Requirement of Pre-Cataract Surgery Authorization - Philippine ...

' (AV/in/i/k- nfitic I'liilipjiiiicK/V
I?"PHILIPPINE HEALTH INSURANCE CORPORATION&. ..\^
^..,|;it-C'L-ii[ic Ruikhnii. 7tW Shav. Heiilvoml. Pas," Oily* * @''
!:i|pHc.ilililine J4I-7-IJ4 v^-jij.l^-.nlih.-n^nli
PhilHcullli Ciiciil.ii-
N,. 0Sq s-nij
- Jj,
TO:ALL ACCREDITED HEALTH CAKE PROVIDERS. PH1LHEALTH
SUBJECT:Rei[iiiic-mciit of Ptc-c.unnict Surgery Aullioiizatiou
MEMRERS, PI I1LHEALTH REGIONAL OFFICES AND ALL
OTHERS CONCERNED
1 o cnsuic qiulnv ;inJ approp, in le provision of sciviccs and ulilization r I'hill ij.--.ilt] @ benefits. n.s well as to
safeguard iiji.iinsl pos-iblt- .iliiist-s and iim-llnc.i! praclicu-s, a!! claims, ccimbitj-funicnu involvmi; mlaracl
A. GciK-ml luK:.^ loi ;i|iplit:;ilion of prc-c;il;uac[ surgciv aullioiiziiliini ict|uest
1.rlilllk-allh sliiill cnly icimbm-si- claims I'm cataracl'snriic-i-n-s lhat have been duly pie-appi.,vcj/pi-eamliori/CLl
rIhi-Li a pic-calai-acl suiyci-v -aullion/.alion icc|ncsl appiovcd b\ Pliill IcaltliK CNCcpl In cases
of childhood' and scc.ndary canuacls ft-.g-., uaumalic, -laiiconialous). Clainii for calaracl sni-ciics
M-ilhoul approved pu--c.u-.liM siiiiyiv anlhoMZalion ic^iicst shall ic-sult to denial of claims.
2 Ml caiaiacl sui^eiic-s inusl be pcrfoimed only in Tlnll ieallh-accietlilL-d health care lacililies (hiisptL-.ils
and ambulaloi-y sln^ical chnicsi -hc-ie the pilisician is alT.lialcd, .is dc-claicd in his 'her accicdltalion
pioflle
3. All cararart mission activ nics endorsed by 11 it- Philippine Academv off. )[-)hthalmolo;^- [^ACJJ that u ill
Lie perUiimc-i.1 in e;o\ ernmcnl lacililies shall iee|niie the prior submission of a pie- cataracl suiyerv
anlhori/alion leijuest and checklist.
@I. I'hill lealth-accreeliled ph\sicians pcifoi miiiL'. calaiact surgeries in facilities other than those dial lliev
are affiliated with as eleelaied in iheir accredilalion piollle will be allowed, provided that the smijjcal
proceelures ale done in governmenl facilities dnrine, missi.)n activities endorsed by the PAO and with
S. l-xistin.c; lequiiemenls and li.iles on eliBibllitv of benelils availnicnt shall apply. An appiovcd precalaracl
snriiCiy aulhon/.aiion i-ecjuest shall not anlomalically L'.n.uanlee the ap[in.n-al of the
corjespoiKlin.u el-ami foi reimbnrsemenl
(i. Direct tiling of claims bv membci/dependent shall not be allowed by the Coipoiation.
D. Piocceliue for Secunni; Pic-c-.itaiael Siifety Aullioiizalioii Rcqucsl
1 All I'hill leallh-acciediled phvsieians ho intend lo elaun loi cataracl suigeri shall notify I'hill lealth
of ihe planned smSni before services aie acuiallv |'rovided, bv submiltmi; a pre-cataiact surL-cry
aulhoii/ation iee]uesl and checklist (Annexes \ & !.]. Ihe rei|iiesl bun must be noted liy the
meelical clnccloi r,r chief of hospnal oi aelmtnistratoi for ambulatory smgical clinic ( \SCj.
2.\ scanned cop\- of ihe pie-calaract surgery auihon/.auon ictjiiesl anel checklist must be sukmittcel via
e-mail lo ihe propel I'hill leallh Regional (Mliee - Bencln Adminisli alion Section (PRO-BASj. The
coiicspondmg e-mail addresses of PK( l-BAS lo which the requests shall be submitted are listed in
\nne-. B.
W1"@1?'-"@"-""-11"@W-:S
F^t^ALTK 1
fe^ouiAWy
Dale:LL_"__\J'-'@
CERTSFlEpJTB^CO?;;
IlWJil2L- | Page 1 of 2

ll-
3. Ml ncccs^.in inlonmium in the pi(--cni:ii;ia suryciy iHithru-izsitiun i.cquest ;md checklist must be
Slli'jjIh The rUOs slmll nut process ic^ucsis with liicrnnplctc nifbimafioii ;ind will reiuin the
k-cisiMii iIk-icoii xvilliin fn-L- (5) woikiiu.; d.iys fimn iLCCipt of llu- c

_ p.hjhnihli 2L>a-I
Republic of the I'lliliptrinvs
PHILIPPINE HEALTH INSURANCE CORPORATION
Cinsuk- 011110 Lluikling. 7()

PRE-CATARACT SURGERY AUTHORIZATION REQUEST
(Adult Cataract)
Date of request:
This is to request approval for my patient ___
will undergo cataract operation at _______
(name of patient)
(age)
and shall claim reimbursement from PhilHealth, under the terms and conditions as agreed for availment
(name of hospital/ASC)
of the Cataract Benefit Package.
Requested by:
Noted by:
Name & Signature of Physician Medical Center Chief/Medical Dir. /
A5C Administrator or any authorized personnel
This Portion to be filled-out by PhilHealth
?Approved*
"Patient is eligible at the time of approval of pre-cataract surgery authorization.
?Disapproved
Reason:___^-
Name and Signature of BAS Head
Tracking number
Date signed
.TH
|p-s
CERT!
Dnl:
A]J2...
s~&
: copy

No.
1
2
3
4
5
6
7
S
q
10
n
12
13
14
15
16
17
18
19
20
PRO1
Region
PROM
PROIMA
PROMIB
PROIVA
PROIVB
PROV
PROVI
PROVII
PROVIM
PROIX
PROX
PROXI
PROXII
PROCAR
PROCARAGA
PROARMM
PRONCR-North
PRONCR-South
PRONCR-Central
EMAIL ADDRESSES FOR PRE-CATARACT SURGERY AUTHORIZATION
c ainis.prrjl(S)philhealtlT.Rov.ph
doknethinJyahoo.com
c aims.pio3(n.'pliilhealth.EOv.ph
benefil.pra3bjfflphilhealth.gov.ph
c ainis.pirj4a(ipphithealthRov.gh
c aims.pm4b(ffiphilhealth.ftovph
hcmd.pro5(5)phi!heali:h.e;ov.ph
pro&.hcclmd[tpginail.com
^nns.pro7(aiphilheallh.Kov.|jh
c ainis.pio8(5)philhealthcovph
rossanapara^jjya(s1vahoo.com
mmalcnto(S5philheaKh.ROv.ph;ba5.prolOiniphilhealth.gov.ph
cubenmd2003(5>yahoo.com
claims.prol2iSphilhealth.gov.ph
claims.|iioca[(5>phi1health.gov.ph
hcdmd.procaiaRaiaphilhealth.Eov.ph
c aims.oioarmmiR'plnlhealthBov.oh:hcdmcf.i]ioarmm(cDohilheaUh.ROv.Dh
c aims.promlat^philhealth.Rovjjh
r aimspiolp@pliillisalth.ROvph
c aims.procic(5>philhealtht;ov.i3h
E-mailAddress
m @ UiAOIT

yl
Annex C. Flowchart for pre-cataract surgery authorization request
:oni|)li_.lerf Checklist and request for
;ur[iciy,-Hilh.:.ri7,-i[ion to PHCI-DAS
PR0-UA5.WI0WS
Completenessof
Cl1Oib,lilV.."..Hi,,l
CllXU
nfoi 1,1110
i,ifl
Fni
lir,
IlL'Cl.llit.JP.1HCT1I
1
I@
I rai O-EJASdotU
I fa
I Jls
[z
ir,. i
o P>" \Sh
i ll
ll for
>EJArj 5Ciiii5 Ihe doonner
isliis/li^rinrlinlp
.- _.-*
F;qu&nALTH
TRO-B^S
adjudicHtoie
I
ithed.it.i.sc.iris
'i f \ l" i on
a..achCc