PhilHealth Hospital Accreditation Guidelines

Policy focus: quality access through accreditation

Accreditation processing is designed to ensure access to quality health care for PhilHealth members.
Accreditation decisions are tied to evaluation of pre-accreditation survey findings and monitoring findings on provider performance.
Hospital accreditation outcomes reflect compliance with benchbook standards of accreditation for hospitals.
The circular requires integration of critical status changes through database file updates tied to documentary proof and licensing validity.

Applications and required documentation

The circular recognizes multiple types of accreditation applications, each with its own documentary requirements.
Initial Accreditation applies to a hospital with no previous accreditation.
Renewal of Accreditation applies to a hospital with active accreditation that filed within the incentive or prescribed filing period, and also to late filers that filed beyond the prescribed filing period but before expiry of accreditation.
Re-accreditation applies when a previous accreditation has lapsed regardless of the length of gap, when a previous renewal application was denied, and when changes trigger re-accreditation needs.
The circular expressly provides “Upgrading” and other re-accreditation triggers, including:
- Level of Hospital Service Capability upgrade to Level 2, 3, or 4;
- Upgrading via accreditation award;
- Transfer of location;
- Increase in accredited beds;
- Additional services (e.g., dialysis service, chemotherapy, CT scan, etc.);
- Change in ownership; and
- Resumption of operation after closure/cease of operation.
Documentary requirements for re-accreditation triggered by change in ownership include proof of ownership consisting of:
- SEC/DTI Certificate; and
- MOA/Deed of Sale/etc.

Renewal, re-accreditation, and effectivity rules

Renewal application filing timing defines eligibility and potential gaps, distinguishing between:
- On-time renewals within the prescribed period; and
- Late filers that filed after the prescribed period but before accreditation expiry.
Renewal applications with concomitant status changes (including bed capacity, hospital level, additional services, transfer of location, change in ownership) take effect on May 1 of the applicable accreditation year.
Such renewal-with-changes applications are considered renewal of accreditation, and require submission of applicable documentary requirements for re-accreditation for each scenario.
If a hospital prefers an earlier date of effectivity of the change, it must file a separate application for re-accreditation.
Hospitals must file applications together with Statements of Intent (SOI) indicating:
- The preferred start date of accreditation; and
- Acceptance of downgrading of accreditation if it does not qualify for the award applied for.
Once an application is received and stamped complete by the Corporation, the SOI shall no longer be changed.
A hospital applying for renewal may change the accreditation award applied for prior to the pre-accreditation survey and before March 31 of the current year; if it does:
- It must submit a letter of intent to the concerned PhilHealth Regional Office; and
- It must file another application for re-accreditation (upgrading) and pay the corresponding regular application fee,
- and the previously paid renewal application fee is forfeited.
After application award change under this rule, the validity of accreditation starts on May 1 of the applicable accreditation year.
Accredited hospitals applying for re-accreditation due to increase in beds, additional services, or change in ownership are not required to undergo a pre-accreditation survey.

Critical file updates and database incorporation

The Corporation must incorporate certain hospital status information in the accreditation database upon receipt of the corresponding documentary requirements.
Critical file updates include:
- Downgrading of hospital category (e.g., L2 to L1, L4 to L3, etc.);
- Decrease in accredited beds;
- Change in validity of accreditation as reflected in the DOH-OSS license;
- Reduction in service capability (e.g., removal of dialysis service); and
- Change in name of IHCP.
Critical file update documentation requires:
- For downgrading, bed decreases, DOH-OSS validity changes, service capability reductions: the corresponding documentary requirements tied to the update category; and
- For change in name of IHCP: a Letter of Intent (LOI) indicating the date of effectivity and DOH license/SB resolution for LGU/Provincial Health Board Resolution indicating the change in name of the hospital.
The circular also mandates critical file updates for:
- Change in medical director/head of the facility (LOI indicating effectivity date and appointment paper/board resolution or its equivalent); and
- Termination of accreditation due to closure/cease of operation (validation report of PhRO and of operation, and notice of closure if available).
Critical file updates take effect as follows:
- Updates 1, 2, 3, and 4 take effect based on the date indicated in the DOH license;
- Updates 5 and 6 take effect on the date of the conduct of the PhRO Accreditation Subcommittee Meeting or on the date reflected in the LOI; and
- Update 7 takes effect on the date of actual closure of the hospital.
Critical file updates do not require application fees and survey.

Survey conduct and compliance mechanics

Each survey team must have at least two (2) surveyors.
Under DOH licensing requirements (Annex A of Department Memorandum No. 2010-0081 on ramps and corridors), ramp requirements apply only when the hospital is:
- A new hospital, or
- An existing hospital that underwent expansion, upgrading involving physical plant/facility, or transfer of site after March 24, 2010;
  otherwise, the ramp evidence is marked N/A in the self-assessment and survey tools.
A provisionally accredited hospital may be re-surveyed only after it is granted provisional accreditation.
Correction of deficiencies requiring only documentary proof (licenses, permits, certifications, written policies for current practices, etc.) no longer requires a re-survey; the hospital submits copies of the documents to PhilHealth.
Document review for compliance using materials like medical charts is limited to those dated at least one (1) week after the last day of the previous pre-accreditation survey and onwards.

Decision-making and accreditation of heads

The Accreditation Subcommittee and Accreditation Committee evaluate pre-accreditation survey findings and recommend action on applications.
The Accreditation Committee correlates survey findings with monitoring findings on the performance of health care providers and with other relevant data to ensure quality access for PhilHealth members.
Based on evaluation, the Committee recommends to the President and CEO, and such recommendation may modify that of the surveyors.
The President and CEO has discretionary prerogative to approve, modify, or deny recommendations from the Accreditation Subcommittees and Accreditation Committee.
The head of the facility (medical director/chief of hospital administrator) who is a physician must have a valid PHIC accreditation prior to approval of the hospital’s accreditation application.

Extensions, provisional accreditation, and validity periods

For accreditation year 2010, accreditation of all accredited hospitals as of April 30, 2010 whose applications for renewal or re-accreditation for the 2010 accreditation year were still on process is extended up to October 31, 2010.
During the 2010 extension, the provisions of PhilHealth Circular No. 8, s. 2008 regarding changes in the DOH One Stop Shop (OSS) license reflected in hospital accreditation still govern.
Accreditation during the period covered by this rule is based on the validity of the hospital’s DOH-OSS license.
Hospitals given provisional accreditation for January 1 to April 30, 2010 due to a pended DOH license are granted regular accreditation.
Starting 2011, hospitals are granted full accreditation validity from May 1 of the current year to April 30 of the ending year of the award.
Claims for patients with admission dates starting January 1 are processed only after submission of updated DOH licenses.
The Corporation updates accreditation records upon receipt of the DOH-OSS license to reflect critical file updates.
Hospitals with gaps in their DOH-OSS license incur corresponding gaps in accreditation tied to those gaps.
Previously paid claims for services rendered during accreditation gaps and periods of reduction in service capability are charged to pending and/or future claims of the facility.
For provisional accreditation due to partial compliance with benchbook standards, the circular provides a rule set that includes:
- A six (6) month extension overlaps with the intended provisional period for the 2010 accreditation year, with application of provisional accreditation as follows:
  - If applications are decided before May 1, 2010, provisional accreditation starts May 1, 2010; and
  - If applications are still on process, extended accreditation runs up to October 31, 2010 and provisional accreditation follows on a case-by-case basis.
- All applications recommended for provisional accreditation (including those extended to October 31, 2010) must comply within four (4) months after the date of survey so the Corporation can validate compliance before the end of provisional accreditation validity.
- The hospital must send a notification of compliance to the PhRO within four (4) months from the start of provisional accreditation to indicate readiness for re-survey.
- Hospitals qualifying only for provisional accreditation due to initial accreditation or re-accreditation are granted provisional accreditation for six (6) months or for the remaining period of the accreditation cycle, whichever is shorter.
- Hospitals granted provisional accreditation must first correct deficiencies to qualify at least as a Center of Safety within provisional validity before applying for re-accreditation for a higher award, except when the hospital is due for renewal for the succeeding accreditation period (in which case, renewal supersedes provisional accreditation rules).
For hospitals awarded as Centers of Quality/Excellence, validity is fixed as follows:
- Centers of Quality (two and three years, respectively) receive full accreditation up to April 30 of the end year of the accreditation period.
- Centers of Excellence (two and three years, respectively) receive full accreditation up to April 30 of the end year of the accreditation period.
For each succeeding accreditation year for Centers of Quality/Excellence, validity is provisional pending submission of updated DOH-OSS licenses and payment of application fees.
Non-submission of updated DOH-OSS license and payment of fees on or before January 31 of the applicable accreditation year results in suspension of processing of claims for patients admitted starting January 1 of the applicable year.

Repeal and inconsistency amendment

All existing issuances inconsistent with PhilHealth Circular No. 15, s. 2010 are repealed and/or amended.