March 14, 2012

PHILHEALTH CIRCULAR NO. 010-12

Rationale

In support of the Aquino Health Agenda to provide Universal Health Care for all Filipinos, also known as Kalusugang Pangkalahatan (KP), and consistent with its execution plan, the Philippine Health Insurance Corporation aims to ensure that all Filipinos have access to quality health services that are efficiently delivered, equitably distributed, fairly financed and appropriately utilized by an informed and empowered public.

To achieve these goals, the Corporation through PhilHealth Board Resolution No. 1587, s. 2012 amended the implementation of the Outpatient Benefit Package and approved a Primary Care Benefit I (PCB1) Package, with the following objectives:

1. Expand the number of services included in the Primary Health Care benefits for PhilHealth members;

2. Increase the utilization rate for services included in the Primary Health Care benefits for PhilHealth members;

3. Enhance incentives for PCB providers to promote healthy behaviour, prevent diseases and/or associated complications, and facilitate appropriate referral; and

4. Ensure complete and timely reporting of health data for monitoring and performance assessment and evaluation purposes.

I. Coverage

For the transition period (CY 2012-2013), the Primary Care Benefit I (PCB 1) package shall be implemented to cover members under the Sponsored Program, Organized Groups and Overseas Workers Programs, and their qualified dependents. DcCEHI

II. Definition of Terms See Annex "C"

III. Services

The following services shall be provided to respond to the health needs of the covered clientele:

A. Primary Preventive Services

1. Consultation the first consultation visit in a given year, which shall, at the least, include the establishment or updating of individual health profile.

2. Visual inspection with acetic acid

3. Regular BP measurements

4. Breastfeeding program education

5. Periodic clinical breast examinations

6. Counselling for lifestyle modification

7. Counselling for smoking cessation

8. Body measurements

9. Digital Rectal Examination

B. Diagnostic Examinations

1. Complete Blood Count (CBC)

2. Urinalysis

3. Fecalysis

4. Sputum microscopy

5. Fasting Blood Sugar

6. Lipid profile

7. Chest x-ray

C. Drugs and medicines CDAEHS

1. Asthma including nebulisation services

2. Acute Gastroenteritis (AGE) with no or mild dehydration

3. Upper Respiratory Tract Infection (URTI)/Pneumonia (minimal and low risk)

4. Urinary Tract Infection (UTI)

IV. Providers

Any government health facility (including but not limited to health centers/rural health centers (HCs/RHUs) and the Out Patient Department of Municipal Health Offices, City Health Offices and government hospitals) that has the capacity and human resources to deliver the PCB 1 package may qualify as Primary Care Benefit (PCB) provider. (Please see Annex "C.1" Standards for Registration as PhilHealth Primary Care Benefit Provider.)

Qualified PCB providers shall register as such by following the process described in Annex "C.2" (Guidelines for Registration as PCB Providers) and submitting the necessary documents including their Performance Commitments (Annex "D") duly signed by the City/Municipal/Provincial Health Officer and the Local Chief Executive, on or before April 30, 2012. The current PhilHealth OPB accredited health facilities (RHUs, HCs, authorized hospitals) are automatically considered as PCB providers for CY 2012.

The PCB providers are responsible to seek out and enlist Sponsored Program members and their qualified dependents assigned to their facilities (Section V.A). They also must facilitate the enlisting of Organized Group members and Overseas Workers Program members residing in their respective localities.

Aside from the services mentioned in Section III above, the PCB providers shall establish a baseline health profile of all PCB 1-entitled members and their qualified dependents using Annex "A.1" (or any equivalent form available in the PCB facility for this purpose), which shall be kept and updated at least annually. Moreover, the PCB providers shall maintain a record of their PCB 1 clientele and the services rendered. (Annexes "A.1" to "A6" or any similar documents found in the facility) DTSaIc

The PCB providers shall ensure that all diagnostic examinations listed in Section III are available to their PCB 1 clientele, when needed. As such, they may forge a Memorandum of Agreement with another health facility to provide those diagnostic tests that are not available in their facility. In addition, the PCB providers shall ensure that PCB 1 clients with health care needs beyond their service capability are referred to appropriate health facilities.

The PCB providers shall be paid through a Per Family Payment Rate (PFPR), which shall be computed and released on a quarterly basis. Through an appropriate administrative issuance (e.g., local Ordinance, Sangguniang Bayan resolution, etc.), the PCB providers shall create and maintain a trust account per province/city/municipality for the PFPR fund.

V. Procedural Guidelines

A. Assignment of PCB 1-covered members and qualified dependents

For the transition period, the Corporation shall assign the Sponsored Program members identified through NHTS-PR to their respective RHU/Health Centre, while the LGU/other sponsored members shall be assigned to the PCB providers managed/owned/designated by their sponsors. Organized Group members and OWP members may choose their PCB providers annually.

PCB 1-entitled members may change PCB provider within the year if they moved to another province/city/municipality, in which case the member must immediately inform the nearest PhilHealth Service Office of such transfer by submitting a Barangay certification signed by the Barangay Chairperson of his/her new residence to continue their entitlement to PCB services. The receiving PCB provider shall receive the PFPR on the quarter following the transfer.

B. Establishing PCB 1 client database in every PCB provider

1. Each facility shall be provided a masterlist of SP members assigned to its facility by the Corporation. The staff of the PCB provider shall be responsible for contacting the members and informing the members that they are eligible for the Primary Care Benefit. Enlistment to the facility is signalled by the member signing the masterlist.

2. OG and OWP members must be enjoined to enlist with the recommended PCB provider in their area. Enlistment to the facility is signalled by the member providing the latter his/her NHIP number and signing its masterlist.

3. The facility shall keep its signed masterlist within its facility but shall submit an updated list of its enlisted members to the appropriate Service Office before the scheduled release of the third and fourth tranche for 2012. For 2013, the facility shall submit a list of enlisted members before December 31, 2012 as basis for the release of PFPR for the first and second quarters. The facility shall also submit an updated list of enlisted members before the scheduled release of succeeding tranches for 2013, as basis for the release of its PFPR.

C. Provision of PCB 1 services

1. All PCB facilities shall provide the services mentioned in Section III of this Circular, as needed by members or their qualified dependents. Moreover, the following services shall be provided within the year, according to the agreed schedule:

a. A set of minimum obligated services (Table 1) shall be provided by the PCB facility to members and their qualified dependents. For CY 2012, the PCB facility shall provide the services as needed by members and their qualified dependents, and report these services by using Annex "A.4" (PCB Semestral Summary of PCB Services Provided). The performance targets for minimum obligated services shall be prepared by the Corporation for 2013. Guidelines for the performance targets shall be issued thru a separate administrative issuance. cIACaT

b. An individual health profile (Annex "A.1" or any similar document available in the PCB 1 facility) must be established or updated at least once annually. The individual health profile shall be summarized using Annex "A.2".

Table 1. Obligated Services

2. Patients with religious and cultural barriers may sign a waiver not to avail of the obligated services like visual acetic acid wash. The signed waiver shall be submitted to their PCB provider. The Provider shall include the number of patients who waived any of such services when they submit Annex "A.4".

D. Maintenance and Submission of Reports. The PCB providers shall maintain the individual health profile (Annex "A.1"), PCB 1 patient ledger (Annex "A.3") and Semestral Report of PCB Services Availed by PCB 1-entitled Members and Dependents (Annex "A.5"). The Providers shall submit Annexes "A.2" and "A.4" on or before June 30th and December 31st of the current year.

E. Payment of PCB 1 Services. The Corporation shall pay the PCB providers through PFPR, which shall be released in four (4) tranches:

1. For 2012, the following tranches shall apply based on the type of membership and enrolment mechanism. (See Table 2) The releases of the PFPR for 1st and 2nd tranches shall be based on the schedule in Table 2 multiplied by the number of assigned SP members in the PCB facility. The releases for the 3rd and 4th tranches shall be computed based on the number of PCB 1 entitled members who enlisted during the preceding quarter. The masterlist of those who enlisted shall be submitted on or before June 30, 2012 as a prerequisite for the release of the third tranche. The masterlist of additional members who enlisted along with Annex "A.2" (PCB Clientele Profile) shall be submitted on or before September 30,

Table 2. Payment of PFPR by type of PCB 1-entitled Members

2. For 2013, the health facilities will be required to submit a masterlist of additional members who enlisted and an updated Annex "A.2" before the start of every quarter. Additionally, the facilities will be required to submit Annex "A.4" before the start of the 1st and 3rd quarter. Table 3 provides the documentary requirements for the release of PFPR for the quarter. AcEIHC

Table 3. Reports Required for the Release of PFPR for 2013

3. For the transition period, an additional incentive of One Hundred Pesos (P100) PFPR shall be released to PCB providers that will submit reports required by the Corporation electronically and in accordance with the format that will be prescribed. Release of this P100 will be pro-rated based on data and timeliness requirements. This additional incentive shall be released, as follows:

a. Data requirements include:

1) Additional P10 PFPR for submission of electronic masterlist of PCB-entitled Members

2) Additional P10 PFPR for electronic consult list including non-NHIP patients with family folder in the facility

3) Additional P10 PFPR for maintenance of general health services list

4) Additional P10 PFPR for maintenance of PCB services provided

5) Additional P10 PFPR for maintenance of FHSIS list

6) No electronic listing: no incentive will be given

b. Timeliness requirement includes:

1) Additional P50 PFPR for daily/real time submission; OR

2) Additional P20 PFPR for weekly (not daily) submission; OR

3) Additional P10 PFPR for monthly (not daily, not weekly) submission; OR

4) Additional P5 PFPR for quarterly submission; OR

5) Additional P1 PFPR for semestral submission; OR

6) No additional incentive on top of the DATA requirement incentive

7) No submissions: no incentive

Table 4 summarizes the total PFPR100 incentive that the PCB provider may get. The amount of PFPR100 that will be released is computed as Total PFPR100 x number of families enlisted with the PCB provider.

Table 4. Release of Additional P100 PFPR based on Electronic Submission of Data

4. The PFPR shall be released within fifteen (15) calendar days from receipt of the complete documents/requirements. Non-submission of the required documents shall mean a delay in the release of the PFPR. The additional P100 PFPR shall be released along with the last tranche for the year. ICHcaD

F. The guidelines for the computation of Per Family Payment Rate (PFPR) based on obligated minimum services for 2013 shall be issued on a separate administrative issuance.

G. The disposition and allocation of the PFPR shall be, as follows:

1. Eighty percent (80%) of PFPR is for operational cost and shall be divided, as follows:

a. Minimum of forty percent (40%) for drugs and medicines (PNDF) (to be dispensed at the facility) including drugs and medicines for Asthma, AGE and pneumonia; and

b. Maximum of forty percent (40%) for reagents, medical supplies, equipments (i.e., ambulance, ambubag, stretcher, etc.), information technology (IT equipment specific for facility use needed to facilitate reporting and database build up), capacity building for staff, infrastructure or any other use related, necessary for the delivery of required service including referral fees for diagnostic services if not able in the facility.

2. The remaining twenty percent (20%) shall be exclusively utilized as honoraria of the staff of the PCB facility and for the improvement of their capabilities as would enable them to provide better health services:

a. Ten percent (10%) for the physician;

b. Five percent (5%) for other health professional staff of the facility; and

c. Five percent (5%) for non-health professionals/staff, including volunteers and community members of health teams (e.g., Women's Health Team, Community Health Team).

VI. Effectivity

This Circular shall take effect on April 1, 2012, 15 days after publication in a newspaper of general circulation. This shall be deposited with the National Administrative Register at the University of the Philippines Law Center.

All PhilHealth Offices through the Public Affairs Department, Public and Media Affairs Unit and Member Relations Division shall undertake appropriate and massive public information campaign efforts especially targeting members of the National Health Insurance Program.

All other provisions of previous issuances which are inconsistent with this Circular are hereby repealed.

VII. Annexes

A. PCB Forms

A1. Individual Health Profile

A2. PCB Clientele Health Profile cESDCa

A3. PCB Patient Ledger

A4. Semestral Summary of PCB Services Provided

A5. Semestral Report of PCB Services Availed by PCB1-entitled Members and Dependents

B. Definition of Terms

C. Guidelines for primary care benefit (PCB) providers

C1. Standards for Registration as PhilHealth Primary Care Benefit provider

C2. Guidelines for Registration as PCB providers

C3. Template MOA with other facility on outsourced services

D. Performance Commitment (PC)

(SGD.) DR. EDUARDO P. BANZON
President and CEO
Philippine Health Insurance Corporation

ANNEX A1

Philippine Health Insurance Corporation

ANNEX A2

PCB Provider Clientele Profile

ANNEX A3

PCB Patient Ledger

ANNEX A4

Quarterly Report Form

ANNEX A5

PCB Form 1A
Quarterly Summary of PCB Services Provided

ANNEX B

Definition of Terms

Acute gastroenteritis (AGE) inflammation of the gastrointestinal tract; symptoms or signs include at least one of the following: diarrhea, nausea, vomiting, abdominal pain, dehydration.

Body measurements measurement of the height (in centimeters), weight (in kilograms), and waist circumference (in centimeters).

Breastfeeding program education provision of information regarding the right of the mother to breastfeed, advantages of breastfeeding, and information regarding support programs.

Chest X-ray a radiologic examination of the chest; single view: postero-anterior (PA) or antero-posterior (AP). This is suggested for, but not limited to, patients with suspected pneumonia.

Complete blood count is a test panel that gives information about the cells in the patient's blood; automated (hemoglobin, hematocrit, red blood cell count, white blood cell count, and platelet count) or manual cell count (erythrocyte, leukocyte, or platelet). Thus is suggested for, but not limited to, patients suspected with anemia and dengue hemorrhagic fever.

Consultation is a type of service provided by a physician initiated by a patient and/or family for evaluation and management which requires three key components: DTAHSI

a history

a physical examination

medical decision making

Counseling and/or coordination of care with other providers are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. The service also includes updating of individual health profile.

Corporation refers to the Philippine Health Insurance Corporation, government owned and controlled corporation duly organized and existing by virtue of "Corporation".

Counseling for lifestyle modification patient and/or family education to encourage health behavior changes during one or more visit(s) to include but not limited to promotion of a healthy diet and nutrition, regular and adequate physical activity, avoidance of substances that can be abused such as tobacco and alcohol, and adequate stress management and relaxation.

Counseling for smoking cessation patient and/or family education during one or more visit(s) concerning harms of smoking, benefits of smoking cessation, risks and benefits of treatment options, and information regarding tools and support programs.

Diarrhea is the passage of unusually loose or watery stools, usually at least three times in a 24-hour period. Frequent passing of formed stools is not diarrhea, nor is the passing of loose, "pasty" stools by breastfed babies.

Digital Rectal Exam is an internal examination of the lower rectum by a physician or nurse to feel the prostate to allow the examiner to estimate the size of the prostate and feel for any lumps or other abnormalities.

Electronic submission refers to submission of documents using internet, IHCP portal, and other means as determined by the Corporation.

Fasting Blood Sugar (FBS) is a test to determine the level of glucose in plasma after an overnight fast. Fasting is defined as no caloric intake for at least 8 hours up to a maximum of 14 hours. This should be considered in patients with, but not limited to, waist circumference of > 80 cm (females) or > 90 cm (males), symptoms/signs of diabetes mellitus (polyuria, polydipsia, weight loss), or those previously diagnosed with diabetes mellitus.

Fecalysis a stool examination for white blood cells, red blood cells, occult blood, parasites, and ova for patients with diarrhea that is suspected to be of infectious origin. This is suggested for, but not limited to, patients with diarrhea.

Hypertension is considered in a patient with BP > 140/90 mmHg, recorded on at least 2 occasions. It may be classified as stage 1 (SBP = 140-159 or DBP = 90-99) or stage 2 (SBP > 160 or DBP > 100).

Lipid Profile a fasting lipoprotein profile including major blood lipid fractions, i.e., total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride; this requires a 9- to 12-hour fast. This is suggested for patients with type 2 diabetes mellitus and for patients with at least two of the following risk factors: hypertension; family history of premature coronary heart disease (coronary heart disease in first-degree relative < 55 years old male or < 65 years female); and/or age > 45 years (male) or > 55 years (female).

Non-health professional are workers not directly engaged in patient care such as but not limited to administrative, security, sanitation and maintenance, dietary or food, and among others.

Non-hypertensive individual with systolic BP of < 140 mmHg or diastolic BP < 90 mmHg in the absence of intake of antihypertensive medications.

Obligated service refers to a service that must be rendered to target clients because it is medically necessary and for the purpose of determining outcome performance as basis for payment.

Organized group is any legally registered organization of the informal sector with an authorized government regulatory body with the aim of providing social protection or social health insurance to its informal sector members such as a microfinance institution, cooperative, non-government organization, and credit union, among others.

PCB Provider refers to any health facility providing services under primary care benefit (PCB).

PCB 1 Package stands for primary care benefits 1 package which includes the following 3 main provisions:

a. primary preventive services

b. diagnostic examinations aIcDCA

c. drugs and medicines

Periodic clinical breast examinations is an examination of the patient's bilateral breasts by a physician or a nurse, who uses his or her hands to feel for lumps or other changes. This should be performed at regular intervals as specified in the circular among the targeted individuals even in the absence of symptoms or signs related to the breasts.

Philippine Health Insurance Corporation a government owned and controlled corporation duly organized and existing by virtue of "Corporation".

Regular blood pressure (BP) measurements auscultatory method of BP measurement using an aneroid or electronic sphygmomanometer at intervals specified in the circular.

Sponsor refers to any individual, company, or institution that fully pays for the coverage of members.

Sputum microscopy a microbiological method of sputum examination for diagnosis and follow-up of patients with pulmonary tuberculosis (TB).

Suspected diabetes mellitus refers to individuals with known risk factors for and/or symptoms and signs suggestive of diabetes mellitus.

Suspected urinary tract infection (suspected UTI) refers to individuals with clinical signs and symptoms of infection referable to the urinary tract.

Urinalysis is the physical, chemical, and microscopic examination of urine for a patient with suspected urinary tract infection (UTI).

Visual inspection with acetic acid (VIA) the primary screening tool for cervical cancer based on acetowhitening, with the cervical intraepithelial neoplasia turning white when exposed to 3-5% acetic acid.

References:

1. Administrative Order (AO) No. 2005-0006 Establishment of a Cervical Screening Program.

2. Clinical Practice Guideline in the Approach and Treatment of Urinary Tract Infection in Children in the Philippine Setting. 2004.

3. Clinical Practice Guideline on the Diagnosis, Treatment, and Control of Tuberculosis by Philippine Practice Guideline Group in Infectious Diseases. Philippine Society for Microbiology and Infectious Diseases and the Philippine College of Chest Physicians. 2000.

4. Department of Health (DOH) Circular No. 2010-0147 Guidelines for Physicians on the Promotion, Protection and Support of Breastfeeding.

5. Department of Health (DOH) Policy Statements: Cervical Cancer Prevention and Control in the Philippines.

6. Diarrhoeal Diseases. World Health Organization. February 2009.

7. Jeronimo J, Morales O, Horna J, Pariona J, Manrique J, Rubi os J, Takahashi R. Visual inspection with acetic acid for cervical cancer screening outside of low-resource settings. Rev Panam Salud Publica. 2005;17 (1):1-5.

8. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Diabetes Mellitus. UNITE FOR Diabetes Philippines. 2011.

9. The Philippine Practice Guidelines on the Diagnosis and Management of Urinary Tract Infection in Adults. 2004.

10. PhilHealth Office Order No. 91 s-2005.

11. "Prostate Cancer Screening." Centers for Disease Control and Prevention. Downloaded from http://www.cdc.gov/cancer/prostate/basic_info/screening.htm. March 2012.

12.

13. RA 9241.

14. Saslow D, et al. Clinical breast examination: practical recommendations for optimizing performance and reporting. CA: A Cancer Journal for Clinicians. 2004; 54 (6):327-344. In Centers for Disease Control and Prevention. "Breast Cancer Screening." Centers for Disease Control and Prevention. Downloaded from http://www.cdc.gov/cancer/breast/basic_info/screening.htm#1. March 2012.

15. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. NIH Publication No. 04-5230. August 2004. HAECID

16. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. NIH Publication No. 02-5215. September 2002.

17. The Treatment of Diarrhoea A Manual for Physicians and Other Senior Health Workers. World Health Organization (WHO). 2005.

ANNEX C1

Standards for Accreditation of PhilHealth Primary Care Package Providers

I. Service Capability

A. Preventive/Screening Services and Health Education

1. Consultation

a) Medicine

b) General Surgery

c) Obstetrics and Gynecology

d) Pediatrics

2. Visual Inspection with Acetic Acid (VIA)

3. Regular blood pressure measurements

4. Breastfeeding Program Education

5. Periodic clinical breast examination

6. Counselling for lifestyle modification

7. Counselling Smoking cessation

8. Body measurements

9. Digital rectal examination (for males)

B. Diagnostic Services

1. Complete Blood Count

2. Urinalysis

3. Fecalysis

4. Sputum microscopy

5. Fasting Blood Sugar (FBS)

6. Lipid profile

7. Chest x-ray

II. Technical Standards

A. General Infrastructure

1. Clear sign bearing the name of the health facility

2. Clear sign indicating it is a PhilHealth provider (for renewal only)

3. Large sign enumerating the health services that the facility provides including the components of the Primary Care Benefit Package

4. Generally clean environment, with prohibition for smoking

5. Adequate lighting/electric supply

6. Adequate clean water supply

7. Sufficient seating for patients in a well ventilated area

8. Examination Area aEcDTC

9. Consultation area (separate from examination area)

10. Safe area for record storage

11. Toilet

12. Adequate signages (entrance and exit)

13. Emergency Preparedness Plans (exit/evacuation plans)

14. Fire safety provision

15. Puncture proof receptacles for disposal of pointed/sharp objects

16. Properly segregated and labeled waste bins for different kinds of wastes

17. Non-slippery floors

18. Provision for hand hygiene/washing

19. Area for cleaning instruments

20. Safe storage for drugs and medicines

21. Safe storage of laboratory reagents (if applicable)

22. Well ventilated sputum collection area (if applicable)

B. Equipment and supplies

1. Non-mercurial BP Apparatus

2. Non-mercurial thermometer

3. Stethoscope

4. Weighing scale (adult)

5. Weighing scale (infant)

6. Tape measure

7. Nebulizer

8. Lubricating jelly

9. Disposable needles & syringes

10. Sterile cotton balls

11. Sterile cotton swabs

12. Applicator stick

13. Disposable gloves

14. Specimen cups/bottles

15. Sterilizer or its equivalent

16. Vaginal speculum (big)

17. Vaginal speculum (small)

18. Decontamination solutions

19. 70% Isopropyl alcohol

20. 3% to 5% Acetic acid

21. Glass slides

22. Storage cabinet for sterile instruments and supplies

C. Additional Requirements for facilities with laboratory services

1. For CBC

a) Microscope

b) Centrifuge

c) EDTA Test tube

d) Capillette

e) Blood lancets

f) pipettes

And if manual

a) Hematoxilin and Eosin stain

b) Hema color

c) Methylene blue stain

d) Microhematocrit reader

e) Hemoglobinometer kit/acid hematin

f) Comparator block

g) Differential counter

h) Hemocytometer

i) Tally counter

Or if automated

a) Hema analyzer

b) Reagents

2. For lipid profile and FBS

a) Plain test tubes THEcAS

b) Blood chemistry analyzer machine

c) Reagents

d) Centrifuge

3. For urinalysis

a) Dip stick for qualitative urine analysis

4. Fecalysis

a) Applicator stick

b) NSS

c) microscope

d) Glass Slides

e) Cover slips

5. For sputum microscopy

a) Microscope

b) Glass slides

c) Bunsen burner

d) Stains for acid fast bacilli (AFB)

D. Additional requirements for facilities with chest x-ray

1. X-ray machine

2. X-ray films

3. Developer and fixative solutions or automatic processor

E. Drugs and Medicines (Based on DOH-recommended buffer stocks)

1. For asthma

a) Inhaled corticosteroids

b) Short acting beta 2 agonists (inhalation solution or metered dose inhaler)

c) Oral or systemic corticosteroids

2. For Acute Gastroenteritis (AGE) with no or mild dehydration

a) Oral Rehydration Salts

3. For Upper Respiratory Tract Infection/Pneumonia (minimal and low risk)

a) Amoxicillin and

b) Macrolide and

c) Beta lactams with beta lactamase inhibitors and/or

d) 2nd generation cephalosporins

4. For Urinary Tract Infection

a) Oral fluoroquinolones and

b) Co-trimoxazole

III. Document Review

A. Department of Health (DOH) license for laboratory (if with laboratory services)

B. DOH license for X-ray (if with x-ray services)

C. Manual of Operations with the following:

a) Mission/Vision (Initial/Re-accreditation)

b) Organizational chart

c) Clinical Practice Guidelines/algorithm in evaluation and management of most common diseases including the following:

1. Hypertension

2. Diabetes Mellitus

3. Bronchial asthma

4. Upper Respiratory Tract infection

5. Acute Gastroenteritis

6. Community Acquired Pneumonia

7. Urinary tract infection HTaSEA

D. Records and Reports

1. Inventory of drugs and medicines

2. Inventory of reagents and chemicals

3. Copies of Certificates of training

4. Annual Statistical Report (including morbidity and mortality)

5. Maintain the following records, or its equivalent, in the health facility

a) Individual health profile in family folders (Annex A1)

b) PCB Patient Ledger (Annex A3) or its equivalent

c) Semestral Report of PCB Services Availed by PCB1-entitled Members and Dependents (Annex A5) or its equivalent

d) Consult list of non-NHIP patients with family folder in the facility

e) Logbook for daily consultation for general health services or its equivalent

f) Field Health Services Information System (FHSIS)

6. Copies of / Electronic reports submitted to PhilHealth

a) Masterlist of PCB-entitled members

b) PCB Provider clientele health profile

c) OPB Quarterly Report form

d) PhilHealth Capitation Fund utilization report

E. Copies of contracts

1. Memorandum of Agreement (MOA) with Interlocal Health Zone/Health System (if applicable) or contract for outsourced laboratory/x-ray services

2. MOA or contract with facilities with higher level of care for referral of patients

F. Manuals and Logbooks

1. Operating manuals of machine (if applicable)

2. Maintenance logbook of machines (if applicable)

3. Quality control of laboratory tests (if applicable)

IV. Human Resource

A. Licensed Doctor

B. Licensed Nurse

C. Licensed Midwife

D. Licensed Medical technologist (if with laboratory services)

E. Licensed Radiology technician (if with x-ray services)

V. Training

A. Training on visual inspection with acetic acid

B. Training on sputum microscopy (if applicable)

ANNEX C2

Guidelines for Registration as Primary Care Benefit Providers

In reference to

1. Health centers, rural health centers or barangay health stations that has a licensed physician, nurse and midwife who can provide at least four (4) hours daily service, five (5) days a week and has the capacity to provide the obligated laboratory tests of the Primary Care Benefit (PCB); CSEHcT

2. Outpatient clinics of Levels 2, 3, and 4 DOH licensed government hospitals as well as Level 1 hospitals with a Level 2 laboratory and licensed radiology service referral facilities, its updated DOH hospital license. For Level 1 government hospital MOA with a L2 hospital and radiology service, but if it has a licensed radiology service, MOA with L2 licensed hospital for the laboratory examinations.

I. Documentary Requirements

The provider shall submit all of the following:

1. Provider Data Record (PDR) completely filled-out

2. Performance Commitment (PC) signed by the City/Municipal/Provincial Health Officer and the Local Chief Executive if the provider would like to receive the Per Family Payment Rate fund (PFPR Fund)

3. For government hospitals updated DOH license, and, if applicable, the updated DOH license of the referral laboratory or radiology service provider

4. Memorandum of Agreement (MOA) if applicable, for referred services (See Annex C3)

5. Proof of payment of Registration Fee (P1,000.00)

Table 1. Schedule of Provider Fees:

6. Sanggunian Resolution or Ordinance authorizing the creation of a trust fund for all PhilHealth payments to government owned health care providers and reflecting that concerned health care providers shall manage the said trust fund in accordance with the guidelines set by the Corporation. This is optional for initial registration. However, it is mandatory for renewal and reaccreditation.

II. Engagement Process

1. All government facilities that are qualified to provide the PCB shall register by filling up the Provider Data Report (PDR) and submit the other documentary requirements stated in Part I, at the PhilHealth Regional, Branch or Service Office.

Registration and Participation documents sent through mail shall be processed at the level of the PhROs. These shall be assessed as to its completeness. Incomplete applications shall be returned/mailed back to registrant for completion. The returned registration form shall be mailed back to PhilHealth Office together with the lacking documents within thirty (30) days from receipt of the returned document. Only postal money order paid to PhilHealth shall be accepted for payment of registration fee.

2. No pre-accreditation survey shall be conducted.

3. A list of applications of PCB Providers recommended for approval of participation in the NHIP by the PhRO Accreditation Subcommittee shall be forwarded to the office of President and CEO for approval.

4. All government facilities that have submitted a signed PC as PCB Providers shall be subject to the Corporation's rules and regulations on accreditation, participation and monitoring.

5. A Certificate of Participation in the NHIP shall be issued only to providers with signed PCs.

III. Validity of Participation

1. The validity of participation for PCB providers shall start on January 1 and end on December 31 of the applicable year.

2. Renewal: Application for renewal of participation may be filed during the prescribed filing period (September 1-30) or during the incentive period (August 1-31), 1 month prior to the filing period of the current year of participation.

IV. Human Resource

1. Accreditation of the health care professional/s is/are not required, but all facility staff, regardless of employment status, is required to be PhilHealth members with updated premium contributions.

2. In case one of the required personnel can no longer deliver services for the clinic within the validity of its accreditation, the clinic management may implement the following measures:

Temporary replacement of said personnel with the same qualifications which may include arrangements within a functional Inter Local Health Zone (ILHZ); or

Temporary assignment of members assigned to the provider to another accredited PCB Provider.

The PFPR for the period of temporary assignment of members to another accredited PCB provider shall be given to the actual provider of the PCB service.

V. Alternative Options for Referral Facilities (For facilities with no laboratory and x-ray services)

1. A provider without laboratory and/nor a licensed medical technologist may participate in the NHIP as a PCB Provider provided that it has a referral system with any of the following laboratory network set-up with applicable supporting documents for validation during the survey: aDSTIC

2. A provider without x-ray services may participate in the NHIP provided that it has a referral system with any of the following x-ray network set-up with applicable supporting documents for validation during the survey:

3. The requirement of a licensed medical technologist, licensed radiologist, laboratory equipment, radiology equipment and supplies within the facility, pertinent to the delivery of the PCB is optional for clinics applying for accreditation with a functional laboratory service referral system (Tables 2 and 3).

ANNEX C3

Template Memorandum of Agreement with Other Referral Facility on Outsourced Services

KNOW ALL MEN BY THESE PRESENTS:

NAME OF PCB PROVIDER, a government office created by the Local Government of _____________, with office address at insert address, represented herein by its _______, Honorable ________________ (hereinafter, referred to as the "PCB Provider");

-and-

NAME OF REFERRAL FACILITY, a health Referral Facility (under the) _________, with office address at insert address, represented herein by its _____________, ___________ (hereinafter, referred to as the "Referral Facility").

WITNESSETH, that:

WHEREAS, there is a need to establish a partnership and referral system with other health service providers/facilities in order to improve the delivery of quality health care to patients;

WHEREAS, the Referral Facility has a diagnostic facility capable of providing up to level 2 laboratory and/or chest x-ray examination services, among others;

WHEREAS, the PCB Provider does not have a complete facility to provide laboratory and/or chest x-ray examination services to its patients and wishes its patients to be provided with the Services (defined below) by the Referral Facility;

WHEREAS, the Referral Facility agrees to provide the Services to the patients of the PCB Provider based on the terms and conditions of this Agreement;

NOW, THEREFORE, for and in consideration of the foregoing premises, the parties hereby agree as follows:

1. Key Terms

1.1. Services The Referral Facility shall provide the following services ("Services") to the patients referred by the PCB Provider in accordance with the terms and conditions of this Agreement: EaDATc

[Insert a description of the Services here]

1.2. Period of Delivery of the Services The Referral Facility shall commence the provision of the Services on insert date here and shall continue until and unless terminated by either Party.

1.3. Place of Delivery of the Services The Referral Facility shall provide the Services at the following location(s): insert details here if applicable

1.4. Price

a. As consideration for the provision of the Services by the Referral Facility, the price for the provision of the Services shall be as follows:

insert price here

b. The payment for referred diagnostic services shall be charged against the Per Family Payment Rate (PFPR) Fund of the accredited PCB Provider. It shall be the responsibility of the LGU concerned to enact the referral and payment system required therefor. These PCB-entitled members and dependents shall not incur out of pocket expenses for such services.

2. General terms

2.1. Warranty The Referral Facility represents and warrants that:

a. it will perform the Services with reasonable care and skill; and

b. the Services provided by the Referral Facility to the patients referred by the PCB Provider under this Agreement will not infringe or violate any intellectual property rights or other right of any third party.

2.2. Limitation of liability

a. Either party's liability in contract, tort or otherwise (including negligence) arising directly out of or in connection with this Agreement or the performance or observance of its obligations under this Agreement and every applicable part of it shall be limited in aggregate to the Price of the Services.

b. Nothing in this Clause will serve to limit or exclude either Party's liability for death or personal injury arising from its own negligence.

2.3. Termination Either Party may terminate this Agreement upon notice in writing if:

a. the other is in breach of any material obligation contained in this Agreement, which is not remedied (if the same is capable of being remedied) within 30 days of written notice from the other Party so to do; or

b. a voluntary arrangement is approved, a bankruptcy or an administration order is made or a receiver or administrative receiver is appointed over any of the other Party's assets or an undertaking or a resolution or petition to wind up the other Party is passed or presented (other than for the purposes of amalgamation or reconstruction) or any analogous procedure in the country of incorporation of either party or if any circumstances arise which entitle a court of competent jurisdiction or a creditor to appoint a receiver, administrative receiver or administrator or to present a winding-up petition or make a winding-up order in respect of the other Party. aSEDHC

Any termination of this Agreement (howsoever occasioned) shall not affect any accrued rights or liabilities of either Party nor shall it affect the coming into force or the continuance in force of any provision hereof which is expressly or by implication intended to come into or continue in force on or after such termination.

2.4. Relationship of the Parties The Parties acknowledge and agree that the Services performed by the Referral Facility, its employees, agents or sub-contractors shall be as an independent contractor and that nothing in this Agreement shall be deemed to constitute a partnership, joint venture, agency relationship or otherwise between the parties.

2.5. Confidentiality Neither Party will use, copy, adapt, alter, or part with possession of any information of the other which is disclosed or otherwise comes into its possession under or in relation to this Agreement and which is of a confidential nature. This obligation will not apply to information which the recipient can prove was in its possession at the date it was received or obtained or which the recipient obtains from some other person with good legal title to it or which is in or comes into the public domain otherwise than through the default or negligence of the recipient or which is independently developed by or for the recipient.

2.6. Notices Any notice which may be given by a Party under this Agreement shall be deemed to have been duly delivered if delivered by hand, registered mail, facsimile transmission or electronic mail to the address of the other Party as specified in this Agreement or any other address notified in writing to the other Party.

2.7. Miscellaneous

a. The failure of either party to enforce its rights under this Agreement at any time for any period shall not be construed as a waiver of such rights.

b. If any part, term or provision of this Agreement is held to be illegal or unenforceable, neither the validity nor enforceability of the remainder of this Agreement shall be affected.

c. Neither Party shall assign or transfer all or any part of its rights under this Agreement without the consent of the other Party.

d. This Agreement may not be amended for any other reason without the prior written agreement of both Parties.

e. This Agreement constitutes the entire understanding between the Parties relating to the subject matter hereof unless any representation or warranty made about this Agreement was made fraudulently and, save as may be expressly referred to or referenced herein, supersedes all prior representations, writings, negotiations or understandings with respect hereto.

f. Neither Party shall be liable for failure to perform or delay in performing any obligation under this Agreement if the failure or delay is caused by any circumstances beyond its reasonable control, including but not limited to acts of God, war, civil commotion or industrial dispute. If such delay or failure continues for at least 7 days, the Party not affected by such delay or failure shall be entitled to terminate this Agreement by notice in writing to the other.

g. This Agreement shall be governed by existing Philippine laws, rules and regulations and the parties agree to submit disputes arising out of or in connection with this Agreement to arbitration before invoking the jurisdiction of the courts.

IN WITNESS WHEREOF, the parties have signed this Agreement on ___________________________ at ____________________.

ACKNOWLEDGEMENT

REPUBLIC OF THE PHILIPPINES}
} S.S.

BEFORE ME, a Notary Public for and in the above jurisdiction this ____ day of ______________ personally appeared:

who appear to me in person and present an integrally complete instrument or document; and, who represent to me that the signatures on the instrument or document, consisting of _____ (___) pages, including this page where the acknowledgement is written, was voluntarily affixed by them for the purpose/s stated in the instrument or document; and declare that they have executed the instrument or document as their free voluntary act and deed, and, if they act in a particular representative capacity, that they have the authority to sign in that capacity.

WITNESS MY HAND AND SEAL on the date and at the place above written.

NOTARY PUBLIC

Doc. No. _____;

Page No. _____;

Book No. _____;

Series of ____.

ANNEX D

Performance Commitment
(Letterhead of Healthcare Provider)

20 March 2012

PHILIPPINE HEALTH INSURANCE CORPORATION
17th Flr., City State Centre Bldg.,
Shaw Blvd., Pasig City

SUBJECT : Performance Commitment for Primary Care Benefit 1 (PCB 1) Provider

Sir/Madam:

This letter of undertaking is being submitted to guarantee our commitment to the National Health Insurance Program (NHIP).

For this purpose, we hereby warrant the following representations:

1. That we are capable of delivering the services expected from the type of healthcare provider that we are applying for.

2. That we are owned by ___________________ and managed by ___________________ and doing business under the name of __________________.

3. That all healthcare professionals in our facility have proper credentials and given appropriate privileges in accordance with our policies and procedures.

4. That we have a signed agreement with our professionals relative to payments of their PhilHealth reimbursements, when applicable.

5. That our officers, employees, other personnel and staff are members in good standing of the NHIP.

Further, we hereby commit ourselves to the following:

6. 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

7. That we shall promptly inform PhilHealth prior to any change in the ownership and/or management of our institution. CScTDE

8. 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

9. That we shall maintain active membership in the NHIP 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 healthcare institution.

10. 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.

11. 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 the NHIP.

12. We commit to ensuring sustainability of our participation in the NHIP by securing applicable licenses/certification/accreditation from concerned agencies.

13. That we shall adhere to pertinent statutory laws affecting the operations of IHCPs including but not limited to the Expanded Senior Citizens Act of 2003 (R.A. 9257), the

14. 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.

15. That we shall deliver the Primary Care Benefit Package 1 services for the duration of the validity of this commitment.

As PCB Provider,

15.1 That we shall be responsible to seek and enlist eligible members and their qualified dependents in our community assigned to our facility.

15.2 That we shall establish a baseline health profile of all PhilHealth members and qualified dependents using Annex A.1 of the PCB 1 Circular, which shall be kept and updated regularly by our facility.

15.3 That we shall submit a consolidated profile of our clientele using PCB Clientele Profile as a documentary requirement for the release of Per Family Payment Rate (PFPR).

15.4 That we shall deliver the services specified in the circular to respond to the health needs of the clientele of our facility.

15.5 That in case there is/are diagnostic examination(s) outsourced from another facility, we shall forge a Memorandum of Agreement (MOA) to ensure quality checks and appropriate processes are provided.

15.6 That we shall abide by the performance targets on the minimum obligated services for all members assigned in our facility set by the Corporation.

15.7 That we shall create/maintain a trust fund for PFPR fund.

15.8 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:

1) Minimum of forty percent (40%) for drugs and medicines (PNDF) (to be dispensed at the facility) including drugs and medicines for Asthma, AGE and pneumonia

2) Maximum of forty percent (40%) for reagents, medical supplies, equipments (i.e., ambulance, ambubag, stretcher, etc.), information technology (IT equipment specific for facility use needed to facilitate reporting and database build up), capacity building for staff, infrastructure or any other use related, necessary for the delivery of required service including referral fees for diagnostic services if not able in the facility ECSaAc

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:

1) Ten percent (10%) for the physician

2) Five percent (5%) for other health professional staff of the facility

3) Five percent (5%) non-health professional/staff, including volunteers

16. That we shall provide and charge to the PhilHealth benefit of the client the necessary services including but not limited to drugs, medicines, supplies, devices, and diagnostic and treatment procedures for our PhilHealth clients.

17. That we shall provide the necessary drugs, supplies and services with no out-of-pocket expenses on the part of the members as contained in PhilHealth's 'No Balance Billing' (NBB) Policy.

18. That we shall maintain a high level of service satisfaction among PhilHealth clients including all their qualified beneficiaries.

19. That we shall be guided by PhilHealth-approved clinical practice guidelines or if not available established and accepted standards of practice.

20. 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.) in conspicuous places accessible to patients, members and dependents of the NHIP within our healthcare facility.

21. That we shall always make available the necessary forms for patient's use.

22. That we shall ensure that clients with needs beyond our service capability are referred to appropriate health facilities participating in NHIP.

23. That we shall maintain a registry of all our clients/patients (including newborns) as provided by the appropriate issuance, which shall be made available to PhilHealth or any of its authorized personnel.

24. That we shall ensure that true and accurate data are recorded/encoded in all patients' records.

25. That we shall regularly submit PhilHealth monitoring reports as required in PhilHealth circulars.

26. 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 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 participating IHCP of 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.

27. 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 participating IHCP of the NHIP.

28. That at any time during the period of our participation in the NHIP, upon request of PhilHealth, we shall voluntarily and unconditionally 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.

29. That 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.

30. That we shall comply with PhilHealth's summons, subpoena, subpoena 'duces tecum' and other legal or quality assurance processes and requirements.

31. 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 assessment(s) at any time relative to the exercise of our privilege and conduct of our operations as participating IHCP of the NHIP.

32. That we shall comply with the corrective actions given after monitoring activities within the prescribed period.

33. 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 to the NHIP.

34. That we shall not directly or indirectly engage in any form of unethical or improper practices as NHIP Benefit 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.

35. That we shall immediately report to PhilHealth, its officers and/or to any of its personnel, any act(s) of illegal, improper and/or unethical practices of IHCP of the NHIP that may have come to our knowledge directly or indirectly.

36. We agree that PhilHealth may deduct from our future payments, all reimbursements paid to our institution during the period of its non-participating status as a result of a gap in validity of our DOH license, suspension of participation, etc.; downgrading of level, loss of license for certain services including any and all other fees due to be paid to PhilHealth.

Furthermore, recognizing PhilHealth's indispensable role in the NHIP, we hereby acknowledge the power and authority of PhilHealth to do the following:

37. 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 of the commitment for any violation of any provision of this Performance Commitment. HcSETI

38. To suspend, shorten, pre-terminate and/or revoke our privilege of participating in the NHIP including the appurtenant benefits and opportunities incident thereto at any time 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 illegal, irregular or improper and/or unethical conduct of our operations.

39. To deny our participation in the NHIP should there be a case, regardless of the nature thereof, filed by us against PhilHealth, its Officers and/or any of its Personnel. Provided that, if in the discretion of PhilHealth, the specific nature of the case is such that it will not directly or indirectly affect a healthy business relationship with us, PhilHealth, upon the recommendation of the Accreditation Committee, may favorably consider the approval of our participation.

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.

Footnotes

1. DOH Administrative Order No. 2010-0036. The Aquino Health Agenda: Achieving Universal Health Care for All Filipinos.

2. DOH Department Order No. 2011-0188. Kalusugang Pangkalahatan Execution Plan and Implementation Arrangements.

3. The following services may be provided by the PCB facility or outsourced to another facility under a Memorandum of Agreement (MOA).

4. Organized Group as defined by the Membership Management Group.