Objectives of the Circular
- Expand coverage to all first-line drug sensitive TB cases, including new and retreatment groups.
- Align the benefit package with updated TB control policies.
- Strengthen financial incentives for healthcare providers to promote better outcomes.
Scope and Coverage
- Benefit covers outpatient TB cases sensitive to first-line anti-TB drugs.
- Includes diagnostic exams, consultation, medication, health education, and counseling.
- Registration groups covered: new cases and retreatment types (relapse, failure, return after default, unknown previous treatment).
- Excludes inpatient admissions, drug-resistant TB, and latent TB infection.
- Provides separate claims for TB and HIV programs for patients co-infected with HIV under treatment.
Benefit Package Details and Payment Scheme
- Fixed case rate of Php 4,000 per TB case, paid in two phases:
- Php 2,500 after the intensive treatment phase.
- Php 1,500 after the continuation (maintenance) phase.
- Referring physicians’ fees and expenses for services done outside the facility are borne by the facility.
Provider Accreditation Requirements
- TB-DOTS providers must be accredited under PhilHealth’s Provider Engagement policies.
- Submission of performance commitments, facility data, accreditation fees, certificates, and updated DOH PhilCAT certificates is compulsory.
- Annual submission of updated documents to maintain accreditation.
- Physicians providing TB DOTS services must individually be accredited with PhilHealth as health professionals.
Claims Filing and Reimbursement
- Claims payable only to accredited TB DOTS facilities.
- Approved claims must correspond to outcomes: cured, completed treatment, died, or treatment failed.
- Claims denied if outcome is lost to follow-up or not evaluated.
- Claims for cases initially on first-line drugs but later found drug-resistant are paid.
- Referral claims must be filed by the referring facility; receiving facilities can't claim.
- TB DOTS claims do not reduce the 45-day annual inpatient benefit limit.
- No balance billing policy applies.
- Claims must be submitted within 60 days after each treatment phase.
- Eligibility requires 3 months premium payment within 6 months prior to treatment phase start.
- Claims with incomplete or inconsistent documentation may be returned or denied after specified deadlines.
Allocation of Funds and Use of Reimbursements
- Public facilities must maintain a trust fund for PhilHealth reimbursements with separate ledgers for TB DOTS funds.
- Allocation guidelines (if none exist) suggest: 40% facility fee, 25% referring physician fee, and 35% health staff services.
- Facility fees cover operational costs, equipment, diagnostics, quality assurance, training, and advocacy.
- Health staff fees are pooled and distributed among personnel directly involved in TB care.
- Facilities must set their own distribution policies, approved by governing authorities, based on expertise and involvement.
Monitoring and Evaluation
- PhilHealth conducts M&E using its framework.
- Public facilities must provide proof of trust fund creation and allocation guidelines.
- Patient records must be maintained and accessible for monitoring purposes.
Effectivity and Repeal
- The circular took effect 15 days post-publication.
- All new and retreatment cases commencing treatment on or after effectivity must comply.
- Previous inconsistent issuances are repealed or amended accordingly.
Annexes
- Definitions of key terms.
- ICD-10 TB codes.
- Instructions and sample forms for claims filing.