Documente Academic
Documente Profesional
Documente Cultură
PHILHEALTH CIRCULAR
No. ~11 ~ OOIIR
SUBJECT Enhanced package rate for the Z Benefits for Standard Risk Acute
Lymphocytic (Lymphoblastic) Leukemia
I. RATIONALE
The package tate fot the Z Benefits for standard risk acute lymphocytic (lymphoblastic)
leukemia is adjusted accordingly as approved thtough PhilHealth Boatd Resolution No.
2177, s. 2016.
II. GUIDELINES
The rules for benefits availment and claims reimbursement shall follow Phi!Health Circular
No. 2015-035 (The Guiding Principles of the Z Benefits). Submission of pre-authorization
requests by contracted healthcare iostitutions (HCI), however, shall be ptior to the end of the
ioduction phase. The example below illustrates the application of this provision.
Table 1. Example illustratiog the date of submission of pre-authorization vis a vis the date of
discharge reflected io the CF2 and the teimbursement decision
The package rate for the Z Benefits for standard risk acute lymphocytic (lymphoblastic)
leukemia shall be five hundred. thousand pesos (Php 500,000) for the complete course of
treatment for thtee (3) years.' This shall be divided iota thtee (3) tranches according to the
followiog scheme:
A separate issuance shall be disseminated once the Department of Health (DOH) has
developed the mechanism for the provision of free cancer medicines for public health care
institution that are contracted to provide the services for the Z Benefits for acute
lymphocytic (lymphoblastic) leukemia.
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This circular shall take effect for all approved pre-authorizations 15 days after publication in
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the Official Gazette or in a newspaper of national circulation and shall be deposited
i"' thereafter at the Office of the National Administrative Register, University of the Philippines
J.!,.o
Law Center.
VI. ANNEXES
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1, Annex "A"
Annex "B,
Pre-authorization checklist and request
Membership Empowerment Form (Filipino version)
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Annex "C"
Annex "D"
Checklist of Mandatory Services (franche 1, 2, and 3)
Z Satisfaction Questionnaire
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--i'l:.• Annex "E" Checklist of Requirements for Reimbursement (franche 1, 2, and 3)
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Interim/OIC Prrsident and C
E~ERNA
Case~o. ______________
Annex "A-ALL"
HEALTH CARE INSTITUTION (HCI)
ADDRESS OF HCI
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·-. Printed name and signature
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Once approved, the contracted HCI shall prlll~ the "apprpv<cd pre,ahthorization f~rm 'ar1d 'h:l':e this
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signed by the parent or guardian and h~a)t!l~car<:"pro'lide!s;,asSappli~able. This form shall be submitted
to the Local Health Insurance Office''<t.!'IIO) ,or the PhjLtfealth1 Regional Office (PRO) when f!llng the
first tranche. ,.····~'"':~J ·· ,..~ - ~r .~<;:· ........<:.~-/"" !f · . ~·
There is no need to attach la9Qfatory results. H~·.r\VeY:~!!·these should be included in the patiehfs chart
and may be checked during tll2. field monitoring'o{th~ Z Benefits. Please do not leave anyj~em blank.
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PRE-AUTHORIZATION REQUEST
Acute Lymphocytic/Lymphoblastic Leukemia (Standard Risk)
This is to request approval for provision of services under the Z benefit package for
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(NAME OF PATIEN1) (NAME OF HCI)
under the terms and conditions as agreed for availment of the Z Benefit Package.
The patient belongs to the following category (please tick appropriate box):
D No Balance Billing (NBB) __ -·-
D Co-pay (indicate amount) Php o0 -- -
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Certified correct by: Certified correct by:
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(Printed name and signatUre) -(Printed name and ~ignature):
Attending Physici~n Executive Director/ Chief oO-Iospital/
·.Medical Director/ Medical Center' Chief
Conforme by:
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Case No.
Annex "B-ME Form"
Mga Panuto:
Instructions:
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PANGALAN NG OSPITAL
...-----·-·-, HEALm CARE INSTITUTION (HCI)
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ADDRESS OF HCI
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i-0- 0
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D Self Emplqyed
0 Filipinong Manggagawa sa ibang bansa
Migrant Worker/ OFW
0 Informal Sector / May sariling pinagkakak.itaan (Halimbawa. Negosyante, Nagmamaneho ng traysikel at taxi,
mga propesyonal, artista, at iba pa)
Informal Sector/ SelfEarning lndividuali (Ex. Blisihess· owner/ trirycle/ taxi drivers/ street vendors, entrepreneurs, profes.rionals1
artists, etc.) · ·
D Filipino na may dalawang pagkamamamayan/ Naturalized Filipin_o Citizen
Filipino with D11al Citizenship/ Naturalized Filipino CitizetJ
D Otg,anized Group D IGrottp Gold
D Maniliti
ludigmt (4Ps/ ccr, MCCTJ
D Inisponsuran
Sponsored
D Bayan I LGU
D Nakatatandang mamamayan I Senior Citizen (RA 10645)
D Iba pa I Others
D Habambuhay na kaanib/ Lifetime Member
3. Napagkasunduang angkop na
alternatibong plano ng gamutan sa
a spital
Applicable alternative Treatment Plan
agreed upon with health care provider
C. Talatakdaan ng Gamutan at Kasunod na Konsultasyon
C. Treatment Schedule and Follow-up Visit/s
1. Pctsa ng unang pagkakaospital o
konsultasyon a
(buwan/ araw / taon)
Date of initial admission to HCI or
consult" (mm/ dd/yyyy)
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pagsasayos ng device. Para naman·sa PD First,
ito ay ang kasunod na pagbisita sa PD Provider.
b For ZMORPH/ CWDS, tbis refers to the
nJeaJHretnmt1jitti11g and a4Jrutmmts of the dtvice. For
the PD First, this refers to the ned 11i.rit to the PD
Pro~·ider.
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a. Kaalipikado ako sa mga itinakdang batayan para sa aking
kondisyon/kapansanan.
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criteria
b. Ipinaliwanag sa akin ang polisiya hinggil sa ' Balance
The "no balance billing" (NBB) poliq was explained to me.
(NBB)
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~5 Paalala: Ang polisiya ng NBB ay maaating makamit ng mga sumusunod na
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miyembro at kanilang kalipikadong makikinabang kapag na-admit sa ward ng
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m ospital: inisponsuran, maralita, kasambahay, senior citizens at miyembro ng
0 iGroup na may kaukulang Group Policy Contract (GPC)
Note: NBB poliq is applicable to the following members 1vhen admitted in ward
accommodation: sponsored, indigent, household help, smior citizms and iGroup members
1vith valid Group Poliq Co11tract (GPC) a11d their qualified dependents.
Mga Saksi:
Witnesses:
Pangalan at lagda ng kinatawan ng ospital: Petsa (buwan/araw/taon)
Printed flame and si2_nature of H CI st4/ member Dale (mm/ dd/:t/lY)
Pangalan at lagda ng asawa/ magulang / pinakamalapit na kamag- Pets a (buwan/arawI taon)
anak/ awtorisadong kinatawan Date (nm;/ dd/.xm)
Printed name and signal/Ire ofspouse/ parent/ next ofkin /authorized guardian or
representative
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Numero ng Telcpono Numero ng CellPhone Email Address
Telephone number Mobile nrmtber
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' ~ ,. H. Numerong maaaring tawagan sa PhilHealth
a"' H. Pbi/Healtb Cont:lct Details
Opisinang Panrehiyon ng PhilHealth
Phi/Health Regiotwl Office No.
l N umero ng telcpono
Hotli11e No1.
Ako ay nagpapatunay na walang pananagutan ang PhilHealth o sinumang opisyal, empleyado o kinatawan
mula sa pahintulot na nakasaad sa itaas sapagkat kusang-loob ko itong ibinigay upang makagamit ng Z
benefits ng PhilHealth.
I hereqy hold Phi!Health or any ofits officers, empi'!JeeS and/ or representatives free from any and all liabilities relative to the
herein-tJJmtiomd consmt which I have volrmtari!J and willingly gitJen in connection 1vith the Z claim for reimbnrsei/JeJJt before
Phi!Health.
Case No. _ _ _ _ _ __
Annex "C1 -ALL"
Tranche 1
ADDRESS OF HCI
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a. Sodium
b. Potassium
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c. Calcium
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~ ~ d. Chloride
e. Magnesium, as needed
i.3 Phosphorous, as needed
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~ c. hydrocortisone
3. Anti-emetics (as indicated)
. - a. ondansetron
~ b. metoclopramide
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4. Pain medications (as indicated)
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a. nalbuphine
b. tramadol
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Case N o _ - - - - - - - ._...-sea.uow>o
Annex "C2 -ALL"
CHECKLIST OF MANDATORY AND OTHER SERVICES
Acute Lymphocytic/Lymphoblastic Leukemia (Standard Risk)
Consolidation, Interim Maintenance and Delayed Intensification Phase
Tranche2
ADDRESS OF HCI
~$ ~ iv. cytarabine
~ \!:::;f-. v. cyclophosphamide
"" vi. methotrexate (IV and oral)
~ vii. 6-mercaptopurine
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Case No. _ _ _ _ _ __
ADDRESS OF HCI
A. Diagnostics
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'R'eVlSed as of May 2017 Page 1 of 2 of Annex C3 -ALL
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ii ~ Revise of May 2017
GJ ~m hilhealth IJ www.facebook.com/PhiiHealth Youla www.youtube.com/teamphilhealth
Page 2· of 2 of Annex C3 -ALL
~ actioncenter@philhealth.gov.ph
Annex "D"
Phil Health
Benefits
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. This survey 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 health care provider or you may contact PhiiHealth call center at 441-7442. Your
responses will be kept confidential and anonymous.
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a For items 4 to 8, please select the one best response by ticking the appropriate box.
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9 How would you rate the services received from the health care institution (HCI) in terms of
.~ ~ availability of medicines or supplies needed for the treatment of your condition?
!...; D adequate
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D inadequate
D don't know
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' .,.:::: Page 1 of 2 of Annex D
Revise a of March 2017
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5. How would you rate the patient's or family's involvement in the care in terms of patient
empowerment? (You may refer to your Member Empowerment Form)
0 excellent
0 satisfactory
0 unsatisfactory
0 don't know
6. In general, how would you rate the health care professionals that provided the services for the z
benefit package in terms of doctor-patient relationship?
0 excellent
0 satisfactory
0 unsatisfactory
0 don't know
7. In your opinion, by how much has your HCI expenses been lessened by availing of the Z benefit
package?
0 less than half
0 by half
0 more than half
0 don't know
Case No ________
Annex "E1- ALL"
HEALTH CARE INSTITUTION (HCI)
ADDRESS OF HCI
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PhilH"Ith
Accreditation No.
I I I -1 I I I I I I 1-1 Date signed (mm/dd/yyyy)
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As of May 201- ·>-eu '~
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Page 1 of 1 of Annex E1- ALL
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Republic oft!Je Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre, 709 Shaw Boulevard, Pasig City
Call Center (02) 441-7442 Trunkline (02) 441-7444
www.philhealth.gov.ph
Case No. _ _ _ _ _ __
Annex "E2 -ALL"
ADDRESS OF HCI
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As of May 2017
2 ~I' Page 1 of 1 of Annex E2 - ALL
Case~o. ______________
Annex "E3 -ALL"
ADDRESS OF HCI
mm/dd/yyyy)
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As bLMou ?Qlf Page 1 of 1 of Annex E3 - ALL