Download Soria_PHA Cebu 2016 - Philippine Hospital Association

PHILHEALTH Updates
Outline
Benefits
Accreditation
Standards- policy statements
Z benefit updates
Policy updates:
SOA (PhilHealth Circular 2016-005)
Dialysis database (PhilHealth Circular 2016-007)
Annex 2 – List of procedure case rates (Revision
3.0) and supplementary guidelines for all case
rates (PhilHealth Circular No. 2016 – 0014)
Spectrum of PhilHealth Benefits
Acute Lymphocytic Leukemia
Early Breast Cancer
Prostate Cancer
Kidney Transplantation
Coronary Artery Bypass Graft
Outpatient
Inpatient
Catastrophic
(PCB & MDG)
(Case Rates)
(Z benefits)
Inpatient cases
Day surgeries
Chemotherapy
Radiotherapy
Hemodialysis
Total Correction of TOF
Closure of VSD
Cervical Cancer
Z Morph
Peritoneal Dialysis
Colon and rectum cancers
Primary Care Benefit
Maternity Care/NSD Package
Prenatal care
Newborn Care Package
TB-DOTS Package
Animal Bite Package
Malaria Package
Outpatient HIV-AIDS Package
Comparative Benefit Expense vs. Premium
Income (CY 2010 – 2015)
Income
Expense
Ben. Exp.
Over Prem.
Ratio
88.4%
95.1%
101.0%
97.2%
89.3%
100.4%
PhilHealth has Expanded the Breadth of the UHC Cube, but Height and Depth are Lacking
Three Dimensions to Consider in Moving Toward UHC
56% OOP
92%
●
●
High level of population
coverage
But last 8% is difficult to target
●
No/little assurance of financial
risk protection
●
No ceiling for out-of-pocket
expenditures except those
covered by the NBB
●
Fragmented
●
Lack of outpatient benefits esp.
drugs
Adapted from a slide courtesy of John Wong, 2016
5
2015 TAT on Good Claims
OFC
TAT
TOTAL CLAIMS
TOTAL PROCESSING
DAYS
TOTAL
31
6,901,699
215,481,549
Accreditation Statistics
PhilHealth-accredited Health Care Institutions, 2001-2015
Source: Accreditation Department, PhilHealth
Accredited Professionals from 2003 to 2015
35000
30000
25000
Number
20000
15000
10000
5000
0
2003
Physician 20014
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
18439
20843
21049
20664
20726
22951
21529
23390
26358
27070
30812
32008
Dentist
210
172
218
238
208
182
195
177
201
232
242
356
384
Midwife
35
66
87
141
147
235
355
354
518
824
1195
2159
1984
Source: Accreditation Department, PhilHealth
PhilHealth Policy Statements on the
Management and Diagnosis of Diseases
What are Policy Statements?
• These are recommendations based on best available
evidence (published evidence) or treatment
protocols
• Expert opinion
• Not all recommendations are translated to policy
statements
Purpose of Policy Statements?
• Education
• Quality assurance
• Policy formulation and monitoring
Legal Basis
Revised IRR of the RA 10606 under Title V (Quality
Assurance and Accreditation) Rule 1 (Quality
Assurance) Section 51 provides:
”implementation of quality
assurance standards as reference for
ensuring quality of care services”
Conditions covered by policy statements
1. Acute Gastroenteritis
2. Urinary Tract Infection in Adults
3. Community-acquired Pneumonia (CAP)
4. Cataract
5. Chronic obstructive pulmonary disease
6. Asthma in adults
Z Benefit for Colon and Rectum CA
Expansion of Contracting for the Z Benefits
• Now includes private HCI’s
• Recent Contract Signing:
– St. Paul Hospital (Ioilo City)
– St. Luke’s Hospital Global City
– Lorma Medical Center (San Fernando, La Union)
– Angeles University Foundation Hospital (Angeles City)
– Mary Mediatrix Medical Center (Lipa City)
Private HCIs CONTRACTED for Z Benefits as of June 2016
PRO Name of HCI
Address
Z Benefit Package
NCR
UNIVERSITY OF THE EAST – RAMON
MAGSAYSAY MEMORIAL MEDICAL CENTER
Sta. Mesa, Manila
Z MORPH
NCR
ST. LUKES MEDICAL CENTER – GLOBAL CITY
Global City, Taguig City
KIDNEY
TRANSPLANTATION (KT)
LORMA MEDICAL CENTER
San Fernando City, La
Union
KIDNEY
TRANSPLANTATION (KT)
I
KIDNEY
TRANSPLANTATION (KT)
III
ANGELES UNIVERSITY FOUNDATION
MEDICAL CENTER
Angeles City, Pampanga
IV-B
MARY MEDIATRIX MEDICAL CENTER
Lipa City, Batangas
CORONARY ARTERY BY
PASS GRAFT (CABG)
Sto. Tomas, Batangas
KIDNEY
TRANSPLANTATION (KT
IV-B
ST. FRANCES CABRINI MEDICAL CENTER
CORONARY ARTERY BY
PASS GRAFT (CABG )
BREAST CANCER
VI
ST PAUL HOSPITAL OF ILOILO
Iloilo City, Iloilo
KIDNEY
TRANSPLANTATION (KT)
PhilHealth Circular No. 2016 - 005
Submission of Statement of Account (SOA)
for All Case Rate Claims Reimbursement
http://www.philhealth.gov.ph/circulars/2016/circ2016-005.pdf
Rationale
 As part of the review of All Case Rates (ACR) in the context of
policy research, the statement of account (SOA) or billing
statement shall be required as attachment to PhilHealth claims
application for ACR
Scope and Coverage
 This policy shall cover all case rate claims of eligible PhilHealth
members and their qualified dependents in all PhilHealth
accredited health care institutions.
Statement of Account (SOA)
For the purpose of standard implementation, the SOA must
contain the following minimum requirements:
 The SOA shall reflect the actual total hospital charges minus
the PhilHealth benefit for the Health Care Institution (HCI) fee.
 Part III item A of Claim Form 2 Certification of Consumption of
Benefits and Consent to Access Patient Record/s must be
consistent with that of the SOA of the patient;
Statement of Account (SOA)
For the purpose of proper implementation, the SOA must contain
the following elements:
 The SOA should be duly signed by the member or his/her
authorized representative (with printed name, relationship to
member and contact number) confirming or concurring with
the Statements therein relative to PhilHealth deductions;
Statement of Account (SOA)
For the purpose of proper implementation, the SOA must contain
the following elements: (continued)
 The signatory in SOA must be the same person as the signatory
in PhilHealth Claim Form 1 under Part III. Member
Certification. In case the signatory in Claim Form 1 is different
from the signatory in the SOA, information for authorized
representative (name, relationship to member, contact
number) should be indicated in the SOA;
 The SOA should have the signature over printed name and
position of the accountant or billing clerk.
Implementing Guidelines
 The original or a certified true copy of the SOA shall be
submitted together with the PhilHealth claim forms for claims
application for ACR.
 Part III- Certification of consumption of benefits and consent to
access patient record/s of PhilHealth Claim Form 2 should be
completely filled out together with the SOA as supporting
document
 The accredited health care institution shall be obliged to
provide assistance to facilitate member requests and concerns,
consistent with PC No. 11 – 2008, page 2
Implementing Guidelines (continued)
 The SOA shall not be required for claims application for the
following:
- TB DOTS
- Maternity Care Package
- Peritoneal Dialysis
- Outpatient Malaria Package
- Outpatient HIV/AIDS Treatment Package
- Animal Bite Treatment Package
- Newborn Care Package (in non-hospital facilities)
Claims Filing
 Claims with incomplete documents shall be returned to
sender. Existing RTS rules shall apply.
 Claims with incomplete entries shall also be returned to
sender for completion.
PHILHEALTH DIALYSIS
DATABASE (PDD)
PhilHealth Circular No. 2016-007
http://www.philhealth.gov.ph/circulars/2016/circ2016-007.pdf
OBJECTIVE
To establish the standard
of
members and dependents who are prescribed with dialysis
or other renal replacement therapy under the PDD,
DEFINITION
Chronic kidney disease (CKD) stage 5 has end stage
renal disease (ESRD) with a GFR of 15 ml/min or less. At
this advanced stage of kidney disease the kidneys have lost
nearly all their ability to do their job effectively, and
eventually dialysis or a kidney transplant is needed to live.
This kind of kidney failure is permanent and is usually
caused by diabetes or high blood pressure.
ICD -10 code
Description
CKD stage 5
N18.5
ESRD
End stage kidney disease
Source: Philippine ICD 10 Modifications. Second edition. May 2014
- is a term used to encompass
life-supporting treatments for renal failure. It includes hemodialysis,
peritoneal dialysis, hemofiltration and renal transplantation.
– blood is removed from the body and filtered
through a man-made membrane called a dialyzer, or artificial kidney,
and then the filtered blood is returned to the body.
-A dialysis technique that uses the
patient's own body tissues inside the abdominal cavity as a filter.
A plastic tube called a dialysis catheter is surgically placed through the
abdominal wall, into the abdominal cavity. A special fluid is then flushed
into the abdominal cavity and washed around the intestines. The
intestinal walls act as a filter between this fluid and the bloodstream. By
using different types of solutions, waste products and excess water can
be removed from the body. This form of dialysis can be done either
manually or by machine at home, thereby avoiding hospitalization or
receiving dialysis treatment at a dialysis center.
DEFINITION…..CONT.
C.
–
is being administered by the National Kidney and
Transplant Institute – Renal Disease Control Program
(NKTI- REDCOP) and includes the following: the End Stage
Renal Disease (ESRD) Registry composed of the
Hemodialysis, Peritoneal Dialysis & Transplant Registries,
and the Chronic Kidney Disease Registry composed of
Biopsy.
GUIDELINES
1. PhilHealth Identification Number (PIN)
2. Certification of Diagnosis and Management – CKD:
Members or dependents diagnosed of chronic kidney disease
stage 5 who are prescribed with hemodialysis, peritoneal
dialysis or other renal replacement therapy shall secure this
certification from a PhilHealth -accredited nephrologist
(Diplomate or Fellow of Philippine Society of Nephrology or
Pediatric Nephrology Society of the Philippines) or an internist
with completed training in nephrology (Diplomate of Philippine
College of Physicians with completed training in nephrology).
The certification shall include the following:
3.PDD Registration Form: completely and correctly
filled out
a.The PDD Registration Forms shall be available in
all accredited health care institutions (HCIs) with
dialysis services, LHIOs, PROs and at the
PhilHealth website.
Guidelines…..cont.
B.
1.The registration and submission shall start on
.
2.Members and dependents diagnosed of CKD
stage 5 (previously known as ESRD) who are
prescribed with hemodialysis, peritoneal
dialysis or other renal replacement therapy
under the PDD.
Registration and Submission
3.To register, they shall be required to submit the following to
an accredited health care institution with dialysis services
with PDD module (see attached Annex):
Registration and Submission
4. They only need to register under the PDD
unless
their registration has been deactivated .
a. Registration of members or dependents who availed of kidney
transplantation or who underwent kidney transplantation or other
related cases under the Z benefits or All Case Rates packages shall
be deactivated under the PDD. If hemodialysis or peritoneal dialysis is
prescribed once more for such cases,
of the
registration shall be required.
b. Updating of registration under the PDD shall warrant the same
requirements (item IV. A).
c. Registered members or dependents who are tagged as expired in the
membership and claims databases shall be
.
d. The PDD Registration Forms and the Certification of Diagnosis and
Management – CKD shall be made
in all accredited HCIs
with dialysis services, LHIOs, PROs and at the PhilHealth website.
Registration and Submission
5.The HCIs shall assist their CKD patients in filling out the
PDD Registration Forms. The
filled out PDD Registration Forms shall be
encoded by the HCIs using the PDD module through the
HCI Portal.
6. After encoding, the HCIs shall ensure the
of
the PDD Registration Forms and other requirements
(original copies) to the LHIOs or PROs within 60 calendar
days from date of approval of registration.
Registration and Submission
shall be collected by the
HCIs for the registration of members or
dependents under the PDD.
PhilHealth Dialysis Database
1. The PDD module shall be developed and integrated in the HCI
Portal. It shall provide
information to all authorized
users. The PDD shall be operational starting
.
2. HCIs with dialysis services shall submit a
to access the PDD. HCIs with dialysis services with
no installed and functional HCI Portal shall be required to apply
and be connected
May 1, 2016. PhilHealth Circular
No. 2 s. 2012 (item II. B and C) enumerated the requirements
on how to participate in the HCI Portal.
PhilHealth Dialysis Database, cont.
3. The Corporation and the HCIs shall ensure the
,
, and
of
patients’ information at all times.
4. A regular process of monitoring and evaluation of the PDD
shall be conducted. Any identified issues and concerns
shall be referred to the concerned offices for resolution.
5. The Corporation shall be the owner of the PDD data. The
information shall be available and accessible to all
authorized users as may be determined by the
Corporation.
PDD and Claims Processing
1. Registration in the PDD shall be a
for
reimbursement of claims for dialysis of patients diagnosed of
CKD stage 5. Non -registration under the PDD shall mean
of reimbursement.
2. To give ample time for PhilHealth members and dependents
on chronic dialysis to register, PhilHealth shall only require
PDD registration for reimbursement of dialysis claims for
admissions or procedures performed starting
.
3. Registration on the same day as filing of claims for dialysis
shall be
provided the regular 45 days benefit
limit is
exhausted.
MONITORING AND EVALUATION
A. The health care providers shall be subjected to the rules on
monitoring and evaluation of performance as provided for in
PhilHealth Circular No. 54, s-2012: Provider Engagement
through Accreditation and Contracting for Health Services
(PEACHeS) and PhilHealth Circular No. 031-2014 re:
B. The HCIs shall accept members or dependents seeking dialysis
services based on their license and facility’s
.
C. The current clinical practice guidelines for the management of
chronic kidney disease shall be the basis for the standard of
care.
IX. ANNEX
The PDD Registration Form and
Certification of Diagnosis and Management - CKD
shall also be made available as downloadable
document at the PhilHealth website:
www.philhealth.gov.ph
RATIONALE
As per Rule I, Sections 35 (objective) and 36 (functions) of
the revised IRR of RA 7875 as amended by RA 9241 and
10606, “the National Health Insurance Program aims to
provide its members with responsive benefit packages. In
view of this, the Corporation shall continuously endeavor to
improve its benefit package to meet the needs of its
members.”
In setting certain provisions in the policy, the
concerned specialty societies and other stakeholders
have been consulted. This and future enhancements
of All Case Rates policies reflect the diversified scopes
of professional practice and prevailing clinical setting.
SCOPE
This Circular shall cover the following revisions for selected procedures
listed in Annex 2 – List of Procedure Case Rates (Revision 2.0):
A. Relative Value Scale (RVS) codes/ procedures with changes in case
rate amount and /or conditions for claiming.
B. Delisting of RVS codes/procedures
C. RVS codes/ procedures that shall be claimed only once in a lifetime
per eye
D. Reimbursement policy for RVS codes 66820 and 66821
E. RVS codes/procedures exempted from the 90 day single period of
confinement rule
F. Other supplementary guidelines
1. Reimbursement of ophthalmic surgical and laser procedures
2. Intraocular lens (IOL)
3. Cataract Pre-surgery Authorization (CPSA) limit
GUIDELINES
The selected procedures listed herein shall now be used for reference by
accredited health care providers and PhilHealth members/dependents in
claiming for PhilHealth reimbursements.
Description
(New)
First
Case Rate
Health Care
Institution
fee
Professional
fee
17000
Destruction by any method,
including laser, w/ or w/o surgical
curettement, a benign facial
lesions or premalignant lesions in
any location, or benign lesions
other than vascular proliferative
lesions, including local anesthesia;
any number of lesions
6,000
3,800
2,200
17106
Destruction of cutaneous vascular
proliferative lesions (e.g. laser
technique)
6,000
3,800
2,200
RVS
code
RVS
code
Description
Removal of foreign body,
65205 external eye; conjunctival,
superficial
Corneal relaxing incision for
65772 correction of surgically
induced astigmatism
Health
(New)
Care
Professio
First
Institution
nal fee
Case Rate
fee
500
300
200
10,000
6,000
4,000
ICD 10
Code
B07
D22.0
D22.1
Description/
Diagnosis
Verruca vulgaris (located
on the palms and soles
and periungual areas)
Nevus of Ota
Maximum
Number of
sessions per
patient
Interval
in between
procedures
6
30 days
6
90 days
Can only
be performed
by
Diplomate/Fellow/
Consultant of
Philippine
Dermatological
Society (PDS)
ICD 10
Code
B07
Description/
Diagnosis
Verruca vulgaris (plantar or
periungual)
L71.9 Rosacea (severe)
D18.0
Q82.5
Hemangioma, any site
Venous malformation
Angioma NOS
except Cherry angioma
Congenital non-neoplastic
naevus (portwine)
Maximum
Interval
Number of
in
sessions per between
patient
procedur
es
6
Can only
be performed
by
30 days
6
30 days
6
30 days
6
30 days
Diplomate/
Fellow/ Consultant
of Philippine
Dermatological
Society (PDS)
The following procedures are temporarily delisted until further notice as
recommended by the medical specialty societies concerned. Hence,
claims for these procedures shall be denied.
RVS Code
17100
17200
11050
11051
11052
Description
Destruction by any method including laser of benign skin lesions other than
cutaneous vascular proliferative lesions on any area other than the face,
including local anesthesia; any number of lesions
Electrosurgical destruction of multiple fibrocutaneous tags; All lesions
Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o chemical
cauterization (such as verrucae or clavi) not extending through the stratum
corneum (e.g., callus or wart) w/ or w/o local anesthesia; single lesion
Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o chemical
cauterization (such as verrucae or clavi) not extending through the stratum
corneum (e.g., callus or wart) w/ or w/o local anesthesia; two to four lesions
Paring or curettement of benign hyperkeratotic skin lesion w/ or w/o chemical
cauterization (such as verrucae or clavi) not extending through the stratum
corneum (e.g., callus or wart) w/ or w/o local anesthesia; more than four
lesions
DELISTING....CONTINUATION
RVS Code
Description
50205
Renal biopsy; by surgical exposure of kidney
65420
Excision or transposition of pterygium; without graft
65771
Radial keratotomy
67042
Vitrectomy, mechanical, pars plana approach; with radial optic
nerve neurotomy (RON)
67043
Vitrectomy, mechanical, pars plana approach; with sheathotomy
for branch retinal vein occlusion
67044
Vitrectomy, mechanical, pars plana approach; with macular
translocation (limited by retinotomy and/or scleral imbrication)
67045
Vitrectomy, mechanical, pars plana approach; with macular
translocation (total)
1. The following procedures shall only be reimbursed once in a lifetime
per eye.
RVS Code
Description
Removal of Eye
65091
65093
Evisceration of ocular contents; w/o implant
Evisceration of ocular contents; w/ implant
65101
Enucleation of eye; w/o implant
65103
Enucleation of eye; w/ implant, muscles not attached to implant
65105
Enucleation of eye; w/ implant, muscles attached to implant
65110
65112
65114
Exenteration of orbit without skin graft, removal of orbital contents;
only
Exenteration of orbit without skin graft, removal of orbital contents;
w/ therapeutic removal of bone
Exenteration of orbit without skin graft, removal of orbital contents;
w/ muscle or myocutaneous flap
2. To reiterate, the following RVS code 66840, 66850, 66852, 66920,
66930, 66940, 66982, 66983, 66984, and 66987 under “Removal
Cataract” shall be claimed only once in a lifetime per eye as listed in
Annex 2 – List of Procedure Case Rates (Revision 1.0) of PhilHealth
Circular No. 008 – 2015. It shall also include RVS code 66830.
To illustrate:
RVS code
Laterality
Date performed
Remarks
66983
Right eye
June 1, 2015
Pay
66983
Left eye
June 3, 2015
Pay
66840
Right eye
September 5, 2015 Denied, under the same
group of “Removal
Cataract”
RVS code
66820
66821
Description
Discission of secondary membranous cataract
(opacified posterior lens capsule and/or anterior
hyaloid); stab incision technique (Ziegler or Wheeler
knife)
Discission of secondary membranous cataract
(opacified posterior lens capsule and/or anterior
hyaloid); laser surgery (e.g., YAG laser) (one or
more stages)
1. Claims for RVS codes 66820 and 66821 shall not be compensable if
done less than 90 days after cataract surgery on the same eye. Both
procedures can only be done once in a lifetime per eye.
To illustrate:
Claim
1
2
3
4
PREVIOUS CATARACT
SURGERIES
Procedure/Date performed
RVS code 66987
Right eye
November 1, 2014
RVS code 66987
Right eye
November 1, 2014
RVS code 66987
Left eye
April 1, 2016
RVS code 66987
Left eye
April 5, 2016
CLAIM
Procedure/
Date performed
RVS code 66820
Right eye
February 15, 2015
RVS code 66820
Right eye
June 15, 2015
RVS code 66820
Left eye
July 1, 2016
RVS code 66820
Left eye
July 1, 2016
REMARKS
Pay
Pay
Pay
Deny claim
2. RVS 66820 and 66821 shall be exempted from the laterality rule. For bilateral
discission procedures (either RVS 66820 or 66821) done in one operative
session or with less than one day interval (within same or different
confinements), the second discission procedure shall be paid at 50% of the case
rate. However, if there is at least one day interval between procedures (within
same or different confinements), the second discission procedure shall be paid
the full case rate.
To illustrate:
Claim
PREVIOUS CATARACT SURGERIES
Procedure/Date performed
1
First Case Rate: RVS code 66821
Right eye
June 15, 2015
Second Case Rate: RVS code 66821
Left eye
June 15, 2015
2
First Case Rate: RVS code 66821
Right eye
July 1, 2016
First Case Rate: RVS code 66821
Left eye
July 3, 2016
CLAIM
Procedure/
Date performed
Pay first case rate full and
50% for second case rate
Pay full case rate for both
claims
3. Both RVS codes 66820 and 66821 shall automatically be subjected to
post-audit.
RVS code
67036
Description
Vitrectomy,
mechanical,
pars plana
approach
Condition/Rules
Can only be performed
by
Exempted from the 90 day Single
Medical Specialist
Period of Confinement rule for the
a. Philippine
following medical indications only:
Academy
a. H43.1 (Vitreous haemorrhage)
of Ophthalmology
b. H44.0 (Purulent endophthalmitis)
(PAO)
2. A justification to support the b. trained in EENT
1.
performance of the procedure
shall be submitted in filing of
or
claims for cases done by the same
surgeon who performed the ocular General Practitioner
surgery
that
led
to
its
with completed
residency training in
complication.
Otherwise, the claim shall be denied.
3. Subject to Automatic Post-Audit
Ophthalmology
....CONTINUATION
RVS
code
67049
67050
Description
Vitrectomy,
mechanical pars
plana approach,
with removal of
dropped IOL
Vitrectomy,
mechanical pars
plana approach;
with
phacofragmentatio
n for dropped lens
nucleus
Condition/Rules
1. If vitrectomy is done in one
confinement with cataract
extraction, PhilHealth shall
reimburse vitrectomy only. If
vitrectomy and cataract extraction
are performed in separate
confinements , both procedures
shall be reimbursed.
2. Subject to Automatic Post-Audit
Can only be
performed by
Medical Specialist
a. Philippine
Academy of
Ophthalmology
(PAO)
b. trained in EENT
1. Ophthalmic surgical (includes cataract surgeries) and ophthalmic
laser procedures shall be reimbursed when performed by an
accredited General Practitioner with Completed Residency Training
in Ophthalmology (PhilHealth Accreditation Number starting with
1501 and 1503) or by a Medical Specialist of PAO or a Medical
Specialist trained in Eye, Ear, Nose, Throat (EENT) (PhilHealth
Accreditation Number starting with 1304 and 1314, respectively)
unless otherwise specified.
2. A General Practitioner with completed residency training shall submit
the certified true copy of the certificate of completed residency
training in Ophthalmology to the concerned PRO for evaluation and
tagging in the accreditation database.
3. The removal of corneal, corneo-scleral and conjunctival sutures
cannot be claimed using the following RVS codes:
RVS code
65205
65210
65222
Description
Removal of foreign body, external eye;
conjunctival, superficial
Removal of foreign body, external eye;
subconjunctival or scleral, with slit lamp
Removal of foreign body, external eye; cornea,
with slit lamp
4. The Food and Drug Administration Philippines - registered intraocular lens
(IOL) sticker or box used in the cataract surgery shall be attached to Claim Form
2 for claiming the following procedures:
RVS code
Description
66984
Extracapsular cataract removal with insertion of intraocular lens
prosthesis (one stage procedure), manual or mechanical technique
(eg, irrigation and aspiration or phacoemulsification), complex,
requiring devices or techniques not generally used in routine
cataract surgery (e.g. iris expansion device, suture support for
intraocular lens, or primary posterior capsullorhexis) or performed
on patients in the amblyogenic developmental stage
Intracapsular cataract extraction w/ insertion of intraocular lens
prosthesis (one stage procedure)
Extracapsular cataract removal w/ insertion of intraocular lens
prosthesis (one stage procedure), (e.g., irrigation and aspiration)
66985
Insertion of intraocular lens prosthesis, not associated with cataract
removal
66986
Exchange of intraocular lens
66987
Extracapsular cataract removal w/ insertion of intraocular lens
prosthesis (one stage procedure), (e.g., phacoemulsification)
66982
66983
In transition, the IOL sticker or box should be labeled with
but not limited to: 1) product or brand name; 2) model or
reference code; 3) manufacturer; and serial number until
August 31, 2016 (1 out of 3 labels should be present and
serial number). Thereafter, all three (3) labels and serial
number should be present. Otherwise, the claim shall be
denied.
As is, one (1) IOL sticker shall be placed on the operative
record and shall be part of the chart. This shall be checked
during monitoring.
5. To reiterate, for cataract surgeries covered by the
Cataract Pre-surgery Authorization (CPSA), PhilHealth
shall authorize only up to a maximum of fifty (50)
approved requests for pre-surgery authorization per
PhilHealth-accredited eye surgeon per month not
exceeding ten (10) scheduled surgeries per day per
PhilHealth-accredited eye surgeon except for those
performed by residents-in- training under the eye
surgeon’s supervision in accredited government or
private HCI with a Philippine Board of Ophthalmology
accredited residency training program. The patients of
residents- in -training not subject to limit shall only
include non-private, service and NBB eligible patients.
To illustrate:
Dr. Juan Dela Cruz, an accredited health care professional has the following
requests for Cataract Pre-Surgery Authorization:
Date of
contemplated
surgery
Classification of
HCI
Category of
patient
Number of
approved CPSA
Included in the
limit per health
care
professional?
Yes or No
August 5, 2015
Private hospital
Private
9
Yes
August 6, 2015
Government
hospital
Private
10
Yes
August 9, 2015
Private ASC
Private
5
Yes
August 11, 2015
Private hospital
Private
9
Yes
5
Yes
2
Yes
2
Yes
August 15, 2015
August 17, 2015
August 19, 2015
Government
hospital with no
accredited
Non-private
residency training
in Ophthalmology
Sponsored
Private ASC
member of
PhilHealth
Sponsored
Private ASC
member of
PhilHealth
....CONTINUATION
Date of
contemplated
surgery
Classification of
HCI
August 20,
2015
Private hospital
with accredited
residency training
in Ophthalmology
August 22,
2015
Government
hospital with
accredited
residency training
in Ophthalmology
August 23,
2015
Private hospital
August 25,
2015
Private ASC
Category of patient
Service patient as part
of training program, with
consultant signing for
patients of
residents
Sponsored member of
PhilHealth as part of
training program, with
consultant signing for
patients of
residents
Private
Private
Total No. of Approved CPSA: 66
Total No. of CPSA not subject to limit: 16
Total No. of Surgeries for August: 66
Number
of
approved
CPSA
Included in the limit per
health care
professional? Yes or No
5
No
11
No
8
Yes
1
Request is denied
because Dr. Dela Cruz
already exceeded the
limit of 50 CPSAs per
month that are subject
to the limit.
6. To reiterate, CPSA shall no longer be
required in cases of childhood and secondary
(e.g. traumatic, glaucomatous) cataracts. The
clinical abstract (original or certified true copy)
or a completely and properly filled out Claim
Form 3 (page 1) shall be attached to CF2 for
monitoring and evaluation. Otherwise, the claim
shall be returned to sender.
TRANSITORY PROVISION
Claims for ophthalmic surgical and
ophthalmic laser procedures by EENT
specialists performed starting July 15, 2015
onwards shall be reimbursed subject to
existing rules and regulations.
MONITORING AND EVALUATION
The health care provider shall be subjected to the rules
on monitoring and evaluation of performance as
provided for in PhilHealth Circular No. 54, s-2012:
Provider Engagement through Accreditation and
Contracting for Health Services (PEACHeS) and
PhilHealth Circular No. 031-2014 re: Health Care
Provider Performance Assessment System (HCP PAS).
This Circular shall be reviewed periodically and as
necessary.
REPEALING CLAUSE
All provisions of previous issuances, circulars, and directives that are
inconsistent with any of the provisions of this Circular for this particular
circumstance wherein the same is exclusively applicable, are hereby amended,
modified or repealed accordingly.
SEPARABILITY CLAUSE
In the event that a 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.
EFFECTIVITY
The new provisions of this Circular shall take effect for claims with admission
dates starting
unless otherwise specified. 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.
EFFECTIVITY
The new provisions of this Circular shall take effect for claims with
admission dates starting
unless otherwise specified. 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.
ANNEX
New case rate amount for selected procedures listed in Annex 2 – List
of Procedure Case Rates (Revision 3.0) pdf file and online inquiry
“Search Case Rates” utility shall be available at www.philhealth.gov.ph
For comments, suggestions, questions:
Email us at
[email protected]
Thank You!