[ PHILHEALTH CIRCULAR NO. 001, January 17, 2012 ]
ONLY SURGICAL PROCEDURES DURING MEDICAL MISSIONS SPONSORED BY GOVERNMENT FUNDS IN ACCREDITED GOVERNMENT FACILITIES ARE COMPENSABLE
For the purpose of this circular, surgical/medical mission is defined as an outreach program for humanitarian non-profit purposes that provide medical and/or surgical services (including medicines, ancillary procedures, surgical interventions, and professional services) at no cost to people who have limited or no means to pay (Sources: PhilHealth Circular No. 19, s. 2007, DOH AO No. 179, s. 2001, the Philippine Academy of Ophthalmology, Inc.)
Based on the abovementioned definition, it is presumed that all the services provided in the mission are already covered and paid for by the sponsor/s or donor/s. As such, PhilHealth shall dispose of claims arising from surgical/medical missions as follows:
All doctors of foreign nationalities who participated and/or performed surgeries in a surgical medical mission should not file, by themselves or through other doctors, claims for reimbursement of benefits for PhilHealth members or dependents. Otherwise, they shall be reported to the Department of Health (DOH) and Professional Regulatory Commission (PRC) for appropriate action.
PhilHealth shall regulary conduct utilization review, validate admissions and evaluate the availment of benefits in accredited facilities. This shall be done in order to monitor the quality of care and to ensure the proper implementation of issuances/policies governing missions involving PhilHealth members/patients as well as other pertinent rules and regulations of the Corporation.
Detection of claims under medical mission or pretext of such mission shall cause withholding of reimbursement subject to further validation. Claims confirmed/validated to be part of a medical mission shall be denied, while reimbursements for other previously paid claims covered by the same medical mission should be refunded by the health care provider to the Corporation or charged to the future claims of the provider notwithstanding legal sanctions. Claims confirmed to have not been done under a medical mission shall be processed accordingly.
All other issuances inconsistent herewith are hereby repealed and modified accordingly. This Circular shall be effective fifteen (15) days from the date of publication in the official gazette and any newspapers of general circulation.
Adopted: 17 January 2012
(SGD.) DR. EDUARDO P. BANZON
President and CEO
Based on the abovementioned definition, it is presumed that all the services provided in the mission are already covered and paid for by the sponsor/s or donor/s. As such, PhilHealth shall dispose of claims arising from surgical/medical missions as follows:
1. Claims involving surgical procedures, including but not limited to cataract extractions (e.g., Phacoemulsification), cleft palate (e.g. Cheiloplasty), ingrown toenail (e.g., excision of nail), or circumcisions, conducted in private facilities during medical/surgical missions shall not be compensated.
2. Claims involving surgical procedures done during medical missions sponsored by the National Government (NG) or Local Government Unit (LGU) conducted in any PhilHealth-accredited government facility (i.e.; Ambulatory Surgical Care Clinics, Level II, III and IV hospitals) shall be compensated provided that the professional fees are pooled for distribution to all facility personnel and subject to provisions stipulated in Rule VIII (Payment of Claims) Section 7 of Implementing Rules and Regulations of RA 7875, as amended by RA 9241.
All doctors of foreign nationalities who participated and/or performed surgeries in a surgical medical mission should not file, by themselves or through other doctors, claims for reimbursement of benefits for PhilHealth members or dependents. Otherwise, they shall be reported to the Department of Health (DOH) and Professional Regulatory Commission (PRC) for appropriate action.
PhilHealth shall regulary conduct utilization review, validate admissions and evaluate the availment of benefits in accredited facilities. This shall be done in order to monitor the quality of care and to ensure the proper implementation of issuances/policies governing missions involving PhilHealth members/patients as well as other pertinent rules and regulations of the Corporation.
Detection of claims under medical mission or pretext of such mission shall cause withholding of reimbursement subject to further validation. Claims confirmed/validated to be part of a medical mission shall be denied, while reimbursements for other previously paid claims covered by the same medical mission should be refunded by the health care provider to the Corporation or charged to the future claims of the provider notwithstanding legal sanctions. Claims confirmed to have not been done under a medical mission shall be processed accordingly.
All other issuances inconsistent herewith are hereby repealed and modified accordingly. This Circular shall be effective fifteen (15) days from the date of publication in the official gazette and any newspapers of general circulation.
Adopted: 17 January 2012
President and CEO