REACHOUT FORUM 2023

August 02, 2023

Free Standing Dialysis Clinics
www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph
 REASONS OF
RETURN TO HOSPITAL (RTH)
CLAIMS

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 MOST COMMON RTH REASONS
1 Claim Form 4 XML Error
2 Discrepancies
3 Required Claim Form
4 Claim Form 4 not properly accomplished
5 Claim Form 2 not properly accomplished

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 REASONS OF
DENIED CLAIMS

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 MOST COMMON DENIAL REASONS
1 Denied due to non-compliance to previous request
2 Case not compensable
3 Patient not registered in database

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 UPDATED PHILHEALTH
CIRCULARS AND ADVISORIES

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 ALL CASE RATES
CIRCULARS AND ADVISORIES

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

PHILHEALTH CIRCULAR NO. 2023-0004
E-SOA For ACR Claims And Identified PhilHealth Benefits

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 SCOPE
This policy shall cover the ACR claims of PhilHealth members in all accredited
HF, excluding claims for COVID-19 Community Isolation Benefit Package (CCIBP),
COVID-19 Home Isolation Benefit Package (CHIBP), outpatient benefits, and Z
Benefits. PhilHealth shall disseminate separate policies for the submission of SOA for
the primary care and outpatient benefits and the Z Benefits.

The following identified outpatient benefits packages are also included in this policy:
 Outpatient HIV/ AIDS Treatment (OHAT);
 TB Dots Package;
 Outpatient Malaria Package; and
 Animal Bite Treatment Package

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph
www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph
www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph
 OCOO Memorandum 2023-155
In reference to the publication of PhilHealth Circular No. 2023-0004, please be
guided on the following:

a. All claims with admission dates starting February 1, 2023, shall be

accepted and processed based on existing policy. This shall include paid
and/or refiled claims.
b. PhilHealth will publish a revision of PhilHealth Circular No. 2023-0004 to
inform the effectivity date and implementation of the eSOA once
accredited health facilities (HFs) comply with the IT certification
requirements of the eSOA or at the most two (2) months from the
orientation of service providers on the enhanced eClaims system.

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

PHILHEALTH CIRCULAR NO. 2023-0009
Institutionalization Of 156 Hemodialysis Sessions

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 SCOPE
This PhilHealth Circular shall apply to PhilHealth members and their dependents
diagnosed with Chronic Kidney Disease Stage 5 (CKD5) who are registered in the
PhilHealth Dialysis Database (PDD).

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 POLICY STATEMENTS
A. Patients diagnosed with CKD5 on hemodialysis treatment shall be allowed
to avail of 156 HD treatment sessions per year based on the prescription of
their nephrologists.
B. All patients diagnosed with CKD5 shall be registered in the PDD in
accordance with PC No. 2016-0007, titled: PhilHealth Dialysis Database
(PDD).
C. The package rate for HD treatment is Php 2,600 per HD session, divided
between health facility (HF) and professional.

Package Rate HF Fee Professional Fee

Php 2,600 Php 2,250 Php 350

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 POLICY STATEMENTS
D. The HD benefits package includes the use of facility and dialysis machine,
PNF drugs as needed, IV solutions, supplies, dialyzer, and professional
fees.
E. The 45-day annual benefit limit shall not apply to the 156 HD benefits
package. In the event that the CKD5 patient on HD needs hospital
confinement, the HD session shall be filed separately and shall not overlap
with the inpatient claim.
F. Unused HD treatment sessions of the current year shall not be carried over
to the succeeding year.
G. The No Balance Billing (NBB) Policy, as stipulated under PC No. 2017-
0017, shall apply to healthcare services contemplated by this Circular.
H. Accredited HF providing services for HD shall be subject to the current
performance monitoring policy of PhilHealth.

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 POLICY STATEMENTS
I. Accredited HF shall comply with all the provisions in their Performance
Commitment and other rules and regulations governing PhilHealth
accreditation.
J. In case delays in filing of claims due to natural calamity or other fortuitous
events, the existing guidelines of PhilHealth on providing special privileges
to those affected by fortuitous events shall apply.
K. In order to educate the general public and increase their awareness of this
benefits package and to promote informed decision-making and
participation among patients, healthcare professionals and HF and other
stakeholders, marketing and promotional activities shall be undertaken
following the integrated marketing and communication plan of PhilHealth.

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 POLICY STATEMENTS
L. Random post-audits shall be conducted upon implementation of this
Circular to monitor, evaluate and revise the policy, as necessary.

In consultation and collaboration with relevant stakeholders, experts and

technical staff representing the Corporation, PhilHealth shall conduct the
policy review of this benefit package as necessary.

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 REPEALING CAUSE
This policy repeals PC No. 0024, s-2015: “New PhilHealth Dialysis Package
(Revision 1)”

“PhilHealth LHIO shall no longer issue

Certification of Benefit Limit Utilization”

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 PHILHEALTH
ADVISORY
NO. 2023-0012

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 PHILHEALTH
ADVISORY
NO. 2023-0017

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 PHILHEALTH
ADVISORY
NO. 2023-0020

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 PHILHEALTH
ADVISORY
NO. 2023-0021

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 PHILHEALTH
ADVISORY
NO. 2023-0023

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 COVID - 19
CIRCULARS AND ADVISORIES

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 PHILHEALTH
ADVISORY
NO. 2023-0005

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

PHILHEALTH CIRCULAR NO. 2023-0003
Full Financial Risk Protection
For Filipino Health Workers With COVID-19 (Revision 1)

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 PHILHEALTH CIRCULAR NO. 2023-0001
Benefit Packages For Inpatient Management Of Confirmed
Coronavirus Disease (COVID-19) And Clarification Of
Coverage Of Probable Cases (Revision 1)

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 PHILHEALTH
ADVISORY
NO. 2023-0015

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 OHAT / Z-BENEFITS
CIRCULARS AND ADVISORIES

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 PHILHEALTH
ADVISORY
NO. 2023-0004

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 PHILHEALTH
ADVISORY
NO. 2023-0006

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 PHILHEALTH
ADVISORY
NO. 2023-0010

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

PHILHEALTH CIRCULAR NO. 2023-0005
Z Benefits Package For Colon And Rectal Cancers
(Revision 1)

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

PHILHEALTH CIRCULAR NO. 2023-0007
Z Benefits For Selected Orthopedic Implants Revision 2

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

 REACH US AT:

BENEFIT ADMINISTRATION SECTION

OFFICIAL EMAIL ADDRESS
reachout.proqc@philhealth.gov.ph
CLAIMS PROCESSING - 8332 3026

RTH/DENIED - 8332 3027

ACCOUNTING - 8332 3028

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph

www.philhealth.gov.ph PhilHealthOfficial teamphilhealth actioncenter@philhealth.gov.ph