Social Health Insurance Coverage and Benefits for Women About to Give Birth Revision 1

June 11, 2015

PHILHEALTH CIRCULAR NO. 025-15

 

I. Background

The National Health Insurance Act of 2013 (Republic Act 10606) and its Implementing Rules and Regulations (IRR)provide that unenrolled women about to give birth shall be covered by National Health Insurance Program. This is to enable all mothers and their newborns to have financial access to essential health services that will ensure their survival and well being. With this commitment to save mothers and newborns by providing them financial risk protection, there is a need to redefine PhilHealth's maternity and newborn care benefits so that these benefits will focus on the health services that the pregnant women must receive throughout their pregnancy and delivery. Also, PhilHealth shifted its provider payment mechanism to case based payment which aims to increase efficiency in health care provision, simplify understanding of PhilHealth benefits by all sectors and improve the process of availing them.

In line with these, and in support of achieving the Millennium Development Goals for maternal and child health, the guidelines for enrollment and benefits of women about to give birth are hereby defined.

II. Scope and Coverage

This Circular shall define policies and procedures that will give financial risk protection to women who are about to give birth.

III. Definition of Terms

1. Women about to give birth — are those who are confirmed pregnant during their first visit to a health care provider and anytime thereafter. They shall also be referred to as pregnant women or expectant mothers in this Circular.

2. Parity — refers to the number of live-born children and stillbirths that have been delivered by the mother.

3. Normal birth/delivery — is characterized by spontaneous onset of labor, low risk at the start of labor, throughout labor and delivery, the infant is born in vertex position, 37 to 42 weeks of completed pregnancy, and mother and child are in good health after delivery.

4. Point of Care Enrollment — is a PhilHealth enrollment mechanism so that the poor who is not yet a PhilHealth member may be enrolled to the National Health Insurance Program as sponsored member. The policy is defined in PhilHealth Circular 32, s-2013 (Implementation of The Point of Care Enrollment Program).

5. Coverage — refers to the entitlement of an individual as PhilHealth member or dependent to the benefits of the National Health Insurance Program.

6. Maternity Care Package (MCP) — is a PhilHealth benefit that covers the complete essential health care services for women about to give birth throughout their pregnancy and normal delivery (during antenatal, intrapartum and immediate postpartum periods) regardless of the type of health care institution where the services are rendered. The services shall include antenatal care, intrapartum monitoring, assist in normal delivery and post-partum care within 72 hours and 7 days after delivery.

7. Normal Spontaneous Delivery (NSD) Package — is a PhilHealth benefit that covers only health services during intrapartum and immediate post-partum period for normal delivery regardless of the type of health care institution. The services shall include monitoring and management of labor, assist in normal delivery and post-partum care within 72 hours and 7 days after delivery.

8. Antenatal Care Package — is a PhilHealth benefit that covers antenatal or pre-natal care services of expectant mothers. The services shall include pre-natal check-ups to screen, detect and manage complications of pregnancy; maternal nutrition; immunizations; and counseling for healthy lifestyle, breastfeeding, and family planning. Previously, the benefit is included in the benefits for normal deliveries but it is not fully utilized because of gaps in the health care delivery network. To promote access of pregnant women to quality antenatal care services that will ensure good outcome of their pregnancy, this benefit is made distinct from the benefits for delivery.

9. PhilHealth Benefit Eligibility Form (PBEF) — is a document produced through PhilHealth Enhanced Health Care Institution Portal that contains the information whether the member or dependent is eligible to avail of PhilHealth benefits in terms of the following: 1) status of membership/dependency; 2) premium contributions; and 3) compliance to 45 days benefit limit. The guidelines are provided in PhilHealth Circular 02, s-2014 [Enhanced Health Care Institution Portal (Formerly Known as Institutional Health Care Provider Portal).

IV. General Guidelines

1. PhilHealth shall ensure that women about to give birth shall have financial risk protection during their pregnancy, delivery and post-partum period through their enrollment to the National Health Insurance Program.

2. PhilHealth shall provide benefits for all maternal deliveries regardless of parity, subject to the provision of qualifying contributions.

3. PhilHealth shall also cover admissions due to pregnancy related conditions such as pre-term labor and pregnancy induced hypertension.

4. Only low risk normal vaginal deliveries shall be compensable in non-hospital facilities. "Low risk" refers to absence of active complications and any maternal or fetal factors that will make the pregnancy at risk for complications. Hence, the following conditions listed in PhilHealth Circular 20, s. 2008 shall not be reimbursed in non-hospital facilities:

a. Maternal age below 19 years old at the date of delivery;

b. First pregnancy in patients with age 35 years and older at the date of delivery;

c. Multiple pregnancy such as twins and triplets;

d. Ovarian abnormality (e.g., ovarian cyst);

e. Uterine abnormality (e.g., myoma uteri);

f. Placental abnormality (e.g., placenta previa);

g. Abnormal fetal presentation (e.g., breech);

h. History of (three) 3 or more miscarriages/abortion;

i. History of (one) 1 still birth;

j. History of major obstetric and/or gynecologic operation (e.g., cesarean section, uterine myomectomy);

k. History of medical conditions (e.g., hypertension, pre-eclampsia, eclampsia, heart disease, diabetes, thyroid disorder, morbid obesity, moderate to severe asthma, epilepsy, renal disease, bleeding disorder);

l. Other risk factors that may arise during present pregnancy (e.g., premature contractions, vaginal bleeding) that warrants referral for further management.

 It is imperative that if the abovementioned conditions were diagnosed during pre-natal care, the pregnant women must be referred to hospitals for appropriate management and care during delivery.

5. Since Geographically Isolated and Disadvantaged Areas (GIDA) have limited access to hospitals, the infirmaries/dispensaries located in these areas may be reimbursed for the normal deliveries of the mothers with conditions listed in Section IV.4 of this Circular.

6. Hospitals shall not refuse women about to give birth who were referred from birthing homes, maternity clinics and infirmaries/dispensaries for higher level of care management.

7. The health care institution and professional must be PhilHealth accredited at the time when they provide care to pregnant women before they can be paid by PhilHealth.

8. The No Balance Billing Policy shall apply to all member sectors and their dependents in accredited public and private maternity clinics/birthing homes. This shall cover all compensable services allowed in accredited public and private maternity clinics/birthing homes.

9. Women about to give birth should have prenatal care at the earliest time possible and keep a record of their pre-natal check-ups in a mother's book or its equivalent at all times. This is to ensure that they will receive continuous, comprehensive and coordinated care during pregnancy, delivery and post-partum.

10. The health care facility providing the pre-natal services shall give pregnant women a mother's book or its equivalent and shall assist them in checking and updating their PhilHealth membership and coverage.

V. Mechanism to Provide Social Health Insurance Coverage

1. Women about to give birth shall be enrolled to the National Health Insurance Program so that they can avail of the appropriate benefit packages provided by PhilHealth.

2. They shall consult a health care provider upon note of signs and symptoms of pregnancy.

3. The health care institution shall check the PhilHealth membership status and coverage of pregnant women upon their first consultation through PhilHealth Enhanced Health Care Institution Portal or other available means of verification.

4. Their membership status and social health insurance coverage may be any of the following:

a. Members under the Indigent Program, Sponsored Program, Overseas Filipino Program, and iGroup Program are entitled to avail of the benefits within the validity period.

b. The benefit entitlement of the following members shall be subject to the three months within six months (3/6) qualifying contributions as provided under PhilHealth Circular No. 32, s. 2014:

i) Members in the Formal Economy, including Kasambahays;

ii) Members in the Informal Economy, specifically Informal Sector Members and Self Earning Individuals; and

iii) iGroup Members whose validity period have already expired.

5. The health care provider shall refer to Medical Social Worker (MSW) or Social Worker for assessment to Point of Care enrollment (POC) the following pregnant women:

a. Those who are not yet registered to PhilHealth;

b. Those who are registered members but are not covered/eligible due to lack of qualifying contributions; or

c. Those who are qualified dependents of their parents (covered or not covered).

 Pregnant women who qualify shall be enrolled as Sponsored member under the Point of Care (POC) and shall be entitled to immediate availment of the benefits. 

6. Pregnant women who were assessed in Item V.4 but did not qualify for Point of Care enrollment shall be covered through the provisions of Section 39b of the Implementing Rules and Regulations of National Health Insurance Act of 2013 following the procedures prior to discharge from health facility, to wit:

a. Submit to the PhilHealth Local Insurance Office (LHIO) or PhilHealth Regional Office (PRO) an accomplished PhilHealth Membership Registration Form (PMRF) and ANY of the following documents:

i. Medical certificate from her physician/midwife confirming the pregnancy;

ii. Photocopy of the laboratory/ultrasound result confirming the pregnancy;

iii. Photocopy of her admission records.

b. They shall be required to enroll or shift under the Informal Economy Program.

c. To avail of the benefits, registered members of the Informal Economy Program without qualifying contributions and are not qualified under the POC Enrolment Program shall be required to pay the prescribed premium/s for one year or the missed and unpaid quarter/s of the applicable year as provided under Sec. 39b of the Revised IRR of RA 10606.

d. If the date of discharge falls on a weekend or on a holiday, registration under the Informal Economy Program and payment of prescribed premium contributions shall be allowed on the next working day.

e. Pregnant women and their qualified dependents who are covered through this provision can automatically avail of the PhilHealth benefits accorded to the members of the Informal Economy, including the benefits for giving birth and newborn care.

f. The privilege accorded to the women about to give birth provided by the provision of Section 39b shall only be availed ONCE per lifetime without interest. Subsequent use of updating premium contributions for the purpose of availing entitlement to benefits shall be subject to prevailing interests as may be prescribed by the Corporation. A separate guideline for this purpose shall be issued accordingly. Also, subsequent admissions after delivery that are not related to pregnancy and post-partum care shall be subject to the rules on qualifying contributions.

g. The calendar year covering the 1st day of hospital admission/confinement shall serve as the reckoning period for the application of Sec. 39b. Hence, it shall be the basis for the computation of premium amount due as well as in the posting of premium payment.

h. In the absence of the Health Care Institution (HCI) Portal or if ever the claim would be denied thru the portal due to lack of qualifying contributions, member may present the PhilHealth Official Receipt (POR) or Certificate of Premium Payment (CPP) to the accredited health care facility as proof of payment and entitlement to PhilHealth benefits.

i. Previous confinement/s prior to availment under Sec. 39b shall not be paid.

7. Pregnant women who are dependents of their parents should enroll as principal members either through POC or provision of Item V.5 of this Circular so that their children shall likewise have social health insurance coverage.

8. PhilHealth shall update the mother's member records and issue PhilHealth Identification Number for the newborn dependent upon processing of claims.

VI. Benefits Package for Women About to Birth

A. Maternity Care Package (MCP)

1. This package covers the essential health services during antenatal period, entire stages of labor, normal delivery and immediate post-partum period including follow-up visits within the first 72 hours and 1 week after delivery.

2. The package code shall be MCP01. The Package Code 59401 shall no longer be used.

3. This Package may be availed in hospitals, infirmaries/dispensaries and birthing homes/maternity clinics with the following rates:

Health Care Institution	MCP Package Rate
Hospitals	Php6,500.00
Infirmaries/dispensaries/Birthing homes/Maternity clinics	Php8,000.00

4. The professional fee shall be 40% of the package rate while the remaining 60% is for the facility fee.

5. The minimum stay of the mother in the facility shall be 24 hours.

6. Availment of this package shall be charged one (1) day to the annual 45-day benefit limit.

7. In line with the current standards of care, pregnant women are encouraged to have the first pre-natal check up during the first trimester of pregnancy with at least 4 pre-natal visits throughout the course of pregnancy. This is to detect and manage danger signs and complications of pregnancy and to reduce the risk of perinatal deaths. However, at this time, PhilHealth shall require at least 4 pre-natal visits during the course of pregnancy.

B. Normal Spontaneous Delivery (NSD) Package

1. This package covers essential health services for normal low risk vaginal deliveries and post-partum period within the first 72 hours and 7 days after delivery.

2. The package code shall be NSD01. The Package Code 59400 shall no longer be used.

3. However, services for Normal Spontaneous Delivery as Package Code 59400 provided in PCF-Infirmary/dispensary by an accredited physician prior to the effectivity of this circular shall be compensable.

4. This Package may be availed in hospitals, infirmaries/dispensaries and birthing homes/maternity clinics with the following rates:

Health Care Institution	NSD Package Rate
Hospitals	Php5,000.00
Infirmaries/dispensaries/Birthing homes/maternity clinics	Php6,500.00

5. Forty percent (40%) of the package rate is for professional fees while 60% is for the facility fee.

6. The minimum stay of the mother in the facility shall be 24 hours.

7. Availment of this package shall be charged one (1) day to the 45-day annual benefit limit.

8. In cases when the pregnant women receives pre-natal care from another facility, the facility where pre-natal care is rendered may claim for Antenatal Care Package while the facility that will assist in normal delivery may claim for NSD Package.

C. Antenatal Care Package (ANC01)

1. This package covers essential health services for women about to give birth during antenatal period regardless of method of delivery and pregnancy outcome (e.g., caesarian delivery, breech extraction)

2. The case rate for this package is Php1,500.00 for which forty percent (40%) is for professional fees while 60% is for the facility fee.

3. The package code shall be ANC01.

4. The requirements for this package are the following:

a. The facility is PhilHealth accredited as hospital, birthing home/maternity clinic, infirmary/dispensary, or Tsekap/Primary Care Benefit 1 provider. Likewise the health care professional shall also be PhilHealth accredited.

b. During antenatal period (i.e., occurring before birth), the women should have qualifying contributions or social health insurance coverage through different mechanisms described in Section V of this Circular.

c. There are at least 4 pre-natal check-ups/visits with the last one during the last trimester of pregnancy. For case/s wherein pregnancy ended prematurely, all applicable prenatal checkups shall be documented. The number of required prenatal check-up is waived.

d. All the essential health services for the pre-natal care are provided.

e. The women about to give birth are referred appropriately to an accredited health care institution for management of labor and delivery.

f. Pre-natal visits and other services given, referrals and outcome of delivery are documented in the mother's record and mother's book or its equivalent.

D. Payment for Cases Referred to Hospitals

1. In cases when women in labor were initially managed in non-hospital facilities but eventually referred to hospitals for higher level of management and delivery, the referring facility shall be reimbursed 10% of the rate of NSD Package.

2. Facilities that provided Antenatal Care Package and initial management of pregnant women who are in labor may claim for both services.

3. The package codes, rates and descriptions are the following:

Description	Package Code	Package Rate
Intrapartum monitoring or	59403	Php650.00
labor watch without delivery
Antenatal care services	ANC02	Php2,150
with intrapartum monitoring		*ANC Package
or labor watch (without		(Php1,500) plus
delivery)		Intrapartum
		monitoring (Php650)

4. Forty percent (40%) shall be for professional fee and 60% is for the facility fee.

E. Other Methods of Deliveries Covered by PhilHealth

1. PhilHealth also covers the following methods of deliveries in accredited hospitals:

Procedure	RVS/	Description	Case Rate
	Package	(Php)
	Code
Cesarean Section (CS)	59513	Caesarian section, primary	19,000.00
	59514	Cesarean delivery	19,000.00
	59620	Cesarean delivery only,	19,000.00
		following attempted vaginal
		delivery after previous
		cesarean delivery;
Complicated Vaginal	59409	Vaginal delivery only (with
Delivery		or without episiotomy
		and/or forceps)	9,700.00
Breech Extraction	59411	Breech extraction	12,120.00
Vaginal Delivery after	59612	Vaginal delivery only, after	12,120.00
Cesarean Section		previous cesarean delivery
		(w/ or w/o episiotomy

2. The Package Code 59402 (Normal Spontaneous Delivery with Bilateral Tubal Ligation shall not be used anymore. Instead, hospitals that provided Maternity Care Package or NSD Package and also performed bilateral tubal ligation may claim the procedure "Ligation or transection of fallopian tube(s) abdominal or vaginal approach, unilateral or bilateral" (RVS Code 58600, Case Rate — Php4,000) as second case rate paid in full.

For Example:

Services provided	Claim	Package/RVS	Case Rate
			Code
Intrapartum care, normal	1st Case Rate	NSD 01	Php5,000.00
delivery and post-partum
care (no pre-natal care)
Bilateral tubal ligation	2nd Case Rate	58600	Php4,000.00

3. Guidelines for availing of benefits and claims filing are stated in Circular 35, s-2013 (ACR Policy No. 2 — Implementing Guidelines on Medical and Procedures Case Rates) and subsequent issuances related to All Case Rates Policy.

VII. Newborn Care Package

Pregnancy and childbirth involve both the mother and the newborn. The Newborn Care Package ensures that newborns have access to health care services within their first hours of life. 

1. This package shall cover essential health services that newborns must receive within the first hours of life regardless of the method of their delivery and presence of comorbidities.

2. The amount of the package shall be Php1750.00 and paid to the facility.

3. The package code shall be 99432.

4. The package has the following components:

Services			Amount (Php)
Essential Newborn Care:
	•	Immediate drying of the baby, early skin to skin contact,
		timely cord clamping, non-separation of mother/baby
		for early breastfeeding initiation, eye prophylaxis,
		vitamin K administration, weighing of the newborn,
		first dose of hepatitis B and BCG vaccine	500.00
	•	Professional fee	500.00
Newborn Screening Test (for metabolic diseases)	550.00
Newborn Hearing Screening Test	200.00
			–––––––––––
Total			Php1,750.00
			==========

5. This package may be availed from health care institutions that provide services for MCP, NSD Package and other methods of delivery.

6. As stated in PhilHealth Circular 09, 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), newborns delivered in hospitals and managed for other morbid conditions (i.e., newborn sepsis, congenital pneumonia) may also claim for NCP as second case rate for health services provided to the newborn.

VIII. Clarification of Benefit for Intrauterine Device (IUD) Insertion and No-Scalpel Vasectomy (NSV)

A. IUD Insertion

1. To provide women access to family planning procedures, aside from hospitals and ambulatory surgical clinics, PhilHealth shall also pay IUD insertion (RVS Code 58300) performed in the following qualified primary care facilities:

a. Birthing homes/Lying-in clinics/maternity clinics;

b. Infirmaries/dispensaries; and

c. HCIs that are accredited as PCB1 and Tsekap providers.

2. The IUD insertion package covers payment for interval or postpartum IUD (PPIUD)

3. The package is worth 2,000 pesos which covers payment for counseling, professional fee, IUD device, and use of the facility and all other related services patients may require.

4. Post-partum IUD may be claimed as a second case rate. This procedure shall be covered by the rule on single period of confinement.

 For example:

Services provided	Claim	Package/	Case Rate
		RVS Code
Intrapartum and immediate post-	1st Case	NSD01	5,000
partum period for normal delivery	Rate
Insertion of intra uterine device	2nd Case	58300	2,000
(IUD)	Rate

5. Accredited midwives shall submit a copy of their certificate on Family Planning Competency Based Training (FPCBT) Level 2, Comprehensive Family Planning (FP) Training Course, or PPIUD Training Course to qualify as providers of IUD insertion. The said FPCBT training must have been conducted by trainers recognized by the Department of Health (DOH).

6. Availment of this benefit shall have a corresponding 1 day deduction in the 45-day annual benefit limit.

B. No-scalpel Vasectomy (NSV)

1. NSV shall also be paid if performed by an accredited physician in PCB1 and Tsekap providers aside from accredited hospitals, infirmaries, ambulatory surgical clinics (ASC).

2. To facilitate processing of this claim, the RVS Code 55250 (Vasectomy, unilateral or bilateral shall be used.

3. Accredited physician in non-hospital facility (e.g., RHUs) shall submit a copy of the NSV training certificate at the nearest PhilHealth Regional Office (PRO). The said training must have been conducted by trainers recognized by the Department of Health (DOH).

IX. Provider Accreditation

1. Accreditation of health care institutions shall be in accordance with the policy on Provider Engagement through Accreditation and Contracting of Health Services as stated in PhilHealth Circular 54, s-2012 and its subsequent issuances.

2. Accreditation of health care professionals shall follow the accreditation process for health care professionals as stated in PhilHealth Circular 10, s-2014 (The New Accreditation Process for Health Care Professionals and Guidelines for Credentialing and Privileging of Professionals).

X. Benefit Availment and Claims Filing

1. For easier verification of eligibility status in the PHIC inquiry module, all accredited health care institutions must have access to PhilHealth Enhanced HCI Portal.

2. For filing of all claims, the following documents shall be submitted to PhilHealth within 60 calendar days after discharge:

a. PhilHealth Benefit Eligibility Form (PBEF) OR

 Other documents required by PhilHealth as proof of eligibility such as Member Data Record (MDR); proof of premium payment (for individually paying and overseas workers members); PhilHealth ID cards (for indigent, sponsored and lifetime members); and other secondary documents as enumerated in PBEF and Circulars 50, s-2012 and PC 01, s-2013 in cases when PBEF is not available.

b. PhilHealth Claim Form 1 (CF1) duly filled out by the member and/or employer. It shall no longer be required if PBEF confirmed (answered "Yes") the eligibility of patient.

c. PhilHealth Claim Form 2 (CF2) duly filled out by health care provider; and

d. Claim Form 3 (CF3) for claims from infirmaries/dispensaries and birthing homes/maternity clinics except claims for Newborn Care Package.

e. Official receipt of Newborn Hearing Screening Test for Newborn Care Package if applicable;

f. Copy of newborn's birth certificate attached to newborn's claim (for Newborn Care Package) and to mother's claim (for updating of her membership data record). A photocopy from the facility without the registry number is acceptable as long as it is stamped as "Certified True Copy" and signed by the records officer/clinic administrator of that facility.

3. An additional requirement for Antenatal Care Package is a copy of pre-natal card or mother's book (Annex D) or their equivalent (i.e., "Pink Form"). The facility where the expectant mothers are referred for delivery shall be indicated in Part II item 4.f of Claim Form 2.

4. Part II Item 7 must have complete diagnosis and ICD-10 Codes including the method/s and outcome of delivery.

5. Claims for Newborn Care Package without the component of Essential Newborn Care and Newborn Screening Test shall be denied.

a. In cases when Newborn Hearing Screening Test was not provided by HCI, the corresponding amount (Php200.00) shall be deducted from the NCP claim.

b. When the said test was paid by the member, official receipt shall be attached to the claims for the Newborn Care Package. The two hundred pesos (Php200.00) shall be deducted from the HCI claim and shall be paid to the member.

6. Claims with incomplete requirements and/or discrepancy/ies shall be returned to sender (RTS) for compliance within 60 calendar days from receipt of notice. Failure to comply shall cause denial of claim. Claims for MCP and Antenatal Care Package without the appropriate dates for the pre-natal visits shall be denied.

7. PhilHealth strongly upholds that the facility shall file the claims after having exhausted the corresponding case rates in providing complete provision of care including pre-natal care for MCP.

8. For Maternity Care Package, PhilHealth shall no longer directly reimburse the member just for the pre-natal care component. In cases when the pregnant women spent for some diagnostic procedures such as laboratory and ultrasound, the facility shall have to reimburse them up to a maximum of one thousand five hundred pesos (Php1500.00).

9. Directly filed claims shall be allowed in the following instances:

a. Facilities did not provide complete health care for mothers and newborns such that patient/member have to spend for drugs and medicines, laboratories and other services that should be available in the facility; and

b. The patient/member is unable to secure required documents for claims filing during weekends/holidays.

10. For directly filed claims, the member shall submit the requirements listed in Section X.2 of this Circular AND a waiver (Annex E) from the health care institution stating that the member paid the full amount for the confinement and no PhilHealth deductions were made.

 The health care institution shall be responsible in filling out appropriate fields in Claims Form 2 and CF 3 and providing supporting documents such as PBEF. It shall also assist the member in filling out Claim Form 1.

11. All directly filed claims shall be processed subject to existing rules and guidelines of the Corporation.

XI. Monitoring and Evaluation

1. To ensure provision of quality health services to PhilHealth members and their dependents, monitoring of the utilization of the benefit packages provided to women about to give birth and their newborns shall be anchored on the Health Care Provider Performance Assessment System of the Corporation.

2. PhilHealth shall likewise strictly monitor but not limited to the following cases:

a. All directly filed claims.

b. Reimbursement (of facilities) for pre-natal care expenses of women about to give birth and newborn hearing screening test.

c. Outcomes of deliveries from birthing homes/maternity clinics and facilities in GIDAs.

d. Health outcomes of all referrals from non-hospital facilities.

3. Claims for Maternity Care Package and Antenatal Care Package that are filed for the same patient during the same period of pregnancy shall be referred for investigation.

4. For monitoring purposes, health care institutions shall maintain copies of patient records in their facility. These records shall have complete documentation of mother's history including but not limited to all her pre-natal consultations from different providers, course in the ward including her progress of labor and the delivery of care such as services provided, drugs and medicines given and procedures performed. Mother's a record in non-hospital facilities shall include a partograph. Newborn's charts shall have complete documentation of the services provided including the essential newborn care. These documents must be made available to PhilHealth personnel at all times. 

XII. Effectivity

This Circular shall take effect 15 days after its publication in a newspaper of general circulation. All other existing issuances and provisions of previous issuances inconsistent with this circular are hereby repealed and/or amended.

XIII. Annexes

1. Annex A — Summary of Requirements for Filing of Claims

2. Annex B — Instructions in Filling-up Claim Form 2

3. Annex C — Sample Claim Form 2

4. Annex E — Sample Copy of Mother's Book

5. Annex D — Waiver Form from HCI for Directly Filed Claims

(SGD.) ALEXANDER A. PADILLAPresident and CEO

ANNEX A

Summary of Documentary Requirements for Filing of Claims

Benefits	List of Documents
For All Claims	PhilHealth Benefit Eligibility Form (PBEF) OR
	Member Data Record (MDR), proof of premium
	payment for individually paying & overseas workers
	program members and PhilHealth ID cards (for
	indigent, sponsored & lifetime members) and other
	secondary documents as enumerated in the PBEF or
	PhilHealth Circulars 50, s. 2012 and PC 01, s. 2013.
	Claim Form 1 — not needed if PBEF answer is YES
	Claim Form 2
Additional Requirements:
Claims from	Claim Form 3 (except NCP)
Infirmaries/Dispensaries & Birthing
Homes/Maternity Clinics
Claims for MCP, NSD Package and	Copy of newborn's birth certificate (to be attached to
other types of delivery	mother's claim) for updating of member data record
Claims for Newborn Care Package	Copy of newborn's birth certificate (a photocopy
(NCP)	without the registry number is acceptable)
	If patient/member paid for newborn hearing
	screening test:
	Copy of official receipt of newborn hearing
	screening test
Claims for Antenatal Care Package	Copy of pre-natal care card or mother's book or its
	equivalent
For Directly Filed Claims	Waiver (Annex E) issued by the facility that the
	member paid the full amount for the confinement and
	no PhilHealth deductions were made.
	Claim Form 3

ANNEX B

Instructions on How to Accomplish Claim Form 2 and Sample Claim Form 2

Note: Claim Form 2 shall be accomplished using capital letters and by checking the appropriate boxes. All items should be marked legibly by using ballpen only. All dates should be filled out in MM-DD-YYY format.

CF 2 Pa	Description	Instructions
Part/Item
Part I	PhilHealth Accredited	WRITE the PhilHealth Accreditation Number,
	Number	name of HCI and the address on the space provided
	Name of Health Care
	Institution
	Address
Part II,	Name of Patient	WRITE the complete name of the patient in this
item 1		format: Last Name, First Name, Name Extension
		(if any), Middle Name
Part II,	Referred by another HCI	Tick appropriate box
item 2		IF yes, write the name and address of referring
		institution
		*In NSD Package, write the name of the facility
		that provided the antenatal care (as applicable)
Part II,	Confinement period
item 3
	Date Admitted	WRITE the date of admission
		For Antenatal Care Package write the date of 1st
		pre-natal visit
	Time Admitted	Write the time of admission
		Blank for Antenatal Care Package
	Date Discharged	WRITE the date of discharge
		For Antenatal Care Package write the date of last
		pre-natal visit
	Time Discharged	WRITE the time of discharge
		Blank for Antenatal Care Package
Part II,	Patient Disposition	TICK the appropriate box
item 4
Part II,	Transferred/referred	TICK the appropriate box
item 4f
		If patient is referred to another facility, write the
		name and address of the facility and reasons for
		referral
		*Claims for Antenatal Care Package (ANC01) and
		Referral Fee (59403) should have the name of the
		facility where the patient is referred to for
		delivery/further management
Part II,	Type of Accommodation	TICK appropriate box
item 5		Blank for Antenatal Care Package
Part II,	Admission Diagnosis/es	WRITE the admitting diagnosis
item 6
Part II,	Discharge Diagnosis	WRITE the diagnosis on discharge
item 7
	ICD 10 Code/s	WRITE the appropriate ICD 10 Code/s
		Codes for method and outcome of delivery must be
		included
	Related Procedures	Leave blank
	RVS Code	WRITE the applicable Package/RVS Code:
		Maternity Care Package: MCP01
		NSD: Package: NSD01
		Cesarean Section: 59513 or 59514 or 59620
		Breech extraction: 59411
		Vaginal delivery after CS: 59612
		NSD with BTL: 59402
		Antenatal Care Package: ANC01
		Intrapartum monitoring (w/o delivery): 59403
		Antenatal Care Package with Intrapartum
		monitoring. ANC02
		Newborn Care Package: 99432
		Insertion of Intra uterine device: 58300
		For No-scalpel vasectomy — Vasectomy,
		unilateral or bilateral: 55250
	Date of procedures	WRITE the corresponding date/s for the
		procedure/s
		*for claims for delivery (i.e., MCP, NSD, etc.)
		write the date of delivery
Part II,	Special consideration	For Claims for MCP and Antenatal Care Package:
item 8 c	MCP Package	WRITE the dates of at least 4 pre-natal visits on
		the spaces provided.
		Leave blank for other claims.
Part II,	Newborn Care Package	TICK the services that are provided
item 8 d		ATTACH the Filter Card Sticker for Newborn
		Screening Test in the space provided
Part II,	PhilHealth Benefits	WRITE the corresponding package/RVS Codes for
item 9		the benefits that will be claimed:
		Maternity Care Package: MCP01
		NSD Package: NSD01
		Cesarean Section: 59513 or 59514 or 59620
		Breech extraction: 59411
		Vaginal delivery after CS: 59612
		Antenatal Care Package: ANC01
		Intrapartum monitoring (w/o delivery): 59403
		Antenatal Care Package with Intrapartum
		monitoring: ANC02
		Newborn Care Package: 99432
		Insertion of Intra uterine device: 58300
		For No-scalpel vasectomy — Vasectomy,
		unilateral or bilateral: 55250
Part II,	Professional Fees	WRITE the accreditation number and the name of
item 10		Physician/midwife on the spaces provided
		AFFIX the signature of the Physician/midwife over
		his/her name then write the date of the space
		provided
Part III	Certification of	TICK first box (PhilHealth benefit is enough to
Section A	Consumption of Benefits	cover HCI and PF charges) if the patient did not
		have any out of pocket expense
		TICK second box the benefit was consumed but
		there is additional cost to the patient then
		accomplish tables a and/or b
Part III	Consent to Access Patient	PRINT the name of the patient and AFFIX his/her
Section B	Record/s	signature over the name
		WRITE the date when this was signed
		Should the patient was unable to sign, tick the
		appropriate boxes
Part IV	Certification of Health Care	PRINT the name of the authorized person to fill-up
	Institution	the claim and his/her designation. AFFIX his/her
		signature above the name.
		This person must review and verify all the entries
		before affixing his/her signature.

ANNEX C

Sample Claim Form 2

 

ANNEX D

Sample Copy of Mother's Book

ANNEX E

Waiver from Health Care Institution for Directly Filed Claims