Question & AnswerQ&A (PHIC PHILHEALTH CIRCULAR NO. 010, S. 2014)
The main objective is to establish a streamlined and effective process for accrediting health care professionals for the National Health Insurance Program (NHIP), strengthen the monitoring system for PhilHealth accredited health care professionals, and recommend guidelines for health care institutions in credentialing and privileging of health care professionals.
All health care professionals currently participating or intending to participate in the NHIP, including physicians, dentists, midwives, and other health care professionals as determined by PhilHealth, as well as the health care institutions where these professionals are affiliated.
Affiliation is the process by which a health care institution accepts a health care professional as part of their health human resource and provides the health care professional with practice privileges in their health care institution.
Continuous accreditation is given to accredited health care providers under basic participation provided they annually comply with requirements prescribed by PhilHealth. It allows uninterrupted participation in the NHIP but may be withdrawn anytime based on Corporation rules.
They must submit the required documents outlined in Annex A of the Circular, including a signed Performance Commitment, among others, to the nearest PhilHealth office.
The Performance Commitment is a document signed by health care professionals indicating their undertaking to provide complete and quality health services to PhilHealth members and dependents and to comply with PhilHealth policies on payments, data management, reporting, and referrals.
Health care institutions must verify credentials of professionals from primary sources, conduct credentialing and privileging of affiliated professionals, mandate updating PhilHealth accreditation, keep records, allow PhilHealth to review documents, and ensure compliance with PhilHealth policies.
Non-submission of required documents on time, official declarations on quality or ethical issues endorsed by national associations or specialty societies after due process, and other reasons as determined by the Corporation.
Violations are dealt with under the provisions of RA 7875 (the National Health Insurance Act), as amended by RA 10606, and its Implementing Rules and Regulations, including sanctions outlined in the Performance Commitment and other related PhilHealth issuances.
Health care professionals may apply any time during the year, submitting complete requirements and paying premium contributions for the applicable quarters plus one or two years. Accreditation validity starts on the date of submission and ends the day before their birthday.
PhilHealth monitors practices through provider performance monitoring and other quality assurance activities, checking for unethical practices, over-utilization, inappropriate referrals, and compliance with standards. Findings affect the professional and affiliated institution's accreditation and may trigger sanctions.
Privileging is the process by which health care institutions grant appropriate practice privileges or benefits to affiliated health care professionals based on their credentials, qualifications, and status.
No. Payment of accreditation fees and certificates of good standing from national associations or specialty societies are no longer required. However, professionals must be listed in their respective associations or societies' databases as declared in the Performance Commitment.
They must ensure all their credentials are legitimate, valid, and updated, maintain good standing with PRC-recognized professional organizations, and submit credentials to affiliated health care institutions for credentialing and privileging.