li1 - Philippine Health Insurance Corporation

@Private - refers to a single occupancy room or
with less than thi.ee beds per room divided by
either a peimrmeni: or se nil-permanent
partition.
@Wmd - icfe-rs to a room with Uiiec 01 moic
beds.
For benefit packages not requiring ilcmiz,iuon PHIC
benefit should be indicated in lie.
Case Type
Check the appropriate box of the coirccr illness case
type whether A,B,C or D Tins is only applicable for
claims with fce-for-service payment mechanism.
Complete ICD-10 Codes
Write die complete ICD 10 code/sof the p-.iuent's
diagnosis. The fust code indicated should be the
piimaiy illness. The succeeding codes shall represent
co-morbidities.
Professional Health Care Provider to fill out items 14 to 16
16
lfia,
161)
16c,
16d
Admission Diagnosis
W'nte die admission diagnosis.
Complete Final Diagnosis
Write the complete final diagnosis of p;iuenfs
illness/injuries including the mam diagnosis ;md
other co-morbidities.
Provide the following information, as applicable::
u The cuologic agent ( e.g;, Escheiichia coli) in
diagnosing infections,
b For benign und malignant tumors, indicate the.
site, moiphology and behavioui.
c.In diagnosing injuries, provide the nature of
die injury, and it possible, the place of
occuncnce and die activity- of die one injured
during die tune of the incident
d.When diagnosing poisoning or advei.se
reaction cases, specify die offending agent
(e.g., drug, chemical).
e.Specify if a condition is a late effect or
sequelae of anodiei condition (e g , pubnonaiy
Tibrosis sequelae of PTB).
For mulaplc conditions, the main oi" primuLy condiuon
must be the Gist diagnosis ihfit should be written
e.g., Patient X is diagnosed with acucc pyelonephritis
with concomitant hypertension and diabetes
Complete Fin.il Diagnosis: acurc bacterial pi,-clonephriDb,
hvpeiiension contioOed, diabetes mclliwr, cono-olled
Professional Fees/Charges
Name of Accredited Professional and
PhilHealth Accreditation No.
Write the nnmc/s of pro regional health care
provider/s who attended and provided services to die
patient with corresponding PluIHealdi
accieditation nmnber/s in the boxes provided.
No. of Visits/ RVS Code and
Inclusive Dates
Indicate die following services rendered to the
patient by die professional
Medical C;ise -
@Indiciite it daily visits with inclusive daiey
@Indicate lrpreopcranve mpadeni consultation
(CP Clearance) inclusive dates
16f
16g
16h/l
Surgical c.isc -
@Indicate die appropriate RVS code rind date
of opeiLition/procedure.
@Anesthesia sendees - Indicate the type of
anesthesia sendees given and date of service/
procedure.
Professional Health Care Services Indicate the
amount of the following items accordingly:
@"Total ..Actual Piofessional Fee Charges'1 refcis
to the total amount of die professional fee
chaigc-d by die health care professional to the
patient before deduction of PhilHealth
Benefit.
@"PhilHealth benefit1' refers to the amount that
will be reimbursed to the professional by
PhrlHealth. The same represents deduction
made from die patient's actual charge as
member's benefit.
@"Amount paid by member" refers to die
payment made by die member after deduction
of PhilHealth benefit This represents die
excess amount shouldered by die member. Tf
full payment was made, indicate the amount
equivalent to actual professional charges.
Signature/Date Signed -
@The professional who actually rendered die
services shall sign in the box provided and
indicate the date of signing following die
pLCSdibed format for date.
Part II - Drugs and Medicines
List down dings and medicines used/consumed during
confinement
@Indicate the generic mime and the corresponding brand
name ot die drug
Illustration: amoxicillin (Amoxil);
@Indicate coiresponding preparation (dose,cap/tab in
mg; syrup/suspension in mg/ml; amp/vial in nag/ml);
@Indicate total quantity used (piece, ampule, vial, etc);
@Indicate the amount per unit;
@"Actual charges" refers to the actual amount charged by
die facil.it}' for ever)- item.
@"PhilHealth benefit" refers to the total amount of
benefits foi all drug? and medicines
@Indicate the total -amount of actual charges and
PliilHealth Benefits for all drugs and medicines
@Foi benefit packages not requiring iiemizanon, only die
totnl amount of PHIC benefit should be indicated.
Part III - X-ray, Laboratories, Supplies and Others
Indicate all diagnostic procedures [imaging, laboratory tests,
etc.) done and supplies and other items used during
confinement
@Indicate total number of procedures/items.
@Indicate the amount per item;
@'"Actual charges" refers to the total amount charged by
die facility foi ever";' item or service rendered;
@"PhilHealth benefit" rcfeis 10 the total amount of
"benefits foi x-ray, laboratories, supplies and others.
@Indicate die total amount far columns Actual Chaiges
and FhilHejilth Benefit