presentation how to properly fillout new cf2 for z ben v2
DESCRIPTION
,nTRANSCRIPT
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