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PhilHealthRegionalOfficeVl
Gaisano
City Capital- Iloilo,LunaSt.,La Paz,ItoiloCity
(033)501-9190
to 62
gov.ph
www.philhealth.
M8
TO:
ALL PHILH
FROM:
LOURDES
ENGAGED HEAITH
CARE INSTITUTIONS
Regional Vic
BERN
THRU:
HCD
ETTE L.
REYNES,V
Chief
DATE:
January30,201,5
SUBJECT:
The Corporation, through the National Health Insurance Program, commits towards achieving
Millennium Development Goal for maternal and child health. This is to ensure survival and well
being of all mothers and their newborns by providing them financial tisk protection. Along with
this is the enhancement of system features to increase efficiency of claims processing.
PhilHealth
Circular No.
ACCOMPLISH
CLAIM
B -
(INSTRUCTION
ON
HOW
TO
paft II, item 8-c. A11 deliveries include and not [mited to MCP, NSD, Cesarean Section &
Breech extraction.
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ANNEXB-INSTRUCTIONSO
CI.AIM FORM 2
/
/
rrate
Note: Claim Form 2 shall be acconrplished using capital letters and by checking the agXlropri
dbe
boxes. All items should I re marked legibly by using ballpen only. AI datey'should
filled out in MM-DD.YYY format.
/
Part I
Patt II,
item 1
Part II,
item 2
Instructions
Description
CF2Pa
paft/
Item
/
/
PhilHealth Accredited
Number
Name of Health Care
Institution
Address
Name of Patient
Confinement petiod
t, ---_ 4
\+-
.s,.1
)ate Admited
lime Admitted
-_-_!
$l
V EEi
igHE
lime Discharged
For Antenatal Cate Packase write the date of last pre-natal visit
WRITE the time of dischatge
E-,1
8l
C)
I)^ar TT
lPatientDisposition
item 4
Part II
item 4f
Transfetred/refetred
Patt II,
tem 5
Tlpe of Accommodation
Part II,
item 6
Part II,
item 7
Admission Diagnosis/es
DischargeDiagrrosis
ICD 10 Code/s
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CF2Pa
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Item
Instructiors
Desctiption
Leave blank
VflRITE the applicablePackage/RVS Code:
Matemity CarePackage:MCP01
NSD PackageNSD01
CesareanSection;59513ot 59514ot 59620
Breech extraction:59411
Vaginal deliveryaftet CS: 59612
NSD 'ffith BTL:59402
Antenatal CarePackage:ANCO1
Intrapartnm monitoring (wlo delivery): 59403
Antenatal CarePackagewith Inttapartuo monitoring: ANC02
432
Newborn CarePackage:99
WRITE the coresponding date/s for the ptocedure,/s
*for claims for delivery (i.e. MCP, NSD, etc.) write the date
of delivew
Fot AII delivedes:
$7RITE the date of last menstrual period (Lt\4P)
Fot Claims fot MCP and Antenatal Care Package:
WRITE the dates of at least 4 pte-natal visits on the spacesprovided,
Leave blank for other claims.
TICI( the servicesthat are provided
ATTACH the Filtet Caid Sticker for Newbom ScteeningTest in the
Related Procedures
RVS Code
Date of procedures
Part II,
item 8 c
Special considetation
MCP Package
Patt II
item 8 d
PartII,
item 9
PhilHealth BeneEts
Part II,
item 10
Professional Fees
Part III
SectionA
soaceotovided
V7RITIE the co*esponding package/RVS Codes for the benefits that
vdll be claimedr
Maternity CarePackage:MCP01
NSDO1
NSD Package:
CesareanSection:59513or 59514ot 59620
Breechextraction;59411
Vaginal deliveryaftet CS: 59612
Antenatal CatePackage;ANC01
Irtrapartum monitoring (w/o deliverl) : 59 403
Antenatal CateP ackzgewith InftaPartum monitodng: ANC02
Newbom CarePackage:99432
WRITE th. a.*.ditation number and the name of Physician/midwife
on the sPacesProvided
AFFD{ the signature of the Physician/midwife over his/her narne
then write the date of the spaceptovided
frcf
Certification of
Consumption of Benefits
Pan III
SectionB
Corrsentto AccessPatient
Record,/s
the name.
Ttris person rnust revierr and ved$r all the entries before affixing
his/her signahre.
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packagebeing clairned"
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MCP 01
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