PHIC Philhealth Circular No. 18 (2003)

(NAR) VOL. 14 NOS. 3-4 / OCTOBER - DECEMBER 2003

[ PHIC PHILHEALTH CIRCULAR NO. 18, S. 2003, May 28, 2003 ]

UPDATED SUMMARY OF DOCUMENTARY REQUIREMENTS IN THE AVAILMENT OF NHIP (MEDICARE) BENEFITS

This summary is a consolidation of applicable requirements in filing claims applications based on related issuances released by the Corporation for easy reference. There are no changes in the current documentary requirements except for consideration of Member Data Record (MDR) as the primary document for proof of dependency for legal dependents of registered Individually Paying Member (IPM) and Non-Paying Member (NPM) in case applicable legal documents are not available. It should be clarified however, that in the medical evaluation of the claim, PhilHealth may still require other or additional documents when deemed necessary for a more accurate evaluation of the claims. Accordingly, this Circular supercedes or amends PhilHealth Circular Nos. 46 46-A, 46-B, 68 (Item 5), 69, and 71 all Series of 1999, PhilHealth Circular Nos. 01, 13, 21 and 28 all Series of 2000, and PhilHealth Circular Nos. 08, 19, 20 and 25 (Item 8) all Series of 2001. All the other provisions of said circulars or issuances which are not inconsistent herewith shall remain in full force and effect. This Circular shall apply only to admissions starting July 1, 2003. Please be guided accordingly. Adopted: 28 May 2003

(SGD.) FRANCISCO T. DUQUE III, MD, MSc President and CEO Updated Summary of Documentary Requirements in the Availment of NHIP (Medicare) Benefits All Claims application should attach the Duly Accomplished PhilHealth Claim form 1 and the following Requirement/s: MEMBERSHIP CATEGORY REQUIREMENTSI. EMPLOYED SECTOR Duly accomplished PhilHealth Claim Form 1 is sufficient. In case item no. 16 (Certification of Employer) in PhilHealth Claim Form 1 is not properly accomplished, require submission of the following: Accomplishment of item 16 of PhilHealth Claim Form 1 AND Any of the following: Photocopy of Employer's Quarterly Remittance Report Form (RF 1) and Photocopy of Duly Validated Revised Contributions Payment Return Form for Employed Sector (ME 5); or Photocopy of Official Receipts of accredited banks II. INDIVIDUALLYPhotocopy of member's PhilHealth ID Card PAYING MEMBER AND Any of the following: Photocopy of Duly validated Contribution Payment Return Form (MI 5). Photocopy of Machine printed receipt/s. Photocopy of Official Receipts of PhilHealth accredited banks. Photocopy of Official receipt/s of the Republic of the Philippines (for over the counter payment).

III. NON-PAYING MEMBERS

A. Registered Non-Paying Photocopy of member's PhilHealth ID Card member with Card PhilHealth ID B. Non-Registered Non- Any of the following: Paying member B.1. SSS Old-Age Retiree - Photocopy of Print-out of Death, A member who has reached Disability and Retirement (DDR) from the age of 60 with 120 any SSS Office indicating that the type of monthly Medicare premium claim is retirement in nature and the contributions. effectivity date of pension. Photocopy of the Retiree-Pensioner Certificate issued by SSS indicating the effectivity date of retirement. B.2. GSIS Old-Age Retiree Any of the following: - A member who hasreached the age of 60 years Photocopy of Certification/Letter of old. To include GSIS Approval of Retirement from the GSIS member who availed of indicating the effectivity date of early retirement and has retirement. reached the age of 60 years Photocopy of Service Record issued by old upon confinement and the employer/s showing rendered service has paid 120 monthly of not less than 120 months exclusive of Medicare premium leave of absences without pay. contributions. Photocopy of Certification/Retirement Gratuity from the employer indicating services of not less than 120 months. Photocopy of retirement voucher issued by GSIS B.3 SSS Survivorship Any of the following: Pensioner PRIOR to Photocopy of Print-out of Death, effectivity of RA 7875 on Disability and Retirement (DDR) from March 4, 1995. any SSS Office indicating that the type of claim is survivorship in nature and the effectivity date of pension. Photocopy of Survivorship Pensioner Certification issued by SSS indicating effectivity date of pension. B.4 SSS/GSIS Disability Any of the following: Pensioner PRIOR to Photocopy of Print-out of Death, effectivity of RA 7875 on Disability and Retirement (DDR) from March 4, 1995 any SSS Office indicating that the type of claim is disability in nature and the effectivity date of pension. Photocopy of Disability Pensioner Certification issued by SSS/GSIS indicating effectivity date of pension or the period of coverage for SSS/GSIS disabled pensioner. B.5. Uniformed AFP, PNP, Any of the following: BJMP and BFP Photocopy of General/Special or Bureau Retirees/Pensioners - Order indicating effectivity date of Those who has reached age retirement from the Service of 56 years old (compulsory Command/Headquarters or Bureau. retirement) and those Photocopy of Certification/Letter of separated for other reasons Approval of Retirement from the GSIS prior to said age and have indicating services of not less than 120 reached the age of 60 prior months. to confinement Photocopy of Statement of Services issued by previous employer showing service of not less than 120 months exclusive of absences without pay.B.6. Retirees and Any of the following: Pensioners who are Photocopy of Certification of Retirement Members of the Judiciary from the Office of the Court Administrator (OCA) or such other concerned office(s) clearly indicating the tenure of Justice/Judge Service Record (leave of absences without pay must be indicated, if any) or duly signed Certification from previous employer/s indicating number of monthly Medicare premium contributions paid. B.7. Retirees who are Any of the following: members of Constitutional Photocopy of Certification of Retirement Commissions and other from the office concerned clearly Constitutional Offices indicating the tenure of the official/employee. Service Record (leave of absences without pay must be indicated, if any) or duly signed Certification from previous employer/s indicating number of monthly Medicare premium contributions paid.

IV. INDIGENT MEMBERS Any of the following: Photocopy of member's valid PhilHealth Membership Identification Card or Original copy of Certification (PhilHealth Form CE 1) from the local PhilHealth Office or Social Welfare and Development Officer or Punong Barangay.

V. DEPENDENTS

A. Dependents of registered Member with PhilHealth ID Card A.1. Employed Sector Document/s required in membership Category 1 A.2. Individually Paying All documents required in Membership Member (IPM) Category II AND photocopy of print-out of Member's Data Record (MDR) A.3. Non-Paying Member Photocopy of member's PhilHealth ID Card (NPM) AND photocopy of print-out of Member's Data Record (MDR)A.4. Indigent Program Member - For dependents whose Photocopy of Valid PhilHealth Membership names are written in Identification Card PhilHealth ID Card - For dependents whose Photocopy of valid PhilHealth Membership names are not written or Identification Card AND any proof of do not appear in dependency as stated in "Types of PhilHealth ID Card Dependents" as applicable OR Original copy of a Certification (PhilHealth Form CE 1) from the Local PhilHealth Office, City/Municipal Social Welfare and Development Officer (C/MSWDO) or a Barangay Captain/original copy of a duly notarized joint affidavit of two disinterested persons certifying the dependency status of claimant to the member. In the absence of MDR or if the name of dependent/s does not appear in the MDR, submit any proof of dependency as stated in "Types of Dependent" as applicable.

B. Dependents of Non- Registered Member B.1 Individually Paying All documents required in Membership Member(IPM) Category II and any proof of dependency as stated in "Types of Dependent" as applicable. B.2 Non-Paying All documents required in Membership Member(NPM) Category III and any proof of dependency as stated in "Types of Dependent" as applicable.

TYPES OF DEPENDENT PROOF OF DEPENDENCY

Child Photocopy of Birth Certificate Illegitimate/Legitimated child Photocopy of Birth Certificate of dependent reflecting the name of member as parent. Legally adopted child Photocopy of Legal adoption papers Stepchild All of the following: Photocopy of Marriage Contract/Certificate between the member and biological parent Photocopy of Birth Certificate of dependentstepchild reflecting the name of biological parent who is the spouse of the member Spouse Photocopy of Marriage Contract/Certificate Parents 60 years old and above All of the following: Photocopy of Birth Certificate of member Photocopy of Birth Certificate of parents or in its absence, Notarized Affidavit of two disinterested person attesting to the date of birth of parent. Disabled child 21 years old and above All of the following: Original copy of Doctor's Certification that the dependent is disabled Photocopy of Birth Certificate of the dependent child AND Photocopy of Marriage Contract/Certificate between the member and biological parent if the dependent is a stepchild or photocopy of Legal adoption papers if the dependent is an adopted child.

MEMBER WHO EXPIRED REQUIREMENTS DURING CONFINEMENT

If member is married: Spouse - claimant ALL of the following: Photocopy of Marriage Contract/Certificate Photocopy of Death Certificate of member Original copy of letter of request to claim for the benefits. Child - claimant ALL of the following: Photocopy of Birth Certificate of claimant Photocopy of Death Certificate of member Original copy of letter of request stating that claimant is authorized by other surviving heir/s of the deceased member to claim for the benefits. If member is single: Parent - claimant ALL of the following Photocopy of Birth Certificate of member Photocopy of Death Certificate of memberOriginal copy of letter of request to claim for the benefits Brother/sister - claimant ALL of the following: Photocopy of Birth Certificate of both member and claimant Photocopy of Death Certificate of member Original copy of letter of request stating that claimant is authorized by other surviving heir/s of the deceased member to claim for the benefits.