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PhilHealth’s benefits package for COVID‑19 testing using RT-PCR

PhilHealth revised the benefits package for COVID‑19 testing using RT-PCR machines. Below are instructions from the released guidelines:

Benefits availment

1. The benefits package shall cover all PhilHealth members who were tested for SARS-CoV-2 using RT-PCR, provided that the conducted tests adhere to the DOH guidelines for expanded testing, and the laboratories are DOH licensed and PhilHealth accredited.
2. Non-members are automatically covered, provided that they complete the member registration upon availment of the benefits package. 
3. During the state of national emergency, the Case Investigation Form (CIF), which is required for claims filing and reimbursement, shall serve as the basis for the PhilHealth Identification number (PIN) assignment, provided that the CIF includes a contact number for validation and verification. The submission of requirements such as PhilHealth Member Registration Form (PMRF) and PIN assignment shall resume upon the lifting of the national emergency.
4. The single period of confinement and 45 days annual benefit limit will not be applied in this benefit package.
Accredited testing laboratories are required to have an electronic health record of all patients who underwent the SARS-CoV-2 testing using RT-PCR. If this is not available, a manual record shall be accepted during the state of national emergency.
5. The benefit package covers the following services or minimum standards:

  • Screening/clinical assessment
  • Specimen collection
  • Specimen handling
  • Conduct of RT-PCR testing, including the test kit and other supplies
  • Analysis and reporting of results

6. For all eligible PhilHealth members, SARS-CoV-2 testing shall not be charged co-payment for these services included in the package.

7. Package rate for SARS-CoV-2 testing using RT-PCR:
Condition for Payment Services covered by PhilHealth Package amount (Php)
All services and supplies for the testing are procured and provided by the testing laboratory Complete service or minimum standards Plate-based: Php 2800
Cartridge-based: Php 2450
Test kits are donated to the testing laboratory Screening or clinical assessment, specimen collection and handling, conduct of RT-PCR testing, and analyzing of result Plate-based: Php 1200
Cartridge-based: Php 700
Test kits are donated to the testing laboratory; cost of running the laboratory, and the RT-PCR machine for testing are subsidized by the government Screening or clinical assessment, specimen collection and handling Plate-based: Php 800
Cartridge-based: Php 500

8. PhilHealth shall pay the package amount directly to the testing laboratory.
9. The testing laboratory shall be responsible for the reimbursement of the swabbing centers or referring facilities who handled the screening, specimen collection, and handling.
10. The benefit package shall be updated as needed to reflect current protocols and standards, including significant changes in market prices of supplies and commodities, among others, in collaboration with relevant institutions, experts, and stakeholders.

Claims filing and reimbursement

1. All claims for SARS-CoV-2 testing shall be filed through the PhilHealth-certified electronic system. While the system is not yet fully functional, submission of claims via electronic media (e.g., compact disk [CD], hard drive, flash drive) shall be allowed.

2. Subject to the requirements for claims filing, all claims shall be filed by the accredited laboratories. Only rendered services from February 1 to April 14, 2020, are reimbursable.

3. Members may be reimbursed for the amount not exceeding the corresponding benefit package, if the benefit was not availed or was not deducted from the actual charges, provided that requirements are complied with.

4. The basis for the payment of claims shall be the package code for the specific testing package availed, which shall be indicated in the SARS-CoV-2 Claims Summary Form. All claims shall be subject to monitoring and post-audit.

5. Claims applications for this benefit package shall be filed separately from other COVID 19 claims. These include claims for test done on patients admitted in PhilHealth-accredited healthcare providers (HCPs) with licensed testing laboratories.

6. The following are required documents for the filing of claims:

  • Accomplished SARS-CoV-2 Claims Summary Form, preferably in XLS, XLSX, or CSV format
  • Scanned copy of the properly accomplished CIF prescribed by the DOH, preferably in PDF format
  • Itemized billing statement, which includes the reader’s fees, preferably in XLS, XLSX, or CSV format
  • For directly filed claims, the original copy of the official receipt and waiver issued by the licensed laboratory indicating that the member paid full amount for the testing and that no PhilHealth deductions were credited. The Claims Signature Form (CSF); Claim Forms 1, 2, 3, 4; and summarized statement of account (SOA) are not required.

7. All claims applications shall have complete attachments as required in this policy. Claims with incomplete attachments shall be returned to the testing laboratory/ HCP, following the existing rule on Return to Sender (RTS).

8. All claims shall be filed within 60 calendar days from the date of the test. If the delay in filing is due to natural calamities or other fortuitous events, 120 calendar days shall be accorded.

9. PhilHealth shall reimburse for repeated tests as prescribed in the DOH guidelines. Dates of repeat tests should be indicated in the SARS-CoV-2 Claims Summary Form.

10. Rules on late filing shall apply.

11. Claims applications shall be processed by PhilHealth within the prescribed period for claims processing, provided that all requirements are complied with.

Philippine Health Insurance Commission. Benefit package for SARS-CoV-2 testing using RT-PCR (Revision 1). PhilHealth Circular No. 2020-0017

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