QuestionsQuestions (PHIC PHILHEALTH CIRCULAR NO. 19, S. 2003)
It is an outpatient TB (anti-tuberculosis) DOTS benefit package included in PhilHealth’s benefits, providing a flat rate payment to accredited DOTS facilities to cover diagnostic work-up, consultation services, and the anti-TB drugs required for eligible beneficiaries in an outpatient setting.
A flat rate of PHP 4,000 per case is paid to an accredited DOTS facility in two separate payments: PHP 2,500 after completion of the intensive phase, and PHP 1,500 after completion of the maintenance phase.
The end of the intensive phase is considered as the date of treatment, and the first payment (PHP 2,500) is paid after that phase is completed.
The end of the maintenance phase is considered as the date of treatment, and the final payment (PHP 1,500) is paid after the maintenance phase ends.
No. The Circular states that PhilHealth shall not pay for additional services rendered or for an extension of treatment.
It is designed for new cases of pulmonary and extrapulmonary tuberculosis for children and adults.
A patient who has never had treatment for TB or has taken antituberculosis drugs for less than one month.
PhilHealth shall not cover: (a) Failure case (sputum smear positive at five months or later in previous treatment), (b) Relapse case (previously treated and later diagnosed bacteriologically positive), and (c) Return after default/RAD case (returns with positive bacteriology after interruption of treatment for two months or more).
For employed and IPP, at least three (3) months of contributions must have been paid within the immediate six (6) months prior to enrollment at the DOTS Center.
All PHIC beneficiaries, regardless of membership type, must have their monthly premium paid during the duration of DOTS treatment.
Enrollment at the DOTS Center must start within the date of effectivity of membership as stated in the ID Card/Eligibility Certificate.
Only outpatient clinics duly accredited by PhilHealth may be providers, and only facilities certified by the Philippine Coalition Against Tuberculosis (PhilCAT) may apply for accreditation. Accreditation is prospective.
Claims for DOTS facilities where the intensive phase was completed prior to accreditation shall not be compensated.
Accredited DOTS centers must submit a copy of the NTP Treatment Card of enrolled PhilHealth beneficiaries or register them to the TB Management Information System of the QARPDG within sixty (60) days of the patient’s enrolment.
A copy of the updated NTP Treatment Card together with the DOTS Claim Form must be submitted within sixty (60) days upon completion of each treatment phase (intensive and/or maintenance phase).
They must be submitted to the Claims Department at the Central Office or the PhilHealth Regional Office.
Payment is made within sixty (60) days upon submission of complete requirements. Claims with incomplete requirements shall be returned to the health facility and must be complied within sixty (60) days from receipt of notice; failure to comply causes denial of the claim.
The package takes effect for DOTS care provided in PhilHealth-accredited facilities where the date of treatment of the intensive phase is on or after May 21, 2003.