Once a PhilHealth member or eligible beneficiary has ailment that requires medical attention, a claim for health benefit such as refund of hospital and medical expenses can be filed.
Conditions before availing benefits
The following must first be met to avail of your PhilHealth benefits:
- Filing for claim of benefits must be within the validity period as stated in your Member data record or MDR or in the payment receipt. This means that if your record indicates the coverage is from January to December of 2019, the health claim must reflect on this specific period.
- The 45 days allowance for room and board of the member and the separate 45 days allowance shared among the dependents have not been consumed yet.
Steps on claiming PhilHealth benefits
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)
- Clear copy of MDR.
- If MDR is not available, submit official receipt of applicable premium payment
- If qualified dependent is 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
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
- MDR or supporting documents
- Proof of applicable premium payments
- 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.
Reminders after claiming benefits
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 PhilHealth:
PhilHealth Head Office Address
Citystate Centre, 709 Shaw Blvd.,
1603 Pasig City, Philippines