The Novel Influenza A (H1N1) outbreak is evolving rapidly and affecting different regions. Its phases include the mild form of influenza like illness (ILI) to the more severe and complicated forms. To mitigate the direct medical cost for the medical treatment of complicated human cases of novel Influenza A (H1N1), PhilHealth through Board Resolution Number 1260, s. 2009 approved a new benefit for PhilHealth members and dependents infected with the Influenza A (H1N1) virus with complication or co-morbidities requiring hospitalization.

Availment of the Influenza A (H1N1) is governed by the following rules:

A. INFLUENZA A (H1N1) BENEFIT

1. The benefit is limited to PhilHealth members and dependents with novel swine-origin influenza A (H1N1) virus infection confirmed by the Department of Health (DOH).

2. Hospitalization benefit for PhilHealth members and dependents is set at a maximum of 75,000 pesos.

3. The benefit is set at a maximum of 150,000 pesos for qualified health care workers (HCWs), who:

a. Rendered service in a DOH-designated hospital for Influenza A (H1N1) and
b. Contracted the disease while performing their duties and or caring for an Influenza A (H1N1) patient as certified or attested by DOH

• Qualified dependents of HCWs who also contracted the disease shall be provided the benefit enumerated in Section A.2 of this Circular.

4. The Influenza A (H1N1) benefit covers payment for the following:

   

Room and Board	Members/Dependents	HCW
	1,500 per day Max = 10,000	1,500 per day Max = 20,000
Drugs/Medicines X-ray, Laboratory and Others -Supplies including personal protective Equipments (PPE) - Transfer services (Ambulance)	50,000	100,000
Operating Room Fee Professional Fee	1,000 per day Max = 15,000	1,000 per day Max=30,000

5. The use of operating room complex and other medically-necessary care may also be covered provided that the total cost shall not exceed the amount of P75,000.00 and 150,000 for HCW.

6. The benefit may be availed by all qualified PhilHealth members and dependents including cases confined abroad.

7. Except for confinements abroad, this benefit covers only cases admitted in hospitals designated by DOH as referral centers (national, sub-national and satellite) for Influenza A (H1N1) and other emerging and re-emerging diseases.

8. Patients admitted in private hospitals may be covered for Influenza A (H1N1) provided that confirmatory tests were coordinated with or confirmed by the Research Institute for Tropical Medicine (RITM) or with DOH Center for Health Development (DOH-CHD) or other DOH certified laboratory.

B. EXCLUSIONS

Excluded from this package are the following:

a. Probable and case under observation of Influenza A (H1N1)

b. All cases of Influenza A (H1N1) admitted in hospitals not designated by DOH

c. Influenza-like illnesses (ILI) and

d. Other seasonal outbreaks of Influenza by established flu virus (e.g., H1N2, H5N1)

• The above-mentioned exclusions (2.a-2.d) are covered by the regular hospitalization benefit of PhilHealth based on the case type of the illness.

e. Systematic Acute Respiratory Syndrome caused by SARS CoV that is covered by the SARS package ( RVS Code 99501)

f. Avian influenza A virus (H5N1) and other subtypes of avian influenza that are covered by the avian influenza (bird flu) package ( RVS Code 99502)

C. BENEFIT AVAILMENT

1 . All claims applications for the Influenza A (H1N1) are required to indicate ICD-10 codes in Claim Form 2. Claim form with no ICD-10 codes will not be processed by PhilHealth.

The following are the ICD-10 codes:

CODE	DESCRIPTION
Influenza due to identified influenza virus
J10.0	Influenza with pneumonia, influenza virus identified
J10.1	Influenza with other respiratory manifestations, influenza virus identified
J10.8	Influenza with other manifestations, influenza virus identified

2. To facilitate processing of this benefit, the following Relative Value Scale (RVS) Code for the availment of Influenza A (H1N1) shall be as follows:

CODE	DESCRIPTIVE TERMS	RVU
99504	Influenza A (H1N1) Package; for members and dependents	Package
99505	for qualified health care workers	Package

3. The following documents are required for filing:

a. PhilHealth Claim Form 1
b. PhilHealth Claim Form 2
c. Member Data Record (MDR)
d. Statement of Account
e. Certification from DOH/RITM and other DOH certified laboratories that patient is a confirmed Influenza A (H1N1) case based on adopted criteria (e.g., positive confirmatory laboratory test-viral culture or PCR), or DOH list of Influenza A (H1N1) patients; for patients confined abroad, they are required to submit copy of confirmatory test for Influenza A (H1N1) duly certified by the Ministry of Health or its equivalent.
f. Certification from DOH that hospital is designated as a referral hospital for Influenza A (H1N1)
g. For qualified HCWs, a certification from DOH containing the provisions enumerated in Section I.2 of this Circular
h. Result of culture and sensitivity test for confirmed cases with secondary infections
i. Other supporting documents as may be required by PhilHealth (e.g., proof of contribution, PhilHealth membership ID)

4. In cases where members are required by hospitals to buy drugs, medicines and supplies or requested to seek out other necessary services (laboratory procedures) from other facilities, reimbursement to members is allowed, provided that:

a. The facility cannot provide the necessary items and services covered by the benefit.
b. These items and services are used during confinement.
c. Official receipts and/or other purchase documents are submitted.
d. The reimbursement to members depends on the actual cost of the receipts submitted but not more than the difference between the maximum benefit and the facility reimbursement
e. The facility acknowledges that the cost of benefits and services it provided is less than the maximum benefit by appropriately filling-up item 12 of Part I of Form 2.

5. Current eligibility rules apply to avail of this benefit (e.g Individually paying members (IPM) should have at least three months of premium payment within the immediate 6 months prior to the month of admission).

6. Availment of the Influenza A (H1N1) Package shall be charged the total number of days confinement against the 45 day annual limit.

7. In addition, availment of this package is also covered by the rule on single period of confinement; meaning, only one (1) Influenza A (H1N1) Package shall be paid within 90 days.

D. EFFECTIVITY

This Circular shall take effect for all admissions starting May 1, 2009.

All other provisions of previous issuances which are not inconsistent with this Circular remain in full force and effect.

Please be guided accordingly.

Adopted: 04 June 2009

(SGD.) DR. REY B. AQUINO
President and CEO