PhilHealth Circular No. 19, s. 2004, states that accredited hospitals are obliged to cover room and board, drugs and medicines, diagnostics, operating room fee and all other necessary care within the amount of the package (P2,500.00) benefit limit for the facility but excluding the P2,000.00 for professional fee for a total package rate of P4,500.00 per Normal Spontaneous Delivery (NSD).

There are circumstances however, where patients are asked to buy drugs/medicines and supplies or engage other services of other facilities. In such cases, and where the providers claim for facility charges is less than the benefit package, reimbursement to member will be allowed subject to the following conditions:

1. The accredited hospital cannot provide the above items and other necessary services covered by the package.

2. The reimbursement will depend on the actual cost but should not be higher than the difference between the claim of the facility and the P2,500.00 package

3. The medicines, diagnostics, supplies and other necessary services were used for NSD during the confinement.

4. The accredited health facility acknowledges that the cost of the medicines, diagnostics and all other necessary services it provided was less than the benefit package of P2,500.00 (for hospital charges).

5. Official receipts and other documentation of the purchases are submitted.

The reimbursements for the difference shall be in accordance with existing rules on claims payment.

This circular does not preclude the facilities' obligation to provide for all the necessary services for NSD Package enumerated above. Compliance with PhilHealth Circular 19, s. 2004 particularly the provision of drug/medicines, and supplies shall be continuously monitored by PhilHealth's Regional Offices and such shall be among the basis for the renewal of accreditation.

This circular shall be applicable for all claims received starting September 1, 2005 and claims currently in process except those already approved for payment.

Adopted: 9 Aug. 2005

(SGD.) LORNA O. FAJARDO, CESO III
Officer-in-Charge
Office of the President and Chief Executive Officer