*.
Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION
Citystate Centre Building, 709 Shaw Boulevard, Pasig City
Healthline 441-7444 www.philhealtl-i.HOv.pli
October 25, 2012
PHILHEALTH CIRCULAR
No. P54 . s-2012
TO:ALL HEALTH CARE PROVIDERS AND ALL OTHERS
CONCERNED
SUBJECT :Provider Engagement through Accreditation and Contracting for
Health Services
I. RATIONALE
Cognizant of its crucial role in achieving Kalusugan Pangkalahatan (KP) or Universal Health Care
(UHC) for all Filipinos, the Philippine Health Insurance Corporation continuously undertakes
Corporate-wide reforms that focus on organizational strengthening, expanding membership,
enhancing benefits, and establishing effective partnership with health care providers. All these
endeavors are geared towards ensuring financial risk protection for all Filipinos.
The attainment of KP requires effective implementation of die National Healdi Insurance Program
(NHIP) in every city and municipality, as well as access of PhilHealth members and dependents to
quality health services delivered by health care providers who willingly participate in die Program.
Thus, the need to remedy die maldistribution of health care facilities and health professionals across
the country, and remove needless barriers in accrediting healdi care providers.
While PhilHealth is mandated to grant accreditation to health care providers to confer them the
privilege of participating in the Program, the Corporation needs to enhance the process of engaging
die henltii care providers to improve the access of PliilHealdi members and dieir dependents to
quality health care services. This engagement process must not only be guided by the National
Health Insurance Act of 1995, as amended, and its Implementing Rules and Regulations, but must
be consistent with the provisions of RA 9485 (Anti-Red Tape Act of 2007), RA No. 10155 (General
Appropriations Act of 2012), DOH AO No. 2010-0036 (The Aquino Healdi Agenda: Achieving
UHC for all Filipinos), and DOH AO No. 2011-0020 (Streamlining of Licensure and Accreditation
of Hospitals).
@..... ._^ @_ ,
s,;l%K i if;Vc0 @ i ;@@}Vf. -<JOH Y !In view of the foregoing and pursuant to PhilHeaLth Board Resolution Numbers 1657 and 1662,
PhilHeakh endeavours to enhance the engagement process with Institutional Health Care Providers
(IHCPs) through accreditation and contracting to participate in the NHIP.
II. OBJECTIVES
The provider engagement through accreditation and contracting for health services aims to:
1.Define the new guidelines in engaging the IHCPs in implementing the NHIP;
2.Establish the incentives and awards system tor IHCPs; and
3.Strengthen the performance monitoring of IHCPs
III. COVERAGE
This Circular shall apply to all IHCPs currently participating or intending to participate in the NHIP.
These include:
1.Hospitals,
2.Ambulatory Surgical Clinics (ASCs);
3.Freestanding Dialysis Clinics (FDCs) ;
4.Primary Care Benefit (PCB) providers, including those providing Outpatient Malaria
Package (OMP) ;
5.Maternity Care Package (MCP) and Newborn Care Package (NCP) providers;
6.TB Directly Observed Treatment Shortcourse (TJOTS) Package providers;
7.Animal Bite Treatment Centers (ABTCs)/Animal Bite Centers (ABCs);
8.Health System Providers (HSP) ;
9.Group HCPs; and
10. Other institutional health care providers as determined by PhilHeakh
IV. DEFINITION OF TERMS
1."Automatic accreditation" @ is an accreditation given to any institutional health care provider
(IHCP) that is licensed or certified by DOH or other certifying body duly recognized by
PhilHealth and has the opportunity to be engaged through Basic Participation with NHIP.
These IHCPs do not require pre-accreditation survey and deliberation by the PRO
Accreditation Sub-committee and the Accreditation Committee.
2."Certification" @ is the process that assures the general public and payers of health care
services that the health facility can deliver safe and effective services to patients.
Certification is required for automatic accreditation of institutional health care providers.
3."Certificate of Eligibility to Participate" (CEP)- is a certificate issued to an institutional
health care provider which has fully complied with the requirements for Basic Participation
set by PhilHeahh.
4."Continuous Participation" - means uninterrupted engagement of IHCPs with PhilHealth
until such engagement is withdrawn or terminated based on the rules set by PhilHealth.
^"r" @"ptjpiA'ri-Tr* i
CGRTirSED t'klZ. COPY J5."Engagement" - is a modified/enhanced method of transaction between PhilHealth and an
IHCP wishing to participate in the NHIP. It encompasses 2 processes: accreditation and
participation.
6."Group IHCPs"- refers to THCPs that have been engaged by PhilHeahh as a
group/corporation under one management (e.g., hospitals or other IHCPs with branches,
extensions or franchises).
7."Health Caie System Providers" (HSP) @ the organization of people, institutions, and
resources to deliver health care services to meet the health needs of target populations.
These include, among others, Interlocal Health Zones (ILHZ), health care facility network
owned and managed by provincial, city and / or municipal governments.
8."Institutional Health Care Providers" (IHCPs) - refers to health facilities that are engaged with
PhiiHealth which includes, among others, hospitals, ASCs, FDCs, PCB, and MCP providers.
9."Initial Engagement" @ refers to the engagement of a health care provider with no previous
accreditation/ engagement with the Corporation.
10."Interlocal Health Zone" (ILHZ)@ refers to "any form of organized arrangement for
coordinating the operations of an array and hierarchy of health providers and facilities
serving a common population within a local geographic area under the jurisdictions of more
than one local government unit", as defined by DOH Administrative Order No. 174 series
of 2004.
11."Participation in NHIP" -a process whereby an institutional health care provider commits
to provide quality health care services and/ or ensure financial risk protection to the NHIP
members and their dependents through its Performance Commitment and in return shall
receive reimbursement from PhilHealth for services provided. There are two levels of
participation in NHIP: Basic Participation and Advanced Participation.
a."Basic Participation" - is the minimum level of participation granted by PhilHealth
to all IHCPs that comply with all the registration requirements including their
Performance Commitment and pass the Pre-accreditation Survey (PAS), where
applicable.
b."Advanced Participation" - a higher level of participation granted by PhilHealth to
IHCPs already engaged for Basic Participation who are able to comply with all the
criteria/requirements set by PhilHealth and pass the mandatory Survey for
Advanced Participation (SAP).
12."Performance Commitment" @ a document signed by IHCPs who intend to participate in
the NHIP, wliich stipulate their undertakings to provide complete and quality health sen-ices
to 1 PhilHealth members and their dependents, and their willingness to comply with
PhilHcalth policies on benefits payment, information technology, data management and
reporting and referral, among others.
13."Pre-accreditation Survey" (PAS) - is a process of assessing and evaluating the compliance of
IHCPs with standards set by the Corporation in providing health care services to NHIP
members and dependents. This includes among others, on-site observation, evaluation of
pertinent documents and, interview of personnel and patients. PAS shall be conducted for
facilities that are not automatically accredited and arc applying for Basic Participation in the
NHIP (e.g., private MCP providers).
$g!@ fvlA. TERES/f A.XDUIAOIT
CERTIFIED TRW COPY ' 14. "'Preferred'Institutional Health Care Provider'" - is a recognition conferred to a health facility
granted Advanced Participation for beyond compliance with PhilHealth policies,
demonstrated higher financial risk protection, excellent quality of cure and better service
satisfaction to its clients/patients.
15."Survey for Advanced Participation" - is a process whereby an IHCP applying for
Advanced 'Participation shall be assessed and evaluated on its compliance with standards set
by PhilHealth, specifically on the areas of quality health care and financial risk protection.
16."Registration"- is the initial step in the participation process where the IHCP submits its
provider profile, Performance Commitment and such other requirements as determined by
PhilHealth, to signify its intention to participate in the NHIP.
17."Third Party Accreditation" - is the accreditation of health care providers whereby
PhilHealth delegates the accreditation function (exclusive of the decision-ma king function to
grant or deny participation to NHIP), to a duly-recognized third part)' accrediting body.
V.GENERAL GUIDELINES:
1.PhilHealth shall adopt the new classification of facilities of DOH based on Administrative
Order No. 2012-0012. Consequently, all IHCPs engaged under Basic Participation and
Advanced Participation must promptly inform the Corporation of any change/s in their
license/status and other material information (which includes, among others,
upgrading/additional sendee capacity, changes in ownership or location) and submit a new
Performance Commitment reflecting the changes. Downgrading of hospital category,
decrease it), authorized beds, re-classification to another type of facility, removal of services,
etc. in die. issued license to operate shall be effected immediately in the HCP database of
PhilHealth.
2.PhilHealth shall streamline the process of engaging the IHCPs through the following
mechanisms:
a.Adopting automatic accreditation of IHCPs licensed or certified by the Department of
Health, or any other certifying body recognized by PhilHealth
b.Delegating the authority to process all IHCP applications tor Basic Participation and
other transactions related to updating provider profiles to PhilHealth Regional Offices
(PROs).
c.Delegating the authority to grant or deny any Motion for Reconsideration to the
Chairperson of the Accreditation Committee, including the authority to act on
unresolved IHCP engagement issues by the PRO and other conditions related to IHCP
engagement.
d.Institutionalizing Continuous Engagement with NHIP (until withdrawn or terminated,
based on the rules set by PhilHenJth)
3.The Performance Commitment establishes a contractual arrangement between PhilHealth
and the IHCP. As such, the terms and conditions embodied in Performance Commitment
as presented by PhilHealth cannot be altered nor revised by the IHCP without express
IA.O )@* f ^ p.'.Y J omo:J|^1l^IAOIT | written approval of PHIC. Any alteration or revision shall render the Performance
Commitment void and without effect.
4.Engagement in the NHIP may be extended to a group of IHCPs such as Health System
Providers (HSP), as well as Group IHCPs, provided that all the IHCPs under the HSP or
Group IHCP comply with the guidelines set by PhLLHealth.
5.Starting 2013, all IHCPs shall have a uniform period of validity of engagement, from January
1 to December 31. The period of validity of engagement of hosptLals, FDCs and ASCs
which submit their applications tor renewal on or before the expiration of their current
accreditation, shall be from May 1, 2013 to December 31, 2013 at which time the IHCP may
be continuously engaged until such engagement is withdrawn/terminated or if the IHCP
fails to submit the requirements be tore March 1 of the succeeding engagement cycle.
6.Upon the effectivky of this Circular, the Corporation shall no longer accept applications for
Centers of Quality and Excellence. IHCPs currently accredited as Centers of Quality and
Excellence shall retain the award until the expiry of the current accreditation and are
considered under Basic Participation. Likewise, applications for Centers of Quality and
Excellence which arc in process upon the cffeclivity of tliis Circular shall be processed as
such and if approved, shall be under Basic Participation. However similar applications which
are denied for the award or with deficiencies during survey, shall automatically participate
under Basic Participation.
7.IHCPs which have ceased operation/closed may re-apply anytime for engagement.
8.PliilHealth shall, after due process, apply sanctions and penalties within the context of RA
7875, as amended, and its Implementing Rules and Regulations.
VI. ENGAGEMENT OF INSTITUTIONAL HEALTH CARE PROVIDERS
The providers' engagement shall encompass the processes of accreditation, and participation
oflHCPs in theNHIP.
A. ACCREDITATION
A.I AUTOMATIC ACCREDITATION
The following types of IHCPs licensed or certified by DOH or other certifying body duly
recognized by PhilHealth are automatically accredited as such :
a.Primary Care Benefit Providers;
b.Maternity Care Package Providers certified as Basic Emergency Obstetric and Neonatal
Care (BEmONC) facility by DOH and. as Newborn Screening Facility (NSF) certified
by the Center for Health Development (CHD) or Newborn Screening Reference Center
(NSRC);
c.TB DOTS Package providers certified by DOH;
I*: W _" i d.Outpatient Malaria Package providers with trained personnel on Outpatient Malaria
Treatment certified by the CHD;
e.All hospitals licensed by DOH;
t*. Ambulatory Surgical Clinics (ASCs) and Freestanding Dialysis Clinics (FDCs) licensed
by DOH;
g. Animal Bite Treatment Centers (ABTC) certified by DOH-CHD;
h. IHCPs accredited by a tliird party accreditor recognized by PhilHealth; and
i. Other facilities as determined by PhilHealth.
A.2. NON-AUTOMATIC ACCREDITATION
IHCPs not so licensed or certified are not qualitled for automatic accreditation. These
providers, including MCP providers not certified as BEmONC facilities and TB DOTS clinics
not DOH-certified, shall undergo PAS to ensure compliance with the standards set by the
Corporation.
B. PARTICIPATION
Participation consists of two levels: Basic participation and Advanced participation.
B.I BASIC PARTICIPATION
1. Application for Basic Participation. IHCPs may apply tor participation in NHIP by
submitting the following requirements:
a.Performance Commitment - duly signed by the Local Chief Executive/owner and
the head of the facility/ Medical Director/ Chief of Hospital. The Performance
Commitment must reflect the service capabilities ot the IHCP.
b.Provider Profile- properly accomplished electronic copy (applicable only for initial
engagement and for the transition period). This should be updated immediately
upon the occurrence ot any change of material information stated in the profile.
c.Participation fee - proof of payment. Annex B provides the Participation Fee
Schedule for IHCPs.
d.Latest audited financial statement/report as stated in item A.I,a of PhilHealth
Circular No. 31, s. 2012 reflecting the income/payments received from PliilHealth.
e.Electronic copies fin JPEG format) of recent photos of the facility, both the interior
and outside surroundings (ex., PhilHealth ward, emergency room, recovery room,
operating room, etc.) completely labeled with the name of the facility and date
taken. Submission shall not be on a yearly basis, IHCPs shall immediately
update/submit pictures, should there be new area/s or change/s in the facility.
1. Statement of Intent (SOI) @ applicable to all IHCPs except PCB 1 providers, which
applied for initial engagement from September to December of the current year.
.^JgV"' The SOI gives the IHCPs the prerogative to choose the preferred start date of their
engagement.
g. Additional requirements for specific IHCP as identified in Annex B.
h. Non-automatically accredited IHCPs shall be subjected to PAS. If deficiencies are
noted during the PAS, the IHCP shall be given sixty (60) days from the last day of
the survey to comply/correct the deficiencies. The result of the PAS shall be part of
the agenda for deliberation and decision by the PRO Accreditation Sub- Committee
or by Accreditation Committee should it be referred by the PRO accreditation
subcommittee.
2.Approval of the Application. The PRO shall review the documents submitted by the
IHCP and approve their application if found compliant with all requirements. It shall issue
the Certificate of Eligibility to Participate (CEP) within seven (7) calendar days from receipt
ot complete requirements of IHCPs for automatic accreditation, or from approval of
application by the Regional Vice President. The effectivity date of initial engagement of
IHCPs wliich apply from January to August shall be on the date of compliance, while for
initial applications filed from September to December, the start date shall either be upon
compliance with requirements or on the next engagement cycle whichever the preference of
the IHCP (as expressed in its SOI) except for PCB1 providers, in which case the effectivity
date shall be on the next quarter.
3.Denied Applications. IHCPs with denied application/gap in the validity/downgrading of
category may file a Motion for Reconsideration (MR) with the Accreditation Committee
within thirty (30) calendar days from receipt of the decision. IHCPs with denied MR may
either file an appeal addressed to the PhilHealth Board of Directors wit Inn fifteen (15)
calendar days from receipt of the notice of denial of MR or opt to file another application
for engagement.
4.Payment rate for health cure sendees. The IHCPs under Basic Participation shall be paid
based on the basic rates for services set by PhilHealth.
B.2 ADVANCED PARTICIPATION
1. Application fonAdvanced Participation. Once the system for Advanced Participation is
established, IHCPs currently engaged in the NHIP through Basic Participation may apply for
initiai engagement for Advanced Participation (only during the first quarter of the year) by
submitting the following:
a.Letter of Intent for Advanced Participation;
b.Accomplished self-assessment tool for Advanced Participation with passing score.
The tool shall consist of two (2) modules: Financial Risk Protection (FRP) Module
and Quality Health Care Modules. IHCPs accredited by an International Accrediting
Organization (IAO) duly recognized by PhilHealth that applied for Advanced
Participation will not be assessed for Quality Health Care Module;c. Advanced Participation Fee.
2. Approval Process. The application tot Advanced Participation shall be processed as
follows:
a.IHCP application for Advanced Participation shall be initially assessed by
PhilHeaLth Regional Office for completeness of requirements/ documents.
b.A survey team consisting of representatives from the AQAS, BMU and legal office
of the concerned PRO and Health Finance Policy Sector (I-IFPS) shall conduct" the
Survey for Advanced Participation (SAP) within thirty (30) calendar days from
receipt of the complete requirements. IHCPs shall be informed of the survey.
c.During the exit conference, the survey team shall issue a post SAP report that will
be acknowledged and signed by both PhilHealth surveyors and the IHCP
representatives. A more detailed assessment summary shall be sent to the IHCP not
later than seven (7) calendar days after the conduct of SAP.
d.The application of an IHCP found to be non-compliant or deficient during the
survey shall be recommended for denial.
e.The Accreditation Committee shall deliberate applications for Advanced
Participation and shall submit its recommendation to the President/CEO for
approval. The decision of the PhilHealth President/CEO shall be final and
executory.
f.No Motion for reconsideration/appeal shall be entertained for denied applications.
IHCPs with denied applications for Advanced Participation shall continue to
participate m NHIP through Basic Participation. They may re-apply for Advanced
Participation in the subsequent year/s.
g.The effectivity of the Advanced Participation shall be on the date of the approval of gapplication by the PliilHealth President/CEO.
3.Termination of Advanced Participation. Any adverse change/s in the license-to-operate
of the IHCP such as downgrading of its category and gap in the validity or adverse fmding/s
during monitoring shall be a ground for termination of the Advanced Participation of said
IHCP after due process.
4.Awards and Incentives. IHCPs which are granted Advanced Participation shall be entitled
to awards and incentives to recognize their exemplary performance, particularly in areas of
ensuring financial risk protection and quality of care. These awards and incentives shall
include, bpt are not limited to the following:
a.National Recognition;
b.Administrative Rewards (e.g. faster release of payments than IHCPs under the Basic
Participation);
c.Financial Incentives (e.g., bonus payments).
#!?__pSfci|IEALTH 1
Date:. M UJilj
CERTiFiED THiiE COPY iC. CONTINUOUS PARTICIPATION
Engaged IHCPs either through Basic and Advanced Participation may continuously participate in
the NHIP until such participation is withdrawn or terminated based on the rules set by the
Corporation. These IHCPs are required to submit the following on or prior to January 31 every year:
1.Updated DOH license;
2.Performance Commitment;
3.Updated ceruhcates issued by the DOH/CHD or any other 3r'' party accrediting body
duly recognized by PhilHealth (if applicable);
4.Latest Audited Financial Statement; and
5.Proof of payment of the participation fee.
The respective PROs shall send through email a reminder letter to the IHCP on the 31st day of
January and another one on the 15th day of February if the requirements are not
submitted/completed before the said date. If the IHCP fails to submit/complete the said
requirements by the end of February despite 2 reminder letters, claims for admissions beginning
March 1 and onwards shall be denied until the IHCP submits the requirement/s.
If the license of the ASC or FDC or the certificate of the TB DOTS provider expires within the
year, the IHCP shall be given 60 days within which to submit the updated license or certificate. If
the IHCP fails to submit such requirement within the sixty (60) day period, claims for admissions
beginning on the 61^1 day and onwards shall be denied until the IHCP submits the requircment/s.
VII. MONITORING AND EVALUATION OF IHCP PERFORMANCE
A.. PliilHenJth shall implement the enhanced monitoring system to ensure that all IHCPs act
in accordance with the Performance Commitment tor winch they were engaged, and
provide a scheme to ensure the. following:
1.Strict compliance with all PhiLHealth policies, rules and regulations on quality
assurance, claims processing and, fraud detection and prevention;
2.Determination of the offenses and violations committed by the participating IHCPs
as a result of the monitoring of their performance, and that will immediately warn of
non- compliance with engagement requirements and violations of the policies, rules
and regulations; and
3.Maintenance of high quality standards ot care being rendered to members by engaged
IHCPs.
B.In order to efficiendy carry out the monitoring of IHCPs, they shall be regularly subjected to
the following: (a) Quality Assurance; and (b) Fraud Detection.
1. Quality Assurance (QA) Monitoring.
All THCPs shall be subjected to QA monitoring so as to minimize if not prevent the
following:
I jL,PiSpp^TH " " "j
SB1*" MA. @fEF!ESJ\A^QuiAO?T"
[_C!HRTiF[KD TRIJ.':; COPY a. Violation of Section 76, Rule XII of the IRR of RA 7875
@Over- and under@utilization of services
@Unnecessary diagnostic and therapeutic procedures and interventions
@Irrational drug use
@Inappropriate referral practices
@Gross unjustified deviations from currently accepted practice guidelines or
treatment protocols
@Use of take, adulterated or mis branded pharmaceuticals or unregistered
drugs
@Use of drugs other than those prescribed in the PNDF and those for which
exemptions were granted by the Board
@Withholding/denial of benefits or services to members and dependents
b.Violation of PhilHealtb Circular Nos. 11, 11-A, 11-B, 15,20, series of 2011, and all
other policies and issuance pertaining to case payment and No Balance Bill (NBB)
policy as follows:
@Non-compliance to No Balance Billing (NBB) Policy (as applicable^
@Split deduction of payments
@Under deduction of PliilHealth case rate
@Up-casing of coding for claims
@Incomplete provision of services
@Non-performance ot required laboratory services
@Performance of sendees beyond service capability
@Refusal to admit Sponsored Members and their dependents
@Non-issuance of official receipts to PhilHealth upon receipt of benefit
payments
c.Mismanagement or unethical/questionable practice patterns as culled from post-
audit, utilization reviews, validated complaints from members/DOH, or from
patient exit surveys that are conducted monthly, quarterly, semi-annual or annually
as deemed appropriate by the Corporation.
IHCP found violating any of the above provisions shall receive feedback from
PliilHealth requesting for prompt action to implement corrective measures addressing
said violations and shall submit plan ot action to correct the same within fifteen days
from receipt of feedback from PliilHealth. Any three violations that were not
corrected or addressed shall be ground for suspension, revocation, denial of
participation and/or filing ot a criminal complaint with the proper courts if warranted,
without prejudice to the reduction or denial of claims as provided in the IRR. Further,
any award granted relative to Advanced Participation, including all incentives
accompanying such award shall subsequently be suspended/revoked after due
process.
Ei^t'* MA. TFiRffSAA. QUIAQIT
Date: "^ _ * ;
CGRT:r;spT:-:;"coPY | 2. Fraud Detection
All IHCPs shall be subjected to fraud monitoring so as to prevent or minimize
offenses and violations of performance commitment and other violations such as:
@Incidence of double-filing of claims, overlapping of claims as supported by the
report generated through the N-Claims system
@Filing of claims for cataract procedures perlormed during medical missions
inconsistent with PHIC Circular 19 s. 2007 and PHIC Circular 01 s. 2012
@IHCPs which have been penalized thrice(3) or more, based on the decision
rendered by the Arbitration Department of this Corporation
@Family confinements defined as "record of at least 4 family members
purportedly confined at the same time except during epidemics" as confirmed
by DOH/concerned agency and other exclusions as determined by the
Corporation
@Weekend confinements defined as "pattern/record or at least 50% of claims
with weekend confinements meaning admitted Friday or Saturday and
discharged on Sunday or early Monday
@Unjusdried admissions beyond accredited bed capacity
C. All other violations of the provisions in the Performance Commitment outside those
enumerated shall be dealt with accordingly. Findings ot violations by the concerned PRO
shall be directly reported to their respective legal section tor appropriate action/s. IHCPs
round guilty shall suffer the penalties provided by existing laws, rules and regulations,
particularly those provided by RA No. 7875, as Amended, and its Implementing Rules and
Regulations.
VIII. SANCTIONS AND PENALTIES
.Any violation of tins Circular, (.he tcnns and conditions of the Per to nuance Commitment
and all existing related PhilHealth circulars, office orders and directives shall be dealt with and
penalized in accordance with the pertinent provisions of RA 7875, as amended, and its
Implementing Rules and Regulations.
IX. REPEALING CLAUSE
All previous PhiLHenkh issuance inconsistent with or contrary to the provisions of this
Circular are hereby revised, modified or repealed accordingly. All provisions of existing issuances
which are not affected by tliis Circular shall remain valid and in effect.
PHfUJe/v~LTH" "@@"1
if -7:T., J&.
Offi.**1 MA. TERBSA A. QU1AOSTX. EFFECTIVITY
This Circular shall take effect fifteen (15) days after publication in a newspaper of general
circulation and shall thereafter deposited with die Office of the National Administrative Register,
University of the Philippines Law Center. This shall cover applications for participation in NHIP
received beginning the effecQvity of this circular.
Dare signed: _ lojzslin.
^w MA TCiR|^A OUIAOIT
Date: ._J1JM12.
12Annex A ADDITIONAL REQUIREMENTS FOR PARTICULAR IHCPs APPLYING FOR
BASIC PARTICIPATION
1. HOSPITALS/AMBULATORY SURGICAL CLINICS/FREESTANDING DIALYSIS
CLINICS
a. DOH License @ with validity applicable to the engagement period applied for
b. DOH licenses for 3 previous years or its required alternative document - for
initial engagement of licensed IHCPs
2.PRIMARY CARE BENEFIT I PROVIDERS
a.MOA with referral facilities - if applicable
b.Location map
3.OUTPATIENT MALARIA PACKAGE PROVIDERS
Certificate of Training in Malaria of a staff in the IHCP issued by DOH/CHDs
4.MATERNITY CARE PACKAGE PROVIDERS
a.Certificate of Compliance as a BEmONC facility (for automatic accreditation)
b.Certificate as Newborn Screening Facility issued by the CHD or Newborn Screening
Reference Center ( NSRC)
c.Any of the following for applicable referral system:
@Proof of Affiliation/MOA with at least a Level 1 PhiLHcalth Engaged Hospital
@MOA with referral physician/s for OB and Pedia cases @ as applicable
@MOA with a DOH-certified BEmONC - CEmONC network (if not BEmONC
Certified)
d.Location map
e.Business Permit (for private THCPs)
5.TB DOTS PACKAGE PROVIDERS
a.Updated DOH - PliilCAT Certificate
b.Location map
6.ANIMAL BITE PACKAGE PROVIDERS
a.Certification as an Animal Bite Treatment Center trom DOH - National Rabies Prevention and
Control Program Office
b.Location map
I Data-. __ iLipll___
| CEtTnFiED_TRiJE COPY [
13Annex B
Schedule of Registration Fees:
In line with the implementation of the DOM's new classification of hospitals, which was effective on
August 18, 2012, the following are Board approved new participation fee of hospitals for 2013. This
participation fee shall likewise be applicable to al] hospitals, which applied tor initial engagement from
August 18, 2012 onwards provided that the issued license has adopted the new classification. Please note
that the participation fees of Level 1 and IV hospitals, which were given a three-year moratorium,
remains as such. Please see table below.
tfrtU
i^0^w\
INSTITUTIONS
AmbulatorySurgicalClinic
(ASCs)
FreestandingDialysisClime
(FDCs)-HDandPD
PrimaryOlreBenefitProviders
(PCB)-formerlyOPB
T"BDOTSPackageProvider
MaternityCarePackageProviders
PCB,MCPandTBDOTS
Providers
PCB(OPB)andTBDOTS
Providers
PCB(OPB)andMCPProviders
MCPandDOTSProviders
AnimalBitePackageProviders
INITIAL
(PRIVATE/
GOVERNMENT)
P5,000.00
P5,000.00
P1,000.00
P1,000.00
P1,500.00
P1,000.00
P1,00000
P1,500.00
P1,500.00
P1,00000(starting2013)
ANNUAL
PARTICIPATIONFEE
P4,000.00
P5,000.00
P1,000.00
P1,000.00
P1,00000
P1,000.00
P1,000.00
P1,500.00
P1,50000
P1,000.00
LevelIHospitals(trader3yearmoratorium)
LevelIHospitals
Level11Hospitals
LevelIIIHospitals(Jiacbmghospital)
LevelIVHospitals(under3yearmoratorium,)
P3,000.00
P5,000.00
P8,000.00
P10,000.00
P10,000.00Annex C.
ACRONYMS
AA - Automatic Accreditation
ABP - Animal Bite Package
ABTC - Animal Bite Treatment Center
AP - Advanced Participation
AQAS - Accreditation and Quality Assurance Section
ASC - Ambulatory Surgical Clinic
BMU - Benefits Monitoring Unit
BEmONC - Basic Emergency Obstetric and Newborn Care
BP - Basic Participation
CAAC - Committee on Administrative Cases Against Health Care Providers and Members
CEP - Certificate of Eligibility to Participate
CHD - Center for Health Development
DOH - Department of Health
DOTS - Directly Observed Treatment Shortcourse
FDC - Freestanding Dialysis Clinic
FRP - Financial Risk Protection
GBPP - Global Budget Payment Program
HCP - Health Care Provider
HFPS - Health Finance Policy Sector
IAO - International Accrediting Organization
II-ICP - Institutional Health Care Provider
ILHZ - Interlocal Health Zone
ISQUA - International Society for Quality in Health Care
LHIO - Local Health Insurance Office
LOI - Letter of Intent
MCP - Maternity Care Package
MMHR - Mandatory Monthly Hospital Report
MOA - Memorandum of Agreement
NCP - Newborn Care Package
NHIP - National Health Insurance Program
NBB - No Balance Billing
NSRC - Newborn Screening Reference Center
PCB - Primary Care Benefit
PES - Pre-engagement Survey
PNDF - Philippine National Drug Formulary
PRO - PhilHealth Regional Office
SAP - Survey for Advanced Participation
SOI - Statement of Intent
TIN - Tax Identification Number
i $&$.'%* MA. TL-niv|j/\ <@.. QUlAO
! CEr.TlFiEO TRijs- COPY
15Revised September 2012
(Letterhead of Healthcare Provider)
(Date)
PHILIPPINE HEALTH INSURANCE CORPORATION
17th Fir., City State Centre Bldg.,
Shaw Blvd., Pasig City
SUBJECT Performance Commitment
Sir/Madam:
To guarantee; our commitment to the National Health Insurance Program ("NHIP"), we respectfully
submit this Performance Commitment.
And for the purposes of this Performance Commitment, we hereby warrant the following
representations:
!.That we are a duly registered/licensed/certified health care facility capable of delivering the
services expected from the type of healthcare provider that we are applying for.
That
under die name ot
No.
own edby
andmanagedby
_____ and doing business
with License/Certificate
3.That all professional health care providers in our facility have proper credentials and given
appropriate privileges in accordance with our policies and procedures.
4.That our officers, employees, and other personnel arc members in good standing of the NHIP.
Further, we hereby commit ourselves to the following:
5.That, as responsible owner(s) and/or manager (s) ot the institution, we shaC be jointly and
severally liable for all violations committed against the provisions of Rep. Act No. 7875 including its
Implementing Rules and Regulations (IRR) and PhdHealth policies issued pursuant thereto.
6.That we shali promptly intorm PhiLHeallh prior to any change in the ownership and/or
management of our institution.
7.That any change in ownership and/or management of our institution shall not operate to
exempt the previous and/or present owner and/or manager from liabilities for violations of Rep.
Act No. 7875 and its IRR.
|_CEf;ViFit:Dj;!v.;J': COPY
168.That we shall maintain active membership in the NHIP as an employer not only during the
entire validity of our participation in the NHIP as an Institutional HealthCare Provider ("IHCP") but
also during the corporate existence ot our institution.
9.That we shall abide with all the implementing rules and regulations, memorandum circulars,
office orders, special orders, and other administrative issuances by PliilHealth affecting us.
10.That we shall abide with all administrative orders, circulars and such other policies, rules and
regulations issued by the Department ot" Health and all other related government agencies and
instrumentalities governing the operations of IHCPs ill participating in the NHIP.
11.That we shall adhere to pertinent statutory laws affecting the operations of IHCPs including but not
limited to the Expanded Senior Citizens Act of 2010 (R.A. 9994), the Breastfeeding Act (R.A. 7600), the
Newborn Screening Act (R.A. 9288), the Cheaper Medicines Act (R.A. 9502), the Pharmacy Law (R.A.
5921), the Magna Carta for Disabled Persons (R.A. 9442), and all other laws, rules and regulations that
may hereafter be passed by the Congress of the Philippines or any other authorized instrumentalities of
the government.
12.That we shall promptly submit reports as may be required by PhilHealth, DOH and all other
government agencies and instrumentalities governing the operations of IHCPs.
13.That we are duly capable of delivering the following services for the duration of the validity of this
commitment (please check, appropriate boxes):
c Level 1 hospital services
c Level 2 hospital services
c Level 3 hospital services
c Specialized services
O Radiotherapy
o Hcmodialysis/Peritoneal Dialysis
o Others (please specify)_^
c Bcnetit package and other services
oTuberculosis Directly Observed Treatment Shortcourse (TB DOTS)
oMaternity Care Package
oNewborn Care Package
oMalaria Package
oPrimary Care Benefit Package 1
oOutpatient HIV/AIDS Package (tor DOH identified hospitals only)
oAmmal Bite Package
oOthers (please specify)____
14. That we shall provide <md charge to the PhilHealth benefit of the client the necessary services
including but not limited to drugs, medicines, supplies, devices, and diagnostic nnd treatment procedures
tor our PhilHenlth clients.
@::mk w
1715.That we, being engaged government/MCP facility, shall provide the necessary drugs, supplies and
services with no out-of-pocket expenses on the part of the sponsored member in the NBB bed/all types
of members in the MCP provider as mandated by the PhilHealth's 'No Balance Billing' (NBB) Policy.
16.That we shall maintain a high level of service satisfaction among PhilHcakh clients including all
their qualified dependents/beneficiaries.
17.That we shall be guided by PhilHealtb-approved clinical practice guidelines or if not available, other
established and accepted standards of practice.
18.That we shall provide a PhilHealth Bulletin Board for the posting of updated information of the
NHIP (circulars, memoranda, IHC materials, price reference index, etc.) in conspicuous places accessible
to patients, members and dependents of die NHIP within our health facility.
19.That we shall always make available the necessary forms for PhilHealth member-patient's use.
20.That we shall treat PhilHealth member-patient with utmost courtesy and respect, assist them in
availing PhilHealth benefits and provide them with accurate information on PhilHealth policies and
guidelines.
21.That we shall ensure that PhilHealth member-patient with needs beyond our service capability are
referred to appropriate PhilHealth-accrediied health facilities.
22.That we shall maintain a registry of all our PhilHealth members-patients (including newborns) and a
database of all claims filed containing actual charges (board, drugs, labs, auxiliary, services and
professional fees), actual amount deducted by the facility as PhilHealth reimbursement and actual
PhilHealth reimbursement, which shall be made available to PhilHealth or any of its authorized
personnel.
23.That we. shall maintain and submit to PhilHealth an electronic registry of physicians including their
helds of practice, official e-mail and mobile phone numbers.
24.That we shall, if connected with e-claims, electronically encode the drugs and supplies used in the
care of the patient in our information system which shall be made available for PhilHealth use.
25.That we shall ensure that true and accurate data are encoded in all patients' records.
26.That we shall only tile true and legitimate claims recognizing the period of filing the same after the
patient's discharge as prescribed in PhilHealdi circulars.
27.That we shall submit chums in the format required by PhilHealth for our facility.
28.That we shall regularly submit PhilHealth monitoring reports as required m PhilHealth circulars and
the PhilHealth Benchbook.
29.That we shall annually submit to PhtlHeahh a copy of our audited financial statement/report.
30.That we shall extend full cooperadon with duly recognized authoriUes of PhilHealth and any other
authorized personnel and instrumentalities to provide access to patient records and submit to any orderly
assessment conducted by PhilHealth relative to any findings, adverse reports, pattern of utilization
^@..-'@'^ MA. T[;Ri-:}A,'(\. OUIAO1T \
GET
^''f\Wus^ =
h:;;.;-!,!@'!; copyand/or any other acts indicative of any illegal, irregular and/or unethical practices in our operations as an
accredited IHCP or' the NHIP that may be prejudicial or tends to undermine the NHIP and make
available all pertinent official records and documents including the provision of copies thereof; provided
that our rights to private ownership and privacy are respected at all times.
31.That we shall ensure that our officers, employees and personnel extend full cooperation and due
courtesy to all PhilHealth officers, employees and staff during the conduct of
assessment/visitation/investigation/monitoring of our operations as an accredited IHCP of the NHIP.
32.That at any time during the period of our participation in the NHIP, upon request of PhilHealth, we
shall voluntarily sign and execute a new 'Performance Commitment' to cover the remaining portion of
our engagement or to renew our participation with die NHIP as the case may be, as a sign of our good
faith and continuous commitment to support the NHIP.
33.That, unless proven to be a palpable mistake or excusable error, we shall take full responsibility for
any inaccuracies and/or falsities entered into and/or reflected in our patients1 records as well as in any
omission, addition, inaccuracies and/or falsities entered into and/or reflected in claims submitted to
PhilHealth by our institution.
34.That we shall comply with PhiiHealth's summons, subpoena, subpoena 'duces tecum' and other
legal or quality assurance processes and requirements.
35.That we shall recognize the authority of PhilHealth, its Officers and personnel and/or its duly
authorized representatives to conduct regular surveys, domiciliary visits, and/or conduct administrative
assessments at any reasonable time relative to the exercise of our privilege and conduct ot our operations
as an accredited IHCP of the NHIP.
36.That we shall comply with PhilHealth corrective actions given after monitoring activities within die
prescribed period.
37.That we shall protect die NHIP against abuse, violation and/or over-utilization of its funds and we
shall not allow our institution to be a part)' to any act, scheme, plan, or contract that may direcdy or
indirectly be prejudicial or detrimental to the NHIP.
38.That we shall not directly or indirectly engage in any form of unethical or improper practices as an
accredited health care provider such as but not limited to solicitation of patients for purposes of
compensability under die NHIP, the purpose and/or the end consideration of which tends unnecessary
financial gain rather than promotion of the NHIP.
39.That we shall immediately report to PhilHealth, its Officers and/or to any of its personnel, any act
of illegal, improper and/or unethical practices of IHCP ot the NHIP that may have come to our
knowledge directly or indirectly.
40.That we shall allow PhilHealth to deduct from our future claims, all reimbursements paid to our
institution during die period ot its non-accredited status as a result of a gap in validity of our DOH
license, suspension of accreditation, etc; downgrading of level, loss of license for certain services
including any and all other tees due to be paid to PlulHealth.
19Furthermore, recognizing and respecting its Indispensable role in the NHIP, we hereby acknowledge the
power and authority of PhiLHealth to do the following:
41.After due process and in accordance with the pertinent provisions of R.A. 7875 and its IRR, to
suspend, shorten, pre-terminate and/or revoke our privilege of participating m the NHIP including the
appurtenant benefits and opportunities at any time during the validity ot the commitment for any
violation of any provision of this Performance Commitment and of R.A. 7875 and its IRR.
42.After due process and in accordance with the pertinent provisions of R.A. 7875 and its IRR, to
suspend, shorten, pre-terminate and/or revoke our accreditation including the appurtenant benefits and
opportunities incident thereto at any tune during the term of the commitment due to verified adverse
reports/findings of pattern or any other similar incidents which may be indicative of any illega!, irregular
or improper and/or unethical conduct of our operations.
We commit to extend our full support in sharing Phil Health's vision in achieving this noble objective of
providing accessible quality health insurance coverage for all Filipinos.
Very truly yours,
J2MA. TER
W.TH
wiA. 1ERSSAA. QUIAOiT
20
(IfLjGUowned/Owner)
HeadofFacility/MedicalDirector/Manager Revised Sept.2012
Annex B - Revised Petformance Commitment for Health System Provider
31 October 2012
PHILIPPINE HEALTH INSURANCE CORPORATION
17thFk\, City State Centre Bldg.,
Shaw Blvd., Pasig City
SUBJECT : Performance Commitment
Sir/Madam:
To guarantee our commitment to the National Health Insurance Program (NHIP), we respectfully
submit this Performance Commitment.
And for the purposes ot this Performance Commitment, we hereby warrant the following
representations:
1. That the following facilities, as guaranteed by the heads of facilities listed in the following table, are
capable of delivering the services expected from the type of healthcare provider that we are
applying for:^_^
2.That all professional healthcare providers m our facility have proper credentials and given
appropriate privileges in accordance with our policies and procedures.
3.That our officers, employees, other personnel and staff are members in good standing of the
NHTP.
Further, we hereby commit ourselves to the following:
21
Nameof
Facility
Typeoffacility
(hospital,RHU,
MC,Lying-in,
TB-DOTS,
ABTCs,etc)
HospitalLevel
(ifapplicable)
License
Number/Certific
ateNumber(if
applicable)
Management
(ifdifferent
fromthe
LGU)4.That, as responsible owner(s) and/or manager(s) of the institution, we shall be jointly and severally
liable for all violations committed against the provisions of R.A /875 including its Implementing
Rules and Regulations and policies.
5.That we shall promptly inform PhilHealth prior to any change in the ownership and/or
management of our institution.
6.That any change in ownership and/or management of our institution shall not operate to exempt
the previous and/or present owner and/or manager from violations of R.A. 7875 including its
Implementing Rules ik Regulations and policies.
7.That we shall maintain active membership in the NHIP as an employer not only during the entire
validity of our participation in the NHIP as an Institutional HealthCare Provider (IHCP) but also
during the corporate existence of our institution.
8.That we shall abide with all the implementing rules and regulations, memorandum circulars, office
orders, special orders and other administrative issuances by PhilHealth affecting us.
9.That we shall abide with all administrative orders, circulars and such other policies, rules and
regulations issued by the Department of Health and all other related government agencies and
instrumentalities governing the operations of IHCPs in participating in die NHIP.
10.That we shall adhere to pertinent statutory laws affecting the operations of IHCPs including but
not limited to the Expanded Senior Citizens Act of 2010 (R.A. 9994), the Breastfeeding Act (R.A.
7600), the Newborn Screening Act (R.A. 9288), the Cheaper Medicines Act (R.A. 9502), the
Pharmacy Law (R.A. 5921), the Magna Carta for Disabled Persons (R.A. 94-12) and all other laws,
rules and regulations that may hereafter be passed by the Congress of the Philippines or any other
authorized instrumentalities of the government.
11.That we shall promptly submit reports as may be required by PhilHealth, DOH and all other
government agencies and instrumentalities governing the operations of IHCPs.
12.That we shall deliver the following services for the duration of the validity of this commitment:
1.Level 1 hospital services
2.Level 2 hospital services
3.Level 3 hospital services
4.Specialized services
a.Radiotherapy
b.HemocUalysis/Peritoneal Dialysis
c.Others (please specify in table)
! ;-@," '' pwlw#.Xlth" 1
!?:@,&T^L|
i ;.;g,S MA. TER53AA. QUIAOIT.
I CS'THFiSO Itibs COPY |
22
NameofFacility CommittedServices(choosefromthe
enumeratedservicesbelow;e.g.1,6a,6b,6c) 5. Benefit package and other services
a.Tuberculosis Directly Observed Treatment Shortcourse (TB DOTS)
b.Maternity Care Package
c.Newborn Care Package
d.Outpatient Malaria Package
e.Primary Care Benefit Package 1 (For government hospitals only)
f.Outpatient HIV/AIDS Package (for DOH identified hospitals only)
g.Animal Bite Package
h.Others (please specify in table)
13.That we shall provide and charge to the PhilHealth beneht of the client the necessary services
including but not limited to drugs, medicines, supplies, devices, and diagnostic and treatment
procedures for our PhilHealth clients.
14.That we, being engaged government/MCP facility, shall provide the necessary drugs, supplies and
services with no out-of-pocket expenses on the part of the sponsored member in the NBB bed/all
types of members in the MCP provider as mandated by the PhilHealth's 'No Balance Billing'
(NBB) Policy.
15.That we shall maintain a high level of service satisfaction among PhilHealth clients including all
their qualified beneficiaries.
16.That we shall be guided by PhilHealth-approved clinical practice guidelines or if not available, other
established and accepted standards of practice.
17.That we shall provide a PhilHealth Bulletin Board for the posting of updated information of the
NHIP (circulars, memoranda, IEC materials, price reference index, etc.) m conspicuous places
accessible to patients, members and dependents of the NHIP within our healthcare facility.
18.That we shall always make available the necessary forms for patient's use.
19.That we shall treat clients with courtesy and respect, assist them m availing PhilHealth benefits and
provide them with accurate information on PhilHealth policies and guidelines.
20.That a functional referral system, which will ensure that patients are managed in appropriate
facilities, shall be established and institutionalized among the signatories of tliis Performance
Commitment.
21.That we shall ensure that clients with needs beyond our service capability are referred to
appropriate PhilHealth-accredited facilities.
22.That we shall maintain a registry of all our PhilHealth members-patients (including newborns) and a
database of all claims filed containing actual charges (board, drugs, labs, auxiliary, services and
professional tees), actual amount deducted by the facility as PhilHealth reimbursement and actual
PhiLHealth reimbursement, which shall be made available to PhilHealth or any of its authorized
personnel.
23.That we shall maintain and submit to PhilHealth an electronic registry of physicians including their
helds of practice, official e-mail and mobile phone numbers.
24.That we shall, if connected with e-claims, electronically encode the drugs and supplies used m the
care ot the padent in our information system which shall be made available for PhilHealth use.
25 Thar we shall ensure that true and accurate data arc encoded in all patients' records.
26.That we shall only file true and legitimate claims recognizing the period of filing the same after the
patient's discharge as prescribed in PhilHealth circulars.
27.That we shall submit claims in the format required by PhilHealth for our facility.
!""-.^h^altVT" "']
C.F.ST!r:SO'ip-..'i COPY 28.That we shall regularly submit PhilHealth monitoring reports as required in PhilHealth circulars and
the PhilHealth Benchbook.
29.That we shall annually submit to PhilHealth a copy of our audited financial statement/report.
30.That we shall extend full cooperation with duly recognized authorities of PhilHealth and any other
authorized personnel and instrumentalities to provide access to patient records and submit to any
orderly assessment conducted by PhilHealth relative to any findings, adverse reports, pattern of
utilization and/or any other acts indicative of any illegal, irregular and/or unethical practices in our
operations as an accredited IHCP of the NHl'P that may be prejudicial or tends to undermine the
NHIP and make available all pertinent official records and documents including the provision of
copies thereof;pivvided that our rights to private ownership and privacy are respected at all times
31.That we shall ensure that our officers, employees and personnel extend full cooperation and due
courtesy to all PhiiHealth officers, employees and staff during the conduct of
assessment/visitation/investigation/monitoring of our operations as an accredited IHCP of the
NHIP.
32.That at any time during the period of our participation in the NHIP, upon request of PhilHealth,
we shall voluntarily sign and execute a new "Performance Commitment" to cover the remaining
portion of our engagement or to renew our participation with the NHIP as the case may be, as a
sign of our good faith and continuous commitment to support the NHIP.
33.That, unless proven to be a palpable mistake or excusable error, we shall take full responsibility for
any inaccuracies and/or falsities entered into and/or reflected in our patients' records as well as in
any omission, addition, inaccuracies and/or falsities entered into and/or reflected in claims
submitted to PhilHealth by our institution.
34.That we shall comply with PhilHealth's summons, subpoena, subpoena 'duces tecum' and other
legal or quality assurance processes and requirements.
35.That we shall recognize the authority of PhilHealth, its Officers and personnel and/or its duly
authorized representatives to conduct regular surveys, domiciliary visits, and/or conduct
administrative assessments at any reasonable time relative to the exercise of our privilege and
conduct of our operations as an accredited IHCP of the NHIP.
36.That we shall comply with PhilHealth corrective actions given after monitoring activities within the
prescribed period.
37.That we shall protect the NHIP against abuse, violation and/or over-utilization of its funds and we
shall not allow our institution to be a party to any act, scheme, plan, or contract that may directly or
indirectly be prejudicial or detrimental to the NHIP.
38.That we shall not directly or indirectly engage in any form of unethical or improper practices as an
accredited health care provider such as but not limited to solicitation of patients for purposes of
compensability under the NHIP, the purpose and/or the end consideration of which tends
unnecessary financial gain rather than promotion of the NHIP.
39.That we shall immediately report to PhilHealth, its Officers and/or to any of its personnel, any act
ot illegal, improper and/or unethical practices ot IHCP of the NHIP that may have come to our
knowledge directly or indirectly.
40.That we shall allow PhilHealth to deduct from our future claims, all reimbursements paid to our
institution during the period of its non-accredited status as a result of a gap in validity of our DOH
license, suspension of accreditation, etc; downgrading of level, loss of license for certain services
including any and all other tees due to be paid to PhilHealth.
Furthermore, recognizing PhilHealth's indispensable role in the NHIP, we hereby acknowledge the
power and authority ot PhiiHealth to do the following:41.After due process and in accordance with the pertinent provisions of R.A. 7875 and its IRR, to
suspend, shorten, pre-terminate and/or revoke our privilege of participating in the NHIP including
the appurtenant benefits and opportunities at any time during the validity ot the commitment for
any violation of any provision of this Performance Commitment and of R.A. 7875 and its IRlt.
42.After due process and in accordance with the pertinent provisions of R.A. 7875 and its IRR, to
suspend, shorten, prc-terminate and/or revoke our accreditation including the appurtenant benefits
and opportunities incident thereto at any time during the terra of the commitment due to verified
adverse reports/Undines ot pattern or any other similar incidents which may be indicative of any
illegal, irregular or improper and/or unethical conduct of out- operations.
We commit to extend our full support in sharing PhiLHealth's vision in achieving this noble objective of
providing accessible quality health insurance coverage for all Filipinos.
Head of Facility/Medical
Director/Manager
With my express conformity,
Local Chief Executive
tSg*S MA. TERUSAA. QUIAOIT
A.O, [v/.eniil-HCLMS/V te?3: _WI/lV._/
CERT:Fi^D^R()i"cOPYRevised Sept.2012
ANNEX C: Specific Provisions for Primary Care Benefit 1 Provider (PC for PCB)
That we shall deliver the Primary Care Benefit Package services tor the duration of the validity of this
commitment.
As PCB1 provider,
That we shall be responsible to seek and enlist eligible members and their qualified dependents in
our community assigned to our facility.
That we shall establish a baseline health profile of all PhilHealtb members and qualified dependents,
which shall be kept and updated regularly by our facility.
That we shall submit a consolidated profile or our clientele using PCB Clientele Profile as a
documentary requirement for the release of Per Family Payment Rate (PFPR).
That we shall deliver the services covered by the PCB1 package to respond to the health needs of die
clientele ot our facility.
That in case there is/are diagnostic examination(5) outsourced from another facility, we shall forge a
Memorandum of Agreement" (MOA) to ensure quality checks and appropriate processes are
provided.
That we shall abide by the performance targets on die minimum obligated services for all members
assigned in our facility set by the corporation.
That we shall create/maintain a trust fund for PFPR fluid.
That we shall abide by the prescribed disposition and allocation of the PFPR as follows:
A.Eighty percent (80%) of PFPR is for operational cost and shall cover:
a.Minimum of forty percent (40%) for drugs & medicines (PNDF) (to be dispensed at the
facility) including drugs &. medicines for asthma, acute gastroenteritis, & pneumonia;
b.Maximum of fort}' percent (40%) for reagents, medical supplies, equipment (i.e.
ambulance, ambubag, stretcher, etc), information technology (IT equipment specific to
the needs of facility for it to facilitate reporting and building up of its database), capacity
building for staff, infrastructure or any other use related, necessary for the deliver}' of
required service including referral fees for diagnostic services if not available in the
facility.
B.The remaining twenty percent (20%) shall be exclusively utilized as honoraria of the staff of
the health facility and in the improvement of their capabilities to be able to provide better
health services:
a.Ten percent (10%) for the physician;
b.Five percent (5%) for other health professional staff of the facility
c.Five percent (5%) for non-health professional/staff, including volunteers.
Local Chief Executive (if LGUowned)/ Owner
Head of Facility/Medical
Director/Manager
26