October 9, 2014

PHILHEALTH CIRCULAR NO. 022-14

I. Background

The

In line with these, and in support of achieving the Millennium Development Goals for maternal and child health, the guidelines for enrollment and benefits of women about to give birth are hereby defined.

II. Scope and Coverage

This Circular shall define policies and procedures that will give financial risk protection to women who are about to give birth.

III. Definition of Terms

1. Women about to give birth are those who are confirmed pregnant during their first visit to a health care provider and anytime thereafter. They shall also be referred to as pregnant women or expectant mothers in this Circular.

2. Parity refers to the number of live-born children and stillbirths that have been delivered by the mother.

3. Normal birth/delivery is characterized by spontaneous onset of labor, low risk at the start of labor, throughout labor and delivery, the infant is born in vertex position, 37 to 42 weeks of completed pregnancy, and mother and child are in good health after delivery. SEcTHA

4. Point of Care Enrollment is a PhilHealth enrollment mechanism so that the poor who is not yet a PhilHealth member may be enrolled to the National Health Insurance Program as sponsored member. The policy is defined in

5. Coverage refers to the entitlement of an individual as PhilHealth member or dependent to the benefits of the National Health Insurance Program.

6. Maternity Care Package (MCP) is a PhilHealth benefit that covers the complete essential health care services for women about to give birth throughout their pregnancy and normal delivery (during antenatal, intrapartum and immediate postpartum periods) regardless of the type of health care institution where the services are rendered. The services shall include antenatal care, intrapartum monitoring, assist in normal delivery and post-partum care within 72 hours and 7 days after delivery.

7. Normal Spontaneous Delivery (NSD) Package is a PhilHealth benefit that covers only health services during intrapartum and immediate post-partum period for normal delivery regardless of the type of health care institution. The services shall include monitoring and management of labor, assist in normal delivery and post-partum care within 72 hours and 7 days after delivery.

8. Antenatal Care Package is a PhilHealth benefit that covers antenatal or pre-natal care services of expectant mothers. The services shall include pre-natal check-ups to screen, detect and manage complications of pregnancy; maternal nutrition; immunizations; and counseling for healthy lifestyle, breastfeeding, and family planning. Previously, the benefit is included in the benefits for normal deliveries but it is not fully utilized because of gaps in the health care delivery network. To promote access of pregnant women to quality antenatal care services that will ensure good outcome of their pregnancy, this benefit, is made distinct from the benefits for delivery.

9. PhilHealth Benefit Eligibility Form (PBEF) is a document produced through PhilHealth Enhanced Health Care Institution Portal that contains the information whether the member or dependent is eligible to avail of PhilHealth benefits in terms of the following: 1) status of membership/dependency; 2) premium contributions; and 3) compliance to 45 days benefit limit. The guidelines are provided in

IV. General Guidelines

1. PhilHealth shall ensure that women about to give birth shall have financial risk protection during their pregnancy, delivery and post-partum period through their enrollment to the National Health Insurance Program.

2. PhilHealth shall provide benefits for all maternal deliveries regardless of parity, subject to the provision of qualifying contributions.

3. PhilHealth shall also cover admissions due to pregnancy related conditions such as pre-term labor and pregnancy induced hypertension.

4. Only low risk normal vaginal deliveries shall be compensable in non-hospital facilities. "Low risk" refers to absence of active complications and any maternal or fetal factors that will make the pregnancy at risk for complications. Hence, the following conditions listed in

a. Maternal age below 19 years old at the date of delivery;

b. First pregnancy in patients with age 35 years and older at the date of delivery;

c. Multiple pregnancy such as twins and triplets;

d. Ovarian abnormality (e.g., ovarian cyst);

e. Uterine abnormality (e.g., myoma uteri); DcTaEH

f. Placental abnormality (e.g., placenta previa);

g. Abnormal fetal presentation (e.g., breech);

h. History of (three) 3 or more miscarriages/abortion;

i. History of (one) 1 stillbirth;

j. History of major obstetric and/or gynecologic operation (e.g., cesarean section, uterine myomectomy);

k. History of medical conditions (e.g., hypertension, pre-eclampsia, eclampsia, heart disease, diabetes, thyroid disorder, morbid obesity, moderate to severe asthma, epilepsy, renal disease, bleeding disorder);

l. Other risk factors that may arise during present pregnancy (e.g., premature contractions, vaginal bleeding) that warrants referral for further management.

It is imperative that if the abovementioned conditions were diagnosed during pre-natal care, the pregnant women must be referred to hospitals for appropriate management and care during delivery.

5. Since Geographically Isolated and Disadvantaged Areas (GIDA) have limited access to hospitals, the infirmaries/dispensaries located in these areas may be reimbursed for the normal deliveries of the mothers with conditions listed in Section IV.4 of this Circular.

6. Hospitals shall not refuse women about to give birth who were referred from birthing homes, maternity clinics and infirmaries/dispensaries for higher level of care management.

7. The health care institution and professional must be PhilHealth accredited at the time when they provide care to pregnant women before they can be paid by PhilHealth.

8. The No Balance Billing Policy as stated in

9. Women about to give birth should have pre-natal care at the earliest time possible and keep a record of their pre-natal check-ups in a mother's book or its equivalent at all times. This is to ensure that they will receive continuous, comprehensive and coordinated care during pregnancy, delivery and post-partum.

10. The health care facility providing the pre-natal services shall give pregnant women a mother's book or its equivalent and shall assist them in checking and updating their PhilHealth membership and coverage.

V. Mechanism to Provide Social Health Insurance Coverage

1. All women shall consult a health care provider upon note of signs and symptoms of pregnancy.

2. The health care institution shall check the PhilHealth membership status and coverage of pregnant women upon their first consultation through PhilHealth Enhanced Health Care Institution Portal or other available means of verification.

3. Their membership status may be any of the following:

a. Registered members or dependents are registered/enrolled members with existing PhilHealth Identification Number (PIN). Whereas registered dependents are those that are declared as qualified dependents in the member's data record which may include pregnant women who are less than 21 years old and are listed as qualified dependents of their parents. HEISca

Their social health insurance coverage may be the following:

i. Covered the member paid their premium contributions for at least 3 months within the six months (3/6) prior to first day of availment of benefits.

ii. Not covered if they do not have the qualifying contributions

Pregnant women who are not covered shall update their premium contributions. Specifically, they shall pay for any missed payment in previous quarter/s and for the remaining quarter/s of the year.

b. Non-registered member are individuals who are not yet recorded in PhilHealth member database and have no PIN. They are not yet covered by social health insurance.

Pregnant women with this status and who are able to pay the premium shall be advised immediately to register and pay the corresponding premium to PhilHealth for the whole year.

4. The health care provider shall refer to Medical Social Worker (MSW) or Social Worker for assessment to Point of Care enrollment (POC) the following pregnant women:

a. Those who are not yet registered to PhilHealth;

b. Those who are registered members but are not covered/eligible due to lack qualifying contributions; or

c. Those who are qualified dependents of their parents (covered or not covered).

Pregnant women who qualify shall be enrolled to PhilHealth through Point of Care as prescribed in

5. Pregnant women who were assessed in Item V.4 but did not qualify for Point of Care enrollment shall be covered through the provisions of Section 39b of the

a. Submit to the PhilHealth Local Health Insurance Office (LHIO) or PhilHealth Regional Office (PRO) an accomplished PhilHealth Membership Registration Form (PMRF) and ANY of the following documents:

i. Medical certificate from her physician/midwife confirming her pregnancy;

ii. Photocopy of laboratory/ultrasound result confirming the pregnancy;

iii. Photocopy of her admission records.

b. Pay to the nearest LHIO or PRO the corresponding annual premium contribution for the current calendar year regardless of the date when their pregnancy was confirmed. The premium rate shall be based on the current annual premium rate for the members of the Informal Economy. Those who only have gaps in the premium contributions shall only pay for the previous quarter/s with missed payment and the remaining quarter/s of the year.

Pregnant women who are covered through this provision can automatically avail of the benefits for giving birth and newborn care.

6. The privilege accorded to the women about to give birth provided by the provision of Section 39b shall only be availed ONCE without penalties. Subsequent use of updating premium contributions for the purpose of availing entitlement to benefits shall be subject to prevailing interests and penalties as prescribed by the Corporation. A separate guideline for this purpose shall be issued accordingly. Also, subsequent admissions after delivery that are not related to pregnancy and post-partum care shall be subject to the rules on qualifying contributions. AaSTIH

7. Pregnant women who are dependents of their parents should enroll as principal members either through POC or provision of Item V.5 of this Circular so that their children shall likewise have social health insurance coverage.

8. PhilHealth shall update the mother's member records and issue PhilHealth Identification Number for the newborn dependent upon processing of claims.

VI. Benefits Package for Women About to Birth

Women about to give birth shall be enrolled to the National Health Insurance Program so that they can avail of the appropriate benefit packages provided by PhilHealth.

A. Maternity Care Package (MCP)

1. This package covers the essential health services during antenatal period, entire stages of labor, normal delivery and immediate post-partum period including follow-up visits within the first 72 hours and 1 week after delivery.

2. The package code shall be MCP01. The Package Code 59401 shall no longer be used.

3. This Package may be availed in hospitals, infirmaries/dispensaries and birthing homes/maternity clinics with the following rates:

4. The professional fee shall be 40% of the package rate while the remaining 60% is for the facility fee.

5. The minimum stay of the mother in the facility shall be 24 hours.

6. Availment of this package shall be charged one (1) day to the annual 45-day benefit limit.

7. In line with the current standards of care, pregnant women are encouraged to have the first pre-natal check up during the first trimester of pregnancy with at least 4 pre-natal visits throughout the course of pregnancy. This is to detect and manage danger signs and complications of pregnancy and to reduce the risk of perinatal deaths. However, at this time, PhilHealth shall just require at least 4 pre-natal visits during the course of pregnancy.

B. Normal Spontaneous Delivery (NSD) Package

1. This package covers essential health services for normal low risk vaginal deliveries and post-partum period within the first 72 hours and 7 days after delivery.

2. The package code shall be NSD01. The Package Code 59400 shall no longer be used.

3. However, services for Normal Spontaneous Delivery as Package Code 59400 provided in PCF-Infirmary/dispensary by an accredited physician prior to the effectivity of this circular shall be compensable. SHaIDE

4. This Package may be availed in hospitals, infirmaries/dispensaries and birthing homes/maternity clinics with the following rates:

5. Forty percent (40%) of the package rate is for professional fees while 60% is for the facility fee.

6. Availment of this package shall be charged one (1) day to the 45-day annual benefit limit.

7. In cases when the pregnant women receives pre-natal care from another facility, the facility where pre-natal care is rendered may claim for Antenatal Care Package while the facility that will assist in normal delivery may claim for NSD Package.

C. Antenatal Care Package (ANC01)

1. This package covers essential health services that women about to give birth during antenatal period.

2. The case rate for this package is Php1,500.00 for which forty percent (40%) is for professional fees while 60% is for the facility fee.

3. The package code shall be ANC01.

4. The requirements for this package are the following:

a. The facility is PhilHealth accredited as hospital, birthing home/maternity clinic, infirmary/dispensary, or TSeKaP (Primary Care Benefit 1) provider. Likewise the health care professional shall also be PhilHealth accredited.

b. During antenatal period, the women have qualifying contributions or social health insurance coverage through different mechanisms described in Section V of this Circular.

c. There are at least 4 pre-natal check-ups/visits with the last one during the last trimester of pregnancy.

d. All the essential health services for the pre-natal care are provided.

e. The women about to give birth are referred appropriately to an accredited health care institution for management of labor and delivery.

f. Pre-natal visits and other services given, referrals and outcome of delivery are documented in the mother's record and mother's book or its equivalent.

D. Payment for Cases Referred to Hospitals

1. In cases when women in labor were initially managed in non-hospital facilities but eventually referred to hospitals for higher level of management and delivery, the referring facility shall be reimbursed 10% of the rate of NSD Package.

2. Facilities that also provided Antenatal Care Package and initial management of pregnant women who are in labor may claim for both services.

3. The package codes, rates and descriptions are the following:

4. Forty percent (40%) shall be for professional fee and 60% is for the facility fee. HSTCcD

E. Other Methods of Deliveries Covered by PhilHealth

1. PhilHealth also covers the following methods of deliveries in accredited hospitals:

2. The Package Code 59402 (Normal Spontaneous Delivery with Bilateral Tubal Ligation shall not be used anymore. Instead, hospitals that provided Maternity Care Package or NSD Package and also performed bilateral tubal ligation may claim the procedure "Ligation or transaction of fallopian tube(s) abdominal or vaginal approach, unilateral or bilateral" (RVS Code 58600, Case Rate Php4,000) as second case rate.

For Example:

3. Guidelines for availing of benefits and claims filing are stated in

VII. Newborn Care Package

Pregnancy and childbirth involve both the mother and the newborn. The Newborn Care Package ensures that newborns have access to health care services within their first hours of life. SAEHaC

1. This package shall cover essential health services that newborns must receive within the first hours of life regardless of the method of their delivery and presence of co-morbidities.

2. The amount of the package shall be Php1750.00 and paid to the facility.

3. The package code shall be 99432.

4. The package has the following components:

5. This package may be availed from health care institutions that provide services for MCP, NSD Package and other methods of delivery.

6. As stated in i.e., newborn sepsis, congenital pneumonia) may also claim for NCP as second case rate for health services provided to the newborn.

VIII. Clarification of Benefit for IUD Insertion

1. To provide women access to family planning procedures, aside from hospitals and ambulatory surgical clinics, PhilHealth shall also pay IUD insertion (RVS Code 58300) performed in the following qualified primary care facilities: TAacIE

a. Birthing homes/Lying-in clinics/maternity clinics;

b. Infirmaries/dispensaries; and

c. HCIs that are accredited TSeKaP providers.

2. For the facilities to qualify to provide IUD insertion benefit, they shall submit a copy of their staff's certificate on Family Planning Competency Based Training (FPCBT) Level 2. The said training must have been conducted by trainers recognized by the Department of Health (DOH) and coordinated with respective DOH Regional Offices. As such, the training certificates must have the signature of the respective DOH Regional Director or his/her representative. An alternative to this is the physician's certificate of residency training on Obstetrics and Gynecology.

3. Availment of this benefit shall have a corresponding 1 day deduction in the 45-day annual benefit limit.

IX. Provider Accreditation

1. Accreditation of health care institutions shall be in accordance with the policy on Provider Engagement through Accreditation and Contracting of Health Services as stated in

2. Accreditation of health care professionals shall follow the accreditation process for health care professionals as stated in

X. Benefit Availment and Claims Filing

1. For easier verification of eligibility status, all accredited health care institutions must have access to PhilHealth Enhanced HCI Portal.

2. For filing of all claims, the following documents shall be submitted to PhilHealth within 60 calendar days after discharge:

a. PhilHealth Benefit Eligibility Form (PBEF) OR

Other documents required by PhilHealth as proof of eligibility such as Member Data Record (MDR); proof of premium payment (for individually paying and overseas workers members); PhilHealth ID cards (for indigent, sponsored and lifetime members); and other secondary documents as enumerated in PBEF and

b. PhilHealth Claim Form 1 (CF1) duly filled out by the member and/or employer. HCTaAS

It shall no longer be required if PBEF confirmed (answered "Yes") the eligibility of patient.

c. PhilHealth Claim Form 2 (CF2) duly filled out by health care provider; and

d. Claim Form 3 (CF3) for claims from infirmaries/dispensaries and birthing homes/maternity clinics except claims for Newborn Care Package.

e. Official receipt Newborn Hearing Screening Test for Newborn Care Package if applicable;

f. Copy of newborn's birth certificate attached to newborn's claim (for Newborn Care Package) and to mother's claim (for updating of her membership data record). A photocopy from the facility without the registry number is acceptable as long as it is stamped as "Certified True Copy" and signed by the records officer/clinic administrator of that facility.

3. An additional requirement for Antenatal Care Package is a copy of pre-natal card or mother's book (Annex D) of their equivalent (i.e., "Pink Form"). The facility where the expectant mothers are referred for delivery shall be indicated Part II item 4.f of Claim Form 2.

4. For purposes of monitoring, the date of last menstrual period (LMP) must be written beside Part II item 8.c of Claim Form 2. Also, Part II Item 7 must have complete diagnosis and ICD-10 Codes including the method/s and outcome of delivery.

5. Claims for Newborn Care Package without the component of Essential Newborn Care and Newborn Screening Test shall be denied.

a. In cases when Newborn Hearing Screening Test was not provided by HCI, the corresponding amount (Php200.00) shall be deducted from the NCP Claim.

b. When the said test was paid by the member, official receipt shall be attached to the claims for the Newborn Care Package. The two hundred pesos (Php200.00) shall be deducted from the HCI claim and shall be paid to the member.

6. Claims with incomplete requirements and/or discrepancy/ies shall be returned to sender (RTS) for compliance within 60 calendar days from receipt of notice. Failure to comply shall cause denial of claim. Claims for MCP and Antenatal Care Package without the appropriate dates for the pre-natal visits shall be denied.

7. PhilHealth strongly upholds that the facility shall file the claims after having exhausted the corresponding case rates in providing complete provision of care including pre-natal care for MCP.

8. For Maternity Care Package, PhilHealth shall no longer directly reimburse the member just for the pre-natal care component. In cases when the pregnant women spent for some diagnostic procedures such as laboratory and ultrasound, the facility shall have to reimburse them up to a maximum of one thousand five hundred pesos (Php1500.00).

9. Directly filed claims shall be allowed in the following instances:

a. Facilities did not provide complete health care for mothers and newborns such that patient/member have to spend for drugs and medicines, laboratories and other services that should be available in the facility; and

b. The patient/member is unable to secure required documents for claims filing during weekends/holidays.

10. For directly filed claims, the member shall submit the requirements listed in Section X.2 of this Circular AND a waiver (Annex E) from the health care institution stating that the member paid the full amount for the confinement and no PhilHealth deductions were made.

The health care institution shall be responsible in filling out appropriate fields in Claims Form 2 and CF 3 and providing supporting documents such as PBEF. It shall also assist the member in filling out Claim Form 1.

11. All directly filed claims shall be processed subject to existing rules and guidelines of the Corporation. TSDHCc

XI. Monitoring and Evaluation

1. To ensure provision of quality health services to PhilHealth members and their dependents, monitoring of the utilization of the benefit packages provided to women about to give birth and their newborns shall be anchored on the Health Care Provider Performance Assessment System of the Corporation.

2. PhilHealth shall likewise strictly monitor but not limited to the following cases:

a. All directly filed claims;

b. Reimbursement (of facilities) for pre-natal care expenses of women about to give birth and newborn hearing screening test

c. Outcomes of deliveries from birthing homes/maternity clinics and facilities in GIDAs.

d. Health outcomes of all referrals from non-hospital facilities.

3. Claims for Maternity Care Package and Antenatal Care Package that are filed for the same patient during the same period of pregnancy shall be referred for investigation.

4. For monitoring purposes, health care institutions shall maintain copies of patient records in their facility. These records shall have complete documentation of mother's history including but not limited to all her pre-natal consultations from different providers, course in the ward including her progress of labor and the delivery of care such as services provided, drugs and medicines given and procedures performed. Mother's record in non-hospital facilities shall include a partograph. Newborn's charts shall have complete documentation of the services provided including the essential newborn care. These documents must be made available to PhilHealth personnel at all times.

XII. Effectivity

This Circular shall take effect 15 days after its publication in a newspaper of general circulation. All other existing issuances and provisions of previous issuances inconsistent with this circular are hereby repealed and/or amended.

XIII. Annexes

1. Annex A Summary of Requirements for Filing of Claims

2. Annex B Instructions in Filling-up Claim Form 2

3. Annex C Sample Claim Form 2

4. Annex E Sample Copy of Mother's Book

5. Annex D Waiver Form from HCI for Directly Filed Claims

(SGD.) ALEXANDER A. PADILLA
President and CEO
Philippine Health Insurance Corporation

ANNEX A

Summary of Documentary Requirements for Filing of Claims

ANNEX B

Instructions on How to Accomplish Claim Form 2 and Sample Claim Form 2

Note: Claim Form 2 shall be accomplished using capital letters and by checking the appropriate boxes. All items should be marked legibly by using ballpen only. All dates should be filled out in MM-DD.YYY format.

ANNEX C

Sample Claim

ANNEX D

Waiver from Health Care Institution for Directly Filed Claims

ANNEX E

Sample Copy of Mother's Book