Availment conditions and procedures


Availment conditions

The following must first be met to avail of your PhilHealth benefits:

• Availment/confinement is within the validity period as stated in the Family Health Card or Member Data Record.
• Must be admitted in an accredited hospital and attended to by accredited physicians.
• Confinement of at least 24 hours (except when availing of outpatient care and special packages) due to an illness or disease requiring hospitalization.
• Availment is within the 45 days allowance for room and board.

Benefit availment procedures For outright/automatic deduction of benefits:

• Present your valid Family Health Card to the admitting/billing section.
• Submit the following prior to discharge from the hospital:
  • Duly accomplished PhilHealth Claim Form 1 (original)
  • Copy of valid Family Health Card
  • Copy of MDR.
    
    If patient is a qualified dependent but not listed in the MDR, submit applicable proof of dependency or PhilHealth Form CE-1.
    
• Agree with your attending physicians on how much is left to be paid for their services over the professional fee (PF) benefit.
• Upon submission of all applicable documents, the billing section will compute and deduct your benefits from your total hospital bill.
• For confinements in DOH-retained hospitals, Sponsored Members will no longer have to pay anything.

For direct filing/reimbursement:

Submit the following to PhilHealth or through the hospital in addition to the documents mentioned earlier within 60 calendar days after discharge:

• PhilHealth Claim Form 2 (to be filled up by the hospital and attending physicians)
• Official receipts or hospital and doctor's waiver
• Operative record for surgical procedures performed

For confinements abroad:

Submit the following within 180 days after discharge. Overseas confinements shall be paid based on Level 3 hospital benefit rates.

• PhilHealth Claim Form 1
• Valid Family Health Card
• MDR/supporting documents/PhilHealth Form CE1
• Original official receipt or detailed statement of account (written in English)
• Medical certificate (written in English) indicating the final diagnosis, confinement period and services rendered.

Post availment reminders:

After the automatic deduction or reimbursement of your benefits, PhilHealth will send you (to the address you have indicated in your claim form) a benefit payment notice or BPN. The BPN is a report of actual payments made by PhilHealth relative to your confinement/availment.

Should there be discrepancies or if you have other concerns pertaining to your benefit availments, you may contact PhilHealth or your health care providers and bring the BPN as reference document.