Essentials in one sentence: PhilHealth pays pre-set package amounts (case rates and program packages) for medically necessary care if the member/dependents are eligible, the facility and physicians are accredited, and the claim stays within benefit limits (days/sessions/amounts). Anything beyond those limits—or not meeting documentation/eligibility—is for the patient’s account unless a “no-balance-billing” rule applies in a government facility to a qualified member.

1) How PhilHealth pays: the architecture

Case-rate system (inpatient & many procedures): Each illness/procedure is mapped to a fixed amount that is deemed to cover both hospital charges and professional fees. Facilities usually get the larger share; doctors share the rest (splits are policy-driven).
Program packages (outpatient/condition-based): Maternal care, TB-DOTS, animal bite treatment, hemodialysis/peritoneal dialysis, chemo/radiotherapy sessions, HIV, etc., have per-session or per-course ceilings and frequency caps.
Z Benefits (catastrophic care): High-cost conditions (e.g., selected cancers, complex surgeries) are covered under bundled packages with pre-authorization and strict entry criteria.
Primary care/Konsulta: Registered members can access defined primary-care services, diagnostics, and medicines within package limits at an enrolled provider.

Key consequence: If the hospital bill or doctor’s fees exceed the PhilHealth package amount, the excess is chargeable to the patient, except when a No-Balance-Billing (NBB) rule applies.

2) Who is covered and when (eligibility constraints)

Membership categories: Employed (formal), self-employed/voluntary, indigent/sponsored, senior citizens (automatic by law), lifetime, OFW, and other special categories.
Contribution compliance: Most paid benefits require the member to be active and contribution-compliant under the then-current look-back rules (PhilHealth updates these by circular). Some categories (e.g., senior citizens and sponsored) have special eligibility lanes.
Accreditation requirement: Facility and attending physicians must be PhilHealth-accredited for direct deduction. Non-accreditation usually pushes the claim to reimbursement, and often claims fail.
Dependent rules: Qualified dependents (spouse without own coverage, minor/unemancipated children, parents meeting age/financial dependency rules) can avail subject to day/session caps and shared limits (see §4).

Failure points: Lapsed contributions, wrong member ID linking to the patient, or using a non-accredited facility/doctor commonly lead to denial or reduced benefits.

3) What is covered (and what typically isn’t)

Covered (if medically necessary and properly coded)

Inpatient confinement for illness/injury with an ICD/RVS-mapped case rate.
Medically necessary surgeries and procedures (inpatient or day surgery).
Outpatient program packages (e.g., dialysis, chemo, TB-DOTS, animal bites, HIV, select diagnostics under Konsulta).
Z Benefits for specific catastrophic conditions (with pre-authorization).

Typically not covered

Non-medically necessary or purely elective procedures (e.g., cosmetic surgery without medical indication).
Screening/executive checkups beyond defined package rules.
Unproven/experimental treatments, supplies, or off-label uses not in benefit packages.
Comfort/amenity upgrades (private rooms, special nursing, deluxe supplies).
Administrative fees and convenience charges outside the package.
Services lacking required pre-authorization (Z Benefits) or not properly documented/coded.

4) Annual limits, frequency caps, and “Single Period of Confinement”

Inpatient days: The member typically has up to 45 days of inpatient benefits per calendar year; qualified dependents share another 45 days among them. Each inpatient confinement consumes days against these caps.
Single Period of Confinement (SPC): Readmissions for the same condition within a defined window can be treated as one confinement for benefit counting, with limited case-rate payment on repeat admissions. (This prevents serial claims for the same illness in quick succession.)
Session-based packages: Dialysis, chemo, radiotherapy, and other outpatient packages have per-session rates and yearly session caps (PhilHealth periodically adjusts these caps; excess sessions are not payable).
Multiple case rates in one confinement: Some admissions can qualify for more than one case rate if there are distinct, properly coded procedures/conditions per rules; otherwise, only one case rate applies.

5) No-Balance-Billing (NBB): when you pay zero

What it is: Qualified members (commonly indigent/sponsored, senior citizens, other policy-identified groups) admitted to government hospitals under ward (non-pay) accommodations should not be charged beyond the PhilHealth package for covered services.
Limits:
- NBB applies only to covered items within the package.
- Upgrades (room, amenities) and non-covered items can be legally billed to the patient.
- In private hospitals, NBB does not generally apply; balance billing is allowed.

6) Cost sharing, private hospitals, and balance billing

Private facilities may charge over and above the case rate. The difference between the bill and the PhilHealth case rate is the patient’s balance (or the HMO’s if HMO agrees to shoulder part of it).
Professional fee ceilings: The case rate’s internal PF allocation can constrain how much is credited to the doctor under PhilHealth; any excess PF falls to patient/HMO unless waived.

Coordination of benefits: HMOs and private health insurance typically treat PhilHealth as primary. The hospital deducts PhilHealth first, then HMO, then the patient pays any residual.

7) Documentation and coding pitfalls (common denial grounds)

Incorrect/insufficient ICD/RVS codes or mismatch with the chart/operative record.
Missing signatures/attachments (discharge summary, histopath, operative notes, benefit eligibility form).
Late claim filing beyond set deadlines (hospitals handle e-claims; member reimbursement has a short filing window).
Eligibility mismatch (member vs. dependent, identity issues).
Non-accredited provider involvement when accreditation is required.

Practical rule: If it isn’t written in the chart, it didn’t happen for claims purposes. Accurate, legible documentation is decisive.

8) Special tracks and their unique limitations

A) Maternity packages

NSD/Caesarean deliveries have fixed case rates; facility level/credentialing rules apply (e.g., birthing homes for NSD within risk criteria).
Risk exclusions and referral triggers (e.g., high-risk pregnancies) can shift coverage settings and affect payability.

B) Dialysis (HD/PD)

Paid per session up to an annual session cap; excess sessions are not payable.
Claims require facility accreditation and complete dialysis logs.

C) Cancer care (chemo/radiotherapy)

Regimen-based or session-based limits; some drugs/techniques may fall outside standard packages unless covered by Z Benefits or specific circulars.

D) MDR-TB/HIV/TB-DOTS

Package-defined diagnostics/meds and strict panel provider rules; non-panel services are typically not payable.

E) Z Benefits (catastrophic)

Entry criteria + pre-authorization are mandatory; failure to meet or missing pre-auth = no Z payment.
Structured bundles mean substitutions outside the bundle are often non-payable unless allowed.

9) Member responsibilities (to avoid surprise balances)

Confirm eligibility before admission (active membership, qualified dependent status, contribution compliance).
Use accredited providers and stay within ward in government facilities to preserve NBB (if you qualify).
Ask for the case rate for your diagnosis/procedure and compare with estimated hospital/doctor charges.
Clarify upgrades (private room, extra supplies)—they are patient’s account unless separately covered by HMO.
Bring required documents (valid ID, MDR/Member Data Record or equivalent, proof of dependency for dependents).
Coordinate with your HMO/insurer early for letters of authority and benefit coordination.

10) Appeals & disputes

Hospital level: Start with the billing/claims office; many issues are fixable (coding, attachments).
PhilHealth level: Providers can refile/appeal denials within the set periods; members can request reconsideration or pursue member reimbursement in narrow cases (e.g., emergencies at non-accredited facilities—payability is limited).
Regulatory/Legal: Persistent disputes may be escalated through PhilHealth’s regional/legal units or via administrative/judicial remedies if due process concerns arise.

11) Quick checklists

Admission checklist (to minimize out-of-pocket)

Active membership; dependent qualified
Accredited facility/doctor
Case rate disclosed; NBB eligibility checked (gov’t facility)
HMO coordination (if any)
Consent on upgrades & non-covered items, in writing

Discharge/billing checklist

PhilHealth deductions correctly applied
Doctor’s PF within credited amount
Non-covered items itemized and explained
Copies of claim forms/SOA/OR retained

12) Illustrative scenarios

Government hospital, indigent member: Pneumonia case rate applied; NBB means no balance for covered items in the ward. If the family opts for a private room, the upgrade is billable.
Private hospital, employed member with HMO: Appendectomy bill exceeds case rate; PhilHealth pays the package, HMO covers part of the excess, patient pays remainder (e.g., surgeon’s excess PF or amenity fees).
Dialysis patient: Uses all annual session caps; subsequent sessions are self-pay/HMO unless a new circular increases the cap (caps are policy-driven and time-bound).

13) Key takeaways (memorize these)

Package amounts, not “full bill”: PhilHealth pays fixed benefits, not open-ended charges.
Eligibility & accreditation decide payability: Lapse on either often means no benefit.
Limits are multi-layered: Days per year, sessions per year, case-rate ceilings, SPC rules, pre-auth (Z), and NBB qualifiers.
Private hospital = possible balance billing: Expect a gap unless NBB applies in a government ward.
Ask early, document always: Clear coding, documents, and benefit apps prevent denials.

Want this tailored?

Share your member category, planned facility, diagnosis/procedure, and whether you qualify for NBB; I can map your likely PhilHealth credit, where balances arise, and a point-by-point plan to keep charges within covered limits.