Pursuant to PhilHealth Board Resolutions Nos. 486 and 501 series of 2002 and to properly guide all concerned in the implementation of the New PhilHealth Maternity Care Package for normal spontaneous delivery, PhilHealth hereby issue its implementing guidelines for your reference effective to all discharges as of May 1, 2003.

BENEFIT PACKAGE:

1. The new PhilHealth Maternity Care Package for normal spontaneous delivery (NSD) utilizes a case payment scheme in claims reimbursement. The Relative Value Unit (RVU) assigned for these procedures (Relative Value Scale code number 59409) shall no longer apply.
   
   
2. Pursuant to PhilHealth Board Resolution No. 501, this package shall only be limited to the first two (2) normal deliveries.
   
   
3. A case rate of 4,500 pesos shall be paid to accredited health care providers regardless of hospital category and length of hospital stay. Even patients managed for less than 24 hours are still eligible for this package.
   
   
4. The case rate shall be divided to 2,000 pesos for the health professional and 2,500 pesos for the health facility. The payment for the health facility is expected to cover for the necessary room and board, drugs and medicines, diagnostics, operating room and all other medically necessary care except for professional fees.
   
   ELIGIBILITY
   
   
5. An individually paying program member (IPP) should comply with the rule on sufficient regularity of premium contributions and should have at least nine (9) months or three (3) quarters of premium payments in the immediate twelve (12) months prior to the normal spontaneous delivery. However, IPP enrolled as a group or through the IPP-OWWA program and for all other types of membership need not satisfy the sufficient regularity rule and are governed by current eligibility requirements.
   
   CLAIMS FILING
   
   
6. The new PhilHealth Package Claim Form No. 4 shall be used in filing claims for the new PhilHealth maternity Care Package. Until this new claim form is distributed to providers, they may still use PhilHealth Claim Form No. 2. However, they shall no longer put itemized charges on Box No. 12 of Part I, Part III and Part IV. Only the total actual charges and PHIC benefit claimed shall be indicated in Box No. 12 of Part I. Example:
   
   CLAIM FORM 2 Part I
   
   

   12. HOSPITAL/AMBULATORYSERVICES			ACTUAL HOSPITAL/ CHARGES	BENEFIT CLAIM
   	a. Room and Board
   	b. Drugs and Medicines
   	c. X-ray/Lab Test/Others
   	d. Operating Room Fee
   	e. Medicines bought and laboratory performed outside hospital during confinement period
   		TOTAL	P2,500	2,500	0.00

   
   
7. No payment for anesthesiologist's professional fee shall be paid for NSD.
   
   
8. Given that reimbursement of providers shall be case-based, official receipts for drugs, medicines, and supplies bought by the member in the pharmacy or outside the facility, which are used during the confinement period must be submitted together with the PhilHealth claim forms. The total amount paid for these items shall be deducted to the case rate amount and shall be made payable to the member.
   
   
9. For continued hospital stay due to conditions not related to delivery, such as hypertensive and diabetes-related conditions, the hospital may seek to be reimbursed based on the case classification of the condition.
   
   In this case, the hospital is required to list down all reimbursable items for the claims to be processed. For deliveries complicated by the aforementioned medical conditions, PhilHealth benefit for operating room shall be as follows: 385 pesos for primary hospitals; 1,140 pesos for secondary hospitals; and 1,350 pesos for tertiary hospitals.
   
   Furthermore, health professionals shall still be reimbursed 2,000 pesos with additional reimbursements for necessary surgeries and procedures and daily consultation fee for the co-management of the appropriate health professional.
   
   
10. For complicated normal deliveries, hospitals shall only submit one (1) claim application.
    
    
11. With the holistic coverage of maternity care by this benefit, all medically necessary care for the newborn, including professional services, medicines and laboratory examinations, is reimbursable and classified as an ordinary medical case type. However, room and board charges shall not be covered unless the newborn child was admitted for other indications. Infant formula is not reimbursable. A separate claim application must be submitted for the newborn child.
    
    
12. Claims must be filed within sixty (60) calendar days from date of discharge.
    
    
13. All claim applications for the Maternity Care Package shall be covered by the rules on ICD-10 requirements by the Corporation.
    
    
14. Availment of the PhilHealth Maternity Care Package shall be charged one-day to the annual 45-day limit.

Adopted: 17 March 2003

(SGD.) FRANCISCO T. DUQUE III, M.D., M.Sc
President and CEO