MqtubEcqfibePhn^jmes PHIUPPINE HEALTH INSURANCE CORPORATION Cilystate Cenlie Building, 709 Sbaw Boolevaid, Pasig City Healtfaline 441-7444 www.philhealth.gov.ph PHILHEALTH CIRCULAR No. ^}ip " W'^3 r TO ALL PHILHEALTH MEMBERS, ACCREDITED AND CONTRACTED HEALTH CARE INSTITUTIONS, PHILHEALTH REGIONAL OFFICES AND ALL OTHERS CONCERNED SUBJECT EXPANDED Z BENEFIT FOR MOBILITY, ORTHOSIS, REHABILITATION, PROSTHESIS HELP PACKAGE (EXPANDED ZMORPH) I. RATIONALE The Philippine Health Insurance Corporation recognizes the potential towards functional ind^endence and productivity of persons widi disabilities, particularly those with spinal or limb loss, deficiency or deformity once they are provided with affordable prostheses or orthoses. Aligned with the mission of Republic Act 7277 or Magna Carta for Disabled Persons PhilHealth therefore seeks to mainstream persons with disabilities into the community by ensuring functionality through integration of prosthetic and orthotic devices provision widi rehabilitation services. Cognizant of the United Nations Convention on the Rights of Persons with Disabilities vision of full and equal enjoyment of PWDs' human rights PhilHealth shall ensure protection of their inherent dignity by ensuring provision of prosthetic and orthotic devices which are safe, appropriate, accessible and of quality. Supportive of the Department of Health Administrative Order 2015-0004 (Revised National PoEcy on Strengthening the Healdi and Wellness Program for PWDs) that atms to remove barriers to health care access, PhilHealth expands scope of assistive technology ftom below the knee prosthesis to aU levels .of limb loss or deficiency and limb or spinal deformity with integrated rehabiUtation services. Pursuant to PhilHealth Board Resolution No. 2124 s. 2016, the ZMORPH shall be expanded to include benefits for prostheses, orthoprostheses and orthoses. v-^ u ^ o Product T ai 1 O O RULES FOR IDENTIFIED TYPE Z 1. The provision of services for Expanded ZMORPH shall be covered under the benefit package and only those cases that strictly fulfill the selections criteria shall be covered. 2. Contracted health care institutions (HCl) should assess all their patients for qualification to the Z benefits. If qualified, these patients should be enrolled in this program. Contracted HCIs shall be responsible for developing an efficient process for assessing Z benefit patients that is appEcable in their own local setting. for Special Benefits Page 1 of 12 \vww.iacebook.com/PiiilHealth 3 ww\v.youtube.coin/teainphilheaIth actioncenter@philheaItb.^v.ph
Transcript
MqtubEcqfibePhn^jmes
PHIUPPINE HEALTH INSURANCE CORPORATIONCilystate Cenlie Building, 709 Sbaw Boolevaid, Pasig City
Healtfaline 441-7444 www.philhealth.gov.ph
PHILHEALTH CIRCULAR
No. ̂}ip " W'^3
r
TO ALL PHILHEALTH MEMBERS, ACCREDITED ANDCONTRACTED HEALTH CARE INSTITUTIONS,PHILHEALTH REGIONAL OFFICES AND ALL OTHERS
CONCERNED
SUBJECT EXPANDED Z BENEFIT FOR MOBILITY, ORTHOSIS,REHABILITATION, PROSTHESIS HELP PACKAGE(EXPANDED ZMORPH)
I. RATIONALE
The Philippine Health Insurance Corporation recognizes the potential towards functionalind^endence and productivity of persons widi disabilities, particularly those with spinal orlimb loss, deficiency or deformity once they are provided with affordable prostheses ororthoses.
Aligned with the mission of Republic Act 7277 or Magna Carta for Disabled PersonsPhilHealth therefore seeks to mainstream persons with disabilities into the community byensuring functionality through integration of prosthetic and orthotic devices provision widirehabilitation services.
Cognizant of the United Nations Convention on the Rights of Persons with Disabilities visionof full and equal enjoyment of PWDs' human rights PhilHealth shall ensure protection of theirinherent dignity by ensuring provision of prosthetic and orthotic devices which are safe,appropriate, accessible and of quality.
Supportive of the Department of Health Administrative Order 2015-0004 (Revised NationalPoEcy on Strengthening the Healdi and Wellness Program for PWDs) that atms to removebarriers to health care access, PhilHealth expands scope of assistive technology ftom belowthe knee prosthesis to aU levels .of limb loss or deficiency and limb or spinal deformity withintegrated rehabiUtation services.
Pursuant to PhilHealth Board Resolution No. 2124 s. 2016, the ZMORPH shall be expandedto include benefits for prostheses, orthoprostheses and orthoses.
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RULES FOR IDENTIFIED TYPE Z
1. The provision of services for Expanded ZMORPH shall be covered under the benefitpackage and only those cases that strictly fulfill the selections criteria shall be covered.
2. Contracted health care institutions (HCl) should assess all their patients forqualification to the Z benefits. If qualified, these patients should be enrolled in thisprogram. Contracted HCIs shall be responsible for developing an efficient processfor assessing Z benefit patients that is appEcable in their own local setting.
3. Pfe-autliotization from PhilHealth based on the approved selections criteria shall berequired prior to provision of services. All requests for pre-authorization shall becompletely and properly accomplished by the contracted HCI by filling out the pre-authorization checklist and request (Annex "A") and submitted by a designated liaisonof the contracted HCIs to the Local Health Insurance Office (LHIO) or to the officeof the Head of the PhilHealth Benefits Administration Section (BAS) in the region forapproval
4. The approved Pre-authorization Checklist and Request (Annex "A") shall be valid for180 calendar days firom the date of approval by PhilHealth. All contracted HCIs areresponsible for tracking the validity of their approved pre-authorizations. ContractedHCIs shall inform PhilHealth and shall submit a new pre-authorization checklist andrequest if services were not provided at the end of the validity period of the priorrequest.
5. While the submission of pre-authorization request is manual^ the pre-authorizationchecklist and request for the Expanded ZMORPH and the properly accomplishedMember Empowerment Form or ME Form (Annex ''B") shall be submitted together.Once the systems are automated, a unique case number shall be generated for everypre-authorization request submitted.
6. The ME Form shall be accomplished together by the attending health careprofessional/s in the contracted HCI and the patient to be enrolled in the ExpandedZMORPH. The ME Form aims to support patients to be active participants in healthcare decision making by being educated and informed of the conditions, allmanagement options. Further the ME Form aims to encourage the attending healthcare professionals in the contracted HCIs to dedicate adequate time to discuss withpatients. The overall goal is to achieve better health outcomes and patientsatis&ction.
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7. PhilHealth members and their qualified dependents must be eligible to avail ofPhilHealth benefits at the time of pre-authorization.
8. The minimum standards of care for Expanded ZMORPH cover the entiremanagement from pre-prosthetic /orthotic assessment up to the conduct of therehabilitation or occupational therapy sessions. These ate based on current standardsof practice and may be updated as needed depending on valid medical evidence that istransfeirable and applicable to the local setting. Updating of medical evidence shall becovered during regular policy reviews in collaboration with pertinent stakeholders.
9. The minimum standards of care for the Expanded ZMORPH are the mandatory services(Table 3) that must be provided to all patients enroUed under the Z benefits in allcontracted HCIs that shall be requited by PhilHealth.
10. Coordination and collaboration with the Reference HCI and among contracted HCIsfor Expanded ZMORPH shall be required for quality improvement and operationalpurposes, such as, but not limited to, pertinent trainings, regular patient audits, patientreferrals, patient tracking, pooled procurement of medicines and supplies, etc.
11. Patients enrolled in the Expanded ZMORPH shall be deducted a maximum of five (5)days from the 45 days annual benefit limit regardless of the actual length of stay in thecontracted HCI in a calendar year. Such deductions shall be made on the curcent yearwhen the pre-authorization is approved. In cases where the remaining annnal benefitlinut is less than five (5) days but at least one (1) day at the rime of pre-authorization,the member shall remain eligible to avail of the Z Benefits, provided that premiumsare updated. Contracted HCIs should remind these patients to regularly updatepremium contributions in order to continue availing PhilHealth benefits.
12. The No balance billing (NBB) policy shall be applicable as stipulated in PhilHealthCircular 3, series of 2014 (Strengthening the Implementation of the No BalanceBilling Policy) and other related issuance. Negotiated fixed co-pay shall be applied foreligible non-sponsored members and their qualified dependents. The fixed co-payshall be reflected in the individual contracts and shall cover for additional services
rendered by the contracted HCI in relation to the Expanded ZMORPH.
If the eligible members or their qualified dependents refuse to avail of the NBB policyand agree to pay the negotiated co-pay, they will be allowed to do so provided theyindicate in the Member Empowerment Form that they are willing to opt out from theNBB and pay the corresponding negotiated co-pay.
13. All claims for the Expanded ZMORPH shall be filed by the contracted HCI according todie schedules set by PhilHealth.
14. The filing of claims shall be done by the contracted HCI within 60 ralendar days from thelast day of the period covered specified in the tranche schedules in Table 4.
15. All mandatory and other services specific to the Expanded ZMORPH, that ensures thesafety and material used, shall be provided to the patient according to the approvedstandards set by the reference HCI.
16. Payment for this package shall be made to the contracted HCIs in full upon filing ofclaims for the specialized medical devices within 60 days from the date the rlaim wasfiled.
17. The professional fees for the Expanded ZMORPH is 10% of the package rate. Ruleson pooling of professional fees for government frcilities shall still apply-
18. All rates are inclusive of government taxes.
19. In cases when the patient expires anytime during the course of service provision orthe patient is lost to follow-up, the pajrment schedule of the corresponding tranchefor the specific phase shall be released as long as the patient received the scheduledservice. The remaining tranche shall not be paid.
'Tost to follow-up" means the patient has not come back as advised for immediatenext rehabilitation treatment visit or within 2 weeks after prosthetic/orthoticprescription has been prescribed. Visiting the clinic for rehabilitation services morethan 2 weeks from advised scheduled treatment visit renders the patient "lost tofollow up."
If the patient has not come back within 4 weeks after the agreed schedule of follow upafter casting and measurement or after fitting and alignment, and would requireadditional re-casting and measurement, the patient may proceed with the succeedingservices for the Z Benefits but the hospital may collect additional for fees for castingand measurement.
Patient will only be allowed a ma-gimnm of one calendar year to avail of the Z benefitsftom casting to rehabilitation services.
20. Contracted HCI shall submit to PhilHealth a sworn decJaration that a patient isexpired or lost to follow-up when filing the claim for the specific treatment phase.
21. All patients availing of the ZMORPH shall be monitored for return to productivity orcommunity reiategration as outcomes in the next six (6) months. Reports may besubjected to monitoring and post-audit by PhilHealth.
22. All patients 50 years of age and above, who are under the Z Benefits, are eligible toavail of pneumococcal vaccination as stipulated in PhilHealth Circular 7, series of2014 (Guidelines for the Oks ang Bakuna ko Laban sa Pulmonya).
III. DESIGNATION OF THE 2 BENEFITS COORDINATOR FOR EXPANDED
ZMORPH
Contracted HCls shall be required to designate at least (1) Z Benefits Coordinator,whose responsibilities may include, but are not limited to the following, as may bedeemed necessary by the contracted HCI:
1. Provide guidance to Z patients by facilitating timely access to the services requiredfor the Z Benefits. Guiding Z patients enrolled in the program to overcomehealthcare barriers in the availment of the said benefits in order to ensure patientadherence to agreed treatment plans with the goal of achieving expected goodoutcomes and ultimate patient satisfiiction;
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2. Coordinate with PhilHealth relevant matters pertinent to the Z Benefits availmentof candidate patients such as filling out of forms and eligibility requirements priorto pre-authorization and to provide feedback and other inputs required byPhilHealth;
3. Encode into the ZBITS Module of the HCI Portal the pertinent information ̂ .e.demographics) of all patients needing prostheses/orthoses, whether or not thepatient fulfills the selections criteria for pre-authorization;
4. Enter pertinent data elements of all patients with approved Pre-authorizationChecklist and Request (Annex "A") in the required fields of the ZBITS Module ofthe HCI Portal These data elements shall be determined by PhilHealth, experts inprostheses/orthoses. Reference HCI and other stakeholders for purposes of qualityimprovement, policy research, and monitoring. Contracted HCIs are encouraged totrain their respective Z Benefits coordinator/s;
5. Other duties and responsibilides that may be assigned by the contracted HCI suchas ensuring completeness and accuracy of all attachments needed for pre-authorization, claims filing and reimbursement, that shall facilitate theimplementation of the Z Benefits.
IV. CRITERIA FOR INCLUSION, MINIMUM STANDARDS OF CARE, ANDPACKAGE RATES FOR EXPANDED ZMORPH
The overall package code for the Z benefit for Expanded ZMORPH is Z015. The followingare the corresponding descriptions, selections criteria, frequency and rates of the package:
A. SELECTIONS CRITERIA
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The following are the selections criteria:
1. Upper and Lower Limb Prostheses
a. Age > 18 years oldb. At least three months post-amputation, if acquiredc. Wheelchair independent, community-ambulator with or without crutches,
cane or walker
d. On physical examination: no fresh or non-healing wound, neuroma orpainful residual limb, no motor strength of <4/5 and limitation of motionof upper and/or lower limbs, no incoordination or poor balance
2. Lower limb orthosis
a. Age >18 years oldb. At least three months post-onsetc. Upper limbs > 4 with fair trunk control and full range of motion, if bilaterald. Unaffected limbs > 3 with fair trunk control and full range of motion, if
unilateral
e. Ambulatory with assistive devicef. No fresh or non-healing wound
2.1 Ankle foot orthoses
a. Weakness or absence of dorsiflexors &/or plantarflexors, +/- grade 1-2spasticity with fiill range of motion achieved passively
b. Equinovarus +/- foot rotation and +/- grade 1-2 spasticity with full rangeof motion achieved passively
c. Pain & Instability secondary to sensory or structural deficit in a CharcotArthropathy
2.2 Knee ankle foot orthoses
Quadriceps MMT of <3 +/- sensory loss ,+/- instability (genu recurvatum)with hip/knee flexion contracture <20 degrees
a. Age >18 years oldb. Upon diagnosis &/or post-operative clearancec. No sensory deficit over body segment of applicationd. Upper and lower limb manual muscle strength of > 3
3.1 Thotacolumbosactai custom molded spinal orthosisa. Thoracolumbar fri2-L2) spinal firactures involving posterior elementsb. Primary or metastatic lesions to the thoracolumbosacral spine
3.2 Lumbosacral custom molded spinal orthosisa. Lumbosacral fractures (L1-L3)b. Primary or metastatic lesions to the lumbosacral spine
The following are the package codes and corresponding rates per laterality:
Table 1. Package codes and rates for Expanded ZMQRPH- Prostheses/orthoprosthesesDescriptioa Package Code Package Rate (Php)
Right Left Both per laterally
1. Prosthesis*
A. Above knee/ kneedisarticulation (AKKD)
Z0151A Z0151B Z0151C 75,000.00
B. Hip disarticulation (HD) Z0152A Z0152B Z0152C 135,000.00C. Below elbow (BE) Z0153A Z0153B Z0153C 50,000.00D. Above elbow (AE) Z0154A Z0154B Z0144C 70,000.00E. Van Ness Rotationplasty Z0155A Z0155B Z0155C 85,000.00
n. Ortho/prostheses**A. Ankle foot Z0156A Z0156B Z0156C 17,500.00
III. Orthoses**
A. Knee ankle foot Z0157A Z0157B Z0157C 35,000.00
B. Hip knee ankle foot Z0158A Z0158B Z0158C 80,000.00* For cases involving more than one amputation, the patient is not allowed to claim twoprostheses simultaneously with the same laterality in either the upper (i.e. BE, AE) or in thelower (AKKD, HD) limb. To illustrate this, please refer to Table 5.
** For cases involving more than one amputation, the patient is not allowed to claim twoorthoses simultaneously with the same laterality.
4. Post-prosthetic/ orthotic fitting prescriptionfor six physical therapy or occupationaltherapy sessions by board certified physicianof the Philippine Board of RehabilitationMedicine
5. Conduct of six physical therapy oroccupational therapy sessions by PRClicensed physical therapist or occupationaltherapist
6. Final discharge disposition by a boardcertified physician of the Philippine Board ofRehabilitation Medicine
When warranted, pre-prosthetic /orthotic rehabilitation shall be
prescribed by a board certified physidanof the Philippine Board ofRehabilitation Medicine and
implemented by a PRC licensed physicaltherapist or occupational therapist
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D. MODE OF PAYMENT AND FILING SCHEDULE
The mode of payment for Expanded ZMORPH shall be given in tranches with thecorresponding amounts and filing schedule with the allowed frequency of availment asfollows:
1. The contracted HCIs shall file rlatms according to existing policies of PhiHealth.
2. An claims shall be filed by the contracted HCIs in behalf of the patients. There shall beno direct filing by members.
3. The contracted HCI shall submit a Haim application per completed tranche.
4. For cases involving more than one amputation, the patient is not allowed to claimtwo prostheses simultaneously with the same laterality in either the upper ̂ .e. BE,AE) or in the lower (AKKD, HD) limb.
Table 5. Examples of cases involving two levels of amputationsExample Decision Explanation
(Left) AKKD and (Left) HD Deny Same laterality in the same level of amputation(lower level). This will involve the sameprostheses in the lower limb.
(Left) AKKD and (Left) BE Pay Same laterality but different levels ofamputation (AKKD at the lower level and BEat the upper level). Patient is ambulatory withassistive device.
(Left) AKKD and (Left) AE Pay Same laterality but different levels ofamputation (AKKD at the lower level and AEat the upper level). Patient is ambulatory withassistive device.
(Left) AKKD and (Right) HD Pay Different laterality(Left) BE and (Left) AE Deny Same laterahty in the same level of amputation
(lower level). This wiU involve the sameprostheses in the upper limb.
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For the initial claim application ̂ e. tranche 1), the following shall be attached:a. Transmittal Form (Annex "H") of all claims for Expanded ZMORPH for
submission to PhilHealth, per claim or per batch of claims;Original copy of the approved Pre-authorization Checklist and Request;Certified true copy of the properly accomplished ME Form/PhilHealth Benefit Eligibility Form (PBEF) printout during the pre-authorizationapplication.
A PBEF that says ''YES" means that the patient is eligible. Submission ofother documents such as Member Data Record (MDR), proof of contributionsand PhilHealth Claim Form 1 (CFl) shall NOT be required;
A PBEF that says "NO" means that the patient MAY NOT be ehgible. TheHCI Portal shall provide the information for documents to be submitted toPhilHealth. These supporting documents shall be attached to the PBEF;
Except for cases covered by the above provision, submission of otherdocuments such as proof of contribution, certificate of eligibility or PhilHealth
CFl, in lieu of die PBEF, shall only be allowed in extreme circumstances andonly upon the approval of PhilHealth.
e. Properly accomplished Claim Form 2
f. Discharge Checklist of Services (Annex "C") for the corresponding tranches
g. Photocopy of completely accomplished Z Satis&crion Questionnaire (Annex'T)")
h. Tranche Requirements Checklist (Annex "E")
6. For succeeding claims, the Transmittal Form, Claim Form 2, the Discharge ChecklistServices (Annex "C"), Photocopy of Z Satisfaction Questionnaire (Annex 'T)'^ andthe Tranche Requirements Checklist for the Z Benefits (Annex ''E") shall besubmitted
7. The Z Satisfaction Questionnaire (Annex 'T)") shall be administered to all Z patientsprior to final discharge disposition firom the contracted HCI. These are validatedduring field monitoring by PhilHealth and shall be used as basis of the Corporation forbenefits enhancement, policy research and quality improvement purposes.
8. Rules on late filing shall apply.
9. If the delay in the filing of claims is due to natural calamities or other fortuitous events,the contracted HCI shah be accorded an extension period of 60 calendar days asstipulated in Section 47 of the Implementing Rules and Regulation (ERR) of theNational Health Insurance Act of 2013 (Republic Act 7875, as amended by RA 9241and RA 10606).
VI. POLICY REVIEW
Pursuant to PhilHealth Circular No. 035-2015, a regular policy review shall be conducted incollaboration with all relevant stakeholders, experts and technical staff representatives fi:omthe Corporation.
3^1. REPEALING CLAUSE
All provisions of previoxis issuances that are inconsistent with any provision of thifg Circularare hereby amended, modified or repealed accordingly.
lI.EFFECTIVITY
This circular shall take effect fifteen (15) days from publication in the Official Gazette orin a newspaper of general circulation and shall be deposited thereafter at the Office of theNational Administrative Register, University of the Philippines Law Center.
Product Team for Special Benefits Page 11 of 12
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DC ANNEXES
The following annexes may be downloaded from the PhilHealth website;www,philhealth.gov.ph
1. Pre-authorization Checklist (Annex "A")2. Member Empowerment Form (Annex ''B")3. Discharge Checklist for Expanded ZMORPH (Annex "C")4. Z Satisfaction Questionnaire (Annex'T)")5. Checklist of Requirements for Reimbursement (Annex "E")
£3N F. ARISPresident ̂ d (lEO
Date signed: | ^
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SUBJECT: Expanded Z benefit for mobility, orthosis, rehabilitation, prosthesis help package (expanded ZMORPH)
PHILIPPIl-^ health insurance CORPOlChysUite Centre, 709 Shaw Boulevard, P^ig City
Call Center (02) 441-7442 Trunkline (02) 441-7444w\vw.philhealth.gov.ph
ION
Case No.ear«l o«ywi«*oPaCrTLXTAOO
Annex "A1 -EMORPH"
HEALTH CARE INSTITUTION (HCI)
ADDRESS OF HCI
PATIENT (Last name. First name. Middle name. Suffix)
PHILHEALTH ID NUMBER OF PATIENT I I I - ff I I I i I I I l-flMEMBER ̂ patient is a dependent) (Last name, Ficst name. Middle name, SujEfix)
PHILHEALTH ID NUMBER OF MEMBER I I I - FT I I I I I I I l-fl
FulfiUed selections ctitetia □ Yes If yes, proceed to pre-authorization application□ No If no, specify reason/s and encode
PRE-AUTHORIZATION CHECKLIST FOR EXPANDED ZMORPHUpper and Lower Limb Prosthesis
Place a (^) if yes or A if not applicableQUALIFICATIONSa. Age >18 years old '
b. At least three months post-amputation, if acquiredc. Wheelchair independent, community-ambulator with or without
crutches, cane or walkerd. On physical examination: no fresh or nonThealing wound,
neuroma or painful residual limb, no motor strength of <4/5 andlimitation of motion of upper and/or lower limbs, noincoordination or poor balance
Place a check mark (^) on the type of prostheses to be fflvcn to the patient:Z Benefits* Right Left Both
1. Lower limb
A. Above knee/ knee disarticulationB. Hip disarticulationC. Van Ness Rotationplasty
n. upper limbA. Below elbow
B. Above elbow
the same laterality in either the same limb.
'i.cpforme by Patient/Parent/Guardian:
Irj S ^
Attested by Attending RehabilitationMedicine Specialist
Revisedlas
Printed name and signaturePhilHealthAccreditation No.
i'rinted name and signature
-nof October 2016 Page 1 of3 of Annex Al — EMORPH
S te^phf health www,.facebook.coin/PhiIHealth Youj^B www.youtube.com/teamphilhealth [email protected]
Note:
Once approved, the contracted hospital shall print the approved pre-authorization form and have thissigned by die padent; parent or guardian and health care providers, as applicable. This form shall besubmitted to the Local Health Insurance Office (LHIO) or the PhilHealth R^onal Office (PRO)\^hen filing the first tranche.
There is no need to attach laboratory results. However, these should be included in the patient's chartand may be checked during the field monitoring of the Z Benefits. Please do not leave any item blank
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Revised as of October 2016 Page 2 of 3 of Annex A1 — EMORPH
PHILIPPLl— HEALTH INSURANCE CORPOF^..ONCi^rstate Cenlre, 709 Shaw Boulevard, Pasig City
Call Center (02) 441-7442 Tninkline (02) 441-7444www.philhealth.gov.ph
PRE-AUTHORIZATION REQUEST FOR EXPANDED ZMORPH
Upper and Lower Limb Prosdiesis
Bawal
A»eroyOTliro "ROTBCTADiICzkeugw ESCURADO
DATE OF REQUEST (mm/dd/yyyy):
This is to request approval for provision of services under the Z benefit package forin
^AME OF PATIENT) (NAME OF HOSPITAL)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);
□ No Balance Billing (NBB)*n Co-pay ^dicate amount) Php*NBB is appficable to sponsored members, indigent; lasambahay, senior ddzens and IGroup members with valid Group PoHc^ Contract (GPQ
Certified correct by: Certified correct by:
(Printed name and signature) .Attending Rehabilitation Medidne.Specialist
(Printed name and signature)Executive Director/Chief of Hospital/Medical Director/ Medical Center Chief
PhilHealth _ _AccraJitation No,
PhilHealth _ _Accreditation No.
(Printed name and signature)Patient/Paxent/Guardian
(For PhilHealth Use Only)
□ APPROVED□ DISAPPROVED (State reason/s) ^
(Printed name and signature)Head, Benefits Administration Section (BAS)
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INITIAL APPUCATION
Activityecetved by LHIO/BAS:
_ ~Eiraorsed to BAS ̂ received by9)1
Q jApproved □ DisapprovededtoHCI:
Initial Date
^his pre-authorization is valid for one hundredgpty (180) calendar days from date of approval
quest.
COMPLIANCE TO REQUIREMENTS□ APPROVED□ DISAPPROVED (State reason/s)
ActivityReceived by BAS:□ Approved D DisapprovedReleased to HCI:
PHILIPP, HEALTH INSURANCE CORPOl\„ . IONCilyslate Centre, 709 Shaw Boulevard, Pasig City
Call Center (02) 441-7442 Tnmkline (02) 441-7444www.philhealth.gov.ph
Case No.
Annex "A2 - EMORPH''
HEALTH CARE INSTITUTION (HCl)
ADDRESS OF HCI
PATIENT (Last name. First name. Middle name. Suffix)
PHILHEAI,TH ID NUMBER OF PATIENT I i |-| I I I I 1 I I I |-| IMEMBER Q£ patient is a dependent) (Last name. First name. Middle name. Suffix)
PHILHEALTH ID NUMBER OF MEMBER I I I -1 I 1 1 I I I I I | -1 |
Fulfilled selections criteria □ Yes If yes, proceed to pre-authorization application□ No If do, specify reason/s and encode
PRE-AUTHORIZATION CHECKLIST FOR EXPANDED ZMORPHLower Limb Orthosis
Place a (^) if yes or NA if not applicableGENERAL QUALIFICATIONS Yes
1. Age >18 years old2. At least 3 months post-onset3. Upper limbs > 4 with fair trunk control and fiill range of motion, if
bilateral
4. Unaffected limbs > 3 with fair trunk control and full range of motion, ifunilateral
5. Ambulatory with assistwe device6. No firesh or non-healing wound
Place a if yes or NA if not applicable
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QUALIFICATIONS SPECIFIC TO ANKLE FOOT ORTHOSISWeakness or absence of dorsiflexors &/or plantarflexors, +/- grade 1-2spasticity with full range of motion achieved passivelyEquinovarus +/- foot rotation and +/- grade 1-2 spasticity with fullrange of motion achieved passivelyPain & Instability secondary to sensory or structural deficit in a CharcotArthropathy
Yes
As of October 2016 Page 1 of 3 of Annex A2 — EMORPH
Place a check mark on the type of ortheses to be given to the patient:
Z Benefits Right Left Both
Ankle Foot Orthosis ■
Knee Ankle Foot Orthosis
Hip Knee Ankle Foot Orthosis
Conforme by Patient/Parent/Guardian: Attested by Attending RehabilitationMedicine Specialist
Printed name and signaturePhilHealth
Accreditation No.
^rinted name and signature
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Note:
""Ipnce approved, the contracted hospital shall print the approved pre-authorization form and have thissigned by the patient, parent or guardian and health care providers, as applicable. This form shall be^bmitted to the Local Health Insurance Office (LHIO) or the PhilHealth Regional Office (PRO)
en filing the first tranche.
ere is no need to attach laboratory results. However, these should be included in the patient's chart. 12 abd may be checked during die field monitoring of the Z Benefits. Please do not leave any item blank.
PHILIPPLl.^ HEALTH INSURANCE CORPORA i iONCitystate Centre, 709 Shaw Boulevard, Pasig Cily
CaU Center (02) 441-7442 Trunkline (02) 441-7444www.philhealth.gov.ph
PRE-AUTHORIZATION REQUEST FOR Z MORPH
Lower Limb Orthosis
Djwst PDpOio hWOvCRO««al tWrvPtm KOIUCTADO
vSktCS:v.\JPJiOO
DATE OF REQUEST (mm/dd/yyyy):
This is to request approval for provision of services under the Z benefit package forin
(NAME OF PATIENl) (NAME OF HOSPITAL)under the terms and conditions as agreed for availmcnt of the Z Benefit Package.
The patient belongs to the following category (please tick appropriate box):
G No Balance Billing (NBB)*D Co-pay ̂ dicate amount) Php*NBB is ̂ jplicablc to sponsored members, indigent kasambahay, senior dtizens and IGroup numbers with valid Group Policy Contract (GPC)
Certified correct by: Certified correct by:
(Printed name and signature)Attending Rehabilitation Medicine Specialist
(Printed name and signature)Executive Director/dhief of Hospital/Medical Director/ Medical Center Chief
PhilHealth _Accrediadon Na
PhilHealth
Accreditation No.
Conforme by:
(Printed name and signature)Patient/Parent/Guardian
(For PhilHealth Use Only)
□ APPROVED□ DISAPPROVED (State reason/s)
^tinted name a.nd signature)Head, Benefits Administration Section (BAS)
INITIAL APPUCATION
Activity,eivedbyLHIO/BAS:orsed to BAS ̂ received byg)lpproved □ Disapproved
O
Initial Date
^el^edtoHCI:?his pte-authodzation is valid for one hundredeiefaW (180) calendar days from date of approval
enuest.
COMPLIANCE TO REQUIREMENTS□ APPROVED□ DISAPPROVED (State reason/s)
ActivityReceived by BAS:D Approved D DisapprovedReleased to HCI:
Initial Date
As of (^toDcr 2016 Page 3 of 3 of Annex A2 — EMORPH
S teamphilhealth www.facebook.coin/PhiIHealth YoutQS www.youtube.com/teamphilhealth [email protected]
Republic of the Philippines
PHILIPPI < HEALTH INSURANCE CORPORA I IONCitystate Centre, 709 Shaw Boulevard, Fasig Cify
Call Center (02) 441-7442 Tninkline (02) 441-7444www.philhealth.gov.ph
Case No.aPFtOTOCTADO
Annex «A3 - EMORPH"
HEALTH CARE INSTTTUTrON (HCI)
ADDRESS OF HCI
PATIENT (Last name. First name. Middle name, Su£fix)
PHIUHEALTH ID NUMBER OF PATIENT I I I - f"! I I I I I I I l-flMEMBER ̂ patient is a dependent) (Last name, First name. Middle name. Suffix)
PHILHEALTH ID NUMBER OF MEMBER | | |-| | 1 1 | | | | | \-\~\
Fulfilled selections criteria □ Yes If yes, proceed to pre-authorization applicationn No If no, specify reason/ s and encode
PRE-AUTHORIZATION CHECKUST FOR EXPANDED ZMORPHSpinal Orthosis
Place a (^) if yes or NA i'not applicableGeneral Qualifications Yes
1. Age >18 years old2. Upon diagnosis &/or post-operative clearance3. No sensory deficit over body segment of application4. Upper and lower limb manual muscle strength of > 3
Place a (v^) if yes or NA if not applicableQualifications for Thoracolumbosacral Spinal Orthosis Yes
1. Thoracolumbar ^12-L2) spinal fcactures involving posterior elements? Primary or metastatic lesions to the thoracolumbosacral spine
Place a (v^) if yes or NA if not applicablet . -
tJJ.
- t
Qualifications for Lumbosacral Spinal Orthosis Yes
Lumbosacral fcactures (L1-L3)Primary or metastatic lesions to the lumbosacral spine
<
As of October 2016 Page 1 of 3 of Annex A3 - EMORPH
Conforme by Patient/Parent/Guardian: Attested by Attending RehabilitationMedicine Specialist
Printed name and signaturePhilHealth
Accreditatioii No.
^tinted name and signature
"■—
si o
uOo
oo
Note:
Once approved, the contracted hospital shall print the approved pre-authorization form and have thissigned by the patient, parent or guardian and health care providers, as applicable This form shall besubmitted to ie Local Health Insurance Office (LHIO) or the PhilHealth Regional Office (PRO)when filing the first trancheThere is no need to attach laboratory results. However, these should be included in the patient's chartand may be checked during the field monitoring of the Z Benefits. Please do not leave any item blank.
As of October 2016 Page 2 of 3 ofAnnex A3 — EMORPH
This is to request approval for provision of services under the Z benefit package forin
(NAME OF PATIElSnQ (NAME OF HOSPITAL)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):
n No Balance Billing (NBB)*n Co-pay ̂ dicate amount) Php -*NBB IS appKcable to sponsored members, indigent, kasambahay, senior citizens ̂ d iGroup members with valid Group PoHcy Contract (GPQ
Certified correct by: Certified correct by:
(Printed name and signature)Attending Rehabilitation Medicine Specialist
(Printed name and signature)Executive Director/Chief of Hospital/Medical Director/ Medical Center Chief
PhflHeahh _Accreditaiion No.
PhilHealth
Accreditation No.
Conforme by:
(Printed name and signature)Patient/Parent/Guardian
(For PhilHealth Use Only)
□ APPROVEDni DISAPPROVED (State reason/s) =
(Printed name and signature)"Head, Benefits Adtninistration Section (BAS)
1 1 INITIAL APPUCA1rioN COMPLIANCE TO REQUIREMENTS1 j Activity Initial Date □ APPROVED
□ DISAPPROVED (State reason/s)Received by LHIO/BAS:E
L
idorsed to BAS (if received byEO):
li: Approved □ Disapproved Activity Initial Date
deased to HCI: Received by BAS:iThis pre-authotization is valid for one hundredeighty (180) calendar days from date of approvalofrequest
□ Approved □ DisapprovedReleased to HCI:
As of October 2016 Page 3 of 3 of Annex A3 — EMORPH
Magpaalam, tumulong, at magbigay kapangyatihaali^omy Support <& Ej/ipo2ver
IV^a Panuto:Instructions:
1. Ipalfliwanag at tutulungan ng kinatawan ng ospital ang pasyente sa pagsasa^t ng !ME form.The heahb care provider shall explain and assist the patient inJilBn^up the MEform.
2. Isulat nang maayos at malinaw ang mga imponnasyon na kmakadangan.IjB^bly print allinformation provided.
3. Paia sa mga Icatannnggng nangangailangan ng sagot na "oo" o "hindi", lagyan ng marWa (V) ang ang)copna kahon.
Eor items requiring a 'fes'^ or "no " responsoy tick appropriately with a check mark (V).4. Gumamit kaiagdagang papel kiing kinakailangan , Lagyan ito ng kanknlang marfen at ilakip ito sa IVfF.
form.
Use additional blank sheets f necessaryy labelproperly and attach secure^ to this ME form.5. Ang kinontratang ospital na magkakaloob ng dalubhasang pangangalaga sa pagpaparami ng kopya ng
ME Form.
The ME form shall be reproduced ly the contracted health care institution (Hd) providing spedali;^ care.6. Tatlong kopya ng ME form ang kailangang ibigay ng kinontratang ospital. Ang mga kopyang naban^t
ay ilalaan para sa pasyente, ospital at PhilHealth.Triplicate copies of the ME form shall be made available fy the contracted HCI—one for thepatient; one as file copy ofthe contracted HCIproviding the spedalie^ed care and one for PhilHealth.
7. Para sa mga pasyenteng gagamit ng Z Mobility Orthoses Rehabilitation Prosthesis Help^^ORPH), ukol sa pagpapalit ng artipisyal na ibabang bahagi ng hita at binti, isulat ang N/Asa tala B2, B3 at D6. Para naman sa Peritoneal Diatysis (PD) First Z Benefits, isulat ang N/Apara sa tala B2 at B3.Forpatients availing ofthe ZMobility Orthoses Rehabilitation Prosthesis Help (ZMORPH) forGtting of the external lowetlimb prosthesis, write N/A for items B2, B3 and D6 and for PD FirstZ Benefits, write N/A for items B2 and B3.
PANGALAN NG OSPITAL
HEALTH CARE mSTHTinON (Ha)
o
RevSfed
RES NG OSPITAL
DPLESSOFHa
IS of November 2016 Page 1 of 8 of Annex B — ME Form
A. Impormasyon nfi; Miyenibro/ PasyentcA. Mem ber/Pa tien t Infoim a lionPASYENTE (Apclyido, Pan^an, Panggitnang Apelyido, Karagdagan sa Pan^an)PATIENT (Last name, First name, Muidle name, Stfffh:)
NUMERO JSIG PHILHEALTH ID NG PASYENTE □ □ - □□□□□□□□□ - □□PHILHEALTH ID NUMBER OF PATIENTMIYEMBRO (kung ang pasycnte ay kalipikadoog oiakikinabaD^ (Apelyido, Paogalan, Panggjtnang Apclyido, Karagda^n saPangalan)AIEMBER (if patient is a dependent) (Last name. First name, Middle name, Sifffix)
NUMERO NG PHILHEALTH ID NG MIYEMBRO □ □ - □□□□□□□□□ - □□PHILHEALTH ID NUMBER OFMEMBERPERMANENTENG TIRAHANPERMANENT ADDRESSPetsa ng Kapanganakan (Buwan/Ataw/Taon)Bhibdqy (mmlddfyj^)
Numero ng TeleponoTelephone Number
Edad
AgeNumero ng CellphoneMobile Number
XasananSex
Email Address
Email Address
Kategoiya bilang Afiyembro:Membership Cat^ory:Q Empleado sa
D GobyemoGovernment
□ PribadoPrivate
□ May-ari ng Kompanya / Enterprise OwnerD Kasambahay / Household He^n Tagamaneho ng Pamilya/ Family driver
□ SelfEmplffyed□ Filipinong Mang^gawa sa ibang bansa
Migrant Workerl OFWD Informal Sector / hfay sadlmg pioagkakakitaan (Halimbawa. Negosyante, Nagmamaneho ng traysikel at taxi,
mga propesyonal, ardsta, at iba pa)It^ormal Sector / Self-Eaming Individuals (Ex. Business onnierj trirycle!taxi driverslstreet vendors, entrepreneurs, professionals,artists, etc.)
IZl Rlipino na may dalav^ang pagkamamamayan/ Naturalised Filipino Citis^enFilipino with Dual Citis^nshipl Naturalised Filipino Citis^n
O Organised Group Q IGroup Gold
□ A^r^taIndigent (dPsJCCT, MCCT)
els'
U1
U
o
n InisponsuranSponsored□ Bayan | LGU□ Nakatatandang mamamayan | Senior Citis^ (^J^ 10645)D Iba pa I Others
ibambuhay na kaanib/ Lifetime Member
Revisfi aslof November 2016 Page 2 of 8 of Annex B - ME Form
Description of condition2. Napagkasiinduang angkop na piano
ng gamutan sa ospitalAfpUcabk Treatment P/an a^eed uponnntb healtfrcare provider
yj n
^3>
U
QQ
oo
3. Napagkasunduang angkop naaltematiboDg piano ng gamutan saospitalApplicable alternative Treatment Planamed rtpon with health care provider
C. Tnlatakdaan ng Gniniitan at Kasunod na KonsiiltasvonC. Treatment Schedule andFoIIow-up Visit/s1. Petsangunang pagkakaospital o
konsultasyon ®(buwan/ araw/taon)Date of initial admission to HCI orconsult!' (mm!dd/yyyy)
" Paia sa ZMORPfT/ mga batang maykapansanan, ito ay tumutukoy sa pagkonsultapain sa lehabilitasyon ng external lower limbpce-pfosthesis/ device. Para naman si PD I^t,ito ay ang pctsa ng konsultasyon o pagdalaw saPD provider bago magnmula ang unang PDexdtangc." Vor ZAIORPH/ duldrea with disabilhks {CfVT>sJ,this nfers/o tlx amsutprior to the proiiritm of tlxderiee and! or nhahiUtalion. ForPD F/rr/, this refers: tothe date of medical consaliaiion or ririi to the PDProtiderprior to the start ofthefirst PD esahan^
2. Petsa ng susunod na pagpapa-ospital o konsultasyon^(buwan/araw/ taon)
Date!s of succeeding admission to HCIorconstdP (mm!dd!yyyy)Pad sa ZMORPH/ mga batang may
kapansanan, ito pctsa ngpa^alapat atpagsasayos ng dennce. Para naman sa PD Rrs^ito ay ang kasunod na pagt^ta sa PD Prondcr.
^ Por2MQRPHICWDS,tlmrefrslollxmeasiaemenS,J}ttiiigardiup'usimeais(f thedetia. Fcrtlx PD First, this refers to the next risit to the PDProiider.
Petsa ng kasunod na pagbisitat (buwan/araw/taon)i Date/ s offolloiv-tp visit/ s'I (mm/ dd/ yyyy)i Para sa ZMORPH/ mga bating may/ kapansanan, ito ay tumutukoy sa rchabilita^onI ng external lower limb post-prosthesis.• « For ZAlORPHICWDfthie refers to the exterml^ loazr limb posi-prosilxsis relMbiBtaiion emsulL
s of November 2016 Page 3 of 8 of Annex B — ME Form
Lagyan ng tsek ang angkop na sagpt o NA kung hindi nauukolP/rf a dnck mark(i) opposite appropriate amwer orl>lA ifnot applicable.
oo !YES
HINDI
NO
1. Ipinaliwanag ng kinatawan ng ospital ang uid ng aking karamHaman.health care provider explained the nature of rrry condition! disability.
2. Ipinaliwanag ng kinalawan ng ospital mga pagpipiliang paraan nggamutan/interbensyon ̂Afy health careprovider explained the treatment options! interventiofd.
^ Para sa ZMORPH, ito ay ukol sa pangangailangan ng pagbibigay at rehabilitasyonpara sa pre at post-device.^For ZMORPH, this rfers to the needforpre- andpost-device provision and rehabilitation.
3. Ipinaliwanag ng kinatawan ng ospital ang mga posibleng mga epekto/ masamangepekto ng gamutan/ interbensyon.The possible side ̂ects!adverse ffects of treatment! intervention were explained to me.
4. Ipinaliwanag ng kinatawan ng ospital ang kailangang serbisyo para sa gamutan ngaking karamdaman/ interbensyon.
health care provider explained the mandatory sendees and other services required for thetreatment of rry condition!intervention.
5. Lubos akong nasiyahan sa paliwanag na ibinigay ng ospital.7 am satisfied with the explanation given tomebyrry health careprovider
6. Naibigay sa akin nang buo ang impormasyon na ako ay mahusay na aalagaan ngmga dalubhasang doktor sa aldng piniling kinontratang ospital ng PhilHealth atkung gustuhin ko mang lumipat ng ospital ay hindi ito maka-aapekto sa akingpagpapagamot
I have been fully informed that I will be caredfor ly all thepertinent medical and alliedspecialties, as needed, present in the PhilHealth contracted HCI of rny choice and thatprferringanother contracted HCI for the said specialb^d care ndll not affect my treatment in any way.
1. Ipinalhs^nag ng kinatawan ng ospital ang kahalagahan ng pagsunod sa panukalanggamutan/interbensyon. Kasama rito ang pagkompleto ng gamutan/interbensyonsa unang ospital kung saan nasimulan ang aking gamutan/interbensyon.My health care provider explained the importance ofadhering to nry treatmentplan!intervention.This includes completing the course of treatment!intervention in the contracted HCI where nytreatment!intervention was initiated.
Paalala: Ang hindi pagsunod ng pasyente sa napagkasunduang gamutan/interbensyon sa ospital aymita^ring magTcsulta sa hindi pagbabayad ng mga kasunod na daims at hindi dapat itong ipasabilang case rates.Note: Non-adbenna of the patient to the t^reed treatment plan! intervention in the Hd mcry result to denial of filed
■j claims for the suaeeding tranches and which should not be filed as case rates.
iJ
evised as of November 2016Page 4 of 8 of Annex B — ME Form
Lagyaii ng isc-k ang sngk^'jp na 5agi>? <» X.\ kiing hiiidi iiauukolPiff d djt.'k markt^} isppos^ar dpprof>nnie timn't-r or j\'.-j if ml applicable.8. Binigyan ako ng ospital Dg talaan ng mga susunod kong pagbisita.My health care provider pave me the schedule! s ofmyfollonf-up visitjs.
IlIXDI
A"0
9. Ipinaalam sa akin ng ospital ang impomiasyon tungkol sa rnaaari kong bingan ngtulong pinansiyal o ibang pang suporta, kung kinak-ailangan.a. Sangay ng pamahalaan (Hah: PCSO, PK'IS, LGU, etc.)b. Civil society o non-government organizationc. Patient Support Groupd. Corporate Foundatione. Iba pa (HaL Media, Religious Group, Politician, etc.)My health care prouder gave me information where to go for financial and other means ofsupport, when needed.a. Government ageny (ex. PCSO, PMS, LGU, etc.)b. Civil society or nongovernment organisationc. Patient Srtpport Grotpd. Corporate Foundatione. Others (ex. Media, Peligious Groip, Politician, etc.)
10. Nabigyan ako ng kopya ng Hstahan ng mga kinontratang ospital para sakarampatang pa^agamot ng aking kondisyon o karamdaman.I have been furnished ly nry health care provider with a list of other contracted HCJsfor thespecialised care of my conation.
11. Nabigyan ako ng sapat na htn^l sa benepisyo at tuntunin ngPhilHealth sa pagpapa-miyembro at pa^amit ng benepisyong naaayon sa Zbenefits:
I have been fuUy informed by my health care provider of the PhilHealthmembership policies and benefit availment on the Z Benefits:
a. Kaalipikado ako sa mga itinakdang batayan para sa akingkondisyon/kapansanan.1 fulfill all selections criteria for r?y condition! disability.
b. Ipinaliwanag sa akin angpolisiya hinggil sa "No Balance Billing" (NBB)The "no balance billing" (NBB)poliy was explained to me.
Paalala: Ang polisij^ ng NBB ay maaaring makamit ng mga sumusunod namiyembro at kanilang kalipikadong makikinabang kapag na-admit sa ward ngospitak inisponsuran, maralita, kasambahay, senior citizens at miyembro ngiGroup na may kaukulang Group Policy Contract (GPC)Flote: NBB policy is applicable to the following members when admitted in wardaccommodation: sponsored, indi^nt, household help, senior citiserts and iGroip memberswith valid Group Poliy Contract (GPC) and their qualified dependents.
Para sa inisponsutan, maralita, kasambahay, senior citizens atmiyembro ng iGroup na may kaukulang Group Policy Contract (GPC)at kanilang kwalipikadong makikinabang, sagutan ang c, d at e.For sponsored, indigent, household help, senior citizens and iGroupmembers with valid GPC and their quaiiGed dependents, answer c, dand e.
Nauunawaan ko na sakahng hindi ako gumamit ng NBB ay maaari akongmagkaroon ng kaukulang gastos na aking babayaran.J undentand that I may choose not to avail of the NBB and may he charged out of pocketexpenses
Revised as of November 2016 Page 5 of 8 of Annex B — ME Form
^ teamphilhealth w\v\v.facebook.Goiii/PhilHealUi Yoiillt||n www.youtube.com/teamphiIheaIlh m [email protected]
d. Sakaling ako ay pumiK ng pribadong doktor o kaya ay na^alipat sa masmagandang kuwarto ayon sa aking kagustuban, nauunawaan ko na hindi na akomaaadng humiling sa pagamutan para makagamit ng pribilehiyong ibinibigay samga pasyente na NBB (kapag NBB, wala nang babayaran pa pagkalabas ngpagamutan)In case I choose aprivate doctor or I choose to ipgrade rrr^ room accomodationj I understandihatl can no longer demand the hospital to^rantme theprivilege given to JSJBB patients(that is, no out of pocketpigment upon dischajgefrom the hospital)
e. Tinatalikdan ko na ang aking pribilehiyo bOang pasyente na NBB at dahil dito,babayaran ko ang anntnang halaga na hindi sakop ng benepisyo sa PhilHealtbI waive mj privilege as an NBB patient and I am willing to pay on top ofmj PhilHealthbenefits
Ang mga sumusunod na katanungan ay para sa mga miyembto ng formalat informal economy at kanilang mga kalipikadong makikinabangThe following ate applicable to formal and informal economy and theirqualided dependents
f. Naiintindihan ko na maaari akong magkaroon ng babayaran para sa halaganghindi sakop ng benepisyo sa PhilHealth.I understand that there may he an additionalpayment on top of PhilHealth benefits.
12. T.imang (5) araw lamang ang babawasan mula sa 45 araw na palugit sabenepisyo sa isang taon para sa buong gamutan sa iii^hVn ng Z benefits.Onlyfive (5) days shall he deductedfrom the 45 confinement days ben fit limitper yearforthe duration of my treatment!intervention under the Z Benefits.
O3U
oo
E. Tungkulin at Responsabilidad ng MiveiubroE. Member Roles and ResponsibilitiesLagyan ng (V) ang angkop na sagot o NA kung hindi nauukolPut a (^) opposite appropriate ansjver or NA ifnot applicable.
OO
YES
HINDI
JVO
1. Nauunawaan ko ang aking tungkulin upang masunod ang nararapat at nakatsikdakong g^utan.I understand that I am responsible for adhering to mj treatment schedule.
2. Nauunawaan ko na ang pagsunod sa itinakdang gamutan ay mahalaga tungo saaking pag^ling at pangunahing kailangan upang magamit ko nang buo ang Zbenefits.
I understand that adherence to vry treatment schedule is important in terms of clinical outcomesand apre-requisite to thefull entitlement of the Z ben fits.
3. Nauunawaan ko na tungkulin kong sumunod sa mga polisiya at patakaran ngPhilHealdi at ospital upang magamit ang buong Z benefit package. Kung sakali nahindi ako makasunod sa mga polisiya at patakaran ng PhilHealth at ospital,
■"itinatalikuran ko ang aking pribilehiyong makagamit ng Z benefits.■ \l understand that it is ny responsibility to follow and comply with all thepolicies andproceduresi \ofPhilHealtb and the health careprovider in order to avail of the fidl Z benefit package. In the^ 1 event that Ifail to comply with policies andprocedures ofPhilHealth and the health care11 wrovider, I waive theprivilege of availing the Z benefits.!> 1
s of November 2016 Page 6 of 8 of Annex B - ME Form
F. Pangalan, Lagda, Thumb Print at PetsaP. Printed Maine, Signature, Thumb Print, and DatePangalan at Lagda ng pasyente:*Printed name and signature of patient*"
*Paca sa mga menor de edad, ang magiilang o tagapag-alaga angpipitma o ma^alagay ng diumb pdnt sa n^Iaa ng pasyente.*Formitsonf theparent or guardian affixes ibeir d^ature or thumbprint hereon behalf of thepatient
Thumb Print^cung hindi makakasolat
ang pasyente)^patient is unable to rvrite)
Petsa
(bmvan/ araw/ taon)
Pangalan at lagda ng nangangalagang Doktor;Printed name and signatttre of Attending Doctor
Petsa (buwan/aiaw/taon)Date (mmlddlym)
Saksi:
Witnesses:
Pangalan at lagda ng Idnatawan ng ospitabPrinted name and signatttre ofHCI staff member
Petsa (buwan/araw/taon)Date (mm/ dd/jpfff)
Pangalan at lagda ng asaw^/ magnlang / pmakamalapit na kamag-anak/ awtotisadong kinatawanPrinted name and signature of spouse! parent/ next of kin / aitthorif(ed guardian orrepresentative
Petsa (buwan/aow/teon)Date (mm/ dd/yyrt)
G. DetaJye ng Tagapag-iignav ng PhilHealth para sa Z benefitsG. PbilHeakh Z Coordinator Contact Details
Pangalan ng Tagapag-ugnay ng PhilHealth para sa Z benefits na nakatalaga sa ospitalName of PhilHealth Z Coordinator assigned at the HCI
Numero ng TeleponoTelephone number
Numero ng CellPhoneMobile number ■
Email Address
H. Numerong maaaring tawagaii sa PhilHealtbH. PhilHaalcii Contact Details
Opisinang Panrehiyon ng PhilHealthPhiMealth P^ponal Office JSfo.Numero ng teleponoHot/iaeNos.
1Q
u
8
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Page 7 of 8 of Annex B - ME FormPage 7 oi 8 o\ AntxQ- »—
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T. Pahinmlot sa pag?uj-an fa ralaan ng pasx"ciircI. Consent to access patient record
J. Pahinmlor na mailagar ang Z •benefit in formadna and tracking svstern ZJ31TS)
f. Consent to enter medical data in the Zbenefit information & tracking system(ZBITS)
Ako ay pumapayag na suriin ng PhilHealth ang akingtalaang medikal upai^ mapatunayan ang katotohananngZ-claimI consent to the examination hy Phi/Hea/th of medicalrecords for the solepurpose of verifying the veracity of the Z-claim
Ako ay pumapayag na mailagay ang akingimpormasyong medikal sa ZBITS na kaOangan sa Zbenefits. Pinahihintulutan ko din ang PhilHealth namaipaalam ang diking personal na impormasyongpangkalusugan sa mga kinontratang ospitaL1 consent to have r?ty medical data entered electronically in theZBJTS as a requirement for the Z Benefits. I authorisePhilHealth to disclose rrry personal health information to itscontractedpartners
Ako ay nagpapatunay na walang pananagutan ang PhilHealth o sinumang opisyal, empleyado o kinatawanmula sa pahintulot na nakasaad sa itaas sapagkat kusang-loob ko itong ibinigay upang makagamit ng Zbenefits ng PhilHealth.
I herdty hold PhilHealth or any of its officers, empltyees and!or representativesfreeJrom any and all liabilities relative to theherein-mentioned consent Tvhich I have voluntarily and ivillingly given in connection with the Z claim for reimbursement b^rePhilHealth.
Buong pangalan at lagda ng pasyente*Printed name and signature of patient*
* Paia sa mga menor de edad, ang magolang o tagapag-alaga ang pipiima oma^alagay ng thumb print sa ngalan ng pasyente.* For ffdmrs, theparent or guardian t^xes their signature or thumbprint here on behalfof the patient.
Thumb print(Kung hindi namakasusulat)
^patient is unableto auite)
Petsa (buwan/aiaw/taon)Date (mm!ddjjjyy)
Buong pangalan at lagda ng kumakatawan sa pasyentePrinted name and signature of patient's representative
Petsa (buwan/aiaw/taon)Date (mmiddlyyyy)
Relasyon ng kumakatawan sa pasyente (Lagyan ng tsek ang angkop na kahon)Relationship of representadve topatient (tick appropriate box)
[~| asawa magulang [] anak fl kapatid PI tagapag-alagaspouse parent child next of kin guartUan
SJ.!
:d
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8
Revised as of November 2016 Page 8 of 8 of Annex B - ME Fonn
PHILIPPINE HEALTH INSURANCE CORPORATIONCitystate Centre, 709 Shaw Boulevard, Pasig Ci^
Call Center (02) 441-7442 Trunkline (02) 441-7444wNVw.nhilhealtlLgGV.ph
?Case No.
Annex "CLl - EMORPH"
DISCHARGE CHECKUST FOR EXPANDED ZMORPH
Lower Limb Prosthesis
Tranche 1
HEALTH CARE INSTITUTION (HCI)
ADDRESS OF HCI
PATIENT (Last name. First name. Middle name. Suffix)
PHILHEALTH ID NUMBER OF PATIENT I I I - FT I I I T I I I I - f"!MEMBER ̂ patient is a dependent) (Last name, First name. Middle name. Suffix)
PHILHEALTH ED NUMBER OF MEMBER I I I - FT I I I I I I I I - f"!
Place a (v^) or NA if not applicable
Certified correct by:
(Printed name and signature)Attending Rehabilitation Medicine Specialist
SO
u
o.Q
TMHealth
tte signed (mm/dd/yyyy)
Certified correct by:
(Printed name and signature)Executwe Director/Chief of Hospital/Medical Director/ Medical Center Chief
PhilHealdi
Accreditsirion No.
Date signed (mm/dd/yyyy)
Conforme by:
(Printed name and signature)Patient/Parent/Guardian
Date signed (mm/dd/yyyy)
CRITERIA Yes
1. Extemallower limb prosthesis provided is as pr^cribed with appropriatepressure tolerant and sensitive areas, well-fitting socket, good suspension, properalignment and stable prosthetic foot while standing and walking
2. The lower limb stump is fiee of pain, blister, vascular compromise,hypersensitivity after 30 minutes of prosthetic weight bearing while standingand/or walking
3. Prosthesis user ambulates within expected gait: parameters and steps up and downfive (5) steps with assistive device
4. Prosthesis user possesses con^etent skill and knowledge regarding prosthesisdonning doffing, cleaning, precautions and falling techniques
Revised of October 2016 Page 1 of 1 of Annex Chi —EMORPH
PHILIPPINE HEALTH INSURANCE CORPORATIONCitystate Centre, 709 Shaw Boulevard, Pasig City
CaU Center (02) 441-7442 Tnmldine (02) 441-7444www.philhealth.gov.ph
Case No.
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Annex "CL3 - EMORPKT
DISCHARGE CHECKUST FOR EXPANDED ZMORPH
Lower Limb Orthosis
Tranche 1
PIEALTH CARE INSTITUTION (HCI)
ADDRESS OF HCI
PATIENT (Last name. First name, Middle name, Su£6x)
PHILHEALTH ID NUMBER OF PATIENT I I I - [~T I I I I I I I I - f"!MEMBER ̂ patient is a dependent) (T.ast name, First name, Middle name. Suffix)
PHILHEALTH ID NUMBER OF MEMBER I I I - F"! I I I I I I I I -1 I
Place a (y') or NA if not applicable
CRITERIA Yes
1. External lower limb orthosis provided is as prescribed with appropriate alignmentand fit
2. The lower limb is free of blisters, vascular compromise, pain, hypersensitivityafter 30 rhinutes of orthosis weight-bearing while standing and/or walking
3. Lower limb orthosis allows safe ambulation with or without assistive device
4. Orthosis user possesses competent sldll and knowledge reg^ding donning,doffing cleaning, precautions and falling techniques
s-3
U
oQ
Certified correct by: Certified correct by:
(Printed name and signature)Attending Rehabilitation Medicine Specialist
(Printed tiame and signature)Executive Director/Chief of Hospital/Medical Director/ Medical Center Chief
PhiirJcalth 1Accreditation No.
PhilHealth 1 _ _Accreditation No. 1
"Date signed (mm/dd/yyyy) Date signed (mm/dd/yyyy)
Conforme by:
(Printed name and signature)Patient/Parent/Guardian
Date signed (mm/dd/yyyy)
Revised as of September 2016 Page 1 of 1 of Annex CL3 — EMORPH
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 yourfriendly health care provider or you may contact PhilHealth call center at 441-7442. Your
responses will be kept confidential and anonymous.
For items 1 to 3, please tick on the appropriate box.
Z benefit package availed is for:
□ Acute iymphoblastic leukemia□ Breast cancer□ Prostate cancer□ Kidney transplantation□ Cervical cancer□ Coronary artery bypass surgery□ Surgery for Tetralogy of Fallot
□ Surgery for ventricular septal defect□ ZMORPH/Expanded ZMORPH□ Orthopedic Implants□ PD First Z benefits□ Colorectal cancer□ Prevention of preterm delivery□ Premature and small newborn
2. Respondent's age is:□ 19 years old & below□ between 20 to 35□ between 36 to 45□ between 46 to 55□ between 56 to 65
n above 65 years old
3. Sex of respondent□ male□ female
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LjJUJ
DUl
ao
r Items 4 to 8, please select the one best response by ticking the appropriate box.
How would you rate the services received from the health care institution (HCI) in terms ofavailability of medicines or supplies needed for the treatment of your condition?□ adequate□ Inadequate□ don't know
of November 2016 Page 1 of 2 of Annex D
*
5. How would you rate the patient's or family's involvement in the care in terms of patientempowerment? (You may refer to your Member Empowerment Form)
6. In general, how would you rate the health care professionals that provided the services for the Zbenefit package in terms of doctor-patient relationship?□ excellent□ satisfactoryn unsatisfactory□ don't know
7. In your opinion, by how much has your HCI expenses been lessened by availing of the Z benefitpackage?□ less than half
