Law Summary
Eligibility Criteria
- The package is available to all National Health Insurance Program (NHIP) members and qualified dependents meeting eligibility and not excluded.
- It covers new cases of pulmonary and extrapulmonary TB in adults and children.
- "New cases" are defined as patients with no TB treatment history or less than one month of prior anti-TB medication.
- Exclusions include failure cases, relapse cases, and return after default (RAD) cases:
- Failure case: Sputum smear positive after 5 months of treatment.
- Relapse case: Previously treated and cured/completed, now again bacteriologically positive.
- RAD case: Interrupted treatment for 2 months or more with positive bacteriology upon return.
- Eligibility by membership type:
- Employed and Individually Paying Program (IPP): minimum 3 months paid contributions within the last 6 months before enrollment.
- Sponsored (Indigent), Pensioner, and Overseas Filipino Worker (OFW): enrollment effective from membership date on ID/eligibility certificate.
- Monthly premiums must be current throughout the treatment duration.
Reimbursement Process
- Accredited DOTS centers must register enrolled PhilHealth beneficiaries via the National Tuberculosis Program (NTP) Treatment Card or the TB Management Information System within 60 days from enrollment.
- For claims, centers must submit updated NTP Treatment Cards and DOTS Claim Forms within 60 days after completing each phase of treatment.
- Payments are processed within 60 days after submission of complete documents.
- Claims with incomplete requirements will be returned with a 60-day compliance period; failure to comply results in claim denial.
Provider Accreditation and Requirements
- Providers must be outpatient clinics accredited by PhilHealth and certified by the Philippine Coalition Against Tuberculosis (PhilCAT).
- Accreditation is prospective; claims for treatments completed before accreditation are not payable.
- Facilities must have computer and internet access to comply with electronic patient registration requirements.
Effective Date
- The package applies to DOTS care where the intensive phase treatment date is on or after May 21, 2003.
- Existing relevant issuances inconsistent with this circular are superseded while others remain effective.
These provisions ensure structured, accessible, and accountable outpatient tuberculosis treatment under the PhilHealth framework.