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Individual Member: Benefit Conditions and Availment Procedures

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Availment Conditions

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

  • Payment of at least three (3) monthly premiums within the immediate six (6) months prior to confinement. For pregnancy-related cases and availment of the newborn care package, dialysis (except those undergoing emergency dialysis service during confinement), chemotherapy, radiotherapy and selected surgical procedures, payment of nine (9) monthly premium contributions within the last 12 months shall be required except for those enrolled under the KASAPI program.
  • Confinement in an accredited hospital for at least 24 hours (except when availing of outpatient care and special packages) due to an illness or disease requiring hospitalization. Attending physicians must also be PhilHealth-accredited.
  • Availment is within the 45 days allowance for room and board.

Benefit Availment Procedures

For outright/automatic deduction of benefits:

  • Submit to the billing section the following prior to discharge from the hospital:

- Duly accomplished PhilHealth Claim Form 1 (original)
- Proof of applicable premium payments
- Clear copy of Member Data Record (MDR)

  • If patient is a qualified dependent but not listed in the MDR, submit applicable proof of dependency.
  • 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 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

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.

For more information contact the PhilHealth corporate office.

Source: Philippine Health Insurance Corporation, http://www.philhealth.gov.ph/members/individually_paying/index.htm

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