* Republic tifthd Philippines

r*PHILIPPINE HEALTH INSURANCE CORPORATION snL'llv.sUic Cjiiul ItinldiiiL! 7()( Nluiw Hi)iiIl-v;ii-cI. P;imli \S\\\

PHILHEALTH CIRCULARNo. 00 If.s-2013

TO:ALL PHILHEALTH MEMBERS, ACCREDITED AND CONTRACTED HEALTH CARE PROVIDERS, PHILHEALTH REGIONAL OFFICES AND ALL OTHERS CONCERNED

SUBJECT :Z Benefits Rate for the Mobility, Orthosis, Rehabilitation,

Prosthesis Help (X MORPH) Package for the Fitting of External Lower Limb Prosthesis Below the Knee

I. RATIONALE

The Philippine Health Insurance Corporation recognizes the potential upwards fiinciionnl independence and producnvay of persons with physical disabilities, panicularlv ihosc with limb loss or dehciency, nncc they -arc provided with the affordable prosihr^cs.

Aliened wiih ihi- mission of Republic Act "2"" or the i\Jagna Carrn for Disabled Persons, Phill-k-nlth seeks ro mainstream and reinlearntc persons with physical disabilities inio the coinmunitv by rendering prosthetic services available

Cognizant of the United Nations Convention on the Rights ol Persons with Disabilities' vision or full and equal cnioyment of human rights bv perst>ns with disabilitys, PhilHealth shall ensure protection of their inherent dignity through prosthetic devices that are safe, appropriate, accessible, and ot quality.

In fulfillment of the aforementioned, Phill iealth Board Resolution No.liTW, s-2iU2 and

Phill Iealth Circular No. 29, s-3U2, 'Xio/vrmii^ I'o/Am on Vml\ Ivu.'/h li<';n;//' i'uck.j'y mr (.,/.\c '/']/.'(' Z", the following :ux' the ser\riccs and raits for the Mobility-. Orrhoais, Rehabilitation, Prosthesis Help (Z MORPH) package for rhe tircinc >@*' exiern.il lower limb prosthesis btrlow the knee.

II. RULES FOR IDENTIFIED Z MORPFI

A.The initial fit tint* of rhe right and/or Jeff lower limb prosthesis below ihe knee shall be covered under ihe benefit package and only those cases thai slnctlv fulfill the selections crnerin shall be covered;

B.All qualified members availing nf rhe /. M( )K1J1 1 shall be required a 3-venr lock- in membership prior to availmenr of the benefit. Emploved members ;i?e required to sign a Z, henetit commitment torm t^r submit a cucfihcait. < it approval.' ai^reemenr from the employer to the lock-in mumbership for the m_-\[ iliree (3j years. The lock-m membership does not apply to li feu me and sponsored-program members;

C.Prc-authorization lrr>m Phill Icn.1 tli based mi the approved selections crikTia fni; Z MORPJI for the fitting of the external lower limb prosthesis below the knee shall be required prior lo availmeni of services. All requests for pre-aulhori/;irion shall be accomplished compleidy by ilie contracted hospnnl ^ind ihr s,ime is

submitted to the I Icael ot the Regional Bcnefiis Administration Section [HAS) lor final approval,

D.The fulfillment of the. approved selections criteria shall be [he basis for approval

ot the pre-iHithorizfition reqiicst;

E.The No Balance Billing (NHB) polio- shall be applied for eligible sponsoixd

prcigLiim members and their qualified dependents. N^gorifitcd fixed co-pnv sluill be jipplit'd for eligible non-sponsored members and their qualified depcndt-nis. In

no instance shall the fixed co-p;i\p exceed the package rale,

F The professional fees for die 7, MORPH for the fitting of eternal lower limb

prosthesis below the knee is 2o"c of the package rate;

G. Pill Jen fs enrolled in the Z benefits shall be deducted ;1 niLiximtnn ot five r'5) d;i\'^ from the 45 days iinnual bcnefii limit and such deduction shall be made onh on the current year during the lining ot the prosthesis. In cases where the remaining annual benefit is less thnii five (5; days, the member shall remain eligible if avail of the Z benefit, provided thai premiums are updated;

IJ. All rates arc inclusive e>f government taxes;

I. Rules on pooling of professional lees lor government facilities shall apply:

]. All mandatory and other services specific to ihc Z MORPH for die fiitmg of

@ limb ; bcl.j i he sate-liny; to

standards set by the reference hospital.

III. CASE TYPE Z BENEFIT FOR THE Z MORPH

Fitting of External Lower Limb Prosthesis Below the Kiiee

1. The package code for the latcrality of the lower limbs is as fo

a.Z010-A for the right lower limb b.Z010-B for the left lower limb c.Z010-C for ihe riglil find lefl lower limbs

The overall package code for rlic 7, MORPI I is Z010, which includes ihe following descriptions and IOD-IH code rellccred in [lie lable below;IDescriptionII CD 10 CODEj

mrY

Transubml (below thu I: nut1'Z44.1

2. 'Hit- packiiet rntc sluill be 15,000 pesos per first right and/or left below the knee lower limb prosthesis and 30,000 pesos if both limbs fur the cninv piv- nnd posr-prosibuLJc man^cmenl of cither thu foot, Minus, finklf or bt,'l')\\' kncL' levc^ of nmpmnljoi].

3.Approved Selections Crticm :

a.Sisnccl Member I'.mpowerment (Mj.'j l-'orm;

b.No associated disabilities or en-morbidities, such as con fractures,

deformities., mental or behavioral incapacity, quiidriparcsis, cardjopulmonary disease;

c.Commiinitv nmbularion with or without cane, crutches or walker;

d.At lensi three i'3j months pust-fimputation, if acquired; and

e.A I. Icasi 15 years and 36-1 days ot a^c, it congenital.

4.The Z MO11P1 i for the fitting of external Inwej- hnil> prosthesis below the kiu-e shall reflect the following mandatorv and other services as indiented in the table below:

MANDATORY SERVICESf. Proprosthcr.ic -.issessmcnt by n bonrtl

certified pliysici.in of ilic Philippine Ht>nrJ of Rchrtbilitaucin Mfthaiic;

2.Prosthetic measurement, tnbricntion and check-out by International Society of Pros the tics ;ind ( >rthotics Category I (prosthetistj of (..ates^ory 2 fprustheuc technici:in'i who ha\rf undergo ml training; in i\ prosfhcUc workshop;

3.J'inal discharge disposition by a board certified physician of the Philippine Board of Rehabilitation Medicine.

he reference and contracted@mil I mve I he responsibility to

Note:I'he. reference and contractedhospitals shall I mvi_- I he responsibility toensure the CLcdcnLuibn^ ot the physicians,prosthensis, prosthetic technicians, physicaland occupational therapists.

OTHER SERVICESWhen w;in.-riiiiL-d, posi-pmsilu'licrchnbiliration pixvjr.tm' ^b;ill beprescribed by n b'jnrd certifiedpliysicum ' if ific I'hihppiiH'BoardoiRcli;ibilit.itionMcdlcuiL and implcmL'iiiccl |iy ;iPRC-llccnso physicaloccupiitionnl Oicnipist.

1 ['osl-proxtlh'tic Rt'lu/hi/.'/Jlitu;t/u-:/ cv.v.vi.-.i' @///./ CHMIWnt>li/i,'H/i-:

f/iih lioiLih1\ with nvasilh'us

5. The payment for this pnckn^c shall lie Fifteen Thousand Pesos (Phpl5,000) per first right and/or left below the knee external lower limb prosthesis and 30,000 pesos if both limbs tor cirlu-i- svmes. anklu, foot oi; Ix-low kiu-e, whicli shnll Lie i/iwn m :i single ir.mchc piiymcni ntrcr rhu p:uitnr h:is rcccr <_xi .ill mnndiiLury ^(_rvicL-s

MODE OFPAYMENT

SniiiL tmncht.

AMOUNT

Php J 5.000.(1(1

FILING SCHEDULE

Within 60 days nftcr i.hu tin-,\\

patient by :i Lv.j;ird Cu-rtificJphysjcum of llic l^hilippinc H';irdol Rchvibilit.ition Mc-dicmc

J5&&1 'HA.TSiW-EAA.OurAoif"

AOjy|ciiieiJc,ELH:

[.}_"@-'@@@ i!'i-;c'F."' @)@;@":'.:.@: f-@;@@@

;t!

IV. CLAIMS FILING FOR Z MORPH

AH chums shall be tiled by the contracted hospitals in behalf nf rhc patient iiccording to the

Implementing Guidelines on the Z Benefit Package ( PhilHcalth Circular 48, sclils of

2OJ2).

V. EFFECTIVITY

This circular shall take effect for all approved pre-authorization starting August 3U, 2013. This

shall be published in any newspaper oi general circulation and a copy thereof deposited

thereafter with the Office of the National Administrative Rc^islcl, University ol the Philippines

1 .aw Center.

VI. ANNEXES

1.Pre - authorization checklist and request for Z MORPH for the Fitting of

External Lower Limb Prosthesis Below rlie Knee ('ANNKX "A")

2.Documentary Requirements for claims tiling

:i. Discharge checklist MORPH (ANNKX "IV")

b.Member Hmpowcvment Form (MR Form) fANNFiX "'C")

c.Z Satisfaction ( >Liesti<mnaire fANNJiX "D"')

Please be guided accordingly

m

1-1 :2$I

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'is

PHILIPPINE HEALTH INSURANCE CORPORATION CihslJlc Ccnlrc Uuildiny. !)' Slidw Uoulcviiul. I'ii.sk (,'il>

Hcullhliiic 441-7444 ujMJlt:iLl|Lia^l2l!

ANNEX "A"

NAMIi Ol; HOSPITAL

NAME OI- PATIENT _

PhilHenlth ID Number

PRE-AUTHORIZATION CHECKLIST FOR Z MORPHFITTING OF EXTERNAL LOWER LIMB PROSTHESIS BELOW THE KNEE

Place a check mad; [^) on the appi:opriate lower limb:

LjRJghc lower limb [Uj.ett I^iwcl limb Dlli^ht <!s: left lower limbs

(Place ;t "'or N.\)

CONJ-ORME BY PATIENT,'LEGAL REPRKSHNTATIYIL:

Signature over printed name of patient or Icpil representative

Dare signed by pfilicnr/le^al representative

Piin. I r,f nl'Anivv A

1.,\gc:itlc^st15venisLind364days

Z.Atleast3monthspot:t-amputati(in,if

acquired

3.Wheelchair:Indcpendcnr-Ojniniumr\"

AmbulatorWithoi;withoLit-pi-<isthe^i^

Withoi;withoutenneorcrutchesorwalker

4.NoCo-morbidities:

a.Noconpesti^'cheartfailureorlschemic

hc-.utdisease

b.Nochronicobstructiveorrcstneuvc

lunjidisease

c.Nosvstcmicnitectioii

d.NomentalorbehavioralincapacitY

5-PhysicalExamination:

Nofreshornon-healingwound

Noneuromaorpainfulresiduallimb

Nomotorstrength<4/5oflowerlimbs

NoLimitationotmotionoflowerlimbs

Noincocjrdinadonorpoorbalajiee

6,l^ightlowerlimbonlv

7.Leftlowerlimbonly

S.Rightandleftlowerlimbs

Yes

n

a

?

a

?aa?a?

a

a

AttestedbyRehabilitation

MedicineSpecialist

(Printedname&Signature)

PHILIPPINE HEALTH INSURANCE CORPORATION CuyiUilc Comic LSuikliiiLi. 70 V Sluw Houlc\ Jid. I'lisij: Cii>

[lojllhtino 441-7444 \^uu.pliillK-:il[|i.uu\ .|ili

ANNEX "A"

PRE-AUTHORIZATION REQUEST FOR Z MORPHFITTING OF EXTERNAL LOWER LIMB PROSTHESIS BELOW THE KNEE

DATE OF REQUEST

Inn is to request approval for provision ot services under the /, benefit piickngc toj-

(NAivm or- patiknt)(NAmj: oi; hospital;

under die terms and conditii >ns as :igreed for :urnilment of rhe / Benehr J^iicknge.

Requested by:

Printed Name &l SignatureAttending Rehabilitation Medicine Specialist

s< k:\.\l service assessment

The patient belongs to the following category (tick appropriate box):? NBU for sponsored program member ? Zero (Jo-pay for non-sponsored mem be i

D EIXED CO-PAY (Indicate Amount) Php'

ASSF.SSKD BY:

Printed N:ime & Siirnnrurc/Designation

rONHRMHD BY:

(Signature over Printed N;inie)

Medical Director / Chief or" Hospital

(I'Vjr PhilHcalrh Use Only)? APPROVED QRrght lower limb PLdt lowcilimb DRight & left Irnvcr limb.s

D DISAPPRO\'F.D

Re-.isoa/s for disapproval:

(Signature over Pfin tod Nnmc)Hu:\d, Bone tits Administration Suction :ljif

Republic itfihe Philipjiiin>sPHILIPPINE HEALTH INSURANCE CORPORATION

CiljsCiilt fonru liuikl.ni;. TOT Sliau- Bouki uid. I'asig Lil) I k-Lillhline 441-^4-14 v\\\.])hi[luvlll[K'j(^ pli

ANNEX "B"DATH.

NAMH OF HOSPITAL.

NAMH Of; PATH @ NT _

PlnlHcilrh ID Number _

DISCHARGE CHECKLIST FOR Z MORPH FITTING OF EXTERNAL. LOWER LIMB PROSTHESIS BELOW THE KNEE

Place ;i check mark ("V ) on the appropriate lower limb pur)Sthesis:

D Right lower limbQ Left Lower LimbD Riu;ht and left lower limbs

(Place i\ Sox NA)^^_

Contirmcd by: _

(Signature and Prinrcd Nnmc)

Modic.il Dirtctoi-/ Chief of Hn.ipiKll

fJONl'ORMC BY PA rri'N'lVU-X;AJ. RliPRI.;.S]:Nl'ATI\'lj;:

Signature over punted name of patient or legul representative

L)>itc tiiiJiitrd by patient/legal repix-senfiitive

iV-:/-

A C V |

l':iSi. li.r 1 of'Annc.s B

CRI'l'IZRiA

socket,L^oodsuspcn,sic>n,ali^nudshankand

stableprostheticfootwhik-standing&walking

2.Thebelowkneestumpisfreeofpain,blister,

viiscuhircompromise,hvpcrsciiMQ\'it\pafter3"

minutesol"prostheticweightbc;innwhilestandinsj;&/orwalleing

surfaceswithinexpectedgaitparameters,md

stepsup&downfive(5)stepswithorwithoutassist]vc,device

4.Prosthesisuserpossessescompetentskilland

knowledgeregardingprosthesisdonning,

dotting,cleaning,precautionsandtailing

techniques

Yes AttestedbyKehabiiitntJon

MedicineSpecialist

(PrintedName&Signature)signed

ANNEX "C"

MEMBER EMPOWERMENT FORM Iwfcrrwv, buppcrrtr e^Wpower

Instructions:1.The healthcare provider shall explain mid assist the patient in filling-up rhc ML1!, form.

2.Legibly print all information provided.3.I''or items requiring a "yes"' or "no"' response, tick appropriately with a check mark (Vh

4.Use additional blank sheets if necessary, label properly anel attach securely to this Ml-', torm.5.The Ml1- form shall be reproduced by the contracted hospital providing specialized cai:e.

6.Duplicate copies of the Mli form shall be made available by the contracted hospital@one for rhc

patient and one as tile copy ot the contracted hospilal providing the specialized care.

7'. For patients availing of the Z MORPH for the fitting of external lower limb prosthesis, write N/A for items B2, B3, C4 and D6.

\. Member/Patient Name of Patient

infoLTnatJooPhilHealth No.

Current age

Birthday Sex

Permanent address "telephone/Mobile N<_>.

Email address

R Clinical [nloimauoii

1. Description of condition

Applicable: L rcLitment Protocol for Z, condition ;tguecd upon with

healthcare- provider

3. Applicable Allernntive Protocol./s lor /, condition nureed upon with

healthcare provider

(]. Treatment

Schedule and

1-oUmv-Lip \"isit/s

1. Dntt; of initial hospital admission or consult '@@@@

I'month/dny/ve;ir)

This icfcrs to the vicinal lower limb p re-prosthese* rchubilitution consult for the Z MOR1M-I

(month/J;iy/\c:ir)

1 This refers m the external lower limb measurement, filling and adjuslmcnis Tot the Z MOKl'H

, t'y@i #!.

':iu< IMS of Annex C

(month -'Vtay; vcai:)

' t'-:'@@@- . H,@ ..vTormil lower limb post-p.osthcsis rL-habililarion consult

4. Emergencies I Write exact date's with cue reason or unei uouru-, .,,.

,u.. ,,@@@,. ,,f f|,,. ,.,-ncraencv)

expected outcomes resulting trom my condition.

Yes. No __

2.Mv healthcare provider explained the treatment options'.

Yes No '' This refers to the need tor pre- and post- external lower limb

prosthesis rehabilitation for the /, MORPH

3.The possible side effects/ udvei.se effects of treatment were

explained to me.

Yes^No..

4.My hcalthcLirc ptovidcr explained the mandatory hen-ices and other

sendees rcLjuircd for the treatment ot my condition.

Yos No_

5.1 am satisfied with tlie cxplsination o;iven to me by my healthcare

provider.

6.I have been fully informed char I will be cared for by all the pe-rrinenr

medical specialties (surgery, medical/ pedintric oncolo^\ .

nephiol<)u;y, rndicj-oncolot^y. and other pertinent specialties as I ma\

that preferring another contracted hospiral for the said specialized

care will not affect my tieatment in any way.

Yes__Nn_

7.My healtlicare pro\ridcr explained the lmpnitance of adhering ro mv

tieatment schedule.

8.My healthcare provider gave me the schedule/s of my follow-up

visit/s.

9. My healthcare provider gave me inf-ormauon where to <ni rnr luiaiiciiil and other me tins ut support, when needed.

\ -....k i, -.

\~F" .|P*JW_-r^yy- \i'.w2..r5..rAniii.-sc

\ @

Nil me- ofifra-nmnit ngmcv (P<-'SO, PMS, 1.( il ", tic)

b) Name of non-govern mental organization/s

c) Nil mi.- of Pnticnl Support Group/s

d) Name of Corporate lound:mon/s

cj Others (Media, Religious Group/s. Politician.' s, etc;

10. I have been furnished by my healthcare pro\'idcr wirli .1 list anj

contact information of other contracted hospitals for the specialized

a\iQ ot my condition.

Yes No_

1 1. I have been fully informed by my healthcare put -vidcr of rlu

PhilHcalth membership policies and benefit availment on the ("!;ise

Type Z:

b.1 understand rhc "no balance billing1"1 ('NBlVi policy for

sp< msoL'ed members. Yes N<.

c.1 understand the hxed co-pay for non-sponsored members.

Yes No

d. Only tire (5) Jays shall be deducted from the 45 days annual

benct.it limit for die duration of my treatment under the case

type /-@ benefit pncktiqe.

^S:;:@@:$$ Y

e. I shall update my premium contributions in order to avail tin-

Case Type /. package and other PhilHcalth benefits. Yes'_ No.

! @',. Member Roles &1. I understand that I ;im responsible for adhering 10 mv treatment

Responsibilitiesschedule.

2.I understand thai" adherence ro my treatment schedule is importanr

in terms of treatment outcomes and a pre-rcquisire to the full

entitlement of the case type Z, benefit.

3.I understand thai it is my responsibility to follow and comply with a I

the policies and procedures ot PhUHealth and the healthcare

provider in order to aval! of the full case type Z benefit package. In

the event that 1 fail to comply with policies and procedures of

PhilHealth and the healthcare provider, 1 waive the privilege of

availing the 7. benefit. Yes'"' H)

I1. Printed Name,Signature or 1 hurnb Print ot Patient, it unable to write.

Signature, Thumb Date (Month/Day/Yearj

Print and Date

Name of Attending Doctor

Signature Date ('Month/Day/Y'car)

Witnesses

1.Name of Hospital staff

Signature

Date (Month/Day'Year)

2.Name of parenc/guardian/spousc/ncxt ot km

Signature

Dare (Month/ Day 'Year')

G. Contact PhilHealth 1.PhilHealth CARKS

2.Oill lis at telephone number:

3.Text us:

4.email us:

[-[. Consent to Access I consent to the exannnnaon by Phi]He;ilth of my medical records ion

Pntient Rccord/sthe sole pui-pcjse of verifying the vemcity of the Z-claim.

r.>-^r-""\

Consent fi Kilter I consent to hnvc my medical J:it:i entered electronically m the /.I>I1S -.i>

Medical D:itn m the a requirement for the C;ise Type '/. I ;uithorize PhilHenlrli to disclose

/. BenefitInt'ormiition &

1 racking System

(/.HITS)

my p<ji>onal health information ti> its onumctcd partners.

I hereby hold PhilHenlth or any ol its officers, employees and/'M"

represent;! fives tree trom any Aiid all liabiiitjes rcl;in\re to the herein-mentioned consent which i have voluntarily and willingly given in

cojinection with ihe /, claim tor i:eimbiusemciit be tore Phil Health.

|. Name of Patient,Nainc ot'Pnticnf

Signature/Thumb Signature 01: Thumb Pant, if unable: to write

Print and DateDiltL" CM<inth/Dny/Veav)

K. Name of Patient's Name of Patient^ Representative.

Representative,Signature Signature and .Date Dace (Month/Ony.'Year)

Rchuionship of check V one:

the

Representative Spouse to the Patient Parent

Child Next of Kin/Guardian

fs

ANNEX "D"

Share your opinion with us! ,@ ...@@@@ VS.J.We would like to know how you feel about the services that pertain to the Z Benefit

Package in order that we can improve and meet your needs. This survey will only take a

few minutes. Please read the items carefully- If you need to clarify items or ask

questions, you may approach your friendly healthcare provider or you may contactPhilHealth call center at 4417442. Your responses will be kept confidential and

anonymous-

For items 1 to 3, please tick on the appropriate box.

I i Coronary Bypass

I.J Surgery for Tetralogy of Jralk>t

U Surgery tor Ventricular Sepia 1 Defect

I I Fitting of external lower limb prosthesis

I. / benefit package availed is for:

I [ Acute J.ymphoblasUc LeukemiaII Coronary Bypass

I I Breast CancerI.J Surgery for Tetralogy of J?alk>t

I I Prostate CancerQ Surgery for Ventricular Scpisil Defect

I I Kidney TransplantII Fitting of external lower limb prosthesis

I ! Cervical Cancer

2.Respondent's age is:

I I 1() years old & below

I I between 20 to 35

I I between 36 to 45

I I between 46 to 55

[ I between 56 co 65

[1 above 65 years old

3.Se.\ of respondent

D male

fi female

For items 4 to 8, please select the one best response by ticking the appropriate box.

4.How would you rate the services received from the hospital in terms of availabihtv of

medicines or supplies needed for the treatment of your condition?

I I adequate

I J inadequate

l"l don't know

$@@@ l':i(H 1"! 2 of Annex D

i^p'3.

5. How would you rnte the patient's or himilv's involvement i empowerments (\ou may reter to your Member Iimpowerme

I "1 excellent

! I SLitushictory

i ! uasntisfaci/oLT

I i cloii't know

\i rliL- euix- m terms of- park-nr

<>. In general, how would you rate I he healthcare professionals th:

Z benefit package in terms of doctor-pntient relationship?

I i excellent

\'\ satistacfury

I I uiisanstiictoLv

I I don't know

In your opinion, by hc>w much has y<>ui: hospital cxpcn

bcnetit packages

I ! less than half

l."i by halt

I I more than halt

I i don't know

K. Overall patient satisfaction (PS mark) is:

i I excellent

I I sarishictOLy

I I uns^tishicrory

I I don't know

V. If you htu'c other comments, please share them below:

services f( n th

; been lessened by nvnilin^ n[ rhe '/,

Thank you. Your feedback is impoLtnnt to us!

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