PhilHealth Claims: How to File a Claim

How It Works:Step 1: Upon Hospital Admission• Proceed to hospital admission desk • Inform staff you're a PhilHealth member • Present PhilHealth ID or provide your PIN • If no ID, provide any valid ID + PIN number • Hospital verifies your eligibility onlineStep 2: Hospital Checks Eligibility• Hospital accesses PhilHealth system • Verifies your contribution status • Checks if you have 9+ contributions paid • Confirms you're eligible for benefits • Determines applicable benefit packageStep 3: Benefit Package Applied• Hospital identifies your diagnosis/procedure • Applies corresponding PhilHealth case rate • Informs you of PhilHealth coverage amount • Explains any balance you may need to pay • In government hospitals: often NO balance billingStep 4: Sign Claim Forms• Hospital prepares PhilHealth claim forms • Patient/representative signs the forms • Usually: Claim Form 1 (CF1) and supporting docs • Review and verify personal information • Keep copy for your recordsStep 5: Hospital Files Claim• Hospital submits claim to PhilHealth electronically • Includes medical records and billing documents • PhilHealth reviews and processes claim • Processing time: 60 days maximum • PhilHealth pays hospital directlyStep 6: Settle Any Balance• Pay any remaining balance at discharge • Get statement of account itemizing charges • PhilHealth benefit will be deducted • Keep all receipts and documentsDocuments You Need:✓ PhilHealth ID (or valid ID with PIN) ✓ Valid government-issued ID ✓ For dependents: Birth certificate or marriage certificate ✓ Member Data Record (MDR) if first claimCommon case rates (after PC 2024-0037 + Apr 2026 maternity hike):• Moderate-risk pneumonia: ~₱29,500 • Dengue: ~₱24,000 • Normal Spontaneous Delivery: ₱29,000 • Cesarean Section: ₱58,000 (Level 1) / ₱62,000 (Level 2-3) • Appendectomy: ~₱36,000 • Hemodialysis: ₱4,000/session (excluded from the 50% hike) • High-risk pneumonia: legacy rate (excluded from the 50% hike) Confirm current rates against PhilHealth Circular 2024-0037 and the latest maternity Circular before relying on the figure.

Covered Illnesses:• All types of cancer/malignancy • Chronic kidney disease needing dialysis/transplant • Acute lymphocytic leukemia • Prostate cancer • Breast cancer • Colon cancer • Other approved catastrophic conditionsBenefit amounts:Z-Benefit case rates are set per condition by PhilHealth Circular, not by a single lifetime cap. Current headline figures: Breast cancer Z-Benefit is ₱1,400,000 (raised in 2024 from ₱100,000). Childhood Acute Lymphocytic Leukemia (standard risk) is ₱500,000. Kidney transplantation (living related donor), CABG, and other packages each have their own case rate — see the Z-Benefit page for the per-condition table.How to Apply:Before Treatment Starts:1. Get medical certificate from doctor - Diagnosis and recommended treatment plan - Doctor must be PhilHealth-accredited 2. Prepare requirements: ✓ PhilHealth Member Data Record (MDR) ✓ Valid ID of member and patient ✓ Medical certificate with diagnosis ✓ Clinical abstract/medical history ✓ Laboratory/diagnostic results ✓ Treatment plan/estimate 3. Go to PhilHealth office: - Submit Z Benefit Application Form - Attach all required documents - Wait for evaluation (5-10 working days) 4. Get Letter of Pre-Authorization: - PhilHealth issues approval letter - Bring to hospital before treatment - Hospital can now proceed with claim 5. During treatment: - Hospital files claims periodically - You monitor benefit utilization - PhilHealth pays hospital directlyImportant Notes:• File BEFORE starting expensive treatments • Must be confined in PhilHealth-accredited hospital • Some treatments need prior authorization • Keep track of benefit utilization • Can be combined with regular case rates

What's covered:• Primary-care consultations • Annual physical examination • Preventive care and health education • 13 routine laboratory tests under the package • Expanded cancer screening • Preventive oral health • Essential medicines from the YAKAP formulary (up to ₱20,000/year per member) • Management of chronic conditionsHow to activate:1. Log in to the Member Portal ( memberinquiry.philhealth.gov.ph) or open the eGovPH app 2. Browse the list of YAKAP-accredited clinics in your area 3. Self-assign yourself (and your dependents) to one provider — this is required before benefits fire 4. Schedule and attend a First Patient Encounter (FPE) at that clinic — the provider activates your YAKAP record in the system 5. Use the clinic for subsequent visits; switch providers later via the portal if neededWhere to find providers:• Rural Health Units (RHU) • Barangay Health Stations • City Health Offices • PhilHealth-accredited private clinics • Community health centersCost to you:Most services are free at government health units. Some private YAKAP providers may charge a small co-pay for services outside the package. There is no separate claim form to fill out — the provider bills PhilHealth directly.

Maternity Package Includes:• Prenatal consultations (at least 4 visits) • Laboratory tests during pregnancy • Delivery (normal or cesarean) • Professional fees (OB-GYN, anesthesiologist) • Newborn care and screening • Postnatal consultationBenefit amounts (effective Apr 30, 2026 expansion):• Normal Spontaneous Delivery: ₱29,000 (under the maternity-package expansion) • Cesarean Section: ₱58,000 (Level 1 hospital) or ₱62,000 (Level 2–3 hospital) • Prenatal care: included under the maternity package and YAKAP outpatient package (8 prenatal visits, 3 postnatal follow-ups) • Newborn care and screening: covered under separate PhilHealth packages — verify the current Circular before relying on a specific amountHow to Claim:During Pregnancy:1. Register with Konsulta provider for prenatal care 2. Attend regular prenatal check-ups (FREE) 3. Get necessary laboratory tests 4. Update PhilHealth contributionsUpon Labor/Delivery:1. Go to PhilHealth-accredited hospital 2. Present PhilHealth ID at admission 3. Inform you're a PhilHealth member 4. Hospital processes maternity claim automaticallyHospital Files Claim:1. Hospital prepares maternity claim forms 2. You sign the claim documents 3. Hospital submits to PhilHealth 4. PhilHealth pays hospital directly 5. You pay any balance (if private hospital)Requirements:✓ PhilHealth ID or PIN ✓ Valid government-issued ID ✓ Marriage certificate (if married) ✓ At least 9 contributions paid ✓ Prenatal records (if available)No Balance Billing:• In government hospitals: Usually FREE • PhilHealth + DOH support = full coverage • Private hospitals: May have balance • Check with hospital before admission

When to File Reimbursement:• Hospital did not file for you • You paid full hospital bill out-of-pocket • Emergency confinement in non-accredited hospital • Foreign hospital confinement (for OFWs) • Hospital was not available to file claimDeadline:• Must file within 60 days from discharge • Late filing may result in claim denial • Extensions possible for valid reasonsRequired Documents:✓ PhilHealth Claim Form 1 (CF1) - accomplished ✓ Proof of payment (Official Receipts) ✓ Hospital Statement of Account (itemized) ✓ Medical certificate with diagnosis ✓ Clinical abstract/discharge summary ✓ Laboratory and diagnostic results ✓ PhilHealth ID or MDR ✓ Valid government-issued IDHow to File Reimbursement:Step 1: Prepare Documents• Compile all original receipts • Get certified true copies of medical records • Fill out PhilHealth Claim Form 1 (CF1) • Download form from PhilHealth website • Complete all required fields accuratelyStep 2: Submit to PhilHealth• Go to PhilHealth branch office • Submit claim with all documents • Get acknowledgment receipt • Note your claim reference numberStep 3: Processing• PhilHealth evaluates your claim • May request additional documents • Processing time: 60 days maximum • You can follow up via phone/onlineStep 4: Receive Payment• PhilHealth issues check or direct deposit • Pick up check at PhilHealth office, or • Receive via bank transfer (if enrolled) • Amount: PhilHealth benefit package only • Not full reimbursement of all expensesImportant:• PhilHealth pays based on case rates • Not full reimbursement of actual bill • Example: If bill is ₱100,000 and case rate is ₱32,000 You only get ₱32,000 from PhilHealth • Keep original receipts until claim is paid