ALL CASE RATES
POLICY NO. 3
PhilHealth Circular No. 9 s. 2014
• ACR POLICY NO. 3 --- ADDITIONAL
LIST OF MEDICAL CONDITIONS FOR
HOSPITALS, NEW RATES FOR
SELECTED CASE RATES IN
PRIMARY CARE FACILITIES–
INFIRMARIES/DISPENSARIES, AND
CLARIFICATION OF EXISTING
RULES ON ALL CASE RATES
SPECIFIC GUIDELINES
Primary Care Facility (PCF) Rates
1. As contained in PhilHealth Circular (PC) 14,
s. 2013 and PC 35, s. 2013, rates for the
following six (6) case rates shall be paid at
70% of the rates stipulated in PC 35, s. 2013
for admissions from January 1, 2014
onwards in primary care facilities–
infirmaries/dispensaries:
Table 1. New Rates for Selected Case Rates in Primary Care
Facilities–Infirmaries/Dispensaries
Group
Old Case Rate
New Case Rate
i. Dengue Fever
10,000
7,000
ii. Pneumonia Moderate Risk
15,000
10,500
iii. Hypertensive
Emergency/Urgency
iv. Acute Gastroenteritis
9,000
6,300
6,000
4,200
v. Asthma in Acute
Exacerbation
vi. Typhoid Fever
9,000
6,300
10,000
7,000
PCF cont...
2. Annex 5 of PC 35, s. 2013 is hereby amended.
The complete list of medical case rates for PCF–
infirmaries/dispensaries is in Annex 1 of this
Circular.
3. Annex 6 of PC 35, s. 2013, List of Procedure
Case Rates for Primary Care Facilities –
Infirmaries/Dispensaries shall still be used as
basis for reimbursement of claims for procedure
case rates in PCF–infirmaries/dispensaries.
SPECIFIC GUIDELINES
Laterality of Procedures
1. An additional character shall no longer be
required for Relative Value Scale (RVS) codes of
cataract package procedures (RVS 66983,
66984 and 66987). Instead, the laterality of the
procedure shall be indicated by checking the
appropriate box in the laterality column of item 7
of Claim Form 2.
Laterality of Procedures
2. However, an additional character shall still be
required for the ICD 10 codes for cataract cases as
provided in PC 17, s. 2013.
SPECIFIC GUIDELINES
Case Rate Code
• Clarification on item ii of Part IV.I.1.d. of PC 35, s. 2013:
Instead of indicating the case rate codes as stated in the
aforementioned Circular, the referral (receiving) hospital
shall indicate the appropriate ICD 10 or RVS code/s in
the first and second (if applicable) case rate field/s in
Claim Form 2 (Part II, item 9).
• There shall be no instance where the case rate codes
are to be used in any of the claims. Only the appropriate
ICD 10, RVS or package codes are required for
reimbursement.
SPECIFIC GUIDELINES
Addendum to List of Medical Case Rates
(Annex 1 of PC 35, s. 2013)
 These case rates shall be available as
first case rate only and reimbursable
among all levels of hospitals.
 complete list in Table 2 of this circular
(Additional List of Medical Case Rates)
Table 2. Additional List of Medical Case Rates (Annex 1 of PC 35,
s. 2013)
FIRST CASE RATE
Health
ICD Code
Description
Profession
Care
Case Rate
al Fee
Institution
Fee
Group: DIABETES MELLITUS WITH COMPLICATIONS OTHER THAN COMA
AND KETOSIS
Insulin-dependent diabetes
mellitus with renal
E10.2+
complications; Glomerular
12,600
3,780
8,820
N08.3*
disorders in diabetes
mellitus
SPECIFIC GUIDELINES
Extension of Deadline
Return to sender (RTS) of claims for
correction/revision/completion shall
be allowed for claims with admission
dates on or before June 30, 2014.
SPECIFIC GUIDELINES
Resuscitation Package
• RA 10606, claims for confinements of less than
24 hours shall be compensated
– if the patient expired even if beyond the
service capability of the HCI.
– the HCI shall be reimbursed a fixed rate of
4,000 pesos with HCI fee and PF computed at
70% and 30% respectively.
Resuscitation Package, cont…
• For purely medical cases and cases where
a procedure has been started but not
completed,
– the HCI shall utilize the code P00000 as the
first case rate code
– the complete and final diagnosis/es shall still
be reflected in item 7 of CF 2.
– For cases where a procedure was completed or where
confinement is more than 24 hours, existing rules shall still apply.
Resuscitation Package, cont…
• P00000 shall be available for all health
care institutions.
• Along with the usual requirements for filing
of claims, the HCI shall also provide proof
that resuscitative measures were done to
the patient in the form of a certified true
copy of the doctor’s and nurse’s notes.
Resuscitation Package, cont…
• P00000 cannot be used as a second case
rate. Also, second case rate may not be
claimed along with code P00000.
• subject to post-audit monitoring and
evaluation.
SPECIFIC GUIDELINES
The time of death shall be the
basis of the time of discharge
in determining the number of
confinement days.
SPECIFIC GUIDELINES
Chemotherapy
Only one (1) cycle of chemotherapy
shall be claimed in the claim form 2.
The HCI shall follow the guidelines on
chemotherapy found in Annex 11 of
PC 35 s. 2013.
SPECIFIC GUIDELINES
Photocopy of records of anesthesia and
surgical or operative techniques shall
be accepted in lieu of original or
certified true copy. Records of
anesthesia shall be required for the
management of all general and spinal
anesthesia.
SPECIFIC GUIDELINES
Special Consideration for Direct
Filing of Claims for Selected Cases
• Denied
• Not Filed
and Adjustment of Reimbursement
Special considerations, cont…
1. Direct filing of members shall be allowed for
all medical conditions listed in Table 2-Additional
List of Medical Case Rates (Annex 1 of PC 35 s.
2013) for all hospital admissions starting
January 1, 2014 until March 20, 2014. Starting
March 21, 2014, direct filing shall no longer be
allowed. Hence, the correct case rate amount
shall be deducted by the HCI prior to the
discharge of the patient.
Special considerations, cont…
2. Direct filing shall also be allowed for
admissions starting January 1, 2014 to
March 20, 2014 for confinements of less
than 24 hours where the patient expired
including confinements beyond service
capability. The member shall be
reimbursed a fixed rate of 4,000 pesos.
Special considerations, cont…
3. The case rate amounts for the
following medical conditions are
adjusted in primary care facilities–
infirmaries/dispensaries:
Case rates adjusted in PCF – Infirmaries/Dispensaries
1
2
3
4
Description
Measles complicated by otitis media; Otitis
media in viral diseases classified elsewhere
Measles with intestinal complications
From
To
2,800
5,460
2,800
6,650
Measles without complications
2,800
5,390
Hyperosmolality and hypernatraemia; Sodium
[Na] excess; Sodium [Na] overload
2,800
5,950
Patients who were admitted in primary care facilities for these four
medical conditions shall be allowed to claim for adjustment of
reimbursement. Requirements for filing of adjustment for
reimbursement include official receipts or its equivalent and a
completely filled-out adjustment form.
Special considerations, cont…
• The complete breakdown of PCF case
rates is found in Annex 1 - Revised Annex
5 of PC 35 s. 2013 of this Circular.
• All claims for special consideration shall
be processed subject to existing rules of
the Corporation.
SPECIFIC GUIDELINES
Single Period of Confinement (SPC)
The reckoning for the SPC shall be
refreshed for all admissions starting
January 1, 2014.
e. g. hospital claim for pneumonia MR
admitted on January 1, 2014 shall be paid
regardless of history of previous
admissions.
SPECIFIC GUIDELINES
The Newborn Care Package (NCP) shall be
included in the list of case rates allowed as
second case rate for hospitals with
admissions starting January 1, 2014.
SECOND CASE RATE
RVS Code
99432
Description
Normal Newborn Care
Package
Case Rate
1,750
Professional
Fee
500
Health Care
Institution
Fee
1,250
EFFECTIVITY
• This Circular shall take effect for all
admissions starting January 1, 2014. It
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.
For comments, suggestions,
questions:
Email us at
[email protected]