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PhilHealthRegionalOfficeVl

Gaisano
City Capital- Iloilo,LunaSt.,La Paz,ItoiloCity
(033)501-9190
to 62
gov.ph
www.philhealth.

M8
TO:

ALL PHILH

FROM:

LOURDES

ENGAGED HEAITH

CARE INSTITUTIONS

Regional Vic

BERN

THRU:

HCD

ETTE L.

REYNES,V

Chief

DATE:

January30,201,5

SUBJECT:

INCLUSION OF THE OF DATE OF LMP (Last Menstrual Period) TO


THE CI.AIM FORM 2

The Corporation, through the National Health Insurance Program, commits towards achieving
Millennium Development Goal for maternal and child health. This is to ensure survival and well
being of all mothers and their newborns by providing them financial tisk protection. Along with
this is the enhancement of system features to increase efficiency of claims processing.

PhilHealth

Circular No.

ACCOMPLISH

CLAIM

22, s. 2014, ANNEX


FORM

B -

(INSTRUCTION

ON

HOW

TO

2) instructs that under Special Considetation for ALL

deliveries, the date of last menstrual period (LMP)

should be written in Claim Forrn 2 at

paft II, item 8-c. A11 deliveries include and not [mited to MCP, NSD, Cesarean Section &
Breech extraction.

For sample claim fotm please seeAnnex B of PC 22, s.2014.

For yout information and guidance

I C teampnllneartn

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ANNEXB-INSTRUCTIONSO
CI.AIM FORM 2

N HOW TO ACCOMPLISH CI-AIM FORM 2 and.SAMPI,I

/
/
rrate
Note: Claim Form 2 shall be acconrplished using capital letters and by checking the agXlropri
dbe
boxes. All items should I re marked legibly by using ballpen only. AI datey'should
filled out in MM-DD.YYY format.
/

Part I

Patt II,
item 1

Part II,
item 2

Instructions

Description

CF2Pa
paft/
Item

/
/

!7RITE the PhitHeaLthAccreditation Numbet, name of HCI and the


addtess on the spaceprovided

PhilHealth Accredited
Number
Name of Health Care
Institution
Address
Name of Patient

WRITE the complete name of the patient in this format:


Last Name. First Name. Name Extension 6f any).Middle Name
Tick appropriate box
IF yes,write the name and addressof refernng institution

Referred bv anothet HCI

*In NSD Package,write the name of the facility that


orovided the antenatal cate (asapplicable)
Patt II,

Confinement petiod

t, ---_ 4

\+-

.s,.1

)ate Admited

WRITE the date of admissron

lime Admitted

$7ritethe time of admission

-_-_!

$l

V EEi

For Antenatal Care Packaeewtite the date of t't p1e-natalvisit

igHE

Blank for AntenatalCatePackaee


)ate Discharged

!?RITE the date of dischatge

lime Discharged

For Antenatal Cate Packase write the date of last pre-natal visit
WRITE the time of dischatge

E-,1
8l

C)

I)^ar TT

Blank for Antenatal Care Packase


TICK the appropriate box

lPatientDisposition

item 4

Part II
item 4f

TICK the appropriate box

Transfetred/refetred

Patt II,
tem 5

Tlpe of Accommodation

Part II,
item 6
Part II,
item 7

Admission Diagnosis/es

If patient is refered to anothet facility, write the name,and addressof


the facility and reasons fot tefetal
*Claims for Antenatal Cate Package(ANC01) and Referral Fee
(59403) should have the name of the facility where
the patient is teferted to for delivery/further
management
TICK appropdate box
Blank fot Antenatal Care.Packase
$flRITE the admitting diagnosis

DischargeDiagrrosis

'{TRITEthe diagnosison dischatge

ICD 10 Code/s

IVRITE the appropriateICD 10 Code/s


Codesfor methodand outcomeof deliverymustbe included

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PhllHcalth
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a
,/

,l

CF2Pa
p^tt/
Item

Instructiors

Desctiption

Leave blank
VflRITE the applicablePackage/RVS Code:
Matemity CarePackage:MCP01
NSD PackageNSD01
CesareanSection;59513ot 59514ot 59620
Breech extraction:59411
Vaginal deliveryaftet CS: 59612
NSD 'ffith BTL:59402
Antenatal CarePackage:ANCO1
Intrapartnm monitoring (wlo delivery): 59403
Antenatal CarePackagewith Inttapartuo monitoring: ANC02
432
Newborn CarePackage:99
WRITE the coresponding date/s for the ptocedure,/s
*for claims for delivery (i.e. MCP, NSD, etc.) write the date
of delivew
Fot AII delivedes:
$7RITE the date of last menstrual period (Lt\4P)
Fot Claims fot MCP and Antenatal Care Package:
WRITE the dates of at least 4 pte-natal visits on the spacesprovided,
Leave blank for other claims.
TICI( the servicesthat are provided
ATTACH the Filtet Caid Sticker for Newbom ScteeningTest in the

Related Procedures
RVS Code

Date of procedures

Part II,
item 8 c

Special considetation
MCP Package

Patt II
item 8 d

Newbom Care Package

PartII,
item 9

PhilHealth BeneEts

Part II,
item 10

Professional Fees

Part III
SectionA

soaceotovided
V7RITIE the co*esponding package/RVS Codes for the benefits that
vdll be claimedr
Maternity CarePackage:MCP01
NSDO1
NSD Package:
CesareanSection:59513or 59514ot 59620
Breechextraction;59411
Vaginal deliveryaftet CS: 59612
Antenatal CatePackage;ANC01
Irtrapartum monitoring (w/o deliverl) : 59 403
Antenatal CateP ackzgewith InftaPartum monitodng: ANC02
Newbom CarePackage:99432
WRITE th. a.*.ditation number and the name of Physician/midwife
on the sPacesProvided
AFFD{ the signature of the Physician/midwife over his/her narne
then write the date of the spaceptovided

frcf

Certification of
Consumption of Benefits

fust box philHealth benefitis enoughto coverHCI andPF


charges)ifthe patientdid not haveanyout ofpocket
exDen6e

second box the benefit was consumed but there is additional


cost to the patient then accomptth t^blqqg
"gdlgl!
PRINT the name of the patient and AFFD( his/het signatute over
the narne
WRITE the date when this was sigred
Should the patient was unable to sign, tick the apptopriate boxes
authorized person to fill-up the claim and
ffi
his/het designation' AFFD( his/her signature above
frcf

Pan III
SectionB

Corrsentto AccessPatient
Record,/s

Certificarion of Health Cate


Institution

the name.
Ttris person rnust revierr and ved$r all the entries before affixing
his/her signahre.

;=EI

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2-

{NEX C-SAMPLECLAIM
(!,ar

Tftis fom mcy tt rcprcdqqd

r0r

cF2
(clalm Fom 2l

PnilHealth
i,-"''g
tbur P'dnil

andl5$gf

hr ,t.a!th

revissd ltovember 2013

HI

Mes#
ITIPORTil{T ITIITIIDER5:
NEASE WRITEIN CA'TTALLEITENS A}ID CIIECX THE A9PROPRIATE@IEs'
'Itb
du,rd be frld{idtn 5ffiY (50) @h.dEr davs fton dcb of dldEge
hm bleds ym$ otF apgortir{ doqrFd!
6es3 ad ti* bre: rcquid h E!: fom m xassuy. dain ftrbt Htltr lToosLb hbfffiUon dsfl Dt bc
Nl hfomu;,

IF yes, wnte the name and


ad&ess of referring instinrtion
*In NSD Package, when
antnatal care is provided by
other facility write the name of
that facility

rA[5E
t, Pht8lth

AaEdttau{

3. AddE:

(PA$) of Haaldr crE tnrtitutis:

ROMERO

tGNACIO

cm$ggg$q:&l
4 ?otcn1 Ditpotitiqn: {id.<t

f1 ".,.0,*

-t2'0

-tr

' 1' 4t

,r^"'

ooly l)

(--l-l

*fX*
tu

jy-

,.dzet

*Claims fot Antenatal Care


Package(ANC01), InttaPartrrm
mouitoring (59403)or both
(ANC02) shouldhrve the nme
of the facilitywherethe patientis

4@

l*oa+rlvrtr (Clrady/5svie)

S.typao,o*nr*al*ffi
6. adrrtstlt*fE

D!@

@,'lilt4&Y

eJd'silurasrdHlbr

l-l a,^l*r*

refcrrcd for delivery/further

0n 6lr /6:

INLABoR
cEPHALlc,
(2001)IREGMNCY
urERt3swEEKSAoG

t, Dish!ru Dilgao5itIe5 (u5.


DilqEF

\ffi
#

Relsted PsldFc.lc

ICD-10 Code/r

(it U.rdt

4y)

Rt/s c!d.

oRn0

OetEqf

10-27-20fi

i via NSI-I 7 37,0

r'

lv

iil

239.2

5J----o-

I tJ.

sr

L tanci.dFdttuJerrd

A{titso
As.ifftI'tedi@l
c nmrioroaraud

ff

Ifpaticnt is refcned to anorher


facility, write the name md
addresiofthe facfiryand reasons
for referral

d'TtfrlDladBrlEdl
-rff

tlE6

:-

l-l o.o**

IE

Write the date & time of


admission and discharge
*For Aote-oatal Care Package
write the date of 1tc aod last
pre-aatal visit Spaces
provided for time shall be left
blank

14

of Patletrtl

t. l{m.

ri@$$

car.lneubjtld:

a Nanre ot Hal$

Rbhr

Sodl

]L.t

rugrn

Botrr

Ri9t{

Eodl

Rbht

&El

nrsht

EoUr

Alght

BoEr

R{tt

Botr

Riglrt

Sout

Righl

Eotl

Right

Eofl

RBt*

Botl

]r*
] r,t
]"o
]r+
] r^*

E=*th
t<
l>,

ll"ft

]L*

lL*
lt.n
-lt"t

L
i

tEft

E.5F

tdMta

MbtdgteFn8

!.,

Bld.d

nadioAh@et (UMC)
Rrditf@rv

rsz-&.rrdrM4e

For Claimsfor MCI and


write
Antenatal CarePackage,
the datesof at least4 Pre-natal
visits,

vF.NuEol

Ll

fl *r,.o.o'

(COE ln

Z-8trcfit

ffi

i.t"o':.--==
4-15-14

LMP:02.,3'2014

NE

Nffbor lrsdng*trni,or*
amnEotne*Uorn
[_l tmmdratc
ontc
lll] ra,ysttn-to*rin
q. fv Ottpadat flfU/ADS na'dard

hdtgc

ku&2l*tv4iv(e4h$dtu

libot

lVa.i tcoa^i**ot*

Hepstli8wcrE6m

f-ll'|gt*ptotjonofdotir^6byffslybEdacelgn1i!66
Write the appropriate code of the
packagebeing clairned"

to.y tlsmbai

MCP 01

ffi teamphilhealth

For NCP dairns,checkthe


appropriateservicesand
attachthe Filter Card Sticker

ro*tor**'mt*|@

n
Elpn9illrit

a rat A* *arr

lOmcaaUo PCeo
Fhlftloefilr

tbbsln (Rlo)

oti6

9. Philx.alth Bcncfttr
fCD lO of

o_tr_4t

Dly 3 ARV

DBy 0 A'RV

All claims for delivery,


WRITE the date of Last
Menstrual Period GIvfI')

sa gvd.trc

l+ilwl. rs 6eieeu

tlts

Wiite &e admitthg & dischatge


diagnosis
Write rhe apptopriate ICD 10
Code/s and checorresponding
Package/RVSCode'

b, s*qd

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