Z Benefit Package Rates for Coronary Artery Bypass Graft Surgery ...
Z Benefit Package Rates for Coronary Artery Bypass Graft Surgery ...
Z Benefit Package Rates for Coronary Artery Bypass Graft Surgery ...
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t.<br />
Republic of the I'liilippina<br />
PHILIPPINE HEALTH INSURANCE CORPORATION<br />
(."ilvsliilc (Anne HuiI-Iiiil;. 7o>> Sh;iv\ I!,hiIcv:iiU. Pmsi- C ii\<br />
1'HILHEA.LTH CIRCULAR<br />
No. QOOJ.s-2013<br />
TO<br />
% : ALL PHILHEALTH MEMBERS, ACCREDITED AND<br />
CONTRACTED HEALTH CARE PROVIDERS, PI-IILHliALTH<br />
REGIONAL OFFICES AND ALL OTHERS CONCERNED<br />
SUBJECT<br />
Z BENEFIT PACKAGE RATES FOR CORONARY ARTERY<br />
BYPASS GRAFT SURGERY. SURGERY FOR TETRALOGY OF<br />
F ALLOT, SURGERY FOR VENTRICULAR SEPTAL<br />
DEFECT /VND CERVICAL CANCER<br />
I.RATIONALE<br />
Pursuant lo Pliilhealth Hoard Resolution No \(>2L) s 2012, and Philheahh Circular<br />
N. 29. s. 2012, '@Govcniiii" Policies on Philhealrh Bench I <strong>Package</strong> <strong>for</strong> Case 1 \ pe<br />
/,", I lie following are the services ;ind rates <strong>for</strong> coronary artery bypass graft surgery<br />
(CABG), surgery tor 1'ctnilogj ol Fnllot f'l'OI1'), sui;gt:i-\ <strong>for</strong> \-ciuricuhu scptnl tlcfccr<br />
fN'SO), :ui(.l ccL'\riCiil cancer.<br />
The illnesses and their u>k ckissiticalion includcLl are ,is fullou-s:<br />
1.Slandard Risk t-llcctivc <strong>Surgery</strong> <strong>for</strong>: Coronnry <strong>Artery</strong> <strong>Bypass</strong> Gi:il;t fCAlKi),<br />
1 dial (~ori-ection of Tetralogy of l-'tillot (TC^I:), nnd Sufgcrv <strong>for</strong> \'cnti-icul,ii<br />
Seplal Defect i.VSD);<br />
2.Cervical Cancer Sla^e 1 u> lliP.:<br />
1 hese condttionh wcie chosen l.insed "ii cunx-ni evidence thai (.[unlily iienlmenl<br />
sii^niticanily me Lenses snrvi\n] rates and c]unlih ot hie. Mmeo\-er, \ ahd<br />
infonniumn ''or these conditions is readily available.<br />
II.RULES FOR IDENTIFIED CASE TYPE Z<br />
A. Only newly diagnosed cases of ccrvioil cancer shall be covered under the<br />
benefit- packa^L. l"or comnary ai-feiT b\'pass trratt sui-gery, total conecuon (>t"<br />
!()[@ and closure ol" \'SO, onl\ those cases lhat strictly fulfill the selections<br />
cnleria sliall be covefed,<br />
P.. Beginning [anuan I, 2n]3, all members availing of rhc Z <strong>Benefit</strong> shall be<br />
i"ec|i.uied :t 3-\eaf lock-in membership prior to availmcni of the benc-fii. Tluli<br />
ick-in membership dues not apply to lifetime mcmbcfs and sp< msorc-d.<br />
C. Pie-authorization from i'hilhcnlih based cm the approved selections en terra<br />
per specific 7. condition shall lie required prior lo nvmlmcni of services. All<br />
rt\]uesis <strong>for</strong> prc-aulhorization shall be completely accomplished by rhe<br />
@fe'^ MA. TERESA A OUIAOIf f<br />
A.O. !V. Cf iioi ItLLMS lV<br />
DatE:._._ih..l3L-<br />
_cc:r?Ti"!i~D t;!;!.1 ?. copy
cnmnicud hi^pii-.il -,mJ submilled io (lie I lend <<br />
AklnnnisL]';iti'.>n Scriiun h>r :ipprnv;il of disapproval;<br />
D.J lie diagnosis during; prc-iuithon/ntion shnil be tht- basis tor rcimburscmcni;<br />
E.No bnhino billing rNBlVi policy shall be applied <strong>for</strong> eligible sponsored<br />
program members ;md [heir ip.i,.s Guilt Nu.ijv<br />
2.The package rale shiill be P55U, III 111 <strong>for</strong> the entire<br />
3.Selections criteria <strong>for</strong> CAlHr<br />
a.Signed Meml.ier 1 ''inpowLTmcnl (Ml'.] lorm<br />
b.Age 1'1-711 yearsf- --<br />
33533 - 335 3 i.<br />
335":<br />
nurse of imUmeni.<br />
'r.l -^ r,
c.Si able Uimnnrv Arim Disease requiring i;,IJ'd'i\T. 1SO|,,\TI;,D<br />
i '**li>ii:iry Arti.TY <strong>Bypass</strong> t imt't <strong>Surgery</strong> t(,AB( '.) with iiulic;i(hiii<br />
hn^cLl on ccu'onnry mi.itoniy, symplcini seven I v, 1A Kmclion,<br />
.in cl/or viability icsts; nun-invasivt tcsltng cnm|')]ficcl aiul<br />
discussed with p;itic?nc<br />
d.CuiTt'iu McJ[c;il Stnms<br />
i. Not in severe dccompensnlfd hcnrl failure (NYK I\'j<br />
it. Not with severe iUigiii;i (i.'CS C'l.iss lllj<br />
lii. No oilier cafdiac/vasculiif procedures/intervenrioi-K<br />
planned to lie i.\nnv with , AlilV AS \<br />
OTHER SERVICES<br />
VMilmnvil hilim.ihuT rc.'.ls ;i^ me ..I,-Ll, nm.'-<br />
opci-.irivcl\ i.L pn.;rM|x-i.lt]->^l' l ;;. ailHl hiaJlial<br />
pl.mlrt I..IHH, AIM T, I' \'V \-INR, IT,S, N;,, I., \l;.<br />
'.dcium, Ill.'N,CR-ir[in.i,-. 11' \C . 11111:1 K :i: , , I,,-.<br />
@s-i.n iphk- ' \l'/l:iri-r.ilj. \2-k-.\J l..( (I.A1U;.<br />
:Oi:D. ll:i:. :is uKlicalf-J<br />
1'i.m..|..t:hivc- .innlui.tii-s il iiiilii-:il.-J (1\ aiul ..r.,]'<br />
Tri-ainuim, ;i. ilh.Iic.huiI. >ur]i ns<br />
3 lV-.ip,-i:unv fvalui-CI' ck-nii<br />
Ik I )pi-i] lli-:ijl Smi.hiit iimli'i KtiKi.il :ni.-;il)t..i.i<br />
Iiiiiiii-.1i.ih- |.si..|iir:Miv. r.nr .11 snf-i.-il U.U<br />
h. VI'L l'i..ph'.l.iM,. wiMi rompn<br />
i-p:um, 1..MW II,<br />
'1 C.ir.li-.iL i;cli:iliilinHic.n<br />
c<br />
Ndnilj/iiri'ii] @@<br />
., In-<br />
(.1<br />
|ilv.M,.tlK-,:,|->v<br />
15Iml>m:Hii.n willi moi.jhI<br />
6 ( >tlicl- s[x^i:ilu saviris vis iuxlU-J, such .<br />
, cIi|..i-ilU-. l.icrul..^.- s<br />
, ol
S. The piivim-iu lor this pnckn^L- shall be Five Hundred Fifty Thousand<br />
pesos (P550,000) tor ilic complete course . No cu-morbid lactors. such as ;iny "I the tt'<br />
ill. Prcopcrntive seizures<br />
iv. Ih.iin abscess<br />
v. Stroke events<br />
vi. Bleeding tlisorclers<br />
vii. InfcctLvc Liidocnrdilis<br />
viii. Dther congenital anomalies<br />
IIP<br />
F'Hi(nsJp\LT[-<br />
TWb<br />
@/gr
1<br />
1<br />
@<br />
4. The approved climcil |v.iilnv;i\s Inr TOl1' shall reflect (lie niandiiloiy and<br />
(iihc-c sci-viri's -.is intliruk'fJ in ilic ml.ilc Lxl >\v.<br />
1.<br />
1<br />
-,<br />
-<br />
s<br />
1<br />
1[.<br />
12.<br />
I'n-i<br />
PIT<br />
IV--i<br />
P.,si<br />
I'lllll<br />
i-apn<br />
Rail]<br />
N^n<br />
l.dn<br />
(Milt<br />
IV'<br />
:iimi<br />
()ti1L<br />
mill<br />
Bio.<br />
I'cdi<br />
I1!<br />
Cn<br />
@p.;<br />
iIk<br />
''I1<br />
o1<br />
ill.<br />
-('<br />
ila<br />
i':11<br />
mn<br />
,fi<br />
dsi<br />
(":<br />
1.1S<br />
,iti<br />
;iriv<br />
lit<br />
.il'. I1CS<br />
al.<br />
lis<br />
pli<br />
ls|\<br />
is.<br />
IUt<br />
'1,|<br />
C.1<br />
PP<br />
IV<br />
MANDATORYSERVICES<br />
(<br />
I<br />
t<br />
1<br />
|<br />
1,<br />
BC|<br />
I'SIII<br />
IT.<br />
\ih;<br />
Lib:..<br />
1;<br />
@iSfll<br />
lidf<br />
1-si<br />
haL.i<br />
latflfl<br />
incv,(<br />
t'nr[@<br />
'II<br />
nt-i.p<br />
asmil<br />
ill:Cl<br />
:il.-.l.<br />
.ii.ln-]<br />
..-Jill:<br />
"illCll<br />
iilcl\<br />
CLIMIl^<br />
nitinn<br />
1'fk-:i<br />
t.llMil<br />
\u<br />
NjKC,i<br />
liK-l:Ufi-k<br />
H)-|I'.l-.<br />
.IV<br />
..Msk-i'.<br />
inKlu.-.,n;<br />
l,...l]Mi.pi<br />
ulpinilui<br />
HIMS)<br />
iick-ai<br />
I'i-Iimill<br />
amin.plv.<br />
@anuictlliMlHi'<br />
Mi!.P'l<br />
ropmijci-<br />
@uplvr^.<br />
@m-.I,,;,<br />
innimmii.<br />
ic-..lisosin<br />
1Post<br />
1Dlhi<br />
(inn<br />
J!.fll@<br />
cipn<br />
'-I'lllli<br />
v,ni<br />
-1IJilit<br />
OTHER<br />
L'l-.uivt1an<br />
cn.iu.iami<br />
nicils.asn<br />
>hali,sp,Mi<br />
11 .,S:i,111.ifI<br />
nanl.iic\<br />
^P^ialiv,t<br />
SERVICES<br />
In<br />
M.<br />
ill.<br />
S<br />
tC<br />
ih,<br />
.ticsasuulnwictl<br />
li<br />
ati-d,suchasoral2'"'<br />
mloral<br />
-Mil<br />
ilnndi'd,.iichas<br />
i-i-sasnrf.li-.l.surll<br />
5. ['he piiynicm tor rlus pnekns^c s!in 11 be Three Hundred and Twenty<br />
.Thousand pesos (PJip 320, 000) lor rhe complete course oi cure which<br />
shall Lie s.i\en m [wo (2) [finches .is follows:<br />
MODE OF PAYMENT<br />
FILING SCHEDULE<br />
Witlim r-.il dais ., frt-r cnmpl,;ti"ii ,,f<br />
Rt-hahillr.Hi..n Usch-isi- Sessions (3"'-4"'<br />
C <strong>Surgery</strong> <strong>for</strong> Closure of Ventricular Scptal Defect<br />
1. Hit p:icl;nSc ende is Z007 which includes the (olluwing ICD-IM and RYS<br />
mils:<br />
ICDHI<br />
(s'-'<br />
MANAGEMENT/PROCEDURES<br />
t:ii.Miifof\.@ilirit-uljiSqiiiilUiliOu-itlioiuailiont<br />
pauli<br />
RVSCODES<br />
Vi!,S1<br />
2 111c p:ick;igc rare sir/ill be P2^n, (UK) <strong>for</strong> the entire CMiu>f of Lrcnimcnr.<br />
3. Selections ctilcn.i <strong>for</strong> suit, cry <strong>for</strong> YSD:<br />
:i. Siiiiu-J Mcnilief 1 ;.mpi)\\i iniLin (Ml-') I'nim<br />
b.:\^v: 1 in 5 vcars + j(.4 Javs<br />
c.2L:)-ccliuC;iL-diMLM-:iphy<br />
l. Isohicct YSD pcnniunbranous, subnoi'tic oi sul.ipulmonic<br />
ii. No combined shun is such :is ,iinal sepl.tl dc-k-ct oj- p.nent<br />
duci.us iiitenosus or .itj-ioventacuhii- scpu\l defed<br />
"JiAOir !<br />
i.
No oilier ussocialcd C\ ID's : such as coarctalion ol ihc anrla,<br />
(ii- model ,iil- id seven- .loilic insiithcii.-nc\. en inoj(i-;i((.' r<br />
sl-\ crc puirnonic strnosi^<br />
iv. Pulmonar\ ;iitcry pressure-: < 5(1 mmlig nv m least 2/'."'> systolic<br />
b!....cl pivs^Lirf<br />
v. QP (jS- > 1.5.1<br />
d. No previous crmlmc suigei.-\- yVA R,inCKl ICtl <br />
i_l<br />
H-<br />
,p<br />
,1<br />
,^<br />
1":<br />
in<br />
all<br />
l.il)<br />
slini<br />
.ii-<br />
1>-<br />
MANDATORY SERVICES<br />
,:h<br />
I'-i Ik-~<br />
l-IS i-1.<br />
H'l<br />
mi<br />
C<br />
.P<br />
\l<br />
(<br />
,i ll.i<br />
1<br />
(<br />
1:<br />
[' all<br />
I'<br />
|><br />
1)1<br />
1<br />
l(<br />
hi<br />
r<br />
i<br />
i<br />
C"M<br />
1'I<br />
\v><br />
@I-.<br />
,.,,,1<br />
1Poslnpi<br />
I,-<br />
il,Nakl.a,\k..I'l<br />
iai:inii-<br />
:lar.an-.li-i-h.,Kii-s,<br />
il:IMs(i-svanrr.iniiin.<br />
HMM.lvi-<br />
2IIllli'l11<br />
riilinon<br />
vninliiM<br />
4IHhii.<br />
.,..P,-i!i:i<br />
OTHER SERVICES<br />
uiivi-anlihis,knulnalr,!<br />
HHI-::lililiir.ll!<br />
i-ih,:r.imlitai.il,-ui.ll:ls12<br />
i\cut.Mlu-nnn-ilnl,.iil-Ii,,<br />
i
.. Cervicul Cancer Chcnioiadialion with Cobalt & Biaehylheiupy (Low<br />
Dosi-) or I'liinm-y Stilgcly <strong>for</strong> Sl;it;e IA1, IA2-1IAI<br />
1. [he packnsy: chi.1l' is ZOOS wliicli nulujcs ihc [ollowini. ICD-lli and RYS<br />
ICD10<br />
Ci'C<br />
[cs<br />
11<br />
1I<br />
(<br />
1.<br />
n<br />
1<br />
'P<br />
.l><br />
1<br />
MANAGEMENT/PKOCI<br />
llli..loi!V<br />
DURES<br />
n7S(l<br />
0!<br />
It<br />
\\<br />
F,<br />
1,<br />
!@@<br />
I;<br />
1.<br />
(.<br />
,1<br />
..<br />
@'<br />
!@<br />
,1<br />
ii<br />
il<br />
IK<br />
.11<br />
,(<br />
'<br />
Si<br />
1<br />
SI<br />
.:l<br />
..I<br />
>.|>:ilt<br />
Ih.-r.,,,)..I..-.-J.,^1suit.,<br />
t;eIAI,,nlv:<br />
'@'I'liMi-.vt'.nn-<br />
,^cJA2-1IA!:<br />
lsti-,i-L,,,,m-.irli<br />
Inn-Ll'.iiv.:,,ul|,.i,.,-.i.,,-lR-I'.l<br />
@.Mill,,UCli,l,,,i-iiil>.il|,i,i!;i.i,|,|,.<br />
i.i,,lLT.,i,i:,l.@<br />
v.illhnu,|,|l:,tL-,,,l<br />
1,,I.,1L-,.,I[Vlvi,<br />
,|,lin'.di-^,nphn.<br />
7.-401<br />
s;'l5n<br />
-^HEALTH ^<br />
Taa7Ferej3a a. quiaoit,<br />
mm MA. TERESA A- @@J|<br />
2. I'hc p;ieLi;j,u i-,iIl- si Kill Li..- IM2H. Ul If) [m(- (Ik- lmhilt course ol Ucntnu-nl.<br />
.') Sdeci ii ins cnlci in<br />
:i. Si-ncd Ml;. l;m-ni<br />
l.i. No pluvious lIr'ukilIil r;i| iy<br />
c. No pL-fviui.is luilioitu'iiipv<br />
cl No uiH-oiiiiotlftl co-nioibiU coiulifions<br />
c. I ivntnu'iii plan from ^yiiL-colunic ono iIdlmsi<br />
A. The :i|i|->i(.vc-J climoil p;ith\\;i\s foi (,t-n-ic:il Cancer Prinmiy Sui^cn sh:\ll<br />
lX'ilcci ilu1 nvAinl'rHiH^1 niul o|1k-i sl-lvilcp ^s iikIk:;iil-l1 in the inblc bclosv.<br />
MANDATORYSEFIVIC<br />
OTHER<br />
SERVICES<br />
@<br />
s.<br />
').<br />
II)<br />
k ,-||-.,liK<br />
1<br />
I1<br />
ioi-pr.cui'ii-.i-.ii.,(.ic:-.Miii<br />
"IK@<br />
)1.S<br />
UI'll<br />
1.<br />
phK<br />
c;pr.sr,,,,n<br />
IS.l-Cll.LlHSt<br />
lIl-1,|,,,,lll<br />
L-l<br />
pi-,,n-ssmi!l<br />
11'-^lo-0in\'in1<br />
:i..Hl.i-alti'.iiu:;l<br />
1Pi.sin,,,@@,*.-a<br />
(iiu,avi.-,ni,isan<br />
@1SiinpuilMedina<br />
,:iill'.:ll,'in.-;,.l<br />
,,H-l,,.ln,,,;,miik<br />
i..n:,,i:.-Jii.ili;cs<br />
nbi.iinsasnul<br />
,.,al)<br />
1:,,.jnlK-im-li-.<br />
liM-n-.n,<br />
J.i:-,:SI-'.liiaii<br />
:.M,,iL<br />
::,ti-il<br />
Inau-il<br />
tlllKS.<br />
5. '11H- piivnu'iit <strong>for</strong> this p:ick;it2,L- slinl! be One Hundred Twenty Thousand<br />
pesos (Php 120, 000) <strong>for</strong> the complete con use of caic which shall be<br />
L>,i\r(.'n in l\ui (2; rnniclu's us tnllou's:<br />
MODEOFPAVMENT<br />
AMOUNT<br />
F1I<br />
\\<br />
1Mti-iinclic<br />
1M00,000<br />
\ITfI'<br />
.INGSCHEDU<br />
is:l!U-|lllf'lliarjr<br />
-Mltin-I-.ISILll-lt,<br />
J3<br />
Inmi<br />
t<br />
2'"1tranche<br />
P20,0110<br />
ulii<br />
,l,tll,@@!::..'I'eKif<br />
,ll,@-,,p
1<br />
I'). Ceivieal Cancer Clienioiadiation with Linear Accelerator &<br />
BrncliylliLTiipy (High Dose)<br />
1. The p;ick:i-c ode is Z009 which includes die inllnwiiu, ICD-IN and RA'S<br />
ICDHI<br />
MANAGEMENT/PROCEDURES<br />
.l.iKy<br />
RVSCODJ2S<br />
575nn<br />
I.!<br />
@.!'<br />
5752"<br />
(--,'-<br />
Cl<br />
r.ipv<br />
.1<br />
Ml\H<br />
.ki.mu<br />
"7T-U11<br />
111<br />
Kinill*.<br />
'-Py(M..I.v.,@@:..,rs,@:,;<br />
"761<br />
@~PrtiiiKEALTH I<br />
2 1 \\c piK-ka-i- iwu- sh:ill Ix- 1M 75, UOO [oi llic fiiiirt o>Lii:?e of trcninu'ii<br />
3. SHivci ii 'iis ceil crin<br />
:i. Si.uiK-tJ Ml"- l;.)Lin<br />
h is.iu prcvioii'; ch'-Miml hcinpy<br />
c No [irc\ im.is r;iilii)i]Ki-;ipy<br />
H@ Van @@reP}eV"*if7 '^ft<strong>for</strong>*M". V I /I']'l ,<br />
\.1; i,' \i .1. iinn:ii'..i-. mi;. ..Ihm ^ -1 -1 -.<br />
I 111:1-1.!^ rlmhi> I I:, 1 I '. .i;;in;iI I rll ] .lr-.ui IJ. @> ll'.k' :llul< ulllll.ll I . 1 @,@;:<br />
5. ( !nin-.|lHi-.i|n ,i-:, , i:-pl.uiii. i'.ii I >..pl:mn)<br />
6 K.ulioil[is ."lint m .1. n-l< I-.1I..U<br />
S r
-to - 1-J<br />
V.CLAIMS FILING<br />
All chin M- sh;i|] Ik- filed hv (he i-iniirnek'd hn^piiuls in lu-lv,ill" <br />
J. On loll Ciiiuxr<br />
ukIlJ ihotrIiii.jv<br />
@M..V!<br />
ENRIQUE T. ONA, MD<br />
Sei:ixi;u:\ <br />
!i i ;.@<br />
t
I'hp)<br />
i.<br />
PHILIPPINE HEALTH INSURANCE CORPORATION<br />
Rifublk uf tht I'hilippiiws<br />
PRE-AUTI-IORIZATION REQUEST<br />
STANDARD RISK ELECTIVE CORONARY ARTERY BYPASS GRAFT SURGERY<br />
n atkof rkquhst_<br />
his is to ret] lie si :ippio\ ill toi provision f ^lt\ ices iiikIct iliu /, lieiifhi p;u L^i.l'C <strong>for</strong><br />
Ill<br />
ex >Mn.r: rr. nami-: < >r iwtikn n(nami- < >!@ 11< >sn iai::<br />
icU-i lIlL- Kl-ll].. and cumin n .us :ls ;i!^ivi il f. H :n ;nlnn-|ll of I Ik- /. IV-lK-rn l':id.:lj.'.f.<br />
a nbb<br />
IUl|IIL-SlL-..l I<br />
l;,xL-i;uii\c Diivcior/ChiLTor I Inl'i<br />
iiiu-J N:imc cv Si^nnuiix-<br />
\lluiJiiH' ( ,;U\lniv:isciil.li- Sur^foii<br />
ll'iir Phllhcnllli l:sc Onl\ i<br />
?APPROVED<br />
?DISAPPROVED<br />
-S.mulmrovcH'rnmxlN.nm.llife' ^&ALTH(<br />
I lead, IViK'fils Adminislniliim Scainn/@ I
Rifuhlh' uj'the riiilippiin'*<br />
PHILIPPINE HEALTH INSURANCE CORPORATION<br />
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Republic nfllw I'liilippina<br />
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VENTRICULAR SEPTAL DEFECT (YSD) CLOSURE<br />
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PHILIPPINE HEALTH INSURANCE CORPORATION<br />
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PHILIPPINE HEALTH INSURANCE CORPORATION<br />
Cily-Utc: Centre Bi.nldiiig. 709 Sliaw Boulevard. Pnr-ia City<br />
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"Si;i"KrTA"i<br />
Sm.m-IA2<br />
SeineHi|<br />
Si:u>l-Ili2<br />
Sli^i-HA1<br />
Sl:iKcI1A2<br />
Stil;;,.1114<br />
SlMyc1IIA<br />
SlnKc-1111)<br />
-<br />
I _-::fi t& I
t i<br />
Kepublk of the Philippines<br />
PHILIPPINE HEALTH INSURANCE CORPORATION<br />
(.@i!\sl;ik- (A'liliv KliiMihl!. "00 Shaw Mtuik'vmi!. I'.ism L \\\<br />
PRE-AUTHORIZATION REQUEST FOR CERVICAL CANCER<br />
Dutc orRt-i|ui.'si_<br />
'Tins is to rccjUL'Si vippiuv.il loi1 prevision ot ser\ ices under ihe /, bunclii pncl^i^c<br />
(COMPJ.KTK NAMK OFl'AriKNT)<br />
(NAMIiOr HOSPITAL)<br />
under ihc terms and conditions n* agreed foi- ;i\ailmcnL of the Z licnefn <strong>Package</strong> lor cervical<br />
I lie | ia lie nl belongs lo the lollowing cal^L'/in (lid; V aj >j")to| trl;ile box).<br />
II NUB<br />
U FIXED CO-PAY ichemo, Inachy low elose, cball or pi-im:iry surgeiA,<br />
0 FIXED CO-PAY (chemo. brachv high dose & linear accelerator)<br />
Kccjui.-sti.-d by.<br />
Nou-il l)\:<br />
Printed Name & Signature<br />
Attending Gynecologic Oncologist<br />
Printed Name & Signature<br />
Medical Director/Chief of Hospital<br />
(l-"oi-Thill k-nllh List- Only;<br />
LI Disapproved<br />
Head, <strong>Benefit</strong>s Administration Suction<br />
fSiu,!i:ilLire over Primed N.imel<br />
Hale:.<br />
'@@@v,c;..::-T---K-^o7r;<br />
,,.:j\f^
RqnMk nfllic I'liMp/iines<br />
PHILIPPINE HEALTH INSURANCE CORPORATION<br />
CilWiilL1 < uilK- rtuililiny. 7t)(> Shiiw hiHikvjirJ. I'iisiu fn><br />
I k-Lillhlinc l-l I-7-I-II \\v\w pliiiliL-jllli.yoy.iih<br />
_D;H
w<br />
i<br />
Reimhlk nfllie Philippines<br />
PHILIPPINE HEALTH INSURANCE CORPORATION<br />
Cil>suilc (A-nlii: Ruiklnm. 7IW Xkiu Roiilo;ird. I'nsiy fii\<br />
SERVICES 1*' Tranche<br />
<strong>Surgery</strong> fot Cervical CA<br />
Stage IA1-1IA1<br />
Check and Indicate<br />
Date Done/ Given<br />
Physician's<br />
Name and<br />
Signature<br />
Con<strong>for</strong>me<br />
(patient's<br />
signature)<br />
3. IVoccduie done<br />
For Stage IA1 alone:<br />
Dare of Procedure :<br />
Gynecologic<br />
( )ncolph (>it'Ct< )in\<br />
4. lilood Ti.";"inskisJ(mi Support<br />
(if indic:ilcJ)<br />
? l;\VB DI'RBC Dl-I'l'<br />
?<br />
^. Postoperative I .nbomton<br />
(when uuiicalcd, if done)<br />
:i (T>C with plaiclcr<br />
Check if applicable and<br />
place date or N.\<br />
h. l .< x;<br />
c. elccirolylcs<br />
(>. Postopemiive McJicjiruins<br />
(;is indicnfccJ, when needed)<br />
:i. An:il^esics<br />
b.Antibiotics<br />
c.l~leni:itinics<br />
(..heck it applicable mid<br />
plncu St:irns/d;tlc or N.\<br />
h m<br />
( a iinpleiutl mid Signed /,<br />
D.<br />
S:itisKieNoil QncsiKHiniiirc<br />
N. ()pcr:iti\f Record ?_<br />
Attested by:<br />
Date:<br />
Name and Signature of Medical Director<br />
n i,,i-,,.,,
nt<br />
! ,Republic dJ the Philippines<br />
>'PHILIPPINE HEALTH INSURANCE CORPORATION<br />
"lOhsUlu CoiHiL- Huililiii!.:. 7()'J Shiiu HihiIla;ii\I. I'.isili C'il><br />
ffy!k-:illliHin.-.|-ll-7-l-N .plnllii:;ill]ii;
Republic iij the I'liHi/iii'ma<br />
PHILIPPINE HEALTH INSURANCE CORPORATION<br />
<br />
lk;;illhlino -I4I-74-N u\\_^iilnlliojilili.in .ph<br />
Dnlc<br />
DiUl1 Dl^cliar^ecl: .<br />
Phill IcmIiIi ID Number<br />
CHECKLIST OF MANDATORY and OTHER SERVICES<br />
CHEMOTHERAPY, BRACHYTHERAPY (LOW DOSE) WITH COBALT<br />
CERVICAL CANCER<br />
TRANCHE 1<br />
(Place ;i ^ and imlKau- slarus or dale dime or oivcn)<br />
(Clicmo,LowDoseBrachy,<br />
Cobalt)<br />
CheckandIndicate<br />
DateDone/Given<br />
Physician'sName<br />
&Signature<br />
Con<strong>for</strong>ms<br />
(Patient's<br />
Signature)<br />
1.I'rc-proccdurt.11,;il.iornl(.)r\-'<br />
n:l.<br />
b.Plateletcount<br />
b.<br />
d.(^Iil'scK-v.w<br />
p\<br />
D<br />
H.lr...-ltj"I<br />
,--&I<br />
S-,,.i<br />
F7^ ;.irn.,/n[ii[ii,.;,uii @,, ,-j,
Republic of the Philippines<br />
PHILIPPINE HEALTH INSURANCE CORPORATION<br />
C'ilWMlo I ciilic lluilding. 70') Sluiu llnulcvaiil. I'asii: fnv<br />
I IcallMiiK -I 11 -74-1-1 u^iU'lHn.Kiillll-L-"1- v)<<br />
SERVICES1"TRANCHE<br />
(Clicnio,LowDoseBiachy,<br />
Cobalt)<br />
CheckandIndicate<br />
DateDone/Given<br />
&Signatuie<br />
Confoinie<br />
(Patient's<br />
Sit>uature)<br />
(ivnucolcit/ic<br />
DatesofProcedure<br />
(startmm/dd/yyendmin/dd/^):<br />
Oncologist<br />
Rndiaiion*)ncohi^isi<br />
[f1.m\dnscHire<br />
DatesofProcedures<br />
lnin/dLl/vy<br />
Ci\nccohitJic<br />
()ncolo^isr<br />
RadimionOncolo^isi<br />
Cl\nccoli>i;ic<br />
()iicolou;lsr<br />
ni.<br />
1ifim.licnri.-tl:iuddone<br />
n4.<br />
Indicatecyclenunibcf<br />
I,II,III,IV,V,VIand<br />
date(lnin/dd/w)<br />
C.Supponmcdic:ili'>ns<br />
f|1.Antiemetics<br />
Iviilnoschon<br />
i@@'Kr<br />
@'@@:@''"j<br />
Cirnnisctron<br />
Mctoclopramldc<br />
Q2.CI-CSI'<br />
||3.1Icmaiiiiics<br />
?4.C.Wilts<br />
D2.<br />
ra<br />
iiliilh,-:il[li ,.,@ nh
m<br />
Republic of the Philippines<br />
PHILIPPINE HEALTH INSURANCE CORPORATION<br />
OhsLilcCuilie I tinkling 7(10 Sl,;iv, iluulcwiiil. Piisiy l'il\<br />
SERVICES1-TRANCHE<br />
(Chemo,LowDoseBiachy,<br />
Cobalt)<br />
CheckandIndicate<br />
DateDone/Given<br />
Physician'sName<br />
&Signature<br />
Con<strong>for</strong>nie<br />
(Patient's<br />
Signature)<br />
-1.Klood'linnsfusionSupport<br />
fifmdiciirvcl)<br />
DIAVUGPKUC?I1I7<br />
n<br />
5.PostircatnicnlMcdicnlions<br />
(homemedic;!lions,il"<br />
indiciilcd)<br />
;i.Amicnk'lics<br />
b.\n;il(mjsics<br />
c.l-k-maiinitjs<br />
d.()iln;is<br />
ru.<br />
nd.<br />
()(.iompkicdandSigned/.<br />
S:itist:iclionOLieslionnaiic<br />
n<br />
7.K:idiniion'I'renlmcni<br />
Siiinniiin<br />
A.1M\ic]
cnr<br />
Ki'piiblic of ilit I'liilippiim<br />
PHILIPPINE HEALTH INSURANCE CORPORATION<br />
:i;ilc ( Vnlic Minldiiiji. 7(I1J SIkiw Jlmil^Minl. I'^ijiCih<br />
I Iciillhline 441-7 14-1 wau plnlhculLli.L'A |>li<br />
Name of Hospiral_<br />
_Dafc Discharged: _<br />
I'lull k:illh 11) Number.<br />
CHECKLIST OF MANDATORY and OTHER SERVICES<br />
CHEMOTHERAPY, BRACHYTHERAPY (LOW DOSE) WITH COBALT<br />
CERVICAL. CANCER<br />
TRANCHE 2<br />
(1'hici.- :i ^ and indicnlr stains or Ontc tloiif < .r (.In un)<br />
DOCUMENT 2NU<br />
TRANCHE<br />
Medical Ccrtificiiie of<br />
Pleasecheckif<br />
applicable<br />
andindicatedate<br />
Name&<br />
Signatureof<br />
Gynecologic<br />
Oncologist<br />
Confomic<br />
(Paticiu's<br />
Signature)<br />
( )LII-l>:lticnl lollow Lip<br />
( .on,sLih:ili
* /Kepiihlk of the Philippines<br />
,VPHILIPPINE HEALTH INSURANCE CORPORATION<br />
CihsLili: f.V-nlif Building. 70') Shim Buulcniril. I'kiji Ci[><br />
^ll.nlihlin,' 4-11-7.144 uuu i -> 11 i 11 il -11 llc;illhliiio r 11 ..ov.nh J-II-7U-I MMMj.ljiilLcaUiii.lv.pli<br />
Date Admit red: __<br />
Date Discharged: _<br />
I'lulHenllh ID Number<br />
CHECKLIST OF MANDATORY and OTHER SERVICES<br />
CHEMOTHERAPY, HIGH DOSE BRACHYTHERAPY AND<br />
LINEAR ACCELERATOR FOR CERVICAL CANCER<br />
TRANCHE 1<br />
(PLiec ;i ^ niul iiulic;ilc st:ilus or Oalc done1 or C 5 i\L-n j<br />
SEK VICES Is I TRANCHE<br />
(Clicmorad + Linear<br />
Accelerator)<br />
Check and Indicate<br />
Date Done/ Given<br />
Con tonne<br />
(Patienfs<br />
Signatnic)<br />
1. l'i;c-prucedure J ,:ibof:;Hory '<br />
a.CMC<br />
b.l'lntulut count<br />
c.Blood typing<br />
d.Colics! X-r;iy<br />
c. \:.CA]<br />
f. l;liS<br />
14. Nji, K, C:i, C;i<br />
h. f Jcntininc<br />
i. AST/ALT<br />
j. l^roiimc<br />
k. I'lifiiiil M lnoinhfjphisiin<br />
lime<br />
1. L' ri(in I\ sis<br />
m. J-lisUipntholooy<br />
n. Imping:<br />
n.!. IX-U IV,<br />
n.2. Ci'Scnn or MRI<br />
o Pilootl suj^porl",<br />
screening, processing<br />
I"), t -vstosccjpy<br />
lj. I'louosigmoidoscopy<br />
@>;/mrlic
L<br />
Republic uj llw Philippines<br />
PHILIPPINE HEALTH INSURANCE CORPORATION<br />
(.'llWiite Centre tluiMiiiLL 709 Slum nnulev;inl. l';isi^ Cil><br />
ItL-iiltliliuc JJ I-7.U-1 unu |iliillic;illli.y\'<br />
-5-i<br />
j<br />
1whenindicated<br />
h';mmliillu';illli-'
.,i,i,<br />
w<br />
Republic of the Vhilippincs<br />
PHILIPPINE HEALTH INSURANCE CORPORATION<br />
(.'il\Nl;ik' Centre Hiiildiim. 70 Slum H(uili;\;inl. I'u^iji C'ii\<br />
(Chcmoiad-t-.Linear<br />
Accelerator)<br />
CheckandIndicate<br />
DateDone/Given<br />
Physician'sName<br />
&Signature<br />
Con<strong>for</strong>me<br />
(Patient's<br />
Signature)<br />
4.l'!')i>d'[ransh-isionSuppoir<br />
lii'indifiiinl)<br />
D[A\;i;DI'RIU;Dl-IP<br />
n<br />
S.I'tjsiircninicniMrtlic;itins'<br />
llvmicmcLlications,if<br />
iiuliciiicd)<br />
;i.AmiL-mciics<br />
h.Analgesics<br />
c.1luiiia!mics<br />
l\.(Mhcrs<br />
na.<br />
ne.<br />
nd.<br />
(').C^miplcrcdandSigned/.<br />
Saiisfaciion(^licslionn-lire<br />
n<br />
7.K:idi:iun1Vcalnicnr<br />
Siimmar\'<br />
A.VcWicRadialH.nfiincar<br />
;Kxckialorj<br />
Vi.liiacluihci/apy("hl^li<br />
dose)"<br />
na.<br />
nb.<br />
Radiation<br />
()nc(jloLis(:<br />
.S.(ChemotherapyTreatment<br />
SummiUTandindicateik.i.of<br />
cvclesc
H<br />
L<br />
Republic of the Philippines<br />
PHILIPPINE HEALTH INSURANCE CORPORATION<br />
Cil>5l.ilc(Vi!Mc Biiikliii" 711') Slum ItaiiL-vml. ]'ii-iy ( il><br />
lle;i!llilniL--lll-7.| II n | -I i j! 11 tr.iji 11 an pli<br />
Name of Mos|"iial_<br />
_D:Ue Discharged: _<br />
Phill-Ie;llh ID Number.<br />
CHECKLIST OF MANDATORY and OTHER SERVICES<br />
CHEMOTHERAPY, HIGH DOSE BRACHYTHERAPY WITH LINEAR<br />
ACCELERATOR FOR CERVICAL CANCER<br />
TRANCHE 2<br />
(Place ;i