How to File PhilHealth Claims

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 (2026):• Pneumonia: ₱32,000 • Dengue: ₱16,000 • Normal delivery: ₱6,500 • Cesarean delivery: ₱19,000 • Appendectomy: ₱31,000 • Cataract surgery: ₱16,000

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 Package:• Up to ₱1.4 million lifetime benefit per illness • Covers chemotherapy, radiation, surgery • Dialysis sessions (up to limit) • Medicines and procedures • Hospital bills related to treatmentHow 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:• Annual physical examination (APE) • Preventive care and health education • Basic diagnostics (blood test, urinalysis, etc.) • Essential medicines for common conditions • Primary care consultation • Management of chronic conditionsKonsulta Benefit:• ₱1,500 per individual per year • Covers consultation, meds, and diagnostics • FREE at government health centers • Minimal co-payment at private clinicsHow to Use Konsulta:1. Find Konsulta Provider: • Visit PhilHealth website for list • Check nearest health center/clinic • Must be PhilHealth-accredited • Government health centers usually FREE 2. Visit During Consultation: • Bring PhilHealth ID or provide PIN • Present valid government ID • Register as Konsulta patient • No advance filing needed 3. Receive Services: • Doctor examines you • Get needed laboratory tests • Receive prescribed medicines • Health education and counseling 4. Payment: • FREE at most government health centers • Minimal payment at private Konsulta clinics • No claim form to fill out • Provider bills PhilHealth directlyAvailable at:• Rural Health Units (RHU) • Barangay Health Stations • City Health Offices • PhilHealth-accredited private clinics • Community health centers

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 (2026):• Normal delivery: ₱6,500 (facility) + ₱2,000 (professional fees) • Cesarean delivery: ₱19,000 (facility) + ₱5,000 (professional fees) • Prenatal care: Covered under Konsulta Package • Newborn care: ₱1,000 newborn care package • Newborn screening: ₱560How 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