EFFECTIVE October 29, 2017, members of the Philippine Health Insurance Corporation (PhilHealth) who are admitted for community-acquired pneumonia (CAP), acute gastro-enteritis (AGE) and urinary tract infection (UTI) will no longer contend with the minimum length-of-stay (LOS) in accredited facilities to avail themselves of their social health insurance benefits.
Through PhilHealth Board Resolution No. 2215 series of 2017 and PhilHealth Circular No. 2017-0028, the LOS as requirement for the three (3) medical conditions have been removed as basis for reimbursing claims. The policy applies to inpatient claims of members and their qualified dependents admitted in accredited health care institutions nationwide.
Dr. Celestina Ma. Jude P. de la Serna, PhilHealth Interim/Officer-in-charge, President and CEO said that the “PhilHealth Board decided to lift the LOS due to reports that members were made to stay in the hospital longer than necessary so that they can avail themselves of the benefits.”
Instead, claims for reimbursement for CAP, AGE, and UTI will be subjected to pre-payment medical review, “and the documentary requirements for these cases shall be requested before payment of claims,” de la Serna stated.
Claims for these conditions, including sepsis, must have the certified true copy of complete clinical chart of patients which indicates history of present illness, course in the ward, vital signs monitoring, doctor’s orders sheet, nurses’ notes, laboratory and imaging results, among others. Claims without these documents will be returned to the health care institution for compliance.
Under the All Case Rates provider payment mechanism, PhilHealth pays P15,000 for moderate risk pneumonia, P32,000 for high risk pneumonia, P6,000 for AGE and coverage for UTI ranges from P6,800 for infection of other parts of urinary tract in pregnancy, P7,500 for UTI for unspecified site; P10,600 for UTI following delivery; and P12,700 for neonatal UTI. (Amelita L. Buted)
(Reference: Dr. Israel Francis A. Pargas, Head Executive Assistant and Concurrent OIC-Vice President for Corporate Affairs Group, Tel. 0917-8089399)