Uepublic of lite l'ltiliJIJiiues
PHILIPPINE HEALTH INSURANCE CORPORATION
C itysta lc Ccmrc B ldg .. 70\1 Shaw 13o uil.:vnrd, l'asig Cily
I h:allhlinc 441 -7444 u·u·u·.t•hi/l,•a/lh.gm·.t•h
Phill lealtll Circular
No. Q() (
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J1.4 '
TO
SUBJ ECT
ALL ACCREDITED HEALTH CARE PROVIDERS,
P HILHEALTH MEMBERS, PHILHEALTI-l REGIONAL
OFFICES, CLAIMS D E PARTMENT, AND ALL OFFICES
CONCE RNE D
Only S urgical Procedures During J.\lledical Mis sions Sponsore d
by Government Funds in Accredited Govcmmcnt Facilities arc
Compensable.
17or th~: purpose.: of tlu~ circ uln r, surgi cal/ m c.:clic:d mi ~sion is ddin ed as an o utreach progra,111
fo r huma nitarian no n -p rofi t purpn~cs that pro,·idc tTH:: c.lical antl/or s urg ical servic~.:s
(including m cdi ci 11t:s, ancillary proc~:du res, ~urgic al in tc rven tio m;, and prn rcssio nal sen ·iccs)
a t 11 0 co~t tu peo ple who have.: limit:l·d o r no m eans to pay (Sources: Phj iJ k alth Circular No.
19, ~.2007, 1)01-1 ,\() No. l 7<J :-;.200 I, The Philippine .\ cadcm y o f O phthalmo logy, Inc.)
Based on th ~: abm-c m l·nJioned ddi1Jit.i o n , it is prl'~umed that all the scn·iccs p ro\' icled in the
nussion an; a lre:1dy con.: rcd a nd p aid for by the s po nso r/s o r clo no r/s. 1\ s such, Ph.illl ealth
shall c.li~po~e of claim s aris ing fro m s urgi cal/medicalmi ~~ions as follows:
1.
C laims in volv ing surgical proced u res, including but no t Lim.it·cd to ca tara ct extractio n:>
(e.g., Phacoemubi fica 1in n), cleFt pal at<:: (e.g., C heilo plas ty), ingrown toenail (e.g.,
exciSIOn o f na il), or circum c isio n s, co nducted in private facil ities during
m edi ca l /~ urgicalmissi o n s ~h:1llnot be compe nsated.
2.
C la i m~ i11\"nh-ing ~u rgic:!l p roccdu rl'~ d o ne.: J u ring m edical mis~ions ~pon~ored b y the
Natiollal (;o,Trn m c.:nt (N( ;) or Local GoYernm ent L1tut (I .GU) cond uc ted in any
Phill lcalth -acc rc.:di ted govl' rn mc nt fac ili1 y (i.l·.; ;\tn bulato ry S u rgical C are CLillic:>,
J ,c,·t·l II , Ill and I\ ' ho~pi t::d s) shall be compe1Jsa tcd provided tha t the professio nal
fees arc poolc.:d ro r Ji~ tribu Li o n to all facility perso nnel an d su bjec t to provi ~ions
stipul:! tcd in Rule V lll (Pa ym en t of Claim~) Section 7 of lmplcmcnt.ing Rule~ a nd
R~:gul a tin ns of IC\ 7H75, as ~l ll\Ct1<kd b y 1{.,\ 924 1.
, \11 d octors or ftm•ih'11 natio na liti l:s \\"hn participntcd a nd /o r p erfo rmed surgeri c.:s in a surgical
tnl:di cal mi ssio n sho uld not ti le, by thL·m seln;s or t h rough other doctors, claims for
reiml)llr~l"lllL'n t or belll·lils fur !'hill kalth tnembl:r:> o r depe ndents. O the rw ise, they shall bl'
repo rtl·d Lu 1hl' Dcparrmcnt of J-1 cal th (D O r-I) and Professio nal l~cgu la tory Comm issio 11
(I'RC) for approp ria te ac1 io n.
'I
Philllea ll"il sha ll rt:gularly conduct utilization review, validate admissions and evaluate the
a\·ailmcnt of benefits in accredited facilities. This shall be done in o rder to m onitor the
(j Ua li ty of care and to ensure the prop er implemen tatio n o f issuances/policies governing
missions in volving P h il! lcalth m embers/ patients as well as other pertinent rules and
regula tions of the Corpo ra ti on.
D e tt:ction of cl:l ims und er " m.edical miss ion" o r pre tex t of such mission shall cause
w it hholding of reimbursement subject tn further nliidaLio n. Clni ms co nlirmed/valitlated to
be part of a m eclicnl missio n shall bt: tlcnied, whik reirnb urscmeuts for o ther previously paid
claims cove red by the samt: medical mission sho uld b e refunded by the health care provider
to the Corp ora tio n o r c harged to the fu ture claims of the provider norwithstanding legal
sanctions. C laims confirmed to ha,·e no t been done u nder a " m edical nl..issio n" shall be
p rocessed accordingly.
A ll othe r iss ua nces inco 11sistent hert:wilh are hereby rt:p caled and m o tl ified accordi ngly.
This circular sha ll be cffecti,·e fiftee n ( IS) days from th e date of publ icadon in the official
gazette and :-~ny ncws}XIJKI"S of gc nL·ral circula ti o n .
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