Guide on filling out the Claim Form 2 PhilHealth Circular 35, s. 2013

PhilHealth Circular 35, s. 2013:

1. CF2 shall be accomplished and submitted for ALL claimapplication except for confinement abroad.

2. CF 2 shall be accomplished using CAPITAL LETTERS and bychecking the appropriate boxes. All items should be markedlegibly by using ballpen only.

3. CF 2 with incomplete information shall not be processed andshall be returned to sender (RTS) for compliance. (Annex 11, PC35, s. 2013; RTS shall apply only for admission date on or beforeMarch 31, 2014, RTS shall no longer apply for admission datestarting April 1, 2014, hence DENIED)

4. Names should be written starting with last name, first name,name extension and middle name. Extensions such as (but notlimited to the following) Jr., Sr., III should be indicated after thefirst name

5. All dates should be filled out following this format: MONTH-DAY-YEAR (MM-DD-YYYY)

6. Time should be filled out following this format: HOUR:MINUTE(HH:MM) following the 12-hour convention. It should beindicated in the appropriate box whether AM (morning) or PM(afternoon and evening)

7. PhilHealth Identification No. (PIN) and PhilHealth Employer No.(PEN) should be filled out following the 2-9-1 format.

8. PhilHealth Accreditation No. (PAN) for institutions andprofessionals should be filled following the prescribed formats.

Parts of the new CF-2

I. Health Care Institution (HCI) InformationII. Patient Confinement InformationIII. Certification of Consumption of Benefits

and Consent to Access Patient Record/sIV. Certification of Health Care Institution

Part I – Health Care Institution (HCI) Information

Part II – Patient Confinement Information

Part II – Patient Confinement Information

Reminder: The ICD 10 &

RVS Codes should match

the codes indicated for

the Z benefits

Example: For Breast cancer, ICD 10 code should be D05, C50.0-C50.9, RVS code 19120

Part II – Patient Confinement Information

Example: Z 0021 –Breast Ca 1st Tranche

Part II – Patient Confinement Information

List the names of accredited

doctors who are members of the

multidisciplinary team that

managed the patient (use

additional sheet if necessary)

Part III – Certification of Consumption of Benefits and Consent to Access Patient Record/s

Part IV – Certification of Health Care Institution

Attachments for CF2 for Tranche 1 only

I. Approved pre-authorization requestII. Checklist of mandatory services for

Tranche 1III. Z satisfaction questionnaire

Claims for Succeeding Tranches

Part I – Health Care Institution (HCI) Information

Part II – Patient Confinement Information

Part II – Patient Confinement Information

Reminder: The ICD 10 &

RVS Codes should match

the codes indicated for

the Z benefits

Part II – Patient Confinement Information

Example: For Breast cancer, ICD 10 code should be D05, C50.0-C50.9, RVS code 19120

Admitting Diagnosis: Z benefit package for Tranche_(no. of succeeding tranche being claimed, example; Tranche 2 or Tranche 3)

Part II – Patient Confinement Information

Example: Z 0022 –Breast Ca 2nd Tranche

Part II – Patient Confinement Information

List the names of accredited

doctors who are members of the

multidisciplinary team that

managed the patient (use

additional sheet if necessary)

Part III – Certification of Consumption of Benefits and Consent to Access Patient Record/s

Part IV – Certification of Health Care Institution

Attachments for CF2 for succeeding tranches

I. Checklist of mandatory services forsucceeding tranches (if claiming forTranche 2, attach checklist ofmandatory services for Tranche 2)

II. Z satisfaction questionnaire

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