Objectives of the Accreditation Process
- Establish an efficient and streamlined accreditation process for NHIP health care professionals.
- Strengthen monitoring systems for accredited professionals.
- Recommend guidelines for credentialing and privileging within health care institutions.
Scope of Application
- Applies to all health care professionals involved or intending to participate in NHIP: physicians, dentists, midwives, and others as determined by PhilHealth.
- Also applicable to affiliated health care institutions.
Key Definitions
- Affiliation: acceptance of a health care professional by an institution granting practice privileges.
- Continuous Accreditation: annual compliance-based accreditation allowing uninterrupted NHIP participation subject to revocation.
- Credentialing: institutional process for assessing and verifying health care professional qualifications.
- Performance Commitment (PC): a binding document where professionals pledge to provide quality services and comply with PhilHealth policies.
- Privileging: granting of appropriate practice rights based on credentials and institutional policies.
General Guidelines on Accreditation
- Licensed professionals are automatically accredited upon submission of required documents, including signed PC.
- Accreditation authority largely delegated to PhilHealth Regional Offices and Accreditation Committee.
- Continuous accreditation institutionalized, valid up to three years based on premium payment.
- Professionals must declare membership in accredited national associations and specialty societies.
- Credentialing and privileging mandated within affiliated institutions.
- Removal of requirements for accreditation fee and certificate of good standing; database inclusion suffices.
- Deadlines for document submission enforce continuous accreditation; failure leads to withdrawal.
Credentialing and Privileging Responsibilities
- Professionals must submit accurate, valid credentials and maintain standing with recognized organizations.
- Health care institutions develop and implement credentialing and privileging policies verifying education, licensure, training, experience.
- Institutions maintain records and contracts of credentialed professionals and allow PhilHealth audit.
- Institutions encouraged to enroll and encourage PhilHealth membership among resident and contracted physicians.
- Institutions accountable for affiliated professional compliance; violations impact institution's accreditation status.
- Conflict of interest provisions apply for professionals involved in credentialing committees.
- PhilHealth verifies credentials during provider monitoring and may withdraw institutional accreditation for noncompliance.
Grounds for Withdrawal of Continuous Accreditation
- Failure to submit required documents timely.
- Quality or ethical issues officially endorsed by national or specialty associations after due process.
- Other corporate-determined reasons.
Monitoring and Evaluation of Professionals
- Accredited institutions assist PhilHealth in practice monitoring.
- Monitoring includes service utilization, appropriateness of procedures and referrals, drug use, safety, ethics.
- Feedback mechanisms inform professionals of findings; negative findings prompt peer review.
- Sanctions, including warnings and penalties, apply after repeated offenses.
- Violations also reported to professional regulatory bodies for further action.
Sanctions and Penalties
- Violations of this Circular, Performance Commitment, or related directives are subject to penalties under RA 7875 (as amended) and IRR.
Repealing Clause
- Inconsistent prior PhilHealth issuances are revised or repealed.
- Unaffected provisions remain in force.
Effectivity
- Effective 15 days after publication in a newspaper of general circulation.
- Applicable to all accreditation applications from the effective date onwards.