Legal basis and policy intent
- The circular is issued pursuant to PhilHealth Board Resolution Nos. 485 and 490, s. 2002.
- The circular mandates inclusion of an Outpatient Anti-tuberculosis or Directly Observed Treatment Short-course (DOTS) Benefits Package in PhilHealth’s Benefits Package.
- The circular is intended to accomplish PhilHealth’s mandate of providing accessible quality health care services to all its members.
Definitions and program structure
- The DOTS Benefits Package is an outpatient benefit package for anti-tuberculosis treatment under the Directly Observed Treatment Short-course (DOTS) model.
- The benefit package is structured around two treatment phases: the intensive phase and the maintenance phase.
- The end of the intensive phase is considered the date of treatment for purposes of the first payment timing.
- The end of the maintenance phase is considered the date of treatment for purposes of the final payment timing.
Benefit amount and what it covers
- A flat rate of PHP 4,000 per case is paid to an accredited DOTS facility in two separate payments.
- The first payment is PHP 2,500 paid after the accredited DOTS center completes the intensive phase.
- The second payment is PHP 1,500 paid after the DOTS center completes the maintenance phase.
- The DOTS facility’s PHP 4,000 covers diagnostic work-up consultation services and anti-TB drugs the patient requires in an outpatient set-up.
- Payment for referral centers, physicians, and other health care workers is settled by the referring DOTS center, not by PhilHealth under this package.
- PhilHealth does not pay for additional services rendered or for an extension of treatment.
- Claim applications by accredited DOTS centers are covered by the Corporation’s ICD-10 requirements.
Eligibility and covered TB cases
- The DOTS Benefits Package is available to all members and qualified dependents of the NHIP who satisfy benefit eligibility criteria and are not disqualified by the exclusion criteria.
- The DOTS package is designed for new cases of pulmonary and extrapulmonary tuberculosis for children and adults.
- A new case is a patient who has never had treatment for TB or who has taken antituberculosis drugs for less than one month.
- PhilHealth excludes the following TB cases from coverage:
- Failure case: a patient who, on previous treatment, is sputum smear positive at five months or later during the course of treatment.
- Relapse case: a patient previously treated for tuberculosis who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive (smear or culture) tuberculosis.
- Return after default (RAD) case: a patient who returns to treatment with positive bacteriology (smear or culture) following interruption of treatment for two months or more.
- Beneficiary eligibility also requires the following contribution and enrollment conditions based on membership type:
- Employed and Individually Paying Program (IPP): three (3) months of contributions must have been paid within the immediate six (6) month period prior to enrollment at the DOTS center.
- Sponsored (Indigent), Pensioner, and Overseas Filipino Worker: eligibility is subject to enrollment at the DOTS center starting within the date of effectivity of membership shown in the ID Card/Eligibility Certificate.
- 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 stated in the ID Card/Eligibility Certificate.
Provider accreditation and prospective application
- Providers of the DOTS benefits package are outpatient clinics duly accredited by PhilHealth.
- Only facilities duly certified by the Philippine Coalition Against Tuberculosis (PhilCAT) may apply for DOTS accreditation.
- DOTS facility accreditation is prospective.
- PhilHealth does not compensate DOTS facilities for claims where the intensive phase were completed prior to the accreditation of the DOTS facility.
- Accredited providers must have computers and access to the Internet to comply with electronic patient registration requirements.
Reimbursement claims process and timelines
- Accredited DOTS centers must submit a copy of the NTP Treatment Card (for enrolled PhilHealth beneficiaries) or register beneficiaries in the TB Management Information System of the Quality Assurance Research and Policy Development Group (QARPDG) within sixty (60) days of the patient’s enrollment to the program.
- For reimbursement, 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).
- Submissions must be made to either the Claims Department at the Central Office or the PhilHealth Regional Office.
- Payment to DOTS centers is made within sixty (60) days upon submission of complete requirements.
- Claims with incomplete requirements are returned to the health facility.
- Returned claims must be complied with within sixty (60) days from receipt of the notice; failure to comply causes denial of the claim.