those under investigation shall be processed and paid within 60 calendar days from receipt thereof.