Guidelines on the Provision of Special Privileges to Those Affected by a Fortuitous Event

November 15, 2013

PHILHEALTH CIRCULAR NO. 034-13

 

I. Objectives:

One of the Guiding Principles and Objectives of R.A. 7875, as amended by the National Health Insurance Act of 2013 (R.A. 10606), states that "the Government shall provide public health services for all groups" this was further explicitly clarified to include "displaced communities and communities in environmentally endangered areas."

The recent fortuitous events that visited our country (or events described as an "act of God" like floods or typhoons; or an "act of man" such as rebellion, insurgencies, and wars) bear witness to the inherent powers of the same to effect displacement of communities in several endangered areas.

Thus, pursuant to PhilHealth Board Resolution No. 1848, s. 2013, the Corporation hereby issues the following guidelines that shall be applied to all those affected by fortuitous events. This is consistent with the mandate of the Corporation to provide responsive health care benefits to its members at all times, more so during a fortuitous event where help is needed the most.

II. Coverage

This Circular shall cover PhilHealth claims of those affected by a fortuitous event that covers any of the following conditions:

1. PhilHealth and non-PhilHealth members including dependents;

2. PhilHealth accredited or non-PhilHealth Accredited Health Care Institutions (HCIs) either privately-owned or government-owned. For non-PhilHealth accredited HCIs it must be DOH licensed or certified by a certifying body recognised by PhilHealth;

3. PhilHealth accredited or non-PhilHealth accredited health care professionals duly licensed by PRC;

4. Claims for treatment done as an outpatient or inpatient relative to the direct and indirect effects of the fortuitous event within the HCI or in an improvised/satellite facility.

5. Transferred from or managed by health care personnel from accredited facilities in an evacuation area, or improvised health care facilities.

III. General Rules

1. Declaration of state of calamity, or state of emergency and analogous certification depending on the fortuitous event are required for the application of this Circular. In the absence of such documents, justification letters from the authorized government agencies may be submitted subject to validation by the concerned PhilHealth Regional Office (PRO).

2. Health care institutions affected by the fortuitous event shall send a letter request for application of this Circular duly signed by the Medical Director/Chief of Hospital or any authorized representative to the concerned PRO. As much as possible include in the letter:

a. Description (or photos) of the effects of the fortuitous event.

b. Explicitly mention if majority of the claims under the HCIs' custody were totally destroyed and can no longer be recovered or reconstructed for the same to be able to avail of the reimbursement option stipulated in Special Privilege No. 8 contained in this circular.

3. The PRO shall undertake the following actions upon receipt of the request/s:

a. Organize a validation team either composed of staff from the concerned LHIO or from the PRO or both to validate the basis of such request. Validation can be through document/news review or survey. The survey shall be conducted only if the current situation posts no danger to the PhilHealth personnel.

b. Send the written request letter of the HCI along with the post validation report, with recommendation, duly signed by all members of the validation team, and the Regional Vice President and Area Vice President containing the recommendation of the PRO to the President and CEO for approval. The recommendation shall include the effectivity date of application of this Circular and special privileges deemed fit for the situation. ADaSEH

c. The PRO and the HCI shall be informed of the decision of the President and CEO through a written communication.

4. Should there be no other authority that has established the specific date of the fortuitous event's end, the concerned PRO shall send a written communication to the PCEO, duly signed by the Regional Vice President and Area Vice President, with regards to the specific end date of application of special privileges. In turn, the Central Office shall inform the PRO of the PCEO's concurrence or denial of their recommendation.

IV. Membership

1. Existing membership rules relative to the qualified principal member and dependents, amount of premium contribution, enrolment/updating requirements remain in effect unless exemption is provided by the Corporation.

2. Patients shall be checked whether he/she is an existing PhilHealth member/dependent or not.

a. PhilHealth member/dependent

a.1 HCIs shall check for eligibility to benefit entitlement that is paid premium contribution for at least three (3) months within the six (6) months prior to first day of availment, or

a.2 If without qualifying contribution as stated in a.1, and has the ability to pay for his/her own premium, the member shall pay in full the required premium contribution for the calendar year or the missed premium contribution/s plus the other premiums to complete the calendar year to be paid at the nearest PhilHealth Office pursuant to Section 39 of the IRR of R.A. 10606.

a.3 Enrollment at Point of Care through the Medical Social Welfare Officer of government HCIs who shall assess patients with no capacity to pay the premium contribution. Patients with no capacity to pay (indigents/critical prior) the premium contribution shall be shouldered by the government HCI stipulated in the Joint Order 2013-0031: Enrolment of Critical Poor under the Sponsored Program of the National Health Insurance Program at Point-of-Care (POC).

a.4 The above provision shall be applicable to private HCIs who are willing to become an HCI sponsor for the indigents/critical poor with expired membership validity.

b. Non-PhilHealth members

b.1 Non-PhilHealth members with capacity to pay shall be instructed to pay in full the premium contribution for the calendar year to the nearest PhilHealth Office.

b.2 Non-PhilHealth members with no capacity to pay the premium contribution shall follow the provisions in item IV.2.(a.3-a.4).

V. Benefit Entitlement

1. Existing inpatient, outpatient and other packages.

2. Emergency cases shall be given utmost priority during the period of the fortuitous event. Elective procedures when performed during the declared/specified period of a fortuitous event shall not be covered by any of the special privileges except for the extension period for the filing of the claim (Special Privilege No. 1)

3. No Balance Billing (NBB) policy shall be in effect for all the applicable cases. Private HCIs are highly encouraged to observe the NBB policy during the period of the declared/specified period of a fortuitous event.

4. Reimbursement shall be based on the provider payment mechanism at the time of admission.

5. Rules on direct filing except the special privileges and other applicable provisions shall still be in effect.

6. PhilHealth benefit deduction upon discharge is mandatory. Direct filing by members shall be allowed if treated in non-accredited HCIs and transfer is impossible/not feasible. The non-accredited HCI should be duly licensed by DOH or certified by a body approved by PhilHealth. TEIHDa

VI. Special Privileges

1. Submission of claims 120 calendar days from the date of discharge.

 This shall also cover claims due for submission for discharges covering the period sixty (60) calendar days before and until the day prior to the actual date of the occurrence of the fortuitous event.

2. Exemption from the forty five (45) day benefit limit and Single Period of Confinement (SPC) for admissions directly or indirectly related to the Fortuitous Event.

3. Reimbursement for both referring and receiving Health Care Institution.

3.l In instances where the patient necessitates transfer both the referring and receiving HCI shall file separate claims and shall both be reimbursed subject to the current limits of the benefit schedule.

3.2 This shall also be applicable to improvised/satellite facilities where patients are brought in for care.

4. Exemption to the less than 24 hour confinement rule.

 These cases may be reimbursed based on the current rules of reimbursement.

5. Priority in processing of claims

 The HCI shall write/stamp on the right upper hand corner of the Claim Form 2 the words "affected by fortuitous event" to facilitate the appropriate tagging of such claim in the system to expedite the processing of claims by PRO/Branches within (30) calendar days or less.

6. Extension on the submission of the required/mandatory HCI reports.

7. Extension of the accreditation validity and/or submission of application of health care providers.

8. Reimbursement for destroyed claims

8.l HCIs with destroyed claims that are due for submission to PhilHealth shall have the option to choose the mode of payment of such claims to be stated in the written request letter. The option could be any of the following: EIDTAa

i. Recovery or reconstruction of claims applications for submission/filing to PhilHealth or

ii. Payment of claims based on the average reimbursement per day of the concerned HCI multiplied by the number of days covering the period from the last submission/filing date up to the date specified by the Corporation. Claims filed by HCIs on or before the date specified by the Corporation which were included in the computation for the payment of claims shall not be processed.

8.2 HCIs shall not be allowed to change the option once it has been approved by the Corporation.

9. Extension of deadline of payment of premium contribution and/or extension of the date of an existing coverage as prescribed by the Corporation.

VII. Monitoring

The health care providers shall be subjected to the rules on monitoring and evaluation of performance as provided for in PhilHealth Circular 54, s. 2012: Provider Engagement through Accreditation and Contracting for Health Services (PEACHeS).

VIII. Repealing Clause

All provisions of previous issuances that are inconsistent with any provisions of this Circular are hereby amended/modified/or repealed accordingly.

IX. Separability Clause

In the event that any 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.

X. Effectivity

This Circular shall take effect for claims brought about by a fortuitous event. This shall also cover valid claims of victims in areas affected by Typhoon Maring, last August 2013; Typhoon Santi, last September 2013; Typhoon Ramil, and the areas in the Visayas Region affected by the earthquake that occurred on October 2013. HICcSA

Further, this Circular 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.

 

(SGD.) ALEXANDER A. PADILLAPresident and CEO