Z Benefit Package Rates for Coronary Artery Bypass Graft Surgery ...

t. 

Republic of the I'liilippina 

PHILIPPINE HEALTH INSURANCE CORPORATION 

(."ilvsliilc (Anne HuiI-Iiiil;. 7o>> Sh;iv\ I!,hiIcv:iiU. Pmsi- C ii\ 

1'HILHEA.LTH CIRCULAR 

No. QOOJ.s-2013 

TO 

% : ALL PHILHEALTH MEMBERS, ACCREDITED AND 

CONTRACTED HEALTH CARE PROVIDERS, PI-IILHliALTH 

REGIONAL OFFICES AND ALL OTHERS CONCERNED 

SUBJECT 

Z BENEFIT PACKAGE RATES FOR CORONARY ARTERY 

BYPASS GRAFT SURGERY. SURGERY FOR TETRALOGY OF 

F ALLOT, SURGERY FOR VENTRICULAR SEPTAL 

DEFECT /VND CERVICAL CANCER 

I.RATIONALE 

Pursuant lo Pliilhealth Hoard Resolution No \(>2L) s 2012, and Philheahh Circular 

N. 29. s. 2012, '@Govcniiii" Policies on Philhealrh Bench I Package for Case 1 \ pe 

/,", I lie following are the services ;ind rates for coronary artery bypass graft surgery 

(CABG), surgery tor 1'ctnilogj ol Fnllot f'l'OI1'), sui;gt:i-\ for \-ciuricuhu scptnl tlcfccr 

fN'SO), :ui(.l ccL'\riCiil cancer. 

The illnesses and their u>k ckissiticalion includcLl are ,is fullou-s: 

1.Slandard Risk t-llcctivc Surgery for: Coronnry Artery Bypass Gi:il;t fCAlKi), 

1 dial (~ori-ection of Tetralogy of l-'tillot (TCÎ:), nnd Sufgcrv for \'cnti-icul,ii 

Seplal Defect i.VSD); 

2.Cervical Cancer Slaê 1 u> lliP.: 

1 hese condttionh wcie chosen l.insed "ii cunx-ni evidence thai (.[unlily iienlmenl 

sii^niticanily me Lenses snrvi\n] rates and c]unlih ot hie. Mmeo\-er, \ ahd 

infonniumn ''or these conditions is readily available. 

II.RULES FOR IDENTIFIED CASE TYPE Z 

A. Only newly diagnosed cases of ccrvioil cancer shall be covered under the 

benefit- packa^L. l"or comnary ai-feiT b\'pass trratt sui-gery, total conecuon (>t" 

!()[@ and closure ol" \'SO, onl\ those cases lhat strictly fulfill the selections 

cnleria sliall be covefed, 

P.. Beginning [anuan I, 2n]3, all members availing of rhc Z Benefit shall be 

i"ec|i.uied :t 3-\eaf lock-in membership prior to availmcni of the benc-fii. Tluli 

ick-in membership dues not apply to lifetime mcmbcfs and sp< msorc-d. 

C. Pie-authorization from i'hilhcnlih based cm the approved selections en terra 

per specific 7. condition shall lie required prior lo nvmlmcni of services. All 

rt\]uesis for prc-aulhorization shall be completely accomplished by rhe 

@fe'^ MA. TERESA A OUIAOIf f 

A.O. !V. Cf iioi ItLLMS lV 

DatE:._._ih..l3L- 

_cc:r?Ti"!i~D t;!;!.1 ?. copy

cnmnicud hi^pii-.il -,mJ submilled io (lie I lend < 

AklnnnisL]';iti'.>n Scriiun h>r :ipprnv;il of disapproval; 

D.J lie diagnosis during; prc-iuithon/ntion shnil be tht- basis tor rcimburscmcni; 

E.No bnhino billing rNBlVi policy shall be applied for eligible sponsored 

program members ;md [heir ip.i,.s Guilt Nu.ijv 

2.The package rale shiill be P55U, III 111 for the entire 

3.Selections criteria for CAlHr 

a.Signed Meml.ier 1 ''inpowLTmcnl (Ml'.] lorm 

b.Age 1'1-711 yearsf- -- 

33533 - 335 3 i. 

335": 

nurse of imUmeni. 

'r.l -^ r,

c.Si able Uimnnrv Arim Disease requiring i;,IJ'd'i\T. 1SO|,,\TI;,D 

i '**li>ii:iry Arti.TY Bypass t imt't Surgery t(,AB( '.) with iiulic;i(hiii 

hn^cLl on ccu'onnry mi.itoniy, symplcini seven I v, 1A Kmclion, 

.in cl/or viability icsts; nun-invasivt tcsltng cnm|')]ficcl aiul 

discussed with p;itic?nc 

d.CuiTt'iu McJ[c;il Stnms 

i. Not in severe dccompensnlfd hcnrl failure (NYK I\'j 

it. Not with severe iUigiii;i (i.'CS C'l.iss lllj 

lii. No oilier cafdiac/vasculiif procedures/intervenrioi-K 

planned to lie i.\nnv with , AlilV AS \ 

OTHER SERVICES 

VMilmnvil hilim.ihuT rc.'.ls ;i^ me ..I,-Ll, nm.'- 

opci-.irivcl\ i.L pn.;rM|x-i.lt]->^l' l ;;. ailHl hiaJlial 

pl.mlrt I..IHH, AIM T, I' \'V \-INR, IT,S, N;,, I., \l;. 

'.dcium, Ill.'N,CR-ir[in.i,-. 11' \C . 11111:1 K :i: , , I,,-. 

@s-i.n iphk- ' \l'/l:iri-r.ilj. \2-k-.\J l..( (I.A1U;. 

:Oi:D. ll:i:. :is uKlicalf-J 

1'i.m..|..t:hivc- .innlui.tii-s il iiiilii-:il.-J (1\ aiul ..r.,]' 

Tri-ainuim, ;i. ilh.Iic.huiI. >ur]i ns 

3 lV-.ip,-i:unv fvalui-CI' ck-nii 

Ik I )pi-i] lli-:ijl Smi.hiit iimli'i KtiKi.il :ni.-;il)t..i.i 

Iiiiiiii-.1i.ih- |.si..|iir:Miv. r.nr .11 snf-i.-il U.U 

h. VI'L l'i..ph'.l.iM,. wiMi rompn 

i-p:um, 1..MW II, 

'1 C.ir.li-.iL i;cli:iliilinHic.n 

c 

Ndnilj/iiri'ii] @@ 

., In- 

(.1 

|ilv.M,.tlK-,:,|->v 

15Iml>m:Hii.n willi moi.jhI 

6 ( >tlicl- s[xî:ilu saviris vis iuxlU-J, such . 

, cIi|..i-ilU-. l.icrul..^.- s 

, ol

S. The piivim-iu lor this pnckn^L- shall be Five Hundred Fifty Thousand 

pesos (P550,000) tor ilic complete course . No cu-morbid lactors. such as ;iny "I the tt' 

ill. Prcopcrntive seizures 

iv. Ih.iin abscess 

v. Stroke events 

vi. Bleeding tlisorclers 

vii. InfcctLvc Liidocnrdilis 

viii. Dther congenital anomalies 

IIP 

F'Hi(nsJp\LT[- 

TWb 

@/gr

1 

1 

@ 

4. The approved climcil |v.iilnv;i\s Inr TOl1' shall reflect (lie niandiiloiy and 

(iihc-c sci-viri's -.is intliruk'fJ in ilic ml.ilc Lxl >\v. 

1. 

1 

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s 

1 

1[. 

12. 

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mill 

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IV 

MANDATORYSERVICES 

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I'SIII 

IT. 

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1; 

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latflfl 

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t'nr[@ 

'II 

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l,...l]Mi.pi 

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HIMS) 

iick-ai 

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@anuictlliMlHi' 

Mi!.P'l 

ropmijci- 

@uplvr^. 

@m-.I,,;, 

innimmii. 

ic-..lisosin 

1Post 

1Dlhi 

(inn 

J!.fll@ 

cipn 

'-I'lllli 

v,ni 

-1IJilit 

OTHER 

L'l-.uivt1an 

cn.iu.iami 

nicils.asn 

>hali,sp,Mi 

11 .,S:i,111.ifI 

nanl.iic\ 

^Pîaliv,t 

SERVICES 

In 

M. 

ill. 

S 

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ih, 

.ticsasuulnwictl 

li 

ati-d,suchasoral2'"' 

mloral 

-Mil 

ilnndi'd,.iichas 

i-i-sasnrf.li-.l.surll 

5. ['he piiynicm tor rlus pnekns^c s!in 11 be Three Hundred and Twenty 

.Thousand pesos (PJip 320, 000) lor rhe complete course oi cure which 

shall Lie s.i\en m [wo (2) [finches .is follows: 

MODE OF PAYMENT 

FILING SCHEDULE 

Witlim r-.il dais ., frt-r cnmpl,;ti"ii ,,f 

Rt-hahillr.Hi..n Usch-isi- Sessions (3"'-4"' 

C Surgery for Closure of Ventricular Scptal Defect 

1. Hit p:icl;nSc ende is Z007 which includes the (olluwing ICD-IM and RYS 

mils: 

ICDHI 

(s'-' 

MANAGEMENT/PROCEDURES 

t:ii.Miifof\.@ilirit-uljiSqiiiilUiliOu-itlioiuailiont 

pauli 

RVSCODES 

Vi!,S1 

2 111c p:ick;igc rare sir/ill be P2^n, (UK) for the entire CMiu>f of Lrcnimcnr. 

3. Selections ctilcn.i for suit, cry for YSD: 

:i. Siiiiu-J Mcnilief 1 ;.mpi)\\i iniLin (Ml-') I'nim 

b.:\^v: 1 in 5 vcars + j(.4 Javs 

c.2L:)-ccliuC;iL-diMLM-:iphy 

l. Isohicct YSD pcnniunbranous, subnoi'tic oi sul.ipulmonic 

ii. No combined shun is such :is ,iinal sepl.tl dc-k-ct oj- p.nent 

duci.us iiitenosus or .itj-ioventacuhii- scpu\l defed 

"JiAOir ! 

i.

No oilier ussocialcd C\ ID's : such as coarctalion ol ihc anrla, 

(ii- model ,iil- id seven- .loilic insiithcii.-nc\. en inoj(i-;i((.' r 

sl-\ crc puirnonic strnosi^ 

iv. Pulmonar\ ;iitcry pressure-: < 5(1 mmlig nv m least 2/'."'> systolic 

b!....cl pivs^Lirf 

v. QP (jS- > 1.5.1 

d. No previous crmlmc suigei.-\- yVA R,inCKl ICtl 

i_l 

H- 

,p 

,1 

,^ 

1": 

in 

all 

l.il) 

slini 

.ii- 

1>- 

MANDATORY SERVICES 

,:h 

I'-i Ik-~ 

l-IS i-1. 

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il:IMs(i-svanrr.iniiin. 

HMM.lvi- 

2IIllli'l11 

riilinon 

vninliiM 

4IHhii. 

.,..P,-i!i:i 

OTHER SERVICES 

uiivi-anlihis,knulnalr,! 

HHI-::lililiir.ll! 

i-ih,:r.imlitai.il,-ui.ll:ls12 

i\cut.Mlu-nnn-ilnl,.iil-Ii,, 

i

.. Cervicul Cancer Chcnioiadialion with Cobalt & Biaehylheiupy (Low 

Dosi-) or I'liinm-y Stilgcly for Sl;it;e IA1, IA2-1IAI 

1. [he packnsy: chi.1l' is ZOOS wliicli nulujcs ihc [ollowini. ICD-lli and RYS 

ICD10 

Ci'C 

[cs 

11 

1I 

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1. 

n 

1 

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1 

MANAGEMENT/PKOCI 

llli..loi!V 

DURES 

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t;eIAI,,nlv: 

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,^cJA2-1IA!: 

lsti-,i-L,,,,m-.irli 

Inn-Ll'.iiv.:,,ul|,.i,.,-.i.,,-lR-I'.l 

@.Mill,,UCli,l,,,i-iiil>.il|,i,i!;i.i,|,|,. 

i.i,,lLT.,i,i:,l.@ 

v.illhnu,|,|l:,tL-,,,l 

1,,I.,1L-,.,I[Vlvi, 

,|,lin'.di-^,nphn. 

7.-401 

s;'l5n 

-^HEALTH ^ 

Taa7Ferej3a a. quiaoit, 

mm MA. TERESA A- @@J| 

2. I'hc p;ieLi;j,u i-,iIl- si Kill Li..- IM2H. Ul If) [m(- (Ik- lmhilt course ol Ucntnu-nl. 

.') Sdeci ii ins cnlci in 

:i. Si-ncd Ml;. l;m-ni 

l.i. No pluvious lIr'ukilIil r;i| iy 

c. No pL-fviui.is luilioitu'iiipv 

cl No uiH-oiiiiotlftl co-nioibiU coiulifions 

c. I ivntnu'iii plan from ^yiiL-colunic ono iIdlmsi 

A. The :i|i|->i(.vc-J climoil p;ith\\;i\s foi (,t-n-ic:il Cancer Prinmiy Sui^cn sh:\ll 

lX'ilcci ilu1 nvAinl'rHiH^1 niul o|1k-i sl-lvilcp ^s iikIk:;iil-l1 in the inblc bclosv. 

MANDATORYSEFIVIC 

OTHER 

SERVICES 

@ 

s. 

'). 

II) 

k ,-||-.,liK 

1 

I1 

ioi-pr.cui'ii-.i-.ii.,(.ic:-.Miii 

"IK@ 

)1.S 

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1. 

phK 

c;pr.sr,,,,n 

IS.l-Cll.LlHSt 

lIl-1,|,,,,lll 

L-l 

pi-,,n-ssmi!l 

11'-^lo-0in\'in1 

:i..Hl.i-alti'.iiu:;l 

1Pi.sin,,,@@,*.-a 

(iiu,avi.-,ni,isan 

@1SiinpuilMedina 

,:iill'.:ll,'in.-;,.l 

,,H-l,,.ln,,,;,miik 

i..n:,,i:.-Jii.ili;cs 

nbi.iinsasnul 

,.,al) 

1:,,.jnlK-im-li-. 

liM-n-.n, 

J.i:-,:SI-'.liiaii 

:.M,,iL 

::,ti-il 

Inau-il 

tlllKS. 

5. '11H- piivnu'iit for this p:ick;it2,L- slinl! be One Hundred Twenty Thousand 

pesos (Php 120, 000) for the complete con use of caic which shall be 

L>,i\r(.'n in l\ui (2; rnniclu's us tnllou's: 

MODEOFPAVMENT 

AMOUNT 

F1I 

\\ 

1Mti-iinclic 

1M00,000 

\ITfI' 

.INGSCHEDU 

is:l!U-|lllf'lliarjr 

-Mltin-I-.ISILll-lt, 

J3 

Inmi 

t 

2'"1tranche 

P20,0110 

ulii 

,l,tll,@@!::..'I'eKif 

,ll,@-,,p

1 

I'). Ceivieal Cancer Clienioiadiation with Linear Accelerator & 

BrncliylliLTiipy (High Dose) 

1. The p;ick:i-c ode is Z009 which includes die inllnwiiu, ICD-IN and RA'S 

ICDHI 

MANAGEMENT/PROCEDURES 

.l.iKy 

RVSCODJ2S 

575nn 

I.! 

@.!' 

5752" 

(--,'- 

Cl 

r.ipv 

.1 

Ml\H 

.ki.mu 

"7T-U11 

111 

Kinill*. 

'-Py(M..I.v.,@@:..,rs,@:,; 

"761 

@~PrtiiiKEALTH I 

2 1 \\c piK-ka-i- iwu- sh:ill Ix- 1M 75, UOO [oi llic fiiiirt o>Lii:?e of trcninu'ii 

3. SHivci ii 'iis ceil crin 

:i. Si.uiK-tJ Ml"- l;.)Lin 

h is.iu prcvioii'; ch'-Miml hcinpy 

c No [irc\ im.is r;iilii)i]Ki-;ipy 

H@ Van @@reP}eV"*if7 '^ftfor*M". V I /I']'l , 

\.1; i,' \i .1. iinn:ii'..i-. mi;. ..Ihm ^ -1 -1 -. 

I 111:1-1.!^ rlmhi> I I:, 1 I '. .i;;in;iI I rll ] .lr-.ui IJ. @> ll'.k' :llul< ulllll.ll I . 1 @,@;: 

5. ( !nin-.|lHi-.i|n ,i-:, , i:-pl.uiii. i'.ii I >..pl:mn) 

6 K.ulioil[is ."lint m .1. n-l< I-.1I..U 

S r

-to - 1-J 

V.CLAIMS FILING 

All chin M- sh;i|] Ik- filed hv (he i-iniirnek'd hn^piiuls in lu-lv,ill" 

J. On loll Ciiiuxr 

ukIlJ ihotrIiii.jv 

@M..V! 

ENRIQUE T. ONA, MD 

Sei:ixi;u:\ 

!i i ;.@ 

t

I'hp) 

i. 


Rifublk uf tht I'hilippiiws 

PRE-AUTI-IORIZATION REQUEST 

STANDARD RISK ELECTIVE CORONARY ARTERY BYPASS GRAFT SURGERY 

n atkof rkquhst_ 

his is to ret] lie si :ippio\ ill toi provision f ^lt\ ices iiikIct iliu /, lieiifhi p;u Lî.l'C for 

Ill 

ex >Mn.r: rr. nami-: < >r iwtikn n(nami- < >!@ 11< >sn iai:: 

icU-i lIlL- Kl-ll].. and cumin n .us :ls ;i!îvi il f. H :n ;nlnn-|ll of I Ik- /. IV-lK-rn l':id.:lj.'.f. 

a nbb 

IUl|IIL-SlL-..l I 

l;,xL-i;uii\c Diivcior/ChiLTor I Inl'i 

iiiu-J N:imc cv Si^nnuiix- 

\lluiJiiH' ( ,;U\lniv:isciil.li- Sur^foii 

ll'iir Phllhcnllli l:sc Onl\ i 

?APPROVED 

?DISAPPROVED 

-S.mulmrovcH'rnmxlN.nm.llife' ^&ALTH( 

I lead, IViK'fils Adminislniliim Scainn/@ I

Rifuhlh' uj'the riiilippiin'* 


'. HW.iliM l-iiiic HinlJiiiLi 70r S'l S scurinu 

prcdlCUvr oTImw m(irt;ilil\ t;is|.; f-'@' 5" i.j 

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1and 

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liIV.ii 

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will 

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fIII 

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ContoniR 

h\I'aiiLii

Republic of the Philippines 


Oly.Udli; Onlie Building, 709 Shaw Boulirl Pas 

Healthline -141-7444 vvw.-.' philhenllli v.o-J |-I- 

_D,Hc- A tin lined : _ 

Nnnu >->t I lospiul 

Dale Di-;duir.LH.'J: 

Nnnii1 of P.uicnr _ 

k-iillh II > Number 

STANDARD RISK ELECTIVE 

CORONARY ARTERY BYPASS GRAFT SURGERY (CABG) 

CHECKLIST Of MANDATORY and OTHER SERVICES 

MANDATORY SERVICES 

Confirmed done / 

Dale signed 

I m>]X Mll\ C I .:\\ Jt H.J I' H\ h.-ilS 

sued ,i> : 

@cbi: 

@rl:lk-K [ auinl 

@Blood l;,pin.L'. 

@Nvi 

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@*-.i-fiiuninc 

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Cilyi.UiteCciHie Buifdmri, 1 

Hîlllilni" 441-744-1 

w yii.v ..pji'iLiîiy.1. p. p y_ eh 

l\ 

Open 

(..one 

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(Jlysl.-He Centie Bi.iiklin,;, 709 .".how Boulevard. Pnsip City 

Hn.-iIUiline 4

:_^__^ >,L-: 

" iRepublic of the Philippines 

KPHILIPPINE HEALTH INSURANCE CORPORATION 

ye? CoiUiL' Binklinn. 709 Shflw Poulevsid. Pnr.ip, Lily 

Mcnllhliiir- -1-1.1-7JJ'l s'nf;w pI'iU'OliHIi r.(-iv I'll 



Nnnic: 

\jil-Sex Thill Icnlih No 

@ijuRr.Mr.Nrsuu r.ki.isr 

I. First Tranche Pay men t 

I'k-il-t Uud, 

1~c7iinplclrd I'lnlliciillh l-XlRMSi AN1.12 

V (ômpk-icd /. S:uist';i

Hinh 

' tRepublic of the Philippines 

.*"PHILIPPINE HEALTH INSURANCE CORPORATION 

*l Him 11 Mine -Ul-744.1 



Vkhv-is: . 

\lv ScsI'hlll li.-.ilrli N.i 

D;]ir wl~ .Vlmissi< >n. 

Dale t"UHch:irjii'. 

I'KANi I II-. 2 Rl MURI-iMI '.N TS CA II @'.< !KI IS I' 

II. Second Tranche Payment 

I. (...inpk-lfd Cmxllac Kchnb l-orm 

Lr. < '< impk-u-

iItqmblk of the I'liilippines 

wPHILIPPINE HEALTH INSURANCE CORPORATION 

I L-.illlilnii1 1 I I -"4-1-1 

PRE-AUTHORIZATION REQUEST 

TETRALOGY OF FALLOT SURGERY 

'I hi-, is If. ix-(.|lksi nppvuv.il tor pniviîon nt services Lindci- llic /. henciit p:i(.k;i:_i,c 

i'NJP].l-:j I.'. NAM I @@.()!@@ 1WI ll'.N I Ii'NAMT. ( )l- I II >M'I I A I.] 

iiihUt I lit.- Ii.-iiik :iiil1 r.injllii.ii:- :l< .l-rccil I', if n\ :illnu-n til" iIk /. lii-iu-lll r;li.k.i;j.L. 

Hi''Jul I,.. 

IVink-d N.init. & SiLMi.iiinx 

AiitnJini* lVdi-.imc Uu-JiJoum/ iIk' I' 'IInw m; caii.lv 'i'v: 

D NliH D l'I\l-:i> CO-I'AV rlmlicitc Amounl) I'll] 

,\ssr>s. .@>srd nv : 

C( INNRMKO in' 

Primed Nnim iS' Si^n.ilurc 

[(.hi ck \ppnipn,m- 1'm>\) 

D ( h:\lr, lVp;irliiK'iil ol"IVdi:iirn. (_,irdl. il( >Ln 

? Chief, Dims>f I'cdialuc 'A1 Sur^'n 

Kxi'CLItlVC OliVCt'ir / ("lllL'l lit MnspUill 

D M'I'Rl IVKD 

D DISAPPROVED 

lor Phillu-illh L:st < )nl\ > 

py^'ÂLTU 

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id. 

inn 

li I.-I1Lirei 

fits 

,x 

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el1 

dl 

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imcl 

Sci.-Hon 

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1).\ .11

1 

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* iIh'pnhlk ufllm I'liiliifina 

rPHILIPPINE HEALTH INSURANCE CORPORATION 

@ih:,l:ik (i-nliv nuililin.9 7|][>NIi;iu l^-uffv ;mf I'.isiji C>{\ 

Name of I lospif-il _____ 

1'hill lL-nhh ID NlhtiIk-l- 

PRE-AUTITORIZATION CHECKLIST 

TETRALOGY OF FALLOT SURGERY 

fPl.Tcc ;l An N.\> 

Jl'Al 

Ill 

:a IK 

Yi> 

IVdiauic

jm7 .p.n : 

',Republic of the Philippines 

WPHILIPPINE HEALTH INSURANCE CORPORATION 

Ufalihhiic -141-7.14.1 ^w..y.[jhilhp,-HlHi p,o.- ph 

TETRALOGY OF I-ALLOT - ELECTIVE TOF REPAIR 

.Uklll.SS 

\j.r Sc: 

Oak' cf liii-lh. 

I'hill kvilili N.. 

I I.Ik- ..f Ailinissm 

lJ:ili- .il l.lisrh.iru, 

i uani i ir i uriii iki ,mi;n rs n n .1 ki.ist 

I. l:i(sl Tranche lJu\meiH 

1.i '.>|-.\ 'il'ômpk-TfJ Ml"i-i )RM_ 

2.r,H'n\ I muiih 2Dcc!i 

1 I :>iiviplc.ic Siu;.;iral I ipu.illw Rcpi.ri 

ii. i nl mope l;ili\ t1 I I'.I'. Ktpi irl,' I niilsiln 'nicic \\ M Inn jd:i\ s [i1 i>l i >p |.\ I Inch I\l-suI 

t. MAND.vn >i;>' i-i ii-;cki.isrorsi:.nvi_rr.s sk_;nij) 

(>. ( .MinpleK-d / S.i11-@ E.ic-mt hi Oucsih .niKinx-SiL'.iK-d 

I I i :(.mpifU\T nnd siyiK'il 1'iiilhciilih Cl-J 

1).\ I !@.

.iilli. i-niii^ riri;c. 

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OU'vUHeCfiihe Buiklnip.. 709 SIihv; BoulevFirr). P.T.igLiI^ 

Ho.illliliiv 4-11-7-MJ www plMlli^.Hlllij'.uv.pli 

TETRALOGY OF FALLOT - ELECTIVE TOF REPAIR 

N.inic: . 

\dthrs- 

Agi-.Si-x rhillk-.illl. 

l");iic of Admission: _ 

'R \NCI II'. 2 l;r.( H.'IRI'.MI ,N 1's Cl M'.CKI.IST 

II. Second Tranche Paymeni 

On-npli-lcJ l'l K:- I'l-Jiairic .:iuli:n: Rcli.ib h-rm \wlli 4 scî' > 

2 Mcihc.il ca-iifk-nlc nl'Ol'D o> nsiilliilii >n 

3. l'osh>[XTniivc 21XtIh . refill :ill,u. 

i) \ rr. coMi'i.i "i i-:i"> 

l.( IN! i )R[\]K: 

I'nticul / C ni.iri.lnn 

l\inutl N;ime ;iik! SiL'.iirin 

Kelniion [o I\ukt 

Documuiu^ Reviewed I 

PnninJ N;hik- & Sh_;nm i \i\ 

I'nnicit Name and Ni^naitir Pnnk-d Nninc .iikI Siini.iinrc 

@'xccum l Direct'h-/Medical denier ( 'hie 

@piLllYlVAL 

ID. 

'" %\n\[:o *'



phillip-HlUi.i'.rK'.nh 

_D;iU- AdmiUu 

Dan- Disch,iic;cd: 

Phil! Icitlth H; Nunibci- 

TETRALOGY OF FALLOT - ELECTIVE TOF REPAIR 

CHECKLIST OF MANDATORY mid OTHER SERVICES 

TRANCHE I 

ITblCC ,1 ^ Iliul idJlLilK- S1.11 U,-. (IT d,\[C (JnlK- Ml1 L'.l\ Clli 

SERVICES1 

IRSI 

lltANCIII^ 

CIlCC 

D.Ke 

ka 

llIlllllCMU' 

11C/GlVL'll 

AI tested by. 

(Niime & Sii>n:iiuie of Atteiidii 

I'livsi.ian) 

1l'i 

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IK''.vn 

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v 

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City^tale Centre Buildim;, 709 Shaw BoliIpvskI Fasig City 

Hr'althlme -111- .'@@1-1-1 www pliilh'.-aUh rov i.h 

4\n,i 

lll'l 

,rli."a;iil.lmk 

l.pk-,1.10 

n-N\il 

l.lici-l,,r.i|>|ili,-:ihkami 

rhn-,Sum:,iliii.-,,i-iiuli.-juh.\ 

(\\ir..i1k--.i,.1i,.;m--I 

1.1 

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il.l..'lull 

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ii.h;Ivi:.-iiik 

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n. 

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ji.hcmiiIi|i| 

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(Nil,1-..1':, 

1llllo 

]',,M,,pSill"illl 

il|..di.HK0 

.i

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1 

t 

Republic o/(/](? Philippines 


Olv^le CcnliP Euildiiif;;. 70? Slm.v r-oiil^vjud, I'ii.iguly 

PostoperativeMedications 

a.Dopainme 

j.Dobutamine 

c.Nitroglycerinedrip 

dMillinone 

e.CalciumGlucondte 

fTiamadoi 

p..Midazolam(sedation] 

hRaniudine 

iOralUigoxm 

1OralFuroseinide 

LOislCoplopnl 

1.OralParacetamolor 

ibuproTen 

mOralAntibiotics 

Checkifapplicableand 

placeStatus/dateorNA 

11A. 

1B._._ 

11C. 

.D. 

11E. 

11F. 

G. 

hi. 

1. 

:L. 

@M. 

rnivin/l .cl',;iI Ciu.mli-.in n\~ I'mkni 

Primed N:iiik' niul Sii_>ii;ii litll>)Ciinii.-nls 

Rcykw,iI I 

led Niiniu & SiîKlHnc 

I.I II- M.I I i '/, MAN \C;i-K 

AllL-Sk-il I 

Nanu1 iiiul Su;ji:iiurc of Atrciuliii^ l'hvsici.'in 

N;iiik- ;iih1 Siîi.uurc


Republic nfllw I'liilippina 

PRE-AUTHORIZATION REQUEST 

VENTRICULAR SEPTAL DEFECT (YSD) CLOSURE 

n.YI'K Ol- kl'.QI iT.S'L 

) re^m-sl .ippniv.il lor provision o| scp/icl;^ ihu.Icl" (Ik1 '/. Li^ncfu prn:l-,;i'.M' {@> 

i'C( 'MI'l.iriT. NAM I @@.()!@ IUTII.NI }! N AMI . (. >l- I l< ISl'ITAJ.) 

Liih.k-r ihi; [(mis ruit.l c< jihIiiions ;is .iL^r

X 

A'f/wW/i1 ol the I'hilippina 


( "lKsUilcC culii: Huiklin-. 7|)

ing: 

i. 



i ilyMnu- CoiUitj Building. 709 Sli.av Dcmlevnid. Pasif? City 

YKNTKK.I.'I.AR SIT'I \l. I'll :i @'! @. \ ot' Aj-)]i|-(.\ i.-d I'ix - AuiIk'I i/;ii[oii t 'lu-cl-Jisl tS: [U't-jucsr 

I .1 1ihi m;ilt>r\ l}i\ ()|u-f:ill\ c I :ilii I 

6. I ll 1 ]":lf >piT-"ll [vc I I ;.l'. l\(.'pi >!@[ @ 1 i":]M^l|-|( i [':11:1c wi I hill ,li];]\s [t s| r >p t \ I tncll Ri; 

7 MANILA l( )l^' (M II X .kl.lSr OI'SI-RX'K.r.S SICiNI .1) 

srTTl.lNKÂL AUSni.y.'l Si~qi_K-J 1>\ -^J_t_^n t l_i i lirijivs n_ 1: n 1 __ 

'). ( J)in| >|rii.(l /, S:ilisf;n:i Kim 1 ûcsiu)im:iin: ^hjiK'il 

M)'."\:SQ d"."\TA JÂSK P.NCt'iQl'D ~"_~" " " "^_""^_ 

livri: f]( )M]m"j;. n'-;n @"" 

datk hii.ia) 

CONI-ORMK 

Prinkx! N.inic ;uul Siijnnmif 

I )< iruiiK'Uls Review f(.l hv: 

l']-inlL\l Niinu-

L 



Cily-Utc: Centre Bi.nldiiig. 709 Sliaw Boulevard. Pnr-ia City 

YKN VRK.VI.AR SI .PI \l. 1)1 IT.' : T - I-J .KCTI VK VSD CI.OSL'RI 

N.inK-: _ 

Addicss 

l)Mw (,1'liillli: _ 

l'liill k'.ilili M,i 

Dan- ,,r Admission 

I'J.ilc- @@! Olsdimyr: 

TR.\N

II. Second Trundic Piiymeni 

( :..ii,|ik-k'J I'l IC- Pcdi-uric ( :.,,@,hac IMv.ili |-,)im will] -I 

2. Mcilicnl ciTlitlciilf : 

.( iNKiRMIv 

kfbilli hi lit 1 ;ilk-iic 

I'l inU'tl Nairn- iiiicl SitMi.ilurr 

I luamiuns Rnim-J I 

I'lillKxl M.inic ls; Si-jjiilluKpi 

in.! ikalti i / man.u;r,R 

Aikstt'd b\ 

.\llcili.lill;4 Plusii:i:iM 

I'rinictI N;inu- ;iikI Sii>n;iUiR' 

i:\CL-Ull\-C nilfClnivMcdlCill (xMUT CIlK'K 

/:

I* 



CitysiateCt-mnj Burkintp, 709 Shnw Boulevmd, PaMECily 

l-lL'.ilihlinr; .141-7-1-J'l wAw.pliillienUh.nov.pli 

_]^):H-c Admit ict! : _ 

Dak- DisclwfK 

Pliill Icillli IO Numlii 

VENTRICULAR SEPTAL DEFECT 

CHECKLIST OF MANDATORY ;ind OTHER SERVICES 

TRANCHE I 

SERVICES 1 IKS1 

TRANCHE 

Check nnd Indicate 

Duu- Done/ Given 

Attested b\: 

(Name & SijriKituie of Anendiii 

PMsiciun) 

.prune l.nl 

IK. ullh pi,, 

@l.n.J f,rm:i 

\._ 

@@:i. k.

1 

L (Republic of the Philippines 

.VPHILIPPINE HEALTH INSURANCE CORPORATION 

nlLhhi),? .1 11-7440 

-I.,\n.n.-Sllicsi:\(U 

nolapjilicnljk'j 

lcI;orN 

\if 

w. 



Cilysl.ni; Centrp Building. 709 Shaw Boulevard, Pasig City 

Hcalthlmc

nrlli 

* tIte/mlilic i>l the I'liiliifines 

>PHILIPPINE HEALTH INSURANCE CORPORATION 

1 li-.ilililiiR- -1-11-74M \\\\u philhi-;i!lh.Lio\ pli 

N.inic ciL'l losplhil 

N;iiik- t if l1aurii(_ 

PRE-AUTIIOR.IZATION CHECKLIST 

CERVICAL CANCER 

i.HWI. 

1 

;. 

1. 

H 

Ni 

Mi 

:.viins 

)|1SV["CSlll 

jlj-|:\-lniis 

,ldi 

hc-i 

>rlKT;ip 

ioiIkt. 

ll'l iceav) 

No 

A1K/Slctill\AHelli.lIIIL',('\IK'()ll(.o 

1. 

5. 

Ir 

()i 

CO 

@alllH'll! 

Colooisl 

idldnns 

il; n1" 

led 

liraCiv 

ai-mnr 

K'C.t) 

inl 

oiric 

I'KKI(.link-illSi:ij;iiih 

Vis 

l);lll-aoiu- 

\lk-slcdh\AllL-iulm^(i\-iuici>l(iijJL-- 

Sta^c:(i;hcnc(,l,,i.isi 

"Si;i"KrTA"i 

Sm.m-IA2 

SeineHi| 

Si:u>l-Ili2 

Sliî-HA1 

Sl:iKcI1A2 

Stil;;,.1114 

SlMyc1IIA 

SlnKc-1111) 

- 

I _-::fi t& I

t i 

Kepublk of the Philippines 


(.@i!\sl;ik- (A'liliv KliiMihl!. "00 Shaw Mtuik'vmi!. I'.ism L \\\ 

PRE-AUTHORIZATION REQUEST FOR CERVICAL CANCER 

Dutc orRt-i|ui.'si_ 

'Tins is to rccjUL'Si vippiuv.il loi1 prevision ot ser\ ices under ihe /, bunclii pnclî^c 

(COMPJ.KTK NAMK OFl'AriKNT) 

(NAMIiOr HOSPITAL) 

under ihc terms and conditions n* agreed foi- ;i\ailmcnL of the Z licnefn Package lor cervical 

I lie | ia lie nl belongs lo the lollowing cal^L'/in (lid; V aj >j")to| trl;ile box). 

II NUB 

U FIXED CO-PAY ichemo, Inachy low elose, cball or pi-im:iry surgeiA, 

0 FIXED CO-PAY (chemo. brachv high dose & linear accelerator) 

Kccjui.-sti.-d by. 

Nou-il l)\: 

Printed Name & Signature 

Attending Gynecologic Oncologist 

Printed Name & Signature 

Medical Director/Chief of Hospital 

(l-"oi-Thill k-nllh List- Only; 

LI Disapproved 

Head, Benefits Administration Suction 

fSiu,!i:ilLire over Primed N.imel 

Hale:. 

'@@@v,c;..::-T---K-ô7r; 

,,.:j\f^

RqnMk nfllic I'liMp/iines 


CilWiilL1 < uilK- rtuililiny. 7t)(> Shiiw hiHikvjirJ. I'iisiu fn> 

I k-Lillhlinc l-l I-7-I-II \\v\w pliiiliL-jllli.yoy.iih 

_D;H

w 

i 

Reimhlk nfllie Philippines 


Cil>suilc (A-nlii: Ruiklnm. 7IW Xkiu Roiilo;ird. I'nsiy fii\ 

SERVICES 1*' Tranche 

Surgery fot Cervical CA 

Stage IA1-1IA1 

Check and Indicate 

Date Done/ Given 

Physician's 

Name and 

Signature 

Conforme 

(patient's 

signature) 

3. IVoccduie done 

For Stage IA1 alone: 

Dare of Procedure : 

Gynecologic 

( )ncolph (>it'Ct< )in\ 

4. lilood Ti.";"inskisJ(mi Support 

(if indic:ilcJ) 

? l;\VB DI'RBC Dl-I'l' 

? 

^. Postoperative I .nbomton 

(when uuiicalcd, if done) 

:i (T>C with plaiclcr 

Check if applicable and 

place date or N.\ 

h. l .< x; 

c. elccirolylcs 

(>. Postopemiive McJicjiruins 

(;is indicnfccJ, when needed) 

:i. An:ilêsics 

b.Antibiotics 

c.l~leni:itinics 

(..heck it applicable mid 

plncu St:irns/d;tlc or N.\ 

h m 

( a iinpleiutl mid Signed /, 

D. 

S:itisKieNoil QncsiKHiniiirc 

N. ()pcr:iti\f Record ?_ 

Attested by: 

Date: 

Name and Signature of Medical Director 

n i,,i-,,.,,

nt 

! ,Republic dJ the Philippines 

>'PHILIPPINE HEALTH INSURANCE CORPORATION 

"lOhsUlu CoiHiL- Huililiii!.:. 7()'J Shiiu HihiIla;ii\I. I'.isili C'il> 

ffy!k-:illliHin.-.|-ll-7-l-N .plnllii:;ill]ii;

Republic iij the I'liHi/iii'ma 


 

lk;;illhlino -I4I-74-N u\\_îilnlliojilili.in .ph 

Dnlc 

DiUl1 Dl^cliarêcl: . 

Phill IcmIiIi ID Number 

CHECKLIST OF MANDATORY and OTHER SERVICES 

CHEMOTHERAPY, BRACHYTHERAPY (LOW DOSE) WITH COBALT 

CERVICAL CANCER 

TRANCHE 1 

(Place ;i ^ and imlKau- slarus or dale dime or oivcn) 

(Clicmo,LowDoseBrachy, 

Cobalt) 

CheckandIndicate 

DateDone/Given 

Physician'sName 

&Signature 

Conforms 

(Patient's 

Signature) 

1.I'rc-proccdurt.11,;il.iornl(.)r\-' 

n:l. 

b.Plateletcount 

b. 

d.(Îil'scK-v.w 

p\ 

D 

H.lr...-ltj"I 

,--&I 

S-,,.i 

F7^ ;.irn.,/n[ii[ii,.;,uii @,, ,-j,



C'ilWMlo I ciilic lluilding. 70') Sluiu llnulcvaiil. I'asii: fnv 

I IcallMiiK -I 11 -74-1-1 uîU'lHn.Kiillll-L-"1- v)< 

SERVICES1"TRANCHE 

(Clicnio,LowDoseBiachy, 

Cobalt) 



&Signatuie 

Confoinie 

(Patient's 

Sit>uature) 

(ivnucolcit/ic 

DatesofProcedure 

(startmm/dd/yyendmin/dd/^): 

Oncologist 

Rndiaiion*)ncohiîsi 

[f1.m\dnscHire 

DatesofProcedures 

lnin/dLl/vy 

Ci\nccohitJic 

()ncoloîsr 

RadimionOncoloîsi 

Cl\nccoli>i;ic 

()iicolou;lsr 

ni. 

1ifim.licnri.-tl:iuddone 

n4. 

Indicatecyclenunibcf 

I,II,III,IV,V,VIand 

date(lnin/dd/w) 

C.Supponmcdic:ili'>ns 

f|1.Antiemetics 

Iviilnoschon 

i@@'Kr 

@'@@:@''"j 

Cirnnisctron 

Mctoclopramldc 

Q2.CI-CSI' 

||3.1Icmaiiiiics 

?4.C.Wilts 

D2. 

ra 

iiliilh,-:il[li ,.,@ nh

m 



OhsLilcCuilie I tinkling 7(10 Sl,;iv, iluulcwiiil. Piisiy l'il\ 

SERVICES1-TRANCHE 

(Chemo,LowDoseBiachy, 

Cobalt) 




&Signature 

Confornie 

(Patient's 

Signature) 

-1.Klood'linnsfusionSupport 

fifmdiciirvcl) 

DIAVUGPKUC?I1I7 

n 

5.PostircatnicnlMcdicnlions 

(homemedic;!lions,il" 

indiciilcd) 

;i.Amicnk'lics 

b.\n;il(mjsics 

c.l-k-maiinitjs 

d.()iln;is 

ru. 

nd. 

()(.iompkicdandSigned/. 

S:itist:iclionOLieslionnaiic 

n 

7.K:idiniion'I'renlmcni 

Siiinniiin 

A.1M\ic]

cnr 

Ki'piiblic of ilit I'liilippiim 


:i;ilc ( Vnlic Minldiiiji. 7(I1J SIkiw Jlmil^Minl. I'îjiCih 

I Iciillhline 441-7 14-1 wau plnlhculLli.L'A |>li 

Name of Hospiral_ 

_Dafc Discharged: _ 

I'lull k:illh 11) Number. 


CHEMOTHERAPY, BRACHYTHERAPY (LOW DOSE) WITH COBALT 

CERVICAL. CANCER 

TRANCHE 2 

(1'hici.- :i ^ and indicnlr stains or Ontc tloiif < .r (.In un) 

DOCUMENT 2NU 

TRANCHE 

Medical Ccrtificiiie of 

Pleasecheckif 

applicable 

andindicatedate 

Name& 

Signatureof 

Gynecologic 

Oncologist 

Confomic 

(Paticiu's 

Signature) 

( )LII-l>:lticnl lollow Lip 

( .on,sLih:ili

* /Kepiihlk of the Philippines 

,VPHILIPPINE HEALTH INSURANCE CORPORATION 

CihsLili: f.V-nlif Building. 70') Shim Buulcniril. I'kiji Ci[> 

^ll.nlihlin,' 4-11-7.144 uuu i -> 11 i 11 il -11 llc;illhliiio r 11 ..ov.nh J-II-7U-I MMMj.ljiilLcaUiii.lv.pli 

Date Admit red: __ 

Date Discharged: _ 

I'lulHenllh ID Number 


CHEMOTHERAPY, HIGH DOSE BRACHYTHERAPY AND 

LINEAR ACCELERATOR FOR CERVICAL CANCER 

TRANCHE 1 

(PLiec ;i ^ niul iiulic;ilc st:ilus or Oalc done1 or C 5 i\L-n j 

SEK VICES Is I TRANCHE 

(Clicmorad + Linear 

Accelerator) 

Check and Indicate 

Date Done/ Given 

Con tonne 

(Patienfs 

Signatnic) 

1. l'i;c-prucedure J ,:ibof:;Hory ' 

a.CMC 

b.l'lntulut count 

c.Blood typing 

d.Colics! X-r;iy 

c. \:.CA] 

f. l;liS 

14. Nji, K, C:i, C;i 

h. f Jcntininc 

i. AST/ALT 

j. l^roiimc 

k. I'lifiiiil M lnoinhfjphisiin 

lime 

1. L' ri(in I\ sis 

m. J-lisUipntholooy 

n. Imping: 

n.!. IX-U IV, 

n.2. Ci'Scnn or MRI 

o Pilootl suj^porl", 

screening, processing 

I"), t -vstosccjpy 

lj. I'louosigmoidoscopy 

@>;/mrlic

L 

Republic uj llw Philippines 


(.'llWiite Centre tluiMiiiLL 709 Slum nnulev;inl. l';isi^ Cil> 

ItL-iiltliliuc JJ I-7.U-1 unu |iliillic;illli.y\' 

-5-i 

j 

1whenindicated 

h';mmliillu';illli-'

.,i,i, 

w 

Republic of the Vhilippincs 


(.'il\Nl;ik' Centre Hiiildiim. 70 Slum H(uili;\;inl. I'uîji C'ii\ 

(Chcmoiad-t-.Linear 

Accelerator) 




&Signature 

Conforme 

(Patient's 

Signature) 

4.l'!')i>d'[ransh-isionSuppoir 

lii'indifiiinl) 

D[A\;i;DI'RIU;Dl-IP 

n 

S.I'tjsiircninicniMrtlic;itins' 

llvmicmcLlications,if 

iiuliciiicd) 

;i.AmiL-mciics 

h.Analgesics 

c.1luiiia!mics 

l\.(Mhcrs 

na. 

ne. 

nd. 

(').C^miplcrcdandSigned/. 

Saiisfaciion(^licslionn-lire 

n 

7.K:idi:iun1Vcalnicnr 

Siimmar\' 

A.VcWicRadialH.nfiincar 

;Kxckialorj 

Vi.liiacluihci/apy("hl^li 

dose)" 

na. 

nb. 

Radiation 

()nc(jloLis(: 

.S.(ChemotherapyTreatment 

SummiUTandindicateik.i.of 

cvclesc

H 

L 



Cil>5l.ilc(Vi!Mc Biiikliii" 711') Slum ItaiiL-vml. ]'ii-iy ( il> 

lle;i!llilniL--lll-7.| II n | -I i j! 11 tr.iji 11 an pli 

Name of Mos|"iial_ 

_D:Ue Discharged: _ 

Phill-Ie;llh ID Number. 


CHEMOTHERAPY, HIGH DOSE BRACHYTHERAPY WITH LINEAR 

ACCELERATOR FOR CERVICAL CANCER 

TRANCHE 2 

(Place ;i

Z Benefit Package Rates for Coronary Artery Bypass Graft Surgery ...

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