PHILHEALTH BENEFITS

BENEFIT COVERAGE
Inpatient Coverage
Subsidies for hospital room and board fees, drugs and medicines, x-ray and other
laboratory exams, operating room and professional fees for confinements of not less
than 24 hours. Please refer to the table of rate ceilings/maximum allowances for
inpatient coverage.
Outpatient Coverage
Day surgeries, dialysis and cancer treatment procedures such as chemotherapy and
radiotherapy.
Special Benefit Packages
Case Rates
TB Treatment through DOTS
SARS and Avian Influenza
Novel Influenza A(H1N1)
Exclusions
Fifth and subsequent normal obstetrical deliveries
Non-prescription drugs and devices
Alcohol abuse or dependency treatment
Cosmetic surgery
Optometric services
Other cost-ineffective procedures as defined by PhilHealth
BENEFIT AVAILMENT CONDITIONS
Eligibility Requirements
The following must first be met to avail of your PhilHealth benefits:
Payment of at least three (3) monthly premiums within six (6) months prior to
the month of confinement.
Confinement in an accredited hospital for at least 24 hours (except when
availing of outpatient care and special packages) due to illness or injury
requiring hospitalization.
Attending physicians must also be PhilHealth-accredited.
The 45 days allowance for hospital room and board is not consumed yet.
Post Availment Reminders
After the automatic deduction or reimbursement of your benefits, PhilHealth will send
the Benefit Payment Notice or BPN to the address indicated in the members claim form.
The BPN is a report of actual payments made by PhilHealth relative to members the
confinement/availment.
Should there be discrepancies between the amounts reflected in the BPN and in the
members final billing statement issued by the hospital, or if the member has other
concerns pertaining to benefit availment, he may contact PhilHealth or the health care
provider. The member must bring the BPN as reference document.

BENEFIT AVAILMENT PROCEDURES
Outright/Automatic Deduction Of Benefits
1. Submit the following to the billing section prior to hospital discharge:
Duly accomplished PhilHealth Claim Form 1
Clear copy of Member Data Record (MDR)
For qualified dependent not listed in the MDR, submit clear copy of applicable proof of
dependency.
2. Agree with your attending physicians on how much is left to be paid for their services
over the professional fee (PF) benefit.
3. Upon submission of all applicable documents, the billing section will compute and
deduct your benefits from your total hospital bill.
Direct Filing/Reimbursement
Submit the following to PhilHealth or through the hospital in addition to the documents mentioned
earlier within 60 calendar days from the date of discharge:
PhilHealth Claim Form 2 (to be filled up by the hospital and attending physicians)
Official receipts of payments made to the hospital and to the doctor's waiver
Operative record, if surgical procedures was performed
Confinement Abroad
Submit the following within180 days from the date of discharge. Overseas confinements shall be
paid based on Level 3 hospital benefit rates and in the Philippine peso equivalent. Overseas
confinements shall be paid based on Level 3 hospital benefit rates.
PhilHealth Claim Form 1
MDR or supporting documents
Original official receipt or detailed statement of account (written in English)
Medical certificate (written in English) indicating the final diagnosis, confinement
period and services rendered.