li1 - Philippine Health Insurance Corporation
li1 - Philippine Health Insurance Corporation 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
Note Check the box provided if official receipts foi drugs find medicines/supplies purchased by member from external sotuces us well as laboratory procedui.es done outside the hospital which are necessary for die confinement, are attached to tlie ckim. Part IV- Certification of Institutional Health Care Provider Signature over Printed Name of Authorized Representative The authorized representative shall write his/he: printed name and aftix his/her signature certifying th.\t the services rendered were recorded in the patient's chart and hospital records and the given information given are true and correct. Official capacity/Designation Write the official capacity/designation of the signatory Date signed Write die date of signing following the prescribed foimat for date. Part V - Consent to Access Patient Records Signature over Printed Name The patient shall write his/her name and affix his/hei signature signifying consent to PlnlHcnlth's verification of die veracity of die information contained in die claim. Date Signed Write the date of signing following the prescribed format for date. Part II Maternity Care Package Tins provides the inform a lion fib our die prenatal consultation, delivery outcome and postpaitum care of the patient. CF3 is not requiic-d in other PhilHealth benefit packages such as Newborn Caie Package. Voluntary Surgical Contraception. Outpatient Malaria and TB-DOTS, regardless of facility level. The tables helow explain the propei wax of accomplishing CF3: Part I Patient's Clinical Record No. 1 2 Description/Procedure PhilHealthAccreditationNumber(PAN) Tinsreferstothecurrentaccreditationmirabeiof theinstitutionalhealthcareproviderassignedby PhilHcalth. Formultipleaccreditation,indicatetheaccreditation numberofthefacilityapplicabletothebenefit claim. WritePANfollowingtheprescribedformat. Vntediecompletenameofthepatientstartingwith ast,firstandmiddlename.Itshouldbeseparatedby comma.Extensionssuchas(butnotlimitedtothe ollownigj]r.,Si.,Hishouldbeindicatedafterthe firstname. Signature Over Printed Name of Patient's Representative The authorized represents!five of the patient may sign on behalf ot the patient. Date Signed Write die date of signing following the prescribed format for date. Relationship of the Representative to the Patient Write die relationship of die leprescntarive to the patient by checking the appropriate box whether spouse, child tor majority age, paient or guaidian/next ot kin. Reason for Signing on Behalf of the Patient Indicate the reason for signing on behalf of die patient whether patient is incapacitated or due to othei reasons (specify). C. Claim Form 3 (CF3) (To be filled out by accredited Health Care Provider) Tins cl.iim form will support the information supplied tn the Claim Foim 2 and shall be used in die evaluation of proper case type determination especially type D cases, emergency cases snd less than 2-1 hour admissions This ij. mandatory m: @Level 1 facilities, @Case type D; @Maternity Care Package, @" Emeigency/ Transferred cases, and @Less than 24-hour confinement Part I - Patient's Clinical Record This is die basis of PhilHcalth to ascertain die patient's clinical liistory, pertinent physical examination findings, laboratory &; diagnostic findings and disposition upon discharge. 3 4 5 (i 7 8. ndicatepatienL'schiefcomplaintforseeking consultationand/orreasonforadmission. followingtheprescribedformatfortime. Indicatethetimewhenthepatientwasdischarged followingtheprescribedformatfoitime. Indicatethechronologicaleventsofpresentillness includingallsignsandsymptoms,prompting consultationandsubsequentconfinementas describedbythepatient/guardian/informant. Indicatetheobjectivefindingsincludingpertinent negativefindingsperorgansystemelicitedduringdie conductofdiephysicalexamination. Indicatesignificantchanges/progressonthepatient's conditionduringconfinement.Mayaddadditional sheetsifnecessary Indicateallsignificantlaboratoryresultsand diagnosticfindings.
- Page 1 and 2: Republic of the Philippines PHILIPP
- Page 3 and 4: MCP[2 | iPhilHealth I Your Partner
- Page 5 and 6: @fc^ PhilHealtn MBramier Your Partn
- Page 7 and 8: GUIDELINES ON THE PROPER ACCOMPLISH
- Page 9: Part V - Consent to Access Patient
- Page 13: theictusonthefirstminute-andfive(5)
Note Check the box provided if official receipts foi<br />
drugs find medicines/supplies purchased by member from<br />
external sotuces us well as laboratory procedui.es done<br />
outside the hospital which are necessary for die<br />
confinement, are attached to tlie ckim.<br />
Part IV- Certification of Institutional <strong>Health</strong> Care<br />
Provider<br />
Signature over Printed Name of Authorized<br />
Representative<br />
The authorized representative shall write his/he: printed name<br />
and aftix his/her signature certifying th.\t the services rendered<br />
were recorded in the patient's chart and hospital records and the<br />
given information given are true and correct.<br />
Official capacity/Designation<br />
Write the official capacity/designation of the signatory<br />
Date signed<br />
Write die date of signing following the prescribed foimat<br />
for date.<br />
Part V - Consent to Access Patient Records<br />
Signature over Printed Name<br />
The patient shall write his/her name and affix his/hei<br />
signature signifying consent to PlnlHcnlth's verification of die<br />
veracity of die information contained in die claim.<br />
Date Signed<br />
Write the date of signing following the prescribed format for<br />
date.<br />
Part II Maternity Care Package<br />
Tins provides the inform a lion fib our die prenatal consultation,<br />
delivery outcome and postpaitum care of the patient.<br />
CF3 is not requiic-d in other Phil<strong>Health</strong> benefit packages such<br />
as Newborn Caie Package. Voluntary Surgical Contraception.<br />
Outpatient Malaria and TB-DOTS, regardless of facility level.<br />
The tables helow explain the propei wax of accomplishing<br />
CF3:<br />
Part I Patient's Clinical Record<br />
No.<br />
1<br />
2<br />
Description/Procedure<br />
Phil<strong>Health</strong>AccreditationNumber(PAN)<br />
Tinsreferstothecurrentaccreditationmirabeiof<br />
theinstitutionalhealthcareproviderassignedby<br />
PhilHcalth.<br />
Formultipleaccreditation,indicatetheaccreditation<br />
numberofthefacilityapplicabletothebenefit<br />
claim.<br />
WritePANfollowingtheprescribedformat.<br />
Vntediecompletenameofthepatientstartingwith<br />
ast,firstandmiddlename.Itshouldbeseparatedby<br />
comma.Extensionssuchas(butnotlimitedtothe<br />
ollownigj]r.,Si.,Hishouldbeindicatedafterthe<br />
firstname.<br />
Signature Over Printed Name of Patient's Representative<br />
The authorized represents!five of the patient may sign on<br />
behalf ot the patient.<br />
Date Signed<br />
Write die date of signing following the prescribed format for<br />
date.<br />
Relationship of the Representative to the Patient<br />
Write die relationship of die leprescntarive to the patient by<br />
checking the appropriate box whether spouse, child tor<br />
majority age, paient or guaidian/next ot kin.<br />
Reason for Signing on Behalf of the Patient<br />
Indicate the reason for signing on behalf of die patient<br />
whether patient is incapacitated or due to othei reasons<br />
(specify).<br />
C. Claim Form 3 (CF3) (To be filled out by accredited<br />
<strong>Health</strong> Care Provider)<br />
Tins cl.iim form will support the information supplied tn the<br />
Claim Foim 2 and shall be used in die evaluation of proper<br />
case type determination especially type D cases, emergency<br />
cases snd less than 2-1 hour admissions<br />
This ij. mandatory m:<br />
@Level 1 facilities,<br />
@Case type D;<br />
@Maternity Care Package,<br />
@" Emeigency/ Transferred cases, and<br />
@Less than 24-hour confinement<br />
Part I - Patient's Clinical Record<br />
This is die basis of PhilHcalth to ascertain die patient's clinical<br />
liistory, pertinent physical examination findings, laboratory &;<br />
diagnostic findings and disposition upon discharge.<br />
3<br />
4<br />
5<br />
(i<br />
7<br />
8.<br />
ndicatepatienL'schiefcomplaintforseeking<br />
consultationand/orreasonforadmission.<br />
followingtheprescribedformatfortime.<br />
Indicatethetimewhenthepatientwasdischarged<br />
followingtheprescribedformatfoitime.<br />
Indicatethechronologicaleventsofpresentillness<br />
includingallsignsandsymptoms,prompting<br />
consultationandsubsequentconfinementas<br />
describedbythepatient/guardian/informant.<br />
Indicatetheobjectivefindingsincludingpertinent<br />
negativefindingsperorgansystemelicitedduringdie<br />
conductofdiephysicalexamination.<br />
Indicatesignificantchanges/progressonthepatient's<br />
conditionduringconfinement.Mayaddadditional<br />
sheetsifnecessary<br />
Indicateallsignificantlaboratoryresultsand<br />
diagnosticfindings.
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