QuestionsQuestions (PHIC PHILHEALTH CIRCULAR NO. 010, S. 2014)
It is anchored on new PhilHealth policies, including the Implementing Rules and Regulations of RA 10606 (amending RA 7875, the National Health Insurance Act of 1995), and related payment policy changes (e.g., the All Case Rates Policy No. 1 / PhilHealth Circular No. 31 s. 2013). The circular’s rationale is to reform accreditation to support Universal Health Care, streamline processes, and comply with the Anti-Red Tape Act (RA 9485).
It applies to physicians, dentists, midwives, and other health care professionals as determined by PhilHealth. It also applies to the health care institutions where these professionals are affiliated.
Affiliation is when an institution accepts a professional as part of its health human resource and grants practice privileges in that institution. Continuous accreditation is uninterrupted NHIP participation subject to annual compliance until withdrawn. Credentialing is the institution’s process to verify and assess applicants’ qualifications for affiliation. PC is a document signed by participating professionals detailing undertakings to provide complete/quality services and comply with PhilHealth policies (benefits payment, IT, data, reporting, referral, etc.). Privileging is the institution’s process of granting appropriate practice privileges based on status, credentials, or qualifications.
Licensed health care professionals by the PRC—specifically physicians, midwives, dentists, and other professionals as determined by PhilHealth—are automatically accredited, provided they submit the required documents (Annex A), including the signed Performance Commitment (PC), to the nearest PhilHealth office.
It delegates processing of applications and updating profiles in PhilHealth database to PhilHealth Regional Offices (PROs), delegates approval/denial of motions for reconsideration (including unresolved accreditation issues referred by PROs) to the Chairperson of the Accreditation Committee, and institutionalizes continuous accreditation subject to withdrawal rules.
They may apply at any time of the year. They may pay premium contributions for the remaining applicable quarter(s) of the current year plus one year or plus two years. Accreditation validity starts from the day of submission of complete requirements and ends one day prior to the professional’s birthday. For continuous accreditation, validity must be minimum 1 year and maximum 3 years based on chosen premium payment period.
Validity begins on the day of submission of complete requirements and ends one day prior to the professional’s birthday.
No. Payment of accreditation fee and certificate of good standing from the national association/specialty society are no longer required for accreditation application. However, their names must be reflected in the database of the declared association/society in the PC.
All health care professionals must declare membership in a national association that is an Accredited Professional Organization by PRC. Physicians must also declare membership in a specialty society recognized by the Philippine Medical Association. These associations/societies are tied to continuing education and professional regulation.
They must sign and submit the Performance Commitment (Annex B) on their subsequent application for continuous accreditation. For continuous accreditation, they must submit documentary requirements not later than 45 days prior to their birthday; failure results in withdrawal of continuous accreditation.
They must immediately inform PhilHealth of changes in their Personal Data Record (Annex C) so PhilHealth can update its database.
Professionals must submit credentials to their affiliated institutions, ensure credentials are legitimate, valid, and updated, and maintain good standing with PRC-recognized professional organizations.
Among others: medical/professional schools accredited by CHED, PRC, training hospital/institution, specialty board, national association of health care professionals, and other hospital affiliations of the professional.
Current license; education and training; experience, ability, and current competence.
The accredited HCI that conferred privileges is held accountable to PhilHealth for reports of noncompliance, including quality of health delivery. Violations of the PC committed by the professional may be counted against the HCI; the HCI may be issued offense warnings and face penalties/sanctions per PhilHealth IRR and related issuances after due process.
PhilHealth verifies during provider performance monitoring and other quality assurance activities, and may validate document authenticity with issuing offices as deemed necessary. PhilHealth may also withdraw accreditation of an HCI that does not conduct credentialing and privileging.
Non-submission of all required documents on the prescribed filing period; official declaration on quality/ethical issues endorsed by the national association after due process; official declaration on quality/ethical issues endorsed by the specialty society (for physicians) after due process; and other reasons determined by PhilHealth.
Includes over-utilization of services; unnecessary diagnostic and therapeutic procedures; irrational medication and prescriptions; inappropriate referral practices; grossly unjustified deviations from accepted standards/treatment protocols; use of fake/adulterated/misbranded pharmaceuticals or unregistered drugs; use of drugs other than those in the latest PNF or without exemptions; unsafe practices (e.g., use of unsterilized instruments); and unethical/questionable practice patterns.
Negative findings are subject to peer review through the QAC; results may constitute an offense/PC violation. Findings are reported to relevant bodies (including PRO legal unit actions, and potentially national association/specialty society, PMA, PRC). Three offenses trigger sanctions consistent with the provisions referenced in the PC 54 s. 2012 framework. Professionals and HCIs involved may face penalties as determined by PhilHealth.
Violations are handled according to RA 7875 as amended by RA 10606 and its IRR. The circular provides that any violation of the circular, PC terms, and related PhilHealth issuances will be dealt with in accordance with the pertinent provisions of these laws and implementing rules.