PhilHealth covers bilateral cataract as two packages The Philippine Health Insurance Corporation (PhilHealth) now covers bilateral cataract surgery under two separate packages at a case rate of P16,000 each. Paid to the health care institution, the package is inclusive of coverage for facility or hospital charges at P9,600 and professional fee charges at P6,400. Previously, cataract surgery for both eyes performed with a less than 90-day interval between each is treated as a single period of confinement and paid under one package rate only. PhilHealth’s policy on single period of confinement bars coverage of re-admissions less than 90 days later for the same illness or injury. Readmission for an illness or injury that has already been managed by a health care provider is highly discouraged and must be avoided. Institutional health care providers (IHCP) and health care professionals must give complete optimum care to patients before discharging them. However, there are medical cases when complete quality care do not happen in one admission or in one instance, but in a series of time-bound interventions that could happen within 90 days. Among these cases is bilateral cataract surgery. With the recently issued PhilHealth Circular 17-2013, PhilHealth exempts bilateral cataract surgery from the 90-day period rule. Now, cataract procedures for both eyes done in the same or different confinement period with at least a one-day interval between each will be paid as two separate packages, effective August 21, 2013. For instance, cataract surgery on the left eye done on August 23 and cataract surgery on the right eye done on August 25 will be covered as two separate packages because there is a one day interval between the two procedures (that is, August 24). This means the member will be able to avail of a total of P32,000 for the procedures on both eyes. Members may avail of this benefit package in PhilHealth-engaged hospitals and ambulatory surgical clinics providing cataract surgery. To ensure quality provision of services and appropriate availment of benefits, PhilHealth requires cataract pre-surgery authorization for all claims involving cataract procedures. All hospitals and ambulatory surgical clinics providing cataract surgery are required to have the IHCP portal installed and activated in their respective facilities through which all authorization requests are coursed. The attending eye surgeon must also be PhilHealth-engaged and duly affiliated with the facility where the surgery will be performed. Eye doctors who perform cataract surgeries are advised to update their affiliation profile with PhilHealth. Members who need to undergo cataract surgery must also update their Member Data Record (MDR) prior to the scheduled operation before the authorization request can be processed. Individually-paying members must present to the facility proof of at least nine monthly contributions within the 12 months immediately prior to availment. Employed members, on the other hand, must have at least three monthly contributions within the six months immediately prior to availment and must have their employer sign Part II of the PhilHealth Claim Form 1. Sponsored and land-based OFW members must ensure that the cataract procedure is performed within the validity period of their coverage. Validity period is reflected in their enhanced MDR. Lifetime members need only present a photocopy of their lifetime member ID. Qualified lifetime members who do not have an updated MDR and PhilHealth ID must first register with PhilHealth before undergoing the cataract surgery. END
Posted on: Mon, 19 Aug 2013 08:20:53 +0000