Vision, Mission, Core Values

of Philhealth
Vision
"Bawat Filipino, Miyembro,
Bawat Miyembro, Protektado,
Kalusugan ng Lahat, Segurado"
Mission
"Benepisyong Pangkalusugang Sapat at De-kalidad para sa Lahat"
Core Values
Integridad
Inobasyon
Agarang Serbisyo
Taos-Pusong Paglilingkod
Pagmamalasakit
Angkop na Benepisyo
Panlipunang Pagkakabuklod
 The National Health
Insurance Program (NHIP)

RA 7875 –
Feb. 14, 1995

RA 9241-
Feb. 10, 2004

RA 10606 –
June 19, 2013
 [REPUBLIC ACT No. 7875]
• This Act shall be known as the “National
Health Insurance Act of 1995”
• AN ACT INSTITUTING A NATIONAL HEALTH
INSURANCE PROGRAM FOR ALL FILIPINOS
AND ESTABLISHING THE PHILIPPINE HEALTH
INSURANCE CORPORATION FOR THE PUR-
POSE.
 [REPUBLIC ACT No. 9241]
• Implementing Rules and Regulations of the National Health
Insurance Act of 1995 (Republic Act No. 7875 As Amended by
Republic Act No. 9241.
• declares that the State shall adopt an integrated and
comprehensive approach to health development which shall
endeavor to make essential goods, health and other social
services available to all the people at affordable cost. Priority
for the needs of the underprivileged, sick, elderly, disabled,
women and children shall be recognized. Likewise, it shall be
the policy of the State to provide free medical care to
paupers.
 [REPUBLIC ACT No. 10606]
• AN ACT AMENDING REPUBLIC ACT NO. 7875, OTHERWISE KNOWN
AS THE “NATIONAL HEALTH INSURANCE ACT OF 2013′′, AS
AMENDED, AND FOR OTHER PURPOSES
• It is hereby declared the policy of the State to adopt an integrated
and comprehensive approach to health development which shall
endeavor to make essential goods, health and other social services
available to all the people at affordable cost and to provide free
medical care to paupers. Towards this end, the State shall provide
comprehensive health care services to all Filipinos through a
socialized health insurance program that will prioritize the health
care needs of the underprivileged, sick, elderly, persons with
disabilities (PWDs), women and children and provide free health
care services to indigents.
What is Accreditation?
- a process whereby the qualifications and capabilities
of health care providers are verified in accordance with
the guidelines, standards and procedures set by the
Corporation.
Why the need for accreditation?
• To participate in the National Health Insurance
Program.
• To assure that health care services rendered by them
are of the desired and expected quality.
Professional Providers
 Who may apply?
• Physicians
• Dentists
• Midwives
• Registered Nurses
 When to apply?
• Initial or Re-accreditation - Anytime
 Renewal
• Not later than 45 days prior to their birthday to ensure their
continuous accreditation to NHIP
 Institutional Providers
 Who may apply?
• Hospitals
• Ambulatory Surgical Clinics (ASCs)
• Free Standing Dialysis Clinics (FSDCs)
• Rural Health Units/Health Centers (RHUs/HCs) as providers of the Out Patient Benefit
Package for sponsored members of PHIC
• Maternity Care Clinics - for low risk, normal spontaneous deliveries
• Anti-TB/DOTS Clinics
 When to apply?
• Initial or Re-accreditation - ANYTIME
• Renewal
– Hospitals, ASCs and FSDCs:
January 1 to 31 of the succeeding year
– OPB, Maternity Care and Anti-TB/DOTS Package Providers:
September 1 - 30 of the current year.
 Sino-sino ba ang
PhilHealth Member?
Lahat ng Pilipino ay dapat Miyembro ng PhilHealth,

Formal Informal Indigent Sponsored Pensioner at

Economy Economy (the poor) Retiree
 Who are the PhilHealth Members?

1. Government employees
2. Private employees
3. All other workers rendering services, whether
in government or private offices such as job
order contractors, project-based contractors,
and the like
4. Owners of micro enterprises
5. Owners of small, medium and large
enterprises
6. Household helpers
7. Family Drivers
Formal
Economy
Benefits of Philhealth:
This section features a variety of comprehensive health
care services -from basic primary care to catastrophic packages
to provide members and their families with the information they
need on benefits and benefits availment. It includes eligibility
requirements, coverage, general guidelines for specific diseases
and selections criteria among others.
Entitlement to Benefits
{at least3 consecutive monthly contributions
within the immediate 6 months prior to
admission
the 45-days allowance for room and board has
not been consumed yet
confinement in an accredited hospital of not
less than 24 hours
• room and board {services of health care
professionals{diagnostic, laboratory, and
othermedical examination services{use of
surgical or medical equipment &
 MANDATED BENEFITS
(Inpatient Hospital Care)
• room and board
• services of health care professionals
• diagnostic, laboratory, and othermedical examination
services
• use of surgical or medical equipment & facilities
• prescription drugs and biologicals
-subject to the limitations stated in Section
• inpatient education packages
 MANDATED BENEFITS
(Outpatient Hospital Care)
• diagnostic, laboratory, and other medical
examination services
• personal preventive services{prescription drugs and
biologicals (subject to the limitations set in Section
37)
• limited to drugs in the Philippine National Drug
Formulary and other PhilHealth Board approved
drugs
• services of health care professionals
 EXCLUSIONS BUT
• Non-prescription drugs and devices
• Alcohol abuse or dependency treatment
• Cosmetic surgery
• Optometric services
• Fourth and subsequent normal obstetrical
deliveries
• Cost-ineffective procedures as be defined by
the Corporation BUT may be included by the
Board after actuarial studies
 Exception to the 24 hr
Confinement
• Emergency case as defined by PhilHealth
• Patient died
• Patient was transferred to another hospital
 Availment Procedures
1. Member accomplishes PhilHealth Claim Form
2. Member submits the accomplished PhilHealth
Claim Form 1 together with the Proof of
Contribution (+ supporting documents) payment
and a copy of his PhilHealth number card to the
hospital Billing Section
3. The hospital will deduct PhilHealth benefits from
hospital bill prior to discharge of thepatient. The
hospital will accomplish PhilHealth Claim Form 2
and submit it togetherwith the PhilHealth Form 1 to
any PhilHealth office for reimbursement.
 Claims Prescription Period
Guidelines
 All claims for payment of services rendered shall be
filed within 60 calendar days fromthe date of
discharge of the patient.
 All claims returned for completion of requirements
shall be re-filed within 60calendar days from receipt
of notice.
 All requests for payment adjustments must be made
within 60 days from date of receipt of check payment
or of the benefit payment notice.
 Confinement in a Non-Accredited
Hospital is possible IF :
• The case is Emergency
• The Hospital has a current Department of
Health(DOH) License
• Transfer/referral to a PhilHealth accredited
hospital is physically impossible.
 CLAIM BENEFITS for
CONFINEMENT ABROAD
o Entitlement to Benefits:
- Member or his/her qualified dependents
- Confinement/ Surgery or OPD Benefits
o Benefit & Claims Filing
- 180 calendar days fr.date of discharge
- always payable to member
-based on applicable benefit schedule, case
type for a Tertiary level hospital
 CONFINEMENT ABROAD cont’d...
• Documentary Requirements:
1. PH Form 1
2. Photocopy of MDR
3. Medical certificate/Abstract (with English
translation
4. SOA with itemized charges and/orORs (proof
of hospital bill and PF)
 CURRENT PHILHEALTH BENEFIT
PACKAGE
• DAY or AMBULATORY SURGERY PROCEDURES and
SURGERIES
• General , Eye, ENT, Urological, Gynecologic,
Orthopedic and other surgeries
• ALSO INCLUDES: DIALYSIS CARE for End Stage Renal
Disease{CHEMOTHERAPY and RADIOTHERAPY for
Cancer cases
• MATERNITY CARE up to 3rdNormal Deliveries (NSD)
• NEWBORN CARE PACKAGE (NCP)
Online Services

• Considered the newest addition to our menu

of electronic services, this section features the
different access points that our stakeholders
can tap to transact with us online. It includes
registration, premium payment and reporting
and even locating our offices nationwide.
REGISTRATION PROCEDURE

EMPLOYED SECTOR
(GOVERNMENT AND PRIVATE)

COMPANY MEMBER-EMPLOYEE
REGISTRATION REGISTRATION

ER1  PMRF
Attachments: for employees without
PhilHealth Identification
 SEC / DTI / CDA
Number (PIN)
Registrations
 License to Operate  ER2
List of newly hired employees
(with and without PIN)
CONTRIBUTIONS
& REPORTING
Magkano ang premium?
Formal Economy
Monthly Salary Premium Personal Employer
Range Rate Share (PS) Share (PS)
Php 8,999.99 and
Php 200 Php 100.00 Php 100.00
below
Php 8,000.00 –
2.5% 1.25% 1.25%
34,999.99
Php 35,000.00 and Php 875.00 Php 437.50 Php 437.50
above

employer

employee
 OBLIGATIONS OF THE EMPLOYER (Rule III, Section 15 of RA 10606)

All government and private employers are required to:

a. Register their employees and their qualified dependents by submitting a list of

their employees complete with their salary base and other documents as may
be required.

b. Report to the Corporation its newly-hired employees within 30 calendar days

from assumption to office.

c. Give notice to the Corporation of an employee’s separation within 30 calendar

days from separation.

d. Keep true and accurate work records for such period and containing such
information as the Corporation may prescribe.

e. Allow the inspection of its premises including its books and other pertinent
records.
 PAYMENT OF PREMIUM CONTRIBUTIONS (Rule III, Section 18 of RA 10606)

b. The monthly premium contribution of employed members shall be remitted by the

employer on or before the date prescribed by the Corporation.

c. The remittance of premium contribution by the employer shall be supported by a

Remittance List to be submitted regularly to the Corporation.

d. The failure of the employer to remit the required contribution and to submit the required
remittance list shall make the employer for reimbursement of payment of properly filed
claim in case the concerned employee or dependent/s avails of Program benefits, without
prejudice to the imposition of other penalties as provided for in this Rules.

f. Failure and/or refusal of the employer to deduct or remit the complete employees’ and
employer’s premium contribution shall not be a basis for denial of a properly filed claim.
In such a case, the Corporation shall be entitled to reimbursement of claims paid from the
erring or negligent employer, without prejudice to the latter’s prosecution and other
liabilities, as may hereafter be provided by this Rules.
 DEADLINE OF PAYMENT and
Re-imposition of Interest on Employer’s Non- and/or
Late Remittances of PhilHealth Premium
Contributions

Applicable to all employers and following shall be observed:

Monthly premium contributions shall be

1 remitted on or before the month following the
applicable period

PENs ending in 0-4 Every 11th -15th day

PENs ending in 5-9 Every 16th – 20th day
 In case the deadline for the payment of
2 premium falls on a weekend or holiday,
payment shall be made on the next working
day

All premium contribution payments beyond

3 the aforementioned shall be charged two
percent (2%) monthly interest

** Reporting schedule is within 5 days after the payment deadline

 Over-the-Counter (Banks)
1. Asia United Bank 19. One Network Bank
2. Banco de Oro (former EPCIB 20. Penbank, Inc.
branches) 21. Philippine Business Bank
3. Bank of Commerce 22. Philippine National Bank(including
4. Bank One Savings & Trust Corp. former Allied Bank branches)
5. Camalig Rural Bank 23. Postalbank, A Savings Bank
6. Century Rural Bank 24. Philippine Veterans Bank
7. Century Savings Bank 25. Planters Development Bank
8. China Bank Savings 26. Rural Bank of Bambang
9. China Bank Corp 27. Rural Bank of Jose Panganiban
10. Citystate Savings Bank 28. Rural Bank of Sta. Catalina
11. Country Builders Bank, Inc. 29. RCBC Savings Bank
12. Development Bank of the Phils 30. Rizal Commercial Banking Corp.
13. East West Rural Bank 31. Robinsons Bank Inc.
14. Enterprise Bank 32. Saviour Rural Bank
15. Land Bank of the Phils. 33. Union Bank of the Phils.
16. Maybank of the Philippines 34. United Coconut Planters Bank
17. Metropolitan Bank & Trust Co. 35. UCPB Savings Bank
18. Moneymall Rural Bank Note: OTC Banks have no service fee
 Non-Banks OVERSEAS
1. CIS Bayad Center* 1. Bank of Commerce***
2. Mlhuillier* 2. Development of the Philippines***
3. SM Retail, Inc.* 3. I-Remit***
4. Philippine Postal Corporation** 4. Land Bank of the Philippines***
5. Local Government Unit** (PROs 5. Philippine Veterans Bank***
CAR, 2, 4A,4B, 5, 6, 8, 10 & 12) 6. Ventaja Corporation***
*Convenience Fee (paid by payors)
**Service Fee (paid by PhilHealth)
***Overseas remittance fee (paid by OFW)

E-Pay
1. E-Gov/Bancnet
(AUB,CBC,CTBC,DBP,EWB,PNB,RCBC,PVB)
2. Bank of the Philippine Islands
3. Citibank, N.A.
4. Security Bank Corporation
5. Union Bank of the Philippines
Note: E-Pay ACAs have no service fee
Electronic Premium Remittance System
(EPRS)
v.3.2
 • EPRS is an acronym
for Electronic
Premium Remittance
System
What is EPRS?
• A web-based
application designed
for PhilHealth
employers, to use in
reporting premium
contributions
 • Register to secure a
How to get user account and
password
access to the
 Registration can be done
EPRS? through walk-in to
nearest
PRO/Branch/LHIOs and
fill-out the POAF*
 or Electronically:
http://www.philhealth.gov.ph/onlineservices
and look for EPRS - ePOAF link

*PhilHealth Online Access Form (POAF)

 • Please check your
Have filled-out email and carefully
the follow the instruction.
POAF/submitte
 You will be required to
d registration confirm your identity
through ePOAF,  Membership clean-up
what’s next?  Install the SSL Certificate
 User account and
password activation
What’s inside
the EPRS?
 web site : www.philhealth.gov.ph

www.twitter.com@teamphilhealth

www.facebook.com/philhealth

address: actioncenter@philhealth.gov.ph

45
 References:

https://www.philhealth.gov.ph/
https://www.doh.gov.ph/node/238
Thank You