Philhealth Coverage for Specific Laboratory Tests in the Philippines

I. Legal Foundation

The Philippine Health Insurance Corporation (PhilHealth) derives its mandate from Republic Act No. 7875 (National Health Insurance Act of 1995), as amended by Republic Act No. 9241 (2004), Republic Act No. 10606 (2013), and most importantly, Republic Act No. 11223 (Universal Health Care Act of 2019).

Section 10 of RA 11223 explicitly mandates PhilHealth to provide coverage for “diagnostic, laboratory, and other medical examination services” as part of the benefit packages. Implementing Rules and Regulations (IRR) of the UHC Act, together with numerous PhilHealth Circulars, define exactly which laboratory examinations are reimbursable, under what conditions, and at what rates.

PhilHealth coverage for laboratory tests is never “unlimited” or “all-inclusive.” It is always package-based: the test must fall within an approved benefit package (inpatient case rate, Z-benefit, Konsulta, maternity, TB-DOTS, animal bite, dialysis, chemotherapy, newborn screening, etc.). Tests performed outside these packages are not reimbursable by PhilHealth, even if medically necessary.

II. Inpatient Laboratory Coverage (All Case Rates Policy)

Under PhilHealth Circular No. 2017-0006 and subsequent amendments (including Circular No. 2023-0012 on updated case rates), all laboratory examinations performed during confinement that are directly related to the final diagnosis are deemed included in the case rate payment.

Key legal principles:

• The hospital receives one fixed case rate (e.g., P55,000 for ischemic heart disease, P30,000 for pneumonia moderate risk, etc.).
• All medically necessary laboratory tests performed during admission are covered by that single payment — no separate reimbursement.
• Excess laboratory requests beyond what is reasonable and necessary for the coded illness may be deducted during claims audit (PhilHealth Circular No. 2018-0021).
• Sponsored members, seniors, and indigent patients are protected by the No Balance Billing (NBB) policy — the hospital cannot charge the patient for any covered laboratory test included in the case rate.

III. Outpatient Laboratory Coverage: The Konsulta Package (Primary Care Benefit)

The single most important benefit for outpatient laboratory examinations is the Konsultasyong Sulit at Tama (Konsulta) Package established under PhilHealth Circular No. 2021-0018, as amended by Circular Nos. 2022-0022, 2023-0016, 2024-0009, and 2025-0004.

As of December 2025, every registered Konsulta provider (public health center, private clinic, or outpatient department of a hospital) is entitled to bill PhilHealth for the following laboratory and diagnostic examinations once per member per year (unless otherwise specified):

1. Complete Blood Count (CBC) with platelet count
2. Urinalysis (routine)
3. Fecalysis (routine) + Fecal Occult Blood Test (FOBT)
4. Fasting Blood Sugar (FBS)
5. HbA1c
6. Lipid Profile (Total Cholesterol, HDL, LDL, Triglycerides)
7. Serum Creatinine (or eGFR)
8. Alanine Aminotransferase (ALT/SGPT)
9. Chest X-ray (PA upright or AP lordotic if needed)
10. Sputum GeneXpert MTB/RIF (for TB suspects – unlimited if clinically indicated)
11. Pap smear (conventional or liquid-based) – once every three years for women 25–64 years old
12. Potassium (serum) – for patients on diuretics or with renal disease
13. Electrocardiogram (ECG) – for members ≥40 years old or with cardiovascular risk factors

Additional notes on Konsulta laboratory coverage (2025 rules):

• All tests are free at the point of service for registered members (no co-pay under UHC).
• Providers receive P600–P1,200 per member per year capitation, out of which laboratory costs are deducted.
• Private laboratories may be contracted by the Konsulta provider, but the member cannot be charged extra.
• Repeat tests within the same year are allowed only if medically justified (e.g., monitoring of diabetes, CKD, or chemotherapy patients) and approved via the e-Claims system.

IV. Specific Benefit Packages with Laboratory Coverage

A. Maternity Care Package (MCP) and Normal Spontaneous Delivery (NSD) Package

• Includes CBC, urinalysis, blood typing, Rh typing, VDRL/RPR, hepatitis B screening, OGCT (75g) for gestational diabetes.
• HIV screening is now mandatory and reimbursable (Circular No. 2023-0027).

B. Expanded Newborn Screening (ENBS)

• PhilHealth pays P600 directly to the Newborn Screening Center for the 28+ disorders panel (RA 9288 and PhilHealth Circular No. 2022-0029).
• The basic 6-disorder screening is fully covered; the expanded panel is also covered under UHC.

C. TB-DOTS Package

• Unlimited sputum GeneXpert MTB/RIF or smear microscopy.
• Drug susceptibility testing (DST) Line Probe Assay or culture is covered under the Enhanced TB Package (P22,500–P33,000).

D. Animal Bite Treatment Package

• Rabies fluorescent antibody test (FAT) on dog brain (if dog dies) is reimbursable under certain conditions.

E. Hemodialysis Package

• All pre- and post-dialysis laboratory tests (CBC, creatinine, potassium, hepatitis profile, Kt/V) are included in the P4,000 per session rate (2025 rate).

F. Chemotherapy Package

• Tumor markers, CBC, liver and renal function tests performed on the same day as chemotherapy administration are included in the per-session rate.

G. Z-Benefit Packages (Catastrophic Illnesses)

• Virtually all laboratory and imaging studies required for staging, treatment planning, and monitoring are covered (e.g., tumor markers for breast/colorectal cancer, PET-CT for lymphoma under specific conditions, prostate biopsy for prostate Z-package, etc.).
• The most generous laboratory coverage in the entire PhilHealth system.

V. Laboratory Examinations Explicitly NOT Covered by PhilHealth (2025)

1. Executive check-ups and annual physical examinations (unless part of Konsulta)
2. Pre-employment laboratory tests
3. Routine drug testing for employment or legal purposes
4. Paternity DNA testing
5. Vitamin D, vitamin B12, ferritin, thyroid panel (unless the patient has a covered thyroid Z-package or is admitted for thyroid storm)
6. Allergy testing (skin or RAST)
7. Hormone panels for infertility (except when part of PCOS management under certain conditions)
8. Genetic testing (except BRCA for breast Z-package, or selected panels for pediatric Z-morph)
9. Heavy metal screening
10. Most tumor markers when done for screening (only for monitoring of known malignancy under Z-package or chemotherapy)
11. Advanced imaging (PET-CT, whole-body MRI) outside approved Z-packages
12. COVID-19 RT-PCR or antigen testing (coverage ended December 31, 2023)

VI. Claims and Reimbursement Rules for Laboratories

• Only PhilHealth-accredited clinical laboratories or hospitals may file claims.
• Direct filing by freestanding laboratories is allowed only for Konsulta, newborn screening, and certain outpatient packages.
• All claims must be filed electronically via e-Claims system within 60 calendar days from discharge or date of service.
• Laboratories must attach the Laboratory Request Form signed by a PhilHealth-accredited physician.
• PhilHealth conducts post-audit; over-requesting of tests can lead to return or denial of claims and possible suspension of accreditation.

VII. Conclusion and Practical Advice for Members and Providers

PhilHealth’s coverage for laboratory examinations is now broader than ever under the UHC regime, particularly through the Konsulta package and case rate system. However, it remains strictly package-driven rather than fee-for-service. The guiding principle is medical necessity within an approved benefit package.

Members are legally entitled to receive all covered laboratory tests without out-of-pocket payment when availed from accredited providers under NBB-eligible categories (indigents, seniors, sponsored members). Any illegal charging should be reported to PhilHealth via the Action Center (02) 8662-2588 or through the official complaints portal.

Providers who perform non-covered tests must inform the patient in writing beforehand and secure a waiver; failure to do so constitutes a violation of RA 11223 and may result in administrative sanctions.

This framework, as of December 2025, represents the most comprehensive laboratory benefit structure in PhilHealth’s history, fulfilling the UHC Act’s promise of accessible diagnostic services for every Filipino.