THE Philippine Health Insurance Corp. (PhilHealth) on Wednesday enumerated the conditions under which qualified patients may receive inpatient benefits.
Under Circular 2026-0013, or Coverage for Inpatient Admissions of Less than 24 Hours, PhilHealth said a stay of less than 24 hours does not automatically qualify for inpatient coverage. The admission must be medically necessary, appropriate and clinically justified, with the basis supported by the patient’s medical records.
Cases that do not require inpatient admission based on existing medical standards, clinical guidelines, the patient’s condition, or PhilHealth policies are considered non-admissible cases and are not covered under the circular.
Admissions without a clinical indication or medical necessity requiring hospital confinement are also considered unnecessary admissions.
PhilHealth said Circular 2026-0013 does not create a new benefit or medical case rate. Instead, it expands eligibility for reimbursement under existing inpatient medical case rates for qualified admissions that end before 24 hours because of death or transfer.
Patients who are dead on arrival, or DOA, are not covered under the circular because they were already dead when brought to the hospital and are not considered to have undergone an inpatient admission. PhilHealth said such cases may be covered under other benefits, including the Outpatient Emergency Care Benefit.
Emergency room consultations, outpatient services, ambulatory procedures and observation cases that do not involve formal inpatient admission are also not covered by the circular.
For patients transferred before completing 24 hours, the admission may remain covered if the transfer is medically appropriate, properly documented and consistent with the patient’s condition.
Under the circular, interhospital or interfacility transfers require a Referral Form and Transfer Consent Form, along with other documents that may be required.
The Referral Form must be signed by the referring physician, receiving physician and nurse on duty of the receiving health facility. The Transfer Consent Form must be signed by the patient or authorized representative, attending or referring physician and a witness.
PhilHealth said incomplete transfer documents may result in denial of the claim.
The circular also allows transfers to a larger facility, a facility of the same level or a smaller or lower-level facility for continuing treatment, step-down care, rehabilitation or convalescence. A patient-requested transfer may also remain covered if it is medically appropriate, properly documented and the receiving facility can provide the required services.
Patients cannot directly file these claims with PhilHealth. The health facility must deduct the applicable PhilHealth benefit from the patient’s hospital bill and file the claim with PhilHealth.
Transportation or ambulance costs for the transfer are not covered by Circular 2026-0013, although PhilHealth said these may be covered under separate policies.
For eligible inpatient admissions lasting less than 24 hours, benefit payment will be based on the actual charges for covered services reflected in the Statement of Account. If the actual charges are lower than the applicable medical case rate, only the actual charges will be paid. If they are higher, payment will not exceed the applicable medical case rate.
PhilHealth said the length of stay begins at the date and time of admission ordered by the attending physician and recorded in the medical record. It ends upon discharge, transfer, receipt by the receiving health facility, death or another documented conclusion of the admission.
If a patient dies before reaching 24 hours after being admitted as an inpatient, payment will be based on the final diagnosis recorded in the medical record and PhilHealth Claim Form and the corresponding medical case rate. It will not be based on the immediate cause of death indicated on the death certificate.
Inpatient admissions lasting more than 24 hours remain covered under the existing All Case Rates system. Claims involving patients with dispositions of improved, recovered, home against medical advice or discharge against medical advice, or absconded are not covered under Circular 2026-0013.
For claims involving several covered medical conditions during one confinement, payment will be based on the applicable medical case rate for the condition that used the most resources, in accordance with PhilHealth’s All Case Rates policies.
Health facilities must submit required documents, including the Claim Signature Form, Claim Form 2, Claim Form 4 and Statement of Account. Additional documents may be required depending on the admission.
PhilHealth said claims may be returned when requirements are incomplete, supporting documents contain discrepancies or forms have incomplete entries. Health facilities have 60 calendar days from receipt of a Return to Hospital notice to submit missing documents, unless a different extension is provided under existing rules.
Denied claims may be challenged through a motion for reconsideration or appeal, according to PhilHealth.
Members and health facilities may seek clarification through PhilHealth’s Customer Assistance, Relations and Empowerment Staff, its Corporate Action Center at actioncenter@philhealth.gov.ph, or the PhilHealth hotline at (02) 8662-2588.
