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    Philhealth Circular: Philippine Health Insurance Corporation

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    Toche Doce
    The Philippine Health Insurance Corporation (PhilHealth) issued Circular 034-2015 with supplemental guidelines and clarifications for pneumonia claims: 1) Claims for moderate or high-risk pneumonia in patients aged 0-18 must have a minimum 4 day (96 hour) confinement or will be denied. This applies to claims from December 7, 2015 onward. 2) Claims for patients discharged against medical advice or who left without permission before 4 days will also be denied, starting December 7, 2015. 3) The 4 day minimum confinement requirement applies to all moderate or high-risk pneumonia claims for patients aged 19 and older, effective September 15, 2015.

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    Philhealth Circular: Philippine Health Insurance Corporation

    Uploaded by

    Toche Doce
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    The Philippine Health Insurance Corporation (PhilHealth) issued Circular 034-2015 with supplemental guidelines and clarifications for pneumonia claims: 1) Claims for moderate or high-risk pneumonia in patients aged 0-18 must have a minimum 4 day (96 hour) confinement or will be denied. This applies to claims from December 7, 2015 onward. 2) Claims for patients discharged against medical advice or who left without permission before 4 days will also be denied, starting December 7, 2015. 3) The 4 day minimum confinement requirement applies to all moderate or high-risk pneumonia claims for patients aged 19 and older, effective September 15, 2015.

    Original Description:

    PhilHealth Circular No. 34 series of 2015. Community-Acquired Pneumonia

    Original Title

    Circ034-2015 - CAP Supplemental

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    The Philippine Health Insurance Corporation (PhilHealth) issued Circular 034-2015 with supplemental guidelines and clarifications for pneumonia claims: 1) Claims for moderate or high-risk pneumonia in patients aged 0-18 must have a minimum 4 day (96 hour) confinement or will be denied. This applies to claims from December 7, 2015 onward. 2) Claims for patients discharged against medical advice or who left without permission before 4 days will also be denied, starting December 7, 2015. 3) The 4 day minimum confinement requirement applies to all moderate or high-risk pneumonia claims for patients aged 19 and older, effective September 15, 2015.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    46 views2 pages

    Philhealth Circular: Philippine Health Insurance Corporation

    Uploaded by

    Toche Doce
    The Philippine Health Insurance Corporation (PhilHealth) issued Circular 034-2015 with supplemental guidelines and clarifications for pneumonia claims: 1) Claims for moderate or high-risk pneumonia in patients aged 0-18 must have a minimum 4 day (96 hour) confinement or will be denied. This applies to claims from December 7, 2015 onward. 2) Claims for patients discharged against medical advice or who left without permission before 4 days will also be denied, starting December 7, 2015. 3) The 4 day minimum confinement requirement applies to all moderate or high-risk pneumonia claims for patients aged 19 and older, effective September 15, 2015.

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    Republic oftile Pllilippines

    PHILIPPINE HEALTH INSURANCE CORPORATION


    Citystate Centre, 709 Shaw Boulevard, Pasig City
    Call Center (02) 441-7442 Trunkline (02) 441-7444
    www.philbealth.gov.ph
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    PHILHEALTH CIRCULAR
    No. 0 3tf - 2{)15

    TO ALL PHILHEALTH MEMBERS, ACCREDITED HEALTH


    CARE PROVIDERS (HCPs), PHILHEALTH REGIONAL
    OFFICES (PROs), AND ALL OTHERS CONCERNED

    SUBJECT Supplemental Guidelines and Clarifications on some of the


    Policies Related to Pneumonia- Moderate Risk and Pneumonia-
    High Risk.

    I. SPECIFIC GUIDELINES
    A. The following are supplemental guidelines for Pneumonill-moderate risk and
    Pneumonill~high risk:
    POLICY PROVISIONS EFFECTIVITY
    Claims for Pneumonill-moderate risk or Pneumonill-
    high risk of patients with age 0 to 18 years and 364 days Claims for admissions
    shall only be reimbursed if the length of stay is at least starting
    4 days (96 hours). Otherwise, the claim shall be denied. December 7, 2015

    Claims for Pneumonill-moderate risk or Pneumonill-


    high risk with disposition of discharge against medical Claims for admissions
    advice (DAMA), home against medical advice (HAMA) starting
    or absconded with less than 4 days (96 hours) December 7, 2015
    confinement shall be denied.

    B. The following are clarifications/reiterations on some of the policies related to


    Pneumonill-moderate risk or Pneumonill-high risk:

    1. The requirement of at least 4 days (96 hours) confinement shall apply to all claims for
    Pneumonill-moderate risk or Pneumonill-high risk of patients 19 years old and above.
    Otherwise, it shall be denied. This became effective for admissions starting
    September 15, 2015.

    2. Claims for Pneumonia-moderate risk or Pneumonill-high risk wherein the patient


    expired and with length of stay of at least 24 hours but less than 4 days (96 hours),
    regardless of the age of the patient shall be reimbursed the full case rate amount as
    applicable following the existing rules on reimbursement

    3. Claims for confinements of less than 24 hours (mcluding confinements for


    Pneumonill-moderate risk or Pneumonill-high risk) where the patient expired shall
    still be reimbursed as resuscitation package following the existing rules of the
    Corporation.

    Page 1 of2

    You!D www.youtube.com/teamphilhealth ~ actioncenter@philhealth.gov.ph


    •>

    4. Provisions stipulated in Phi!Health Circnlar 23 s-2015: Policy Statements on the


    Diagnosis, Empiric Management, and Prevention of Commnnity-Acqnired
    Pneumonia (CAP) in Immunocompetent Adults as Reference by the Corporation in
    Ensuring Quality of Care shall serve as a guide to health care practitioners. However,
    specific provisions maybe explicitly stated to affect reimbursement i.e denial of
    claims for Pneumonia-moderate risk or Pneumonia-high risk with less than 4 days
    confinement.

    5. Paid claims prior to the effectivity of the requirement of at least 4 days confinement
    for Pneumonia-moderate risk or Pneumonia-high risk shall be subjected to
    monitoring/validation by the Corporation pursuant to Phi!Health Circnlar 31, s-2014
    : Health Care Provider Performance Assessment System (HCP PAS).

    II. REPEALING CLAUSE

    All provisions of previous issuances, circnlars, and directives that are inconsistent with any
    of the provisions of this Circnlar for this particular circumstance wherein the same is
    exclusively applicable, are hereby amended, modified or repealed accordingly.

    III. SEPARABILITY CLAUSE

    In the event that a part or provision of this Circnlar 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.

    IV. EFFECTIVITY

    This Circnlar 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.

    Page2of2

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