The Philippine Health Insurance Corp. (PhilHealth) removes the length of stay requirement as basis for reimbursing claims for pneumonia, acute gastroenteritis, and urinary tract infection. This applies to all in-patient admissions in PhilHealth accredited institutions.

According to the PhilHealth Circular No. 2017-0028, which was signed by Dr. Celestina Ma. Jude P. Dela Serna on September 25, 2017, the following guidelines must be met for claim reimbursements:

  1. The length of stay (LOS) shall not be the basis for claims reimbursement for pneumonia, acute gastroenteritis and urinary tract infections. Claims for confinements that fall below the recommended LOS shall not be denied.
  2. All claims application for pneumonia, acute gastroenteritis, urinary tract infection and sepsis shall require submission of their corresponding certified true copy of complete clinical chart of patients, which details the history of present illness, course in the ward, vital signs monitoring, doctor’s order sheet, nurses’s notes, laboratory and imaging results, among others.
  3. Claims application without the required attachment of certified true copy of patient clinical charts shall be returned to sender.
  4. For all other conditions, clinical charts and other related documents shall be made available upon request by the Corporation.
  5. The Corporation reserves the right to subject any and/or all claims application for pneumonia, acute gastroenteritis, and urinary tract infection to pre-payment medical review.
  6. Application of existing policies shall apply during pre-payment medical review. Any violation of the policies of the Corporation shall cause the denial of the claim.
  7. PhilHealth may subject other conditions or surgical procedures to pre-payment medical review and submission of complete clinical charts or other documents as deemed necessary thru the issuance of an advisory anchored on this circular.

For more information about the circular, please see attached PDF in this post below.


Source: PhilHealth