f$&Republic of the Philippines
m PHILIPPINE HEALTH INSURANCE CORPORATION
Cityslate Centre Building, 705 5haw Boulevard, Pasig City
Healthlino 44 1-7444 www PhilHezilth.nw.ph
PHILHEALTH CIRCULAR
NoQ^s. 2012
TO ":ALL PHILHEALTH-CONTRACTED HEALTHCARE
PROVIDERS FOR THE Z BENEFIT PACKAGE
SIJBIECT :IMPLEMENTING GUIDELINES ON THE Z BENEFIT PACKAGE
I. BACKGROUND
A new case type Z under the PhilHealth classiiication of illnesses coven tor a unique set of catastrophic
illnesses delined in PhilHeahh Circular No. 29 s. 2012; ,ind a corresponding benefit package called the Z
Benefit Package was developed (PliilHealth Circular No. 30 s.2012). "J.liLs package aims to increase financial
risk protection for PhilHealth members, especially the underprivileged, through the delivery of quality care
using cost-efficient interventions that are based on approved clinical protocols and guidelines. It also aims to
increase awareness among people at-risk and enabling healthcare providers to capture them at the most early
stage of the illness to ensure better survival.
The Z benefit package defuies a new strategic approach to paying for "catastrophic" illnesses because
reimbursements are scheduled according to deliveiy of the mandatory services as provided in the protocols
and/or guidelines. The payment scheme not only eases the process ol reimbursement for these illnesses with
repetitive procedures, but ensures thai patients are j*iven the acceptable standards of care at the appropriate
time. Further, the package was designed to strengthen doctor-patient relationship in healthcare deliveiy. It
recognizes the importance of patient involvement and has therefore integrated in its process a mechanism of
evaluating deliveiy oi care through patient feedback. To minimize patients being lost to follow-up who are
stricken Wh these illnesses as a consequence of several factors, the process using the Z Benefit Information
and Tracking System (ZBITS) shall be employed to monitor these patitnts, while empowering them to be
actively involved in their care.
Owing to the multi-disciplinary - interdisciplinary nature of care needed for case type Z illnesses, the package
shall be implemented only by hospitals contracted by PhilHealth to provide the mandatory semces.
PhilHeahh has initially contracted 22 government hospitals nationwide to implement the package.
II. OBJECTIVES*
This Circular will:
1.Provide a procedure for filing of case type Z claims for reimbursement;
2.Describe the mechanism of establishing a patient information and tracking system that will monitor
delivery ot care and patient adherence to treatment;
3.Establish a datekeeping mechanism through pre-authorization, which ensures that patients are screened
accordingly and assured of the treatment based on approved protocols.
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I miitvr..
w lH^ylRepublic of the Philippines
m PHILIPPINE HEALTH INSURANCE CORPORATION '<"}
Citystate Centie Building, 709 Shaw Boulevaid, Pasig City
Healthline ^'11-7^1^1^1 www PfiilHrpaith.pov.pi^
All patients who did not qualify dining the pre-ntithonziiuon st;ige tor case type Z may still avail of the other
PhilHealth benefits under a different pa\inent scheme, such as c;ise raies and fee-for-service.
III. GUIDELINES FOR AVAILING OF THE BENEFIT
Only hospitals contracted by PhiiHeakh to provide services for case type Z may iiie a cl.iim for the Z Benefit
Package. Non-contracted hospitals providing service to patients with case type Z illness wlio are cunemly
availing of the Z-Benefit Package shall not be reimbursed for services stipulated in the mandatory services
imder PhilHeakh Circular No. 30, s. 2012. Tlie.se non-contracted hospitals shall check with PhilHealth if
patient is ahead}" registered under the Z Benefit Package and in such case, advise die member 10 inform their
contracted hospital of any request for transfer. Any transfer to a non-contracted hospital shall mean a
waiver of the patient's Z benein, such that any claim iiied m the non-contracted hospital for any type Z
related services from registry of that Z illness to the Z benefit package shall not be reimbursed by PhilHealth
in the next three (3) years.
A. ELIGIBILITY CHECK
AL1 contracted hospitals shall iollow their existing process of checking eligbjiity requirements lor
availment of PhilHeakh benefits, to determine:
Qualified premium contributions; Beginning January 1, 2013, the 3-year lock in membership
"with continuous premium payment shall apply (refer to PhilHealth Circular No. 029, senes of
20 U)
Principal member and their qualified dependents.
Minimum of one day remaining balance from the 45-day annual benefit limit
For contracted hospitals with health information system capable ol on-line checking, eligibility
check may be done thru the e-clnims system
However, owing to the special nature of the benefit, an additional eligibility rule shall be required:
1. Only newly diagnosed cases are eligible, hence, eligibility check shall require retrieval of the
member's claims history in the past two years (thru the N-claims confinement journal) in
order to establish compliance with this policy. A newly diagnosed case is defined as a patient
who has not received any of the mandatory services and/or other services for the specific
illness included in the Case Type Z Benefit Package, except for kidney transplant patients.
While this requirement may not yet be checked on-line, requests to check eligibility may be done at the
Benefits Administration Section (BAS) in the PhilHeakh Regional Offices.
The BAS shall check compliance with all eligibility requirements and issue a certification of eligibility.
This certificate shall be sent back to die contracted hospital preferably within two (2) working days from
date of receipt o! request of certiiication of eligibility. Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Otvstate Centre Building, 7U9 5haw Boulevard, Pa5ig City
Eligibility checking shall be done only once throughout the entire availmem of the benefit, e.g., for
acute lmphoblastic leukemia which will be paid in three (3) tranches for a period of three (3) years,
the eligibility check shall be done only on the first year of the 3 years prior to the pre-anthorization.
B. PRE-AUTHORIZATION
Once the member has complied with all the eligibility rules as prescribed, the contracted hospital shall
proceed with the conduct of services required tor pre-authorization. The hospital shall submit a request
lor pre-authorization approval to the PhilHealth Regional Olfice-Benehts Administration Section (PRO
BAS). To laciliuue the request, a pre-authorization checklist (Annex "A") for each of the case type Z
illnesses shall be provided to the PRO-BAS. The list shall be checked agamsi all supporting documents
submitted by the hospital, including the ME Form (Annex "B"), which serves as a compliance validation
lo the selections criteria for pre-authorization.
If the member/patient met the selections criteria for, pre-authorization, the BAS Head shall provide his
stamped approval or his/her signature over printed name on the pre-authorization request, with the dale
of approval, and sends this back to the hospital immediately, preferably on the same day the request was
received by the BAS. The BAS shall be given a maximum of two working (2) days to send back the
approval/disapproval notice. If the request was sent on a weekend, the hospital must be informed
immediately on the first working dayol the following week In the event that a pre-authorization request
is required for emergency cases, such as cadaveric kidney transplantation, and the request falls on a
weekend or holiday, die BAS Head shall make his/her contact information such as official mobile
number and email available to the contracted hospital for approval/disapproval ol request lor pre-
authoiization. However, the contracted hospital shall still submit the pre-authorization request form to
the BAS immediately on the 1 allowing working da}", for the approval/disapproval of said request.
C.REGISTERING PATIENTS IN THE Z BENEFIT INFORMATION TRACKING
SYSTEM (2BITS)
All contracted hospitals through their ZBITS coordinator shall be required to encode all patients with
diagnosed case npe Z illness in the ZBITS. These data shall be submitted to the reference hospital lor
consolidation. All data elements in the system must be completely filled out and updated regularly. A
separate issuance shall be issued for details of the ZBITS process.
D.FILING OF CLAIMS BY CONTRACTED HOSPITALS
After receipt of the pre-authoiization approval and prior to filing of a claim, all contracted hospitals must
render all mandatory and other services as prescribed in the approved protocols.
To file a claim, the contracted hospital shall accomplish the following and shall submit all claims to the
PRO BAS:%0&Republic of the Philippines
^ PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre Building, 709 5HaW ROUlPVJird, PasiC City
Hcalthline 4^1-744-1 www.PhilHealtli pov.pli
1.Tile hospital shall submit claim application per completed tranche using the manual or eclaiir
system.
2.Tlie hospital shall be required to submit an accomplished PbilHealth CP 2 (foi" manual) o
Module 2 (for eclaims) as follows:
.i. Pan 1
-Fill out *s 1-10
-n 11 it to d need not be filled out
-For # 1 le (Benefit Package) indicate the tranche amount under the PhtlHealth
Benefit column.
-H 12, Indicate Case Type Z
-U 13, indicate the corresponding Benefit Package Code
(refer to PbilHealtli Circular U 30 s. 2012 for the codes)
-# 14, pnmaiy condition is the case type Z illness
-H 15, similar to # 14
-* 16a, indicate PAY TO HOSPITAL
-# 16 c.d.c need not be filled oul
flie RVS codes for nil procedures included in the mandatory services and/or other services
mder n Gise Type Z .ire locked to the Package Code. The lock ensures that for any claim
iled by the same patient/member done in a non-contracted hospital using any of the preJentified RVS codes relative to the treatment of the particular case type Z illness shall be
enied by the system.
- 0 161, indicate the Benefit Package Code nnd the tranche payment being filed,
e.g., acute lympliocytic leukemia, 1-" tranche payment
b. Pan II and III need not be filled out; dings/medicines thai are pare of the mandatoiy
sen-ices are already included in the checklist. Pans IV and V must be filled out.
3.Hospitals shall file claims according to existing policies and in line with the filing schedule stated
in Plulhealth Circular No. 30 s. 2012,
4.Rules on late filing shall still apply.
5.Documents to be submitted to the PRO:
@Accomplished PHIC Claim Form 2 or Module 2 for eclaims
@Checklist Form of mandatory services (with tick boxesjand corresponding dates
when the sejvice was given
@Results of diagnostics, laboratory tests
@Photocopy oi the ME Form signed .md dated by the patient/member and attending
doctor upon availment of the Case Type Z Benefit
\m 1:0.1'J.yMaiRnfijfiRepublic of the Philippines
IB PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre Building, 709 Shaw Boulevard, Pasie City
1.The hospital shall submit claim application per completed tranche using the manual or eclaims
system.
2.The hospital shall be required to submit an accomplished PhilHcakh CF 2 (for manual) or
Module 2 (for eclaims) as follows:
a. Pan J
-Fill out #s 1-10
-# 11 a to d need noi be filled out
-For# lie (Benefit Package) indicate the tranche amount under the PhilHealth
Benefit column.
-# 12, Indicate Case Type Z
-# 13, indicate the corresponding Benefit Package Code
(refer to PliilHeahh Circular # 30 s. 2012 for the codes)
-# 14, pnmarv condition is ihe case type Z illness
-U 15, similar to M 14
-# 16a, indicate PAY TO HOSPITAL
-0 16 e,d,e need not be lillecl out
The RVS codes for all procedures included in the mandatory services and/or other services
under a Case Type Z are locked to the Package Code. The lock ensures that for any claim
filed by the same patient/member done in a non-contracted hospital using any of ihe pit-
identified RVS codes relative to die treatment of the particular case type Z illness shall be
HpiiipH hvthe svslem.
zoon
- 0 16f, indicate Lbe Benefit Package Code and the tranche payment being tiled,
e.g., acute lymphoeytic leukemia, 1st tranche pa)Trient
b. Pait II and III need not be filled out; drugs/medicines that arc part of the mandatory
sen'ices are already included in the checklist. Pans IV and V must be filled out.
3.Hospitals shall liJe claims according to existing policies and in line with die filing schedule stated
in Philhealth Circular No. 30 s. 2012.
4.Rules on late filing shall suli apply.
5.Documents to be submitted to die PRO:
@Accomplished PH1C Claim Form 1 or Module 1 for eclaims
@Checklist Form of mandatory services (with tick boxes)and corresponding dates
when the service was given
@Results of diagnostics, laboratory tests
@Photocopy of the ME Form signed and dated by the patient/member and attending
doctor upon avaiLment of the Gise Type Z Benefit
V ^ w-tf -^ .
'Ml.!>-.
*M ': Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
GtystatE Centre Building, 709 Shaw Boulevard, Penig City
@Photocopy of MOA, ii applicable, lor services done outside of the com reeled
hospital.
@Patient satisfaction mark (lound m the Z satistaction questionnaire which is
encoded in the ZBITS)
@Proof ol qualifying conttibution
E. EVALUATION OF CLAIM
1. A filed claim shall undergo medical evaluation by the BAS. Since one claim covers for a
series ot mandatory sen-ices done over a period of lime, a separate checklist lor the
mandatory services and other sen-ices shall be submitted by the hospital. Dining the
evaluation, the e valuator checks lor the list of sendees cones ponding to the requested
tranche and the patient must conionn to each through a signature, signifying that he/she
received the service. The filed claim may be appreciated using the e-claims system vis-a-vis
the ZBTTS or paper evaluation.
Example:
THF CK T TST for FT RST TRANCHE (ALL)
r \* f ^
,(?r._
*H
CHEMOTHERAPY
a)vincn-uine
b)L-asparaguuise
c)mcilioirex.ite(IV,ITandoral),
d)6-mt'icaptopuime
f)cvclophosphamide
1)(.yinrabine(IVandIT),
g)eioposide,
h)lioxoixibicin,
i)undansetron.
j)tramadol,
k)bonem.irrowexamination
(wii.liattachedresult)
!)imniunoplienorypinc,
(^vndiatl.ichclrcsull)
STATUS
>/
-J
DATES
l-/13-'2O\l
ft/24/2012
6/26/2012
AttestedbvAttendingPhysicianand
Patient/Guardian||/jRepublic of the Philippines
^ PHILIPPINE HEALTH INSURANCE CORPORATION
Gtystate Centre Building, 709 Shaw Boulevard, Pas:g City
Hoalthline 441-7444 www FhilHeakh.p,ov.ph
2.There shall be no Return to Hospital (KY! h claims for the Z Benefit. The ZBITS/papcr
checklist comains all the mandatory semces that must be given to the patient and this shall be
validated with all supporting documents attached. Supporting documents shall include results for
all laboratory and diagnostic work-tips. The other sen'ices in the checklist may or may not be
given as scheduled.
3.All claims shall be processed by PhilHealih wkliLn 30 days from receipt of claim.
4.For all good claims filed on FIRST tranche, 5 da)? shall automatically be deducted from the
required remaining 45 day annual benefit limit. There shall be no more deductions from the 45
da)"S lor the succeeding tranches.
5.Claims shall be denied payment in the following instances:
@If a mandatory service was not given.
@II initials of the member/patient are missing in the checklist at anyone time dining the
delivery of the service;
@II there is no PS mark; or
@Late f iling
Ail denied claims may stdl be applied for motion for reconsideration (PHIC Circular No. 3. s. 2008
for Motion for Reconsideration)
F.REIMBURSEMENT
For the existing system, claims shall be encoded into the N-claims for payment processing until such lime
that electronic adjudication is implemented All vouchers shall be PAID TO HOSPITAL. There shall be no
direct 1 iling of members. The amount is fixed per illness and per tranche payments. (Refer to I'hilHealth
Grcular No. 030, series of 2012 lor the rates and amount per tranche.)
G.MONITORING AND EVALUATION
Reference hospitals shall consolidate all data and generate quarterly and annual reports. Tins shall be the basis
for incentive computations, current and projected drug/laboratory utilization, patient adherence, and
assessment of health outcomes that shall be prepared.
All contracted hospitals shall be subject to monitoring niles of PhilHcalth as stipulated in both the
Performance Commitment and the Z-Beneik Contracts. Anv violation noted and validated troni monitoring
activities shall be a ground for sanctions and penalties as provided in both contracts.
.I^mIlliRepublic of the Philippines
SB PHILIPPINE HEALTH INSURANCE CORPORATION
Cytale Centre Building, 703 5liaw Boulevard, Posig City
IV. ATTACHMENTS:
1.Ceiiificate of Eligibility
2.Pre-authorization Request dz Checklist (Annex "A")
3.ME Form (to be reproduced by the hospital) (Annex "B")
4.Checklist form oi mandatory sewices (Annex "C")
5.Z- satisfaction questionnaire (to be reproduced by hospital) (annex "D")
6.Original or certified true copy of approved pre-authorization request & checklist
V. EFFECTIVITY
This guideline shall take ellect lor pre-iuitliorizations approved beginning June 21, 201.2.
DR. EEfUARDOjP. BANZON
PiMidthu_aiad-@EO
Date signed"@'@''? @'@
u+1) -
fcfeJJTVrcANNEX “A” – (ALL)
DATE ___________________________________________________________
NAMEOFHOSPITAL _______________________________________________
NAMEOF PATIENT ________________________________________________
PhilHealth IDNumber _____________________________________________
PRE‐AUTHORIZATIONCHECKLIST (ACUTE LYMPHOBLASTIC LEUKEMIA)
(Place aorNA)
QUALIFICATIONS Yes Attested by Attending MD
1. Age (1‐10)
2. No CNS involvement based on CSF cell
count/diff count
3. Ifmale, no testicularinvolvement
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
PRE‐AUTHORIZATIONREQUEST
DATEOF REQUEST___________________________
Thisisto request approvalfor provision ofservices underthe Z benefit package for
________________________________________ in _______________________________________
(NAMEOF PATIENT) (NAMEOFHOSPITAL)
underthe terms and conditions as agreed for availment ofthe Z‐Benefit Package.
The patient belongsto the following category: FIXEDCO‐PAY NBB
Requested by: Noted by:
_____________________________ ______________________________
PrintedName&Signature PrintedName&Signature
Attending Physician ExecutiveDirector/Chief ofHospital
(For PhilhealthUseOnly)
APPROVED
DISAPPROVED
________________________________
(Signature over PrintedName)
Head, Benefits Administration Section
DATE: ___________________________
DIAGNOSTICS Yes Date done Attested by
Attending MD
White blood cell count <50,000/µL
Immunophenotype Result(precursor B type)ANNEX “A” – (BREAST CA)
DATE ___________________________________________________________
NAMEOFHOSPITAL _______________________________________________
NAMEOF PATIENT ________________________________________________
PhilHealth IDNumber _____________________________________________
PRE‐AUTHORIZATIONCHECKLIST (BREAST CANCER)
(Place aorNA)
QUALIFICATIONS Yes Attested by Attending MD
1. No previous chemotherapy
2. No previousradiotherapy
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
PRE‐AUTHORIZATIONREQUEST
DATEOF REQUEST___________________________
Thisisto request approvalfor provision ofservices underthe Z benefit package for
________________________________________ in _______________________________________
(NAMEOF PATIENT) (NAMEOFHOSPITAL)
underthe terms and conditions as agreed for availment ofthe Z‐Benefit Package.
The patient belongsto the following category: FIXEDCO‐PAY NBB
Requested by: Noted by:
______________________________ ______________________________
PrintedName&Signature PrintedName&Signature
Attending Physician ExecutiveDirector/Chief ofHospital
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
(For PhilhealthUseOnly)
APPROVED
DISAPPROVED
________________________________
(Signature over PrintedName)
Head, Benefits Administration Section
DATE: ___________________________
DIAGNOSTICS (Check one) Yes Date
done
Attested by Attending MD
Stage:
Stage 0 TisN0M0
Stage IA T1N0M0
Stage IB T0, T1N1M0
Stage IIA T0, T1N1M0 or T2N0M0
Stage IIB T2N1M0 or T3N0M0
Stage IIIA T0, T1, T2N2MO or T3N1N2M0______________________________________________________________________________________________________________________________________________________
teamphilhealth
www.facebook.com/PhilHealth info@philhealth.gov.ph
Annex “A” - KT
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre, 709 Shaw Boulevard, Pasig City
Healthline 441-7442 www.philhealth.gov.ph
DATE: ______________________________
NAMEOFHOSPITAL, CITY _______________________________________________
NAMEOF PATIENT _____________________________________________________
(Last) (First) (Middle)
PhilHealth IDNumber __________________________________________________
PRE‐AUTHORIZATIONCHECKLIST (KIDNEY TRANSPLANT)
CONFORME BY PATIENT (Place aorNA)
QUALIFICATIONS YES CONFORME
Age >10 and <70 years
On chronic dialysis because of end stage renal disease exceptfor pre‐emptive kidney
transplantation
For Medical Social Service patients,must have a certification fromthe socialservice unit ofthe
hospitalthat patientis eligible for a kidney transplant and they canmaintain anti‐rejection
medicinesforthe nextthree (3) years. (WriteNA [NOT APPLICABLE]for pay patients)
ATTESTEDBYATTENDING NEPHROLOGIST or TRANSPLANT SURGEON (Place aorNA)
QUALIFICATIONS YES CONFORME
With irreversible renal disease that progressesto end stage renal disease.
No previous history of cancer(except basal cellskin cancer),should beHIV negative,Hepatitis B
surface antigen negative, andHepatitis C antibody negative.
Absence of currentsevere illness(Congestive heartfailure Class 3‐4, liver cirrhosis(findings of
small liver with coarse granular/heterogeneous echo pattern with signs of portal hypertension),
chronic lung disease requiring oxygen, etc).
Absence ofthe following: hemiparalysis, leg amputation because of peripheral vascular disease,
mental incapacity such thatinformed consent cannot bemade, and substance abuse for atleast
6months priorto start oftransplant work‐up.
For CMV IgGnegative recipient, donorshould be CMV IgGnegative.
ATTESTEDBYATTENDING NEPHROLOGIST or TRANSPLANT SURGEON
(Place aorNA)
*NOtestisrequired
DIAGNOSTICS YES CONFORME
For pre‐emptive kidney transplant and diabetic: 24‐hour urine creatinine clearance or calculated
glomerularfiltration rate (GFR) (CKD‐EPI formula) or nuclearGFR should be lessthan 20ml/min
/1.73m2
For pre‐emptive kidney transplant and non‐diabetic: lessthan 15ml/min /1.73m2
Low risk:
a. Primary kidney transplant(no previoussolid organ transplant)*
a.Historical Past Panel Reactive Antibody (PRA) Class 1&2 negative or historical PRA lessthan
or equalto 20%
c.No donorspecific antibody (DSA) in the potentialrecipient
d. Atleast 1HLA‐DRmatch
e. Single organ transplant *______________________________________________________________________________________________________________________________________________________
teamphilhealth
www.facebook.com/PhilHealth info@philhealth.gov.ph
PRE‐AUTHORIZATIONREQUEST
DATEOF REQUEST: _________________________
Thisisto request approvalfor provision ofservices underthe Z benefit package for
________________________________________ in ___________________________________
(NAMEOF PATIENT) (NAMEOFHOSPITAL)
under the terms and conditions as agreed for availment ofthe Z‐Benefit Package.
The patient belongsto the following category: PAY CO‐PAY SERVICE
Requested by: Noted by:(For SERVICE and CO‐PAYONLY)
________________________________ ______________________________________
(Signature over PrintedName) (Signature over PrintedName)
ATTENDINGNEPHROLOGISTOR Check the appropriate box:
TRANSPLANT SURGEON Chair,Department of AdultNephrology
Chair,Department of PediatricNephrology
Chair,Department ofOrgan Transplantation
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
(For PhilhealthUseOnly)
APPROVED
DISAPPROVED
________________________________
(Signature over PrintedName)
Head, Benefits Administration Section
DATE: ___________________________ANNEX “A” – (PROSTATE CA)
DATE ___________________________________________________________
NAMEOFHOSPITAL _______________________________________________
NAMEOF PATIENT ________________________________________________
PhilHealth IDNumber _____________________________________________
PRE‐AUTHORIZATIONCHECKLIST (PROSTATE CANCER)
(Place aorNA)
QUALIFICATIONS Yes Attested by Attending MD
1. Male patients age up to 70 years old
2. No previousradiotherapy
1. No uncontrolled co‐morbid conditions
(Place aorNA)
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
PRE‐AUTHORIZATIONREQUEST
DATEOF REQUEST___________________________
Thisisto request approvalfor provision ofservices underthe Z benefit package for
________________________________________ in _______________________________________
(NAMEOF PATIENT) (NAMEOFHOSPITAL)
underthe terms and conditions as agreed for availment ofthe Z‐Benefit Package.
The patient belongsto the following category: FIXEDCO‐PAY NBB
Requested by: Noted by:
____________________________ ______________________________
PrintedName&Signature PrintedName&Signature
Attending Physician ExecutiveDirector/Chief ofHospital
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
(For PhilhealthUseOnly)
APPROVED
DISAPPROVED
________________________________
(Signature over PrintedName)
Head, Benefits Administration Section
DATE: ___________________________
DIAGNOSTICS (check one) Yes Date
done
Attested by
Attending MD
Stage:
(T1a‐T2c), PSA level 10 to 20 ng/ml, Tumor Grade
(Gleason’sscore of 2‐7)
Low risk: T1‐T2a and Gleason score 2‐6, and PSA <10
ng/ml
Intermediate risk: T2b to T2c, Gleason score of 7, and
PSA 10‐20 ng/ml
Localized prostate cancer
Stage IIB T2N1M0 or T3N0M0
Stage IIIA T0, T1, T2N2MO or T3N1N2M01
ANNEX “B” – ME FORM
MESSAGE FROM THE PRESIDENT&CEO
To our dearmember,
Our warmest greetingsfromPhilHealth.
We are pleased to share with you our Z benefit package, a package that was created to provide
financialrisk protection tomemberslike you who are affected by catastrophic conditionsthat can be
financially debilitating. Thisis why, as your partner in health, we want to be with you at this critical
time and take partin yourjourney towards wellness.
What you’re holding now is called the Member Empowerment (ME) Form. Asthe name suggests, it
aims to empower you by providing the information that you need to know to adhere to your
treatment – the benefitsincluded in this package,treatment choices and options,reminders on your
treatment schedule and follow‐ups, and your roles and responsibilities as a member. It also leads
you to support programs, like education and counselling, and otherfinancialsupportsystems.
Just a friendly reminder: Please remember to complete the ME Form properly to make sure that
your claims and reimbursements will be processed efficiently. We’d like to serve you as best as we
can.
Sincerely hoping for yourspeedy recovery and good health,
DR. EDUARDOP. BANZON
President&CEO
PhilippineHealth Insurance Corporation2
ANNEX “B‐1” – ME FORM
MEMBER EMPOWERMENT FORM
Inform, support & empower
Instructions:
1. The healthcare providershall assistthe patientin filling‐up the ME form.
2. Legibly print all information provided.
3. Foritemsrequiring a “yes” or “no” response,tick appropriately with a checkmark (√).
4. Use additional blank sheetsif necessary, label properly and attach securely to this ME form.
5. The ME formshall be reproduced by the contracted hospital providing specialized care.
6. Duplicate copies ofthe ME form shall be made available by the contracted hospital—one forthe
patient and one asfile copy ofthe contracted hospital providing the specialized care.
Note: This ME Formis being translated into Filipino and will be circulated assoon as approved by PhilHealth.
Member/Patient
Information
Name of Patient
PhilhealthNo.
Current age
Birthday
Sex
Permanent address
Telephone/MobileNo.
Email address
Clinical Information Description of condition or diagnosis
Treatment Protocol agreed upon with healthcare provider
Alternative Protocol/s agreed upon with healthcare provider
Treatment Schedule
and Follow‐up Visit/s
Date of initial hospital admission (month/day/year)
Date/s ofsucceeding hospital admission/s(month/day/year)
Date/s offollow‐up visit/s(month/day/year)3
Emergencies(Write exact date/s with the reason or brief description ofthe
nature ofthe emergency)
Member Education 1. My healthcare provider explained the nature ofmy condition.
Yes ___No ___
2. My healthcare provider explained the treatment options.
Yes ___No ___
3. The possible side effects/adverse effects oftreatment were explained to
me.
Yes___ No___
4. My healthcare provider explained themandatory services and other
servicesrequired forthe treatment ofmy condition.
Yes___ No___
5. I amsatisfied with the explanation given tome bymy healthcare
provider.
Yes___ No___
6. I have been fully informed that I will be cared for by all the pertinent
medical specialties (surgery, medical/ pediatric oncology/ nephrology,
radio‐oncology, and other pertinent specialties as I may need) present
in the Philhealth contracted hospital of my choice and that preferring
another contracted hospital for the said specialized care will not affect
my treatmentin any way.
Yes___No ____
7. My healthcare provider explained the importance of adhering tomy
treatmentschedule.
Yes ___No ___
8. My healthcare provider gaveme the schedule/s ofmy follow‐up visit/s.
Yes ___No ___
9. My healthcare provider gaveme information where to go forfinancial
and othermeans ofsupport, when needed.
Yes ___No ___
a) Name of government agency (PCSO, PMS, LGU, etc)
i. ______________________________________
ii. ______________________________________
iii. ______________________________________
b) Name of non‐governmental organization/s4
i. ______________________________________
ii. ______________________________________
iii. ______________________________________
c) Name of Patient SupportGroup/s
i. ______________________________________
ii. ______________________________________
iii. ______________________________________
d) Name of Corporate Foundation/s
i. ______________________________________
ii. ______________________________________
iii. ______________________________________
e) Others(Media, ReligiousGroup/s, Politician/s, etc)
i. ______________________________________
ii. ______________________________________
iii. ______________________________________
10. I have been furnished bymy healthcare provider with a list and contact
information of other contracted hospitalsforthe specialized care ofmy
condition.
Yes___ No___
11. I have been fully informed by my healthcare provider of the Philhealth
membership policies and benefit availment on the Case Type Z:
a. Ifulfill allselections criteria formy condition. Yes___ No ___
b. I understand the “no balance billing” (NBB) policy forsponsored
members.
Yes___ No___
c. I understand the fixed co‐pay for non‐sponsoredmembers.
Yes___ No___
d. Only five (5) daysshall be deducted fromthe 45 days annual benefit
limitforthe duration ofmy treatment underthe case type Z benefit
package.
Yes___No___
e. Ishall updatemy premiumcontributionsin orderto availthe Case
Type Z package and other Philhealth benefits.
Yes___ No___
Member Roles&
Responsibilities
1. I understand thatI amresponsible for adhering tomy treatment
schedule.
Yes___ No___
2. I understand that adherence tomy treatmentschedule isimportantin
terms oftreatment outcomes and a pre‐requisite to the full entitlement
ofthe case type Z benefit.
Yes___ No___5
3. I understand thatitismy responsibility to follow and comply with allthe
policies and procedures of Philhealth and the healthcare providerin
orderto avail ofthe full case type Z benefit package. In the eventthatI
failto comply with policies and procedures of Philhealth and the
healthcare provider, I waive the privilege of availing the Z benefit.
Yes___No___
PrintedName,
Signature, Thumb
Print andDate
Signature/Thumb Print of Patient
Date (Month/Day/Year)
Name of Attending Doctor
Signature
Date (Month/Day/Year)
Witnesses
1. Name ofHospitalstaff
Signature
Date (Month/Day/Year)
2. Name of parent/guardian/spouse/next of kin
Signature
Date (Month/Day/Year)
Contact Philhealth 1. Philhealth Cares
2. Call us attelephone number:
3. Text us:
4. email us:
Consentto Access
Patient Record/s
I consentto the examination by Philhealth ofmymedicalrecordsforthe
sole purpose of verifying the veracity ofthe Z‐claim.
Consentto Enter
MedicalData in the Z
BenefitInformation&
Tracking System
(ZBITS)
I consentto havemymedical data entered electronically in the ZBITS as a
requirementforthe Case Type Z.
I hereby hold PhilHealth or any of its officers, employees and/or
representatives free from any and all liabilities relative to the herein‐
mentioned consent which I have voluntarily and willingly given in
connection with the Z claimforreimbursement before PhilHealth.
Name of Patient,
Signature/Thumb
Print andDate
Name of Patient
Signature/Thumb Print
Date (Month/Day/Year)6
Name of Patient’s
Representative,
Signature andDate
Name of Patient’s Representative
Signature
Date (Month/Day/Year)
Relationship ofthe
Representative to the
Patient
___ Spouse
___ Parent
___ Child
___Next of Kin/Guardian1
Annex “C” -ALL
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre, 709 Shaw Boulevard, Pasig City
Healthline 441-7442 www.philhealth.gov.ph
DATE: ______________________________
NAMEOFHOSPITAL _______________________________________________
NAMEOF PATIENT ________________________________________________
PhilHealth IDNumber _____________________________________________
CHECKLIST FOR MANDATORYANDOTHER SERVICES
ACUTE LYMPHOCYTIC LEUKEMIA: TRANCHE
Mandatory andOther Services Status(place a
√ if done or
NA)
Dates Conforme
A.Chemotherapy
1. Vincristine
2. L‐asparaginase
3. Methotrexate
a. IV (intravenous)
b. IT (intrathecal)
c. Oral
4. 6‐mercaptopurine
5. Cyclophosphamide
6. Cytarabine
a. IV (intravenous)
b. IT (intrathecal)
7. Etoposide
8. Doxorubicin
B.Other drugs
1. Dexamethasone
2. Prednisone
3. FolinicAcid
A. Antiemetics
1. Ondansetron
2. Metoclopramide
B. Emergency Medicines(when
necessary)
1. Epinephrine
C. Pain Medications
1. Tramadol
2. Morphine
3. Others(specify)
D. Sedatives(priorto procedure)
1. Midazolam
2. Nalbuphine
3. Propofol
4. Atropine
5. Ketamine2
Annex “C-1” - ALL
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre, 709 Shaw Boulevard, Pasig City
Healthline 441-7442 www.philhealth.gov.ph
DATE: ______________________________
NAMEOFHOSPITAL _______________________________________________
NAMEOF PATIENT ________________________________________________
PhilHealth IDNumber _____________________________________________
Mandatory andOther Services Status(place a
√ if done orNA)
Dates Conforme
E. Laboratory andDiagnostic
Procedures
1. Bone Marrow Examination
2. Immunophenotyping
3. CSF analysis
4. Cytospin
5. Complete Blood Count
6. PT/PTT
7. BUN
8. Creatinine
9. ALT
10. Bilirubin
11.Uric acid
12. Serum electrolytes
13. Serum phosphorus
14.Urinalysis
15. Chest X‐ray
16. 2‐Dechocardiography
17.Abdominal ultrasound
18. Blood culture and sensitivity (as
indicated)
19.Urine culture and sensitivity (as
indicated)
20.Other culture and sensitivity
analyses(asindicated)
F. Blood Support
1. Crossmatching
2. Screening
3. Processing
G. Antimicrobials/antifungals depending
on the sensitivity pattern ofthe
particular contracted hospital which
includesthe following (if indicated):
1. Meropenem
2. Vancomycin
3. Ceftazidime
4. Ciprofloxacin
5. Cefepime
6. Piperacillin
7. Tazobactam
8. Fluconazole
9. amphotericin1
Annex “C” Breast CA
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre, 709 Shaw Boulevard, Pasig City
Healthline 441-7442 www.philhealth.gov.ph
DATE: ______________________________
NAMEOFHOSPITAL _______________________________________________
NAMEOF PATIENT ________________________________________________
PhilHealth IDNumber _____________________________________________
CHECKLIST FOR MANDATORYANDOTHER SERVICES
BREAST CANCER: 1
ST TRANCHE (SURGERY)
Mandatory andOther Services Status
(place a √ if
done orNA)
Dates Conforme
A.CP Clearance
B.Technique
C.Laboratory:
1. CBC
2. Creatinine
1. FBS
2. Calcium
3. AST/ALT
4. ECG
5. Alkaline Phosphatase
6. Chest X‐ray
7. AbdominalUltrasound
8. ER/PR Assay
9. HER2/ neu expression
10. Histopath/Cytology
11. LiverUltrasound
12. Bone Scan (if patient hassymptoms
related to bone or elevated
alkaline)
13. CT Scan of whole abdomen (if
abdominal ultrasound is
inconclusive butthere are
symptomsreferable to the
abdominal organs)
14. Blood Support(cross matching,
screening, processing)
D.Complete list of drugs given (e.g.
antibiotics, pain relievers, etc. ifindicated):
1.
2.
3.2
Annex “C” Breast CA
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre, 709 Shaw Boulevard, Pasig City
Healthline 441-7442 www.philhealth.gov.ph
DATE: ______________________________
NAMEOFHOSPITAL _______________________________________________
NAMEOF PATIENT ________________________________________________
PhilHealth IDNumber _____________________________________________
CHECKLIST FOR MANDATORYANDOTHER SERVICES
BREAST CANCER: 2
nd TRANCHE (CHEMOTHERAPY)
Mandatory andOther Services Status
(place a √ if
done orNA)
Dates Conforme
A. Complete List ofDrugsGiven:
1. Chemotherapy drugs
a. Forfavorable risk profile
1) Doxorubicin
2) Cyclophosphamide
b. For unfavorable risk profile
1) Doxorubicin
2) Cyclophosphamide
3) Docetaxel or
Paclitaxel
2. Hormonotherapy drugs – for
ER(+)/PR(+)/(‐): ifindicated
a. Tamoxifen or
b. Aromatase Inhibitor Letrozole
3. Antiemetic drugs
a. Ondansetron
b. Metoclopramide
4. Fluorouracil(ifindicated)
5. Methotrexate (ifindicated)
6. Granulocyte stimulating factor(if
indicated)
7. Antibiotics(ifindicated)
a.
b.
c.
B. Radiation therapy (ifindicated)1
Annex “C”KT
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre, 709 Shaw Boulevard, Pasig City
Healthline 441-7442 www.philhealth.gov.ph
DATE: ______________________________
NAMEOFHOSPITAL _______________________________________________
NAMEOF PATIENT ________________________________________________
PhilHealth IDNumber _____________________________________________
CHECKLIST FOR MANDATORYANDOTHER SERVICES
ENDSTAGE RENALDISEASE ELIGIBLE FOR KIDNEY TRANSPLANT (LOWRISK)
Mandatory andOther Services Status(place a
√ if done orNA)
Dates Conforme
A. CP‐clearance for donor(ifindicated) and recipient
B. Pre‐transplant evaluation/labs(Phases1,
2, 3 and 4)for donor and recipient candidates
C. Transplantation surgery with living or deceased donor
D. Hemodialysis or peritoneal dialysis during
admission fortransplantation, ifindicated
E. Immunosuppressantinduction therapy, unlessidentical
twin orfullHLA‐antigenmatch
F. Immunologic risk‐ Atleast 1HLA‐DRmatch between
donor and recipient. primary kidney transplant,single organ
transplant, PRA class 1&2 negative or PRA<20%; no donor
specific antibody
IMMUNOSUPPRESSIONOPTIONS (CHOOSE 1, 2OR 3ONLY):
1. Calceineurin inhibitor +mycophenolate +
prednisone with or withoutinduction
a. Cyclosporine +mycophenolatemotetil or
mycophenolate sodium+ prednisone OR
b. Tacrolimus +mycophenolatemofetil or
mycophenolate sodium+ prednisone
2. Calcineurin inhibitor +mTOR inhibitor + prednisone with
or withoutinduction
a. Low‐dose Cyclosporine + Sirolimus + prednisoneOR
b.Low‐dose Cyclosporine + Everolimus + prednisone
3. Calcineurin inhibitor Cyclosporine + azathioprine +
prednisone with or withoutinduction
INDUCTIONTHERAPIES (CHOOSE 1 or 2ONLY)
1. Interleukin‐2‐receptor antibody (Basiliximab)
20 mg IV for 2 doses
2. Lymphocyte depleting agents
a. Alemtuzumab 30mg IV single dose OR
b. Rabbit anti‐thymocyte globulin 1.0‐1.5mg per kg
per day for 3 doses
ANTI‐REJECTIONTHERAPY, IF INDICATED
1.Methylprednisolone 500mg IV per day for 3 days
Post‐transplantlaboratorymonitoring of donorfor one
year, and for onemonth forrecipient
OTHER SERVICES
a.)Graftrenal biopsy, ifindicated
The following tests, ifindicated:
b.)Chest CT‐scan
c.)Dipyridamole sestamibi nuclearscamor dobutamine stress
echocardiogram
d.)Endoscopy
e.)Colonoscopy
f.)Pulmonary function test2
ENDSTAGE RENALDISEASE ELIGIBLE FOR KIDNEY TRANSPLANT (LOWRISK)
Mandatory andOther Services Status(place a
√ if done orNA)
Dates Conforme
1. Laboratory Monitoring for RECIPIENT
TIMEAFTERHOSPITALDISCHARGE FOR
TRANSPLANTATION
a.) 1 WEEK
Complete blood count, creatinine,fasting blood sugar,
potassium,therapeutic drugmonitoring (one drug only)
b.) 2WEEKS
Complete blood count, creatinine,fasting blood sugar,
SGPT, lipid profile,therapeutic drugmonitoring (one drug
only)
c.) 3WEEKS
Complete blood count, creatinine,fasting blood sugar
d.) 4 WEEKS
Complete blood count, creatinine,fasting blood sugar
2. Laboratory Monitoring forDONOR
TIMEAFTERHOSPITALDISCHARGE FORNEPHRECTOMY
a.) 2OR 4 WEEKS
Complete blood count, creatinine, urinalysis
b.) 3 MONTHS
creatinine, urinalysis
c.) 6 MONTHS
creatinine, urinalysis
d.)12 MONTHS
creatinine, urinalysis
* urine protein/creatinine ratio can be done once within the year, ifindicated3
Laboratory Monitoring for RECIPIENT
TIME AFTERHOSPITALDISCHARGE FOR
TRANSPLANTATION
LAB TEST
1 WEEK Complete blood count, creatinine,fasting
blood sugar, potassium,therapeutic drug
monitoring (one drug only)
2 WEEKS Complete blood count, creatinine,fasting
blood sugar, SGPT, lipid profile,therapeutic
drugmonitoring (one drug only)
3 WEEKS Complete blood count, creatinine,fasting
blood sugar
4 WEEKS Complete blood count, creatinine,fasting
blood sugar
Laboratory Monitoring for DONOR
TIME AFTERHOSPITALDISCHARGE FOR
NEPHRECTOMY
LAB TEST
2OR 4 WEEKS Complete blood count, creatinine, urinalysis
3 MONTHS creatinine, urinalysis
6 MONTHS creatinine, urinalysis
12 MONTHS creatinine, urinalysis
* urine protein/creatinine ratio can be done once within the year, ifindicated1
Annex “C” Prostate
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre, 709 Shaw Boulevard, Pasig City
Healthline 441-7442 www.philhealth.gov.ph
DATE: ______________________________
NAMEOFHOSPITAL _______________________________________________
NAMEOF PATIENT ________________________________________________
PhilHealth IDNumber _____________________________________________
CHECKLIST FOR MANDATORYANDOTHER SERVICES
PROSTATE CANCER
Mandatory Service Status
(place a
√ if done
orNA)
Dates Conforme
A. CP Clearance
B. Operation Technique
1. Radical prostatectomy OR
2. Laparoscopic prostatectomy
C. Chest X‐ray
D. Laboratory:
1. Creatinine
2. FBS
3. CBC
4. Electrolytes
5. ECG
E. AbdominalUltrasound (as needed)1
ANNEX “D” Z SatisfactionQ
We would like to know how you feel about the services that pertain to the Z Benefit Package in
order that we can improve and meet your needs. Thissurvey will only take a few minutes. Please
read the items carefully. If you need to clarify items or ask questions, you may approach your
friendly healthcare provider or you may contact PhilHealth call center at 4417444. Yourresponses
will be kept confidential and anonymous.
Foritems 1 to 3, please tick on the appropriate box.
1. Z benefit package availed isfor:
Acute Lymphoblastic Leukemia
Breast Cancer
Prostate Cancer
Kidney Transplant
2. Patient’s age is:
19 years old&below
between 20 to 35
between 36 to 45
between 46 to 55
between 56 to 65
above 65 years old
3. Sex ofrespondent
male
female
Foritems 4 to 8, please selectthe one bestresponse by ticking the appropriate box.
4. How would you rate the servicesreceived from the hospital in terms of availability of medicines
needed forthe treatment ofthe condition?
inadequate
adequate
don’t know
Share your opinion with us!