PhilHealth Case Rates Search 2026: List, Search & How to Claim

PhilHealth
Case Rates

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List of Procedure Case Rates List of Medical Case Rates

Quick Answer

A PhilHealth case rate is a fixed peso amount PhilHealth pays toward a specific diagnosis or procedure, deducted straight from your hospital bill instead of reimbursed as cash. Every covered condition, from dengue to appendectomy to a cesarean section, has its own pre-set amount listed in PhilHealth’s official case rate schedule, and that amount stays the same no matter which accredited hospital you’re admitted to.
What changes from hospital to hospital is how much of your total bill that fixed amount actually covers. A ₱15,000 case rate for pneumonia might wipe out most of your bill at a small provincial hospital, but only cover a fraction of it at a large private tertiary center. Understanding the structure, not just the peso figures, is what actually helps you predict your out-of-pocket cost before admission.

What Are PhilHealth Case Rates?

Case rates are PhilHealth’s payment method for covered medical conditions and procedures, replacing the older system where hospitals billed PhilHealth separately for every service rendered. Instead of itemized billing, each diagnosis or procedure is assigned one lump-sum rate that covers the hospital’s charges and the attending doctors’ professional fees together.
PhilHealth introduced this system in phases starting in 2011, expanding it into the “All Case Rates” policy that now covers thousands of conditions and procedures. The goal was to make benefits predictable, since a member can check a case rate before admission rather than guessing what a fee-for-service claim might eventually cover. In January 2025, PhilHealth raised roughly 9,000 of these packages by 50 percent, which is why older lists circulating online understate current coverage.

How the Case Rate System Actually Works

Each case rate is split into two components: a health facility fee and a professional fee, bundled into one payout. The facility portion covers room and board, medicines, laboratory tests, and supplies, while the professional fee portion covers the doctors and surgeons involved. Hospitals deduct the entire case rate from your bill before discharge, and any remaining balance is what you pay out of pocket. You can check PhilHealth Benefits in details and see what is covered in it.

This is also why the same diagnosis can feel very differently “covered” depending on where you’re treated. A Level 1 hospital with lower baseline charges might have a bill the case rate nearly fully absorbs, while a Level 3 tertiary hospital with higher rates for the same condition leaves a larger balance. The case rate doesn’t change; only how far it stretches against your specific bill does.

Who CanFirst Case Rate vs. Second Case Rate

The first case rate refers to the condition or procedure that used the most medical resources during your confinement, while the second case rate covers an additional, separately compensable condition treated in the same stay.

When both apply, PhilHealth pays the first case rate in full and 50 percent of the second, unless that condition is exempted from the reduction.

This matters for patients managing more than one issue at once, such as someone hospitalized for pneumonia who also undergoes hemodialysis during the same admission.

Not every secondary diagnosis automatically qualifies as a second case rate PhilHealth maintains a specific list of eligible conditions, and hemodialysis, radiotherapy, and blood transfusion are notable examples paid in full even as a second case rate rather than at the reduced rate.

How to Look Up Your Specific Case Rate

Use PhilHealth’s official Case Rate Search tool on philhealth.gov.ph, where you can search by benefit description, ICD-10 diagnosis code, or RVS procedure code to find the exact amount for your condition. This is the most reliable source, since third-party lists online are often outdated after circulars adjust specific rates.

If you don’t know the medical code for your condition, searching by plain description, such as “pneumonia” or “appendectomy,” usually returns the relevant entries.

Your attending physician or the hospital’s PhilHealth desk can also confirm the exact case rate for your diagnosis, often faster than searching yourself during an active admission.

Example Case Rates for Common Medical Conditions

The table below gives approximate current figures for frequently searched conditions, reflecting the case rate structure after the 2025 adjustment. Treat these as a general reference rather than a final number, since severity classification, comorbidities, and periodic circular updates can shift the exact amount for your specific case.

Condition	Approximate Case Rate
Dengue Fever (Grade I)	₱8,000–₱12,000
Dengue Fever with Warning Signs (Grade II)	₱16,000–₱24,000
Pneumonia, Moderate Risk	₱15,000–₱22,000
Pneumonia, High Risk	₱32,000–₱48,000
Urinary Tract Infection	₱6,000–₱9,000
Acute Gastroenteritis	₱6,000–₱9,000
Typhoid Fever	₱14,000–₱21,000
Essential Hypertension	₱9,000–₱13,500

Example Case Rates for Common Procedures

Procedure	Approximate Case Rate
Normal Spontaneous Delivery	₱14,000–₱29,000 (facility level dependent)
Cesarean Section	₱58,000–₱62,000
Appendectomy	₱24,000–₱36,000
Cholecystectomy	₱31,000–₱46,500
Cataract Surgery	₱8,000–₱16,000 per eye
Hemodialysis	₱6,350 per session
Hysterectomy	₱30,000–₱45,000

Maternity case rates were expanded separately in April 2026, which is why normal delivery and cesarean rates sit noticeably higher than most other medical case rates. If you’re specifically researching childbirth coverage, checking current maternity rates directly gives you a more precise number than the general table above.

What a Case Rate Actually Covers

A case rate is meant to be comprehensive for its assigned condition. It typically bundles in room and board at the ward level, medicines administered during confinement, lab and diagnostic tests ordered for that diagnosis, supplies used during treatment, and the professional fees of your attending physicians and surgeons. You don’t file separate claims for each test or medication; everything tied to that diagnosis falls under one case rate amount.

What it doesn’t cover is anything outside the standard package, such as a private room upgrade, elective procedures unrelated to your diagnosis, or treatments explicitly excluded from that case rate’s scope. If your doctor orders additional tests unrelated to your primary diagnosis, those charges apply separately and aren’t absorbed by the deduction.

No Balance Billing: When Your Stay Is Truly Free

No Balance Billing (NBB) is a PhilHealth policy that prevents accredited public hospitals from charging qualified members anything beyond their case rate for basic ward accommodations. When it applies, typically for indigent, sponsored, and certain other member categories admitted to a public facility’s basic ward, your out-of-pocket cost for the covered condition effectively becomes zero.

NBB generally doesn’t extend to private hospitals or to members who choose a private or semi-private room instead of the basic ward. If you’re eligible and want to take full advantage of it, confirming your membership category with the hospital’s PhilHealth desk before admission is more reliable than checking after your bill is finalized.

Benefit Limits: The 45-Day and 90-Day Rules

PhilHealth previously enforced a shared 45-day room-and-board limit per member per year, alongside a separate 45-day allowance for dependents, though the standard annual day limit for regular hospitalization has since been removed under recent policy updates. Certain specific benefits, including hemodialysis, still carry their own session-based limits, such as 90 allowable sessions counted against a yearly cap, where each session equals one day of confinement for accounting purposes.
The Single Period of Confinement (SPC) rule is a related concept worth understanding: admissions and re-admissions for the same illness within a 90-calendar-day window are generally treated as one continuous confinement rather than separate claims. This matters if you’re readmitted shortly after discharge for a related condition, since PhilHealth may deny a case rate it considers a continuation of your earlier claim.

Requirements to Use Your Case Rate Benefit

An active PhilHealth membership

meaning your contributions are currently based on your membership category.

A valid PhilHealth number or Member Data Record (MDR)

A PhilHealth ID that is presented at admission.

A completed PhilHealth Claim Form 1 (CF1)

Download CF1 Form or it is usually provided and filled out at the hospital’s PhilHealth desk.

Admission to a PhilHealth-accredited facility

since case rates only apply automatically at accredited hospitals and clinics.

A valid government-issued ID

used to confirm your identity
against your membership record.

For most confinements, the hospital handles claims filing directly, so members typically only need to provide these documents at admission rather than submit anything to PhilHealth themselves afterward.

Common Mistakes That Lead to Denied or Reduced Claims

Assuming every secondary diagnosis qualifies as a second case rate. Only conditions on PhilHealth’s approved list are compensable this way.
Getting readmitted for a related condition within 90 days. Under the SPC rule, this can result in a denied claim if PhilHealth considers it a continuation of the earlier admission.
Choosing a non-accredited facility. Case rates don’t apply automatically outside accredited hospitals, forcing a slower reimbursement process instead.
Letting contributions lapse before a planned procedure. Voluntary, self-employed, and OFW members especially need current contributions, since an inactive account disqualifies that admission.
Assuming the case rate is paid in cash. It’s a maximum deduction against your bill, not money handed to you, so a smaller bill means a smaller deduction, not a full payout.

Troubleshooting a Denied or Disputed Case Rate

If a claim is denied or you believe the wrong case rate was applied, start by asking the hospital’s PhilHealth desk for the specific reason on your Statement of Account or denial notice.

Many disputes come down to a documentation gap, an outdated membership status, or a diagnosis coded differently than expected, all of which the hospital’s PhilHealth officer can usually clarify faster than a hotline call. If the issue remains unresolved, escalate to PhilHealth’s Corporate Action Center directly, bringing your MDR, CF1 copy, and billing statements as reference.

Tips to Get the Most Out of Your Case Rate

Check the official Case Rate Search tool before a planned procedure so you know roughly what to expect, rather than relying on outdated figures from an old blog post. Ask the hospital’s PhilHealth desk, not the general billing counter, when you have specific questions about eligibility.

Choosing a Level 1 or Level 2 accredited facility for routine, non-complicated conditions can mean the case rate covers a much larger share of your bill than the same treatment at a large tertiary hospital. Keeping your contributions current well before you anticipate needing hospitalization avoids the scramble of catching up during an actual emergency.

Frequently Asked Questions

A case rate is a fixed peso amount PhilHealth pays toward a specific diagnosis or procedure, deducted directly from your hospital bill rather than paid to you in cash. Every covered condition has its own pre-set amount in PhilHealth’s official schedule.

The first case rate is the condition or procedure that used the most medical resources during confinement, and it’s paid in full when applicable. It’s determined by resource use, not necessarily which diagnosis is medically the primary one.

A second case rate covers an additional, separately compensable condition managed during the same confinement, generally paid at 50 percent of its listed amount. Only conditions on PhilHealth’s approved list, such as hemodialysis or blood transfusion, qualify, and some are paid in full rather than at the reduced rate.

Use PhilHealth’s official Case Rate Search tool on philhealth.gov.ph, searching by description, ICD-10 code, or RVS code. This gives the most current figure, since older printed or third-party lists are frequently outdated.

No. The case rate is a maximum deduction applied to your bill, not a cash payout, so charges beyond the case rate become your responsibility. If your actual bill is lower than the case rate, you’re only charged the smaller amount.

No Balance Billing means qualified members, typically indigent and sponsored categories, pay nothing beyond their case rate for basic ward care at public hospitals. It generally doesn’t extend to private hospitals or upgraded rooms.

The blanket annual day limit for standard hospitalization has been removed under recent updates, though specific benefits like hemodialysis still carry their own session-based caps. Checking current circulars or the hospital’s PhilHealth desk confirms what applies to your benefit.

This is often due to the Single Period of Confinement rule, which treats readmission for the same illness within 90 days as a continuation of the earlier confinement. Confirming the exact denial reason with the hospital’s PhilHealth officer clarifies whether this rule applied.

Yes, the peso amount for a given condition is the same nationwide at accredited facilities, but how much of your total bill it covers varies by hospital level and pricing. Lower-tier hospitals with smaller overall bills tend to have the case rate cover a larger share of the total cost.

PhilHealth adjusts rates periodically through official circulars, with a notable 50 percent increase applied across roughly 9,000 packages effective January 2025. There’s no fixed annual schedule, so checking the official search tool close to when you need the benefit beats relying on memory of past rates.

Dayon

I’m Dayon, and I run PhilHealthPH.com. I got tired of confusing, outdated instructions every time I had to deal with PhilHealth online, so I started writing the guides I wished existed — clear, current, and focused on actually getting the task done. Everything here is checked against PhilHealth’s official site and updated whenever their process changes.