4.

02
March, 02, 2018
PhilHealth
Department of Family and Community Medicine

TOPIC OUTLINE (Font Size 8pt)

I. History of PhilHealth Core Values
II. PhilHealth’s Vision and Mission  Integridad
a. Vision  Inobasyon
b. Mission
c. Core Values  Agarang Serbisyo
III. Coverage and Exclusions  Taos-Pusong Paglilingkod
a. Coverage  Pagmamalasakit
b. Nature and Scope  Angkop na Benepisyo
c. Exclusions  Panlipunang Pagkakabuklod
IV. Benefits Covered by PhilHealth
a. Inpatient Coverage
b. Outpatient Coverage COVERAGE AND EXCLUSIONS
c. PhilHealth Benefit Packages Coverage
d. TSeKaP (Tamang Serbisyo Para sa Kalusugan ng  All Filipinos shall be mandatorily covered under the
Pamilya/formerly PCB1) Program
 The Program shall be compulsory in all provinces, cities and
HISTORY OF PHILHEALTH municipalities nationwide
o The Corporation, DOH, LGUs, and other agencies
 The Philippine Medical Association introduced the MARIA including Non-Governmental Organizations (NGOs) and
Project which prioritized aid to communities in need of other National Government Agencies (NGAs) shall
medical assistance ensure that members in such localities shall have access
o The call to serve the rural indigents echoed since the to quality and cost-effective health care services
early ’60s
 The Project would then be considered a valuable precursor Nature and Scope
to the Medicare program
 The Program shall cover the following members and their
o From which a medical care plan for the entire
dependents:
Philippines was created
 Republic Act 6111 or the Philippine Medical Care Act of
1969 Members in the Formal Economy
o August 4, 1969  Those formal contracts and fixed terms of employment
o Signed by President Ferdinand E. Marcos including workers in the government and private sector,
o Implemented in August 1971 whose premium contribution payments are equally shared
 In the 1990s, a vision for a better, more responsive by the employee and the employer
government health care program was prompted by the  Government Employee
passage of several bills that had significant implications on o Regular
health financing o Casual
 House Bill 14225 and Senate Bill 01738 which became o Contractual
The National Health Insurance Act of 1995 or Republic  Private Employee who renders service in any of the
Act 7875 following:
o February 14, 1995 o Corporations, partnerships, or single proprietorships,
o Signed by President Fidel V. Ramos NGOs, cooperatives, etc.
 The law paved the way for the creation of the Philippine o Foreign governments or international organizations
Health Insurance Corporation (PhilHealth) with quasi-state status based in the Philippines which
o Mandated to provide social health insurance coverage entered into an agreement with the Corporation to
to all Filipinos in 15 years’ time cover their Filipino employees in PhilHealth
o Foreign business organizations based abroad
PHILHEALTH’S VISION AND MISSION  Other workers rendering services, whether government
Vision or private offices, such as job orders, project-based
contractors
 Bawat Filipino, Miyembro
 Owners of Micro Enterprises
Bawat MIyembro, Protektado
Kalusugan ng Lahat, Sigurado  Owners of Small, Medium and Large Enterprises
 Household Help
Mission o Defined in the Republic Act 10361 or “Kasambahay
Law”
 Benepisyong Pangkalusugang Sapat at De-kalidad para sa
 Family Drivers
Lahat

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Members in the Informal Economy o Hospitalizations without definite diagnosis and without
 Migrant Workers treatment
 Informal Sector o Initial diagnosis which did not turn out as the final
o Street hawkers diagnosis
o Market vendors o Low risk illnesses
o Pedicab and tricycle drivers o Cesarean section without indication
o Small construction workers o 5th normal delivery and subsequent normal deliveries
o Home based industries and services o Outpatient diagnostic tests
 Self-Earning Individuals, professional practitioners such o Emergency room treatments for non-emergency cases
as: o Costs at referring hospital when transferred
o Doctors o The same illness within 90 days
o Lawyers o Major surgeries performed at level 1 hospitals
o Engineers o Treatment for alcohol abuse and other dependencies
o Artists cosmetic surgery
o Architects o Optometric services
o Businessmen o Medicines taken as out-patient, even those prescribed
 Filipino with Dual Citizenship by doctors
o Filipinos who are also citizens of other countries o Ordinary dental services or cosmetic dental treatments
 Naturalized Filipino Citizens o Outpatient consultations with doctors
o Those who have become Filipino citizens through o Psychiatric or mental illnesses or behavioral disorders
naturalization as governed by Commonwealth Act No. that do not require hospital admission
473 or the Revised Naturalization Law o Second or 3rd surgical procedure performed at the
 Citizens of other countries working and/or residing in same site of primary surgical procedure in a single
the Philippines operative session
o Foreign citizens with valid working permits o Second or 3rd illness that occur during hospitalization
or after surgery (for case rate conditions)
Indigent o Maternity services for special cases performed at non-
hospital facilities
 Persons who have no visible means of income or whose o Animal bites treated at facilities not accredited by the
income is insufficient for family subsistence, as identified by Department of Health (DOH) as Centers for Animal Bite
the DSWD based on specific criteria set for this purpose in Treatment
accordance with the guiding principles set forth in Article I
of the Act
BENEFITS COVERED BY PHILHEALTH
Objective
Sponsored Member
 The program aims to provide its members with responsive
 A member whose contribution is being paid by another benefit packages
individual, government agency, or private entity according
 In view of this, the corporation shall continuously to
to the rules as may be prescribed by the Corporation
endeavor to improve its benefit package to meet the needs of
its members
Lifetime Member
 A member who has reached the age of retirement under the Functions
law and has paid at least one hundred twenty (120) monthly
 Introduce additional benefit items and improve those
premium contributions
already being provided
 Retirees/Pensioners from the Government Sector
 Develop the appropriate provider payment mechanisms
 Retirees/Pensioners from the Private Sector
 Continuously improve the system for benefit availment
 Uniformed Members of the AFP, PNP, BJMP and BFP
 Strictly monitor the implementation of benefit availment.

Members of PhilHealth
Inpatient Coverage
 Who have reached the age of retirement as provided by law
 PhilHealth provides subsidy for:
and have met the required premium contributions of at least
o Room and board
120 months
o Drugs and medicines
o Laboratories
Exclusions o Operating room and professional fees for confinements
 The Corporation shall not cover expenses for health services, of not less than 24 hours
which the Corporation and the DOH consider cost-  Benefits have rate ceilings or maximum allowances for the
ineffective through health technology assessment coverage
 The Corporation may institute additional exclusions and o Depends on:
limitations as it may deem reasonable in keeping with its  Type of hospital (tertiary or secondary)
protection objectives and financial sustainability  Case types
 Some of these conditions are:  Patients can only avail the benefits from accredited Health
Care Institutions (HCIs) and must have at least 3 months

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premium contributions within the 6 months prior to the
month of availment.
 Members can check the following at their official website
(http://www.philhealth.gov.ph):
o Compensable medical or surgical cases
o Breakdown of fees/rates being paid for by PhilHealth
o Accredited hospitals and physicians
o Categories of hospitals where a certain case may be
availed of
o Compensable illnesses
Guidelines for Inpatient Coverage
 These benefits are paid to the accredited Health Care
Institution (HCI) through All Case Rates
 The case rate amount shall be deducted by the HCI from
the member’s total bill, which shall include professional
fees of attending physicians, prior to discharge
 The case rate amount is inclusive of hospital charges and
professional fees of attending physician
 Availment condition:
o Member must have at least three (3) months’
premium contributions within the immediate six (6)
months prior to the month of availment
 Documents needed:
o Copy of the Member Data Record or PhilHealth Benefit
Eligibility Form (PBEF)
o Duly accomplished PhilHealth Claim Form 1
 Where available: all accredited HCIs
 Only admissible cases shall be reimbursed
Outpatient Coverage
 Outpatient coverage includes:
o Day surgeries
o Dialysis and cancer treatment procedures
(chemotherapy and radiotherapy) in accredited
hospitals and free-standing clinics
Day Surgeries (Ambulatory or Outpatient Surgeries)
 Includes elective (non-emergency) surgical procedures
ranging from minor to major operations, where patients are
safely sent home within the same day for post-operative care
 Payments for the procedures are made to the accredited
facility through All Case Rates
o The case rate amount shall be deducted by the HCI from
the member’s total bill, which shall include professional
fees of attending physicians, prior to discharge
o The case rate amount is inclusive of hospital charges
and professional fees of attending physician
 Availment condition:
o Member must have at least three (3) month’s
premium contributions within the immediate six (6)
months prior to the month of availment
 Documents needed:
o Copy of Member Data Record
o Duly accomplished PhilHealth Claim Form 1
 Where available: Accredited Ambulatory Surgical Clinics
(ASCs)
Radiotherapy
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 The case rate for radiotherapy using cobalt is Php 2,000 per
session and Php 3,000 per session for linear accelerator
 Includes radiation treatment delivery using cobalt and
linear accelerator
 Claims for multiple sessions may be filed using one (1) claim
form for both inpatient and outpatient radiation therapy
 May be availed of even as a second case rate (full case rate
amount)
 45 days benefit limit: One session is equivalent to one day
deduction from the 45 allowable days per year
 If procedure is done during confinement, only the total
number of confinement days shall be deducted
 Exempted from Single Period of Confinement (SPC) rule
(admissions and re-admissions due to same illness or
procedure within 90-calendar day period)
 Availment condition:
o Member must have at least three (3) months’
premium contributions within the immediate six (6)
months prior to the month of availment
 Where available: Accredited HCIs including Primary Care
Facilities that are accredited for the said service
Hemodialysis
 The case rate for hemodialysis is Php 2,600 per session
 Covers both inpatient and outpatient procedures
including emergency dialysis procedures for acute renal
failure
 Claims for multiple sessions may be filed using one (1) claim
form for both inpatient and outpatient hemodialysis
 May be availed of even as a second case rate (full case rate
amount)
 90 days benefit limit: One session is equivalent to one day
deduction from the 90 day allowable days per year
 If procedure is done during confinement, only the total
number of confinement days shall be deducted
 Exempted from SPC rule (admissions and re-admissions
due to same illness or procedure within 90-day calendar day
period)
 Availment condition:
o Member must have at least three (3) months’
premium contributions within the immediate six (6)
months prior to the month of availment
 Where available: All Accredited HCIs
Outpatient Blood Transfusion
 The case rate for outpatient blood transfusion is Php 3,640
(one or more units)
 Includes drugs and medicine, X-ray, labs and others,
operating room
 Covers outpatient blood transfusion only
 One day of transfusion of any blood or blood product,
regardless of the number of bags, is equivalent to one
session
 May be availed of as second case rate (full case rate amount)
 45 days benefit limit: One session for each procedure is
equivalent to one day deduction from the 45 allowable days
per year
 Exempted from the SPC rule
 Where to avail: All accredited HCIs
 PhilHealth

PhilHealth Benefit Packages  Enhanced Out-Patient Benefit (OPB) package to ensure

Benefit Package Price that all Filipinos have access to quality health services that
Maternity Care Package 8,000 are efficiently delivered, equitably distributed, fairly
financed and appropriately utilized
Normal Spontaneous Delivery Package 6,500
 Main provisions include primary preventive services,
Caesarean section 19,000 diagnostic examination, and therapeutic services
Dengue I and II 8,000-16,000  Caters to members under the Indigent Program (IP),
Pneumonia I and Pneumonia II 15,000-32,000 Sponsored Program (SP), Organized Groups or iGroups
Essential Hypertension 9,000 (OG/IG) and Overseas Workers Programs (OWP) and their
CVA I and II 28,000-38,000 qualified dependents
 Benefit includes a comprehensive health profile upon
Acute Gastroenteritis 6,000
enlistment, consultations, and when clinically necessary,
Asthma 9,000 selected diagnostic tests and medicines for common medical
Typhoid fever 14,000 conditions
Newborn Care Package in Hospitals and  Drugs and medicines are dispensed to cover the complete
1,750
Lying In Clinics course of treatment for infectious diseases or monthly
Radiotherapy 3,000 supply of maintenance medicines for the
Hemodialysis 4,000 noncommunicable diseases identified in the benefit
package as guided by treatment protocols
Appendectomy 24,000
Cholecystectomy 31,000
Preventive Services
Dilatation and Curettage 11,000
 Consultation
Thyroidectomy 31,000  Visual inspection with acetic acid
Herniorrhaphy 21,000  Regular BP measurements
Mastectomy 22,000  Breastfeeding program education
Hysterectomy 30,000  Periodic clinical breast examination
Cataract surgery 16,000  Counselling for lifestyle modification
 Counselling for smoking cessation
 Body measurements
MDG Related Benefit Packages
 Digital rectal examinations
Benefit Package Price
Outpatient Malaria Package 600 Diagnostic Examinations
Outpatient HIV-AIDS 30,000  As recommended by the doctor:
Outpatient Anti-tuberculosis Treatment o Complete Blood Count
though Directly-Observed Treatment 1,000-4,000 o Urinalysis
Short-course (DOTS) Package o Fecalysis
Voluntary Surgical Contraception o Sputum microscopy
4,000
Procedures o Fasting blood sugar
Animal Bite Treatment Package 3,000 o Lipid profile
o Chest x-ray
Benefit Package Exclusions
Drugs and Medicines
 Regardless of the number of previous deliveries, PhilHealth
can now pay the benefit maternity of all members  Asthma including nebulization services
o Before, only up to the fourth delivery was covered; fifth o Inhaled short acting beta 2 agonist
and subsequent normal obstetrical deliveries were o Inhaled corticosteroid
excluded o Oral corticosteroids
 The following health services cannot be paid for through  Acute gastroenteritis (AGE) with no or mild dehydration
PhilHealth: o Oral rehydration salts (ORS)
o Drugs and devices which are not prescribed by a doctor  Upper respiratory tract infection (URTI)/Pneumonia
o Treatment for alcohol abuse or dependency (minimal and low risk)
o Cosmetic surgery o Amoxicillin and Erythromycin (adult and pediatric
o Optometric services preparation)
o Other cost-ineffective procedures as defined by  Urinary Tract Infection (UTI)
PhilHealth o Fluoroquinolones

Tamang Serbisyo Para sa Kalusugan ng Pamilya No Billing Program

(TSeKaP)  Regardless whether it’s a public or private TSeKaP provider,
the “No Balance Billing” policy will apply
 Formerly Primary Care Benefit Package 1 (PCB1)
 Reintroduced as TSeKaP last 2015 to make the package
itself easier to recall for its members and their dependents
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 Indigents and sponsored members do not have to pay any
amount beyond what PhilHealth pays for during hospital
admission.
 Indigent/Sponsored Program members  entitled to the No
Balance Billing (NBB) program when admitted in
government-owned hospitals/ health facilities
 Referral forms for admission: “these members shall not
incur any out-of –pocket expenses in accordance to the NBB
policy”
Provider
 Any healthcare institution that meets accreditation
standards, information system and application requirements
for Tsekap can apply for and be granted accreditation by
PhilHealth
 These facilities include the following, but are not limited in
benefit provision:
o Outpatient department of licensed hospitals and
infirmaries/primary care facilities, Ambulatory
Surgical Clinics and Dialysis Clinics with a
secondary laboratory and a level 1 radiologic
service
o Outpatient department of government-owned
licensed hospitals and infirmaries/primary care
facilities, Outpatient Department/ clinics of
Provincial/Municipal or City Health Offices, and
Health Centers (HCs)/Rural Health Units (RHUs)
without laboratory/ radiologic services but has a
network on DOH licensed secondary laboratory
and at least level 1 radiologic service
o Outpatient Department/ clinic of
Provincial/Municipal or City Health Offices with a
secondary laboratory and level 1 radiologic service
capability
o Privately-owned clinic with an in house licensed
secondary laboratory and at least level 1 radiologic
service capability. Any drug outlet that meets the
corresponding standards, information system, and
application requirements as Tsekap drug outlet can
apply for and be granted accreditation by
PhilHealth.
Eligible Members
 Indigent and Sponsored Program (SP) members and their
qualified dependents
o Include those members identified under the NHTS-
PR and those enrolled by the LGUs (municipal, city
and provincial governments), Senators, House
Representatives, private institutions and other
national agencies.
 Organized Groups/ iGroups (OG/IG) members and their
qualified dependent
 Overseas Workers Program (OWP) members and their
qualified dependents
o Coverage of OWP members pertain only to land
based overseas Filipino Workers since sea- based
OFW are included in the employed sector
 Department of Education (DepEd) personnel and their
qualified dependents
Dependents
 Legitimate spouse who is not a member
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 Unmarried and unemployed legitimate, legitimated,
acknowledged and illegitimate children as appearing in the
birth certificate, and legally adopted or stepchildren below
twenty-one 21 years of age
 Children who are 21 years old or above but suffering from
congenital disability, either physical or mental, or any
disability acquired that renders them totally dependent
on the member for support
 Parents who are 60 years old or above, not otherwise an
enrolled member, whose monthly income is below an
amount to be determined by the Corporation in accordance
with the guiding principles
 For initial implementation:
o only SP /IP members and their qualified
dependents can avail of the Tsekap services
o Qualified members and their dependents shall
initiate their participation by enlisting with an
accredited Tsekap provider
o Enlistment to a private Tsekap provider does not
prevent them from availing the regular public
health services provided by government health
facilities
o members must enlist first with their chosen Tsekap
providers in order to avail of the corresponding
services under the benefit package
o The same Tsekap services are available to their
qualified dependents. Any health service availed
that are not included in the Tsekap benefit may
incur additional fees that may be charged to the
patient
o During the initial year of implementation, the
member can enlist anytime within the year. This
allows the member and his/her dependents to
avail of Tsekap services from their chosen provider
for the current year
o For the succeeding years of implementation,
members must renew their enlistment with their
chosen provider, or enlist with a new provider, on
or before the last working day of March of the
succeeding year
o For 2015, those enlisted in an accredited PCB1
provider in 2014 shall remain enlisted in the
PCB1 provider unless the member decides to
transfer to another provider and /or the facility is
not accredited as a PCB 1 Tsekap provider
o Unlike in the pilot implementation of Primary Care
Benefit Package 2 (PCB2) wherein medications
were limited to one member, there is NO LIMIT
for any member of the family to avail of any of
the drugs in the Tsekap package
o Tsekap drug benefit is charged on a pooled fund
and all eligible patients who will require medicines
should be prescribed medicines on the list.
PhilHealth shall pay for drugs received by the
eligible beneficiary according to the Tsekap
guidelines
Implementing guidelines for Primary Care Benefit 2 Package
(Out-Patient Medicines for Hypertension, Diabetes and
Dyslipidemia)
 Out-of-pocket spending continues to increase
o 42% - 46% of households' spending on health
care is spent on medicines

o Among the poorest families, this even reaches
more than 50%
 Cardiovascular diseases and diabetes contribute 37% of
total deaths in 2009 while their prevalence continues to
increase over time
 prevalence of hypertension increased from 22% to 25%,
and diabetes from 3.4% to 4.8% between 2003 and 2008
 PhilHealth PCB2 will pay for out-patient medicines for
PhilHealth qualified members or dependents with
hypertension, diabetes and dyslipidemia, long before their
conditions become catastrophic
 Objectives:
o Improve access to outpatient medicines for
hypertension, diabetes and dyslipidemia for all
eligible indigent and sponsored members and their
dependents
o Reduce number of hospitalization related to NCDs;
o Improve health outcomes of patients with NCDs;
o Promote rational drug use among members with
NCDs
 Innovation sites to carry out package
o Municipality of Pateros, Metro Manila
o Province of Capiz
o Palawan- Puerto Princesa City, Busuanga, Coron,
Culion and Linapacan
 Innovation sites were chosen based on willingness of the
LGU to participate, current implementation of PCB1 and
availability of connectivity to carry out electronic
requirements of PCB2
 Medicines included in the PCB2 package
o hydrochlorothiazide (25 mg, 50 mg) tablet
o metoprolol tartrate (50 mg, 100 mg) tablet
o enalapril maleate (5 mg, 10 mg, 20 mg) tablet
o amlodipine (besilate/ camsylate) (5 mg, 10 mg) tablet
o metformin hydrochloride (500 mg, 850 mg, 1 g) tablet
o glibenclamide (2.5 mg, 5 mg) tablet
o aspirin (80 mg, 325 mg) tablet
o simvastatin (10 mg, 20 mg, 40 mg) tablet
Selection of Eligible Member/Dependent
 All PCB1 eligible members and dependents, 25 years old
and above and under the following conditions shall be
screened and assessed using the WHO Package for Essential
Non-communicable Diseases (PEN guidelines)
cardiovascular risk profile:
o without established cardiovascular or
cerebrovascular diseases
o have not undergone coronary revascularization or
carotid endarterectomy
 Members or dependents screened using the PEN guidelines,
with more than thirty percent (>30%) cardiovascular
risk within ten (10) years are eligible to avail of PCB2.If
more than one member of the family is eligible, the family,
guided by the physician, shall decide who will avail of the
PCB2
 Members/ dependents who do not fall in the >30% risk,
are still entitled to PCB1 services as stated in the PC 10 s. of
2012. Further, they may also avail of the Complete
Treatment Pack (ComPack) provided by DOH or other
necessary services/ drugs and medicines available in the
PCB 1 provider as prescribed by the physician
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Prescription of Drugs and Assessment
 The PCB1 provider physician shall prescribe a maximum of
one month's supply of medicines.
 He/she shall instruct the patient regarding prescribed
follow-up and monthly BP monitoring and refilling of
prescription.
 Any prescription given after the cut-off date will be
medications for the following month.
o In this case, the patient may be given the ComPack
medicines for his/her consumption for the
remaining days of the month.
 For hard to reach areas, the schedule for dispensing and
follow-up may be adjusted to suit the local conditions,
balancing access and quality care.
Suspension of PCB2 Benefits
 The member failed to claim the medicine from the PCB2
provider for two (2) consecutive months.
 The member failed to fulfill any one provision stated in the
patient's contract.
 A member whose eligibility for the PCB2 was suspended
may have his/her eligibility reinstated by presenting a
recommendation letter from his PCB 1 provider to the
respective LHIO
Termination of PCB2 Benefits
 Death of the beneficiary.
 Two (2) consecutive PCB2 benefit suspensions.
Transfer of PCB2 Benefits
 Benefit is terminated due to death of the beneficiary
 Benefit is terminated due to two (2) consecutive
suspensions of PCB2 benefit.
 If the current beneficiary chooses to transfer the PCB2
benefit to another qualified member/dependent of his/her
family, as guided by the recommendation of the PCB 1
physician.
 Transfer of benefit to another member of the family
terminates the benefit of the previous beneficiary.
CASE TYPE CLASSIFICATION
Revised Case Type Classification
 Pursuant to the approved PhilHealth Board Resolution No.
1208, s. 2009
 Aimed to update and rationalize the current case type
classification
 Make benefits more responsive to the members’ needs
Case Type
 Assessment of complexity of illness assigned to a case after
discharge
 Measured on a 4 scale system

Modifications in Case Type Assignment
 Cases/conditions considered for automatic upgrade of
case type
 For the following illnesses/condition, the corresponding
case type shall be considered applicable, provided the
diagnosis and ICD-10 code are clearly stated in the claim
form.
General Rules for Case Typing
 For coding and reimbursement of medical claims:
o Case type will be based on the ICD-10 of the primary
illness or main condition.
o Primary illness or main condition: condition identified
at the time of discharge as being the main reason for the
patient’s confinement, whether it is for receiving care or
for investigation of a current illness or injury
o Example:
 Hospital claimed for a lower reimbursement, PhilHealth
shall reimburse to the member within the amount of the
remaining benefit, provided the claim is supported by an
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Official Receipt (OR) and Statement of Account (SoA)
issued by the hospital.
 There is a discrepancy between the final diagnosis and the
management based on part three (III) and four (IV) of the
Claim Form 2:
o PhilHealth may return the claim to the
hospital with request for a properly
accomplished
o PhilHealth Claim Form 3 and other
appropriate documents (copy of clinical chart,
laboratory result, radiology result and other
ancillary procedures) deemed necessary for
proper evaluation.
 The member or hospital request for a higher case type other
than those specified in this circular
o PRO -Benefit Administrative Sections may refer such
requests to the Quality Assurance Committee (QAC) for
their evaluation and recommendation.
o For such claims, reiterated that the complete diagnosis
and its applicable lCD 10 code should be clearly stated
in the PhilHealth Claim Form 2 and a properly
accomplished PhilHealth Claim Form 3 should be
submitted.
 For claims with surgical procedure/s and other services, the
case type shall be based on the corresponding Relative Value
Unit (RVU) assigned to the procedure.
 For claims with 2 or more surgical procedure/s (multiple
surgeries), the case type shall be based on the procedure
with the highest RVU.

 In cases where the case type for the medical diagnosis and
the surgical procedure are different, the higher case type
shall predominate.
All Case Rate Payment Scheme
 Case Rate: a fixed rate or amount that PhilHealth will
reimburse for a specific illness/case (fees of health
professionals, and all facility charges - room and board,
diagnostics and laboratories, drugs, medicines and supplies,
operating room fees and other fees and charges)
 Case-based payment (per case payment): payment
method that reimburses to health care providers a
predetermined fixed rate for each treated case or disease
General Policies on Case Rate Payment
 Case rates is the preferred mode of payment.
 Objective: To reduce the out-of-pocket expenditures of
patient-members. Case rates not added to expenses.
 For certain surgical procedures, surgical case rates shall be
paid in full whether done as in-patient or out-patient (ie. day
surgeries).
 All CR payments shall be paid to the account of the HCI.
o HCI made accountable to PhilHealth and to its
beneficiaries for all that happens
to the patient beneficiary while under the HCI’s care.
o HCI to facilitate the payment to health care
professionals (HCP) not exceeding 30 calendar days
upon receipt of the reimbursement or to an agreed time
frame. PhilHealth shall regularly inform the HCPs of
payments made to the HCI through a furnished copy of
the Notice of Paid Claims and/or Notice of Denied
Claims.
o The HCI shall withhold the expanded withholding tax on
payments to doctors or medical practitioners for their
professional fees. In addition, the HCI shall withhold the
final value added tax (VAT) on Government Money
Payment (GMP), if applicable.
o PhilHealth shall withhold the income tax as per BIR
policy against the case rate amount to be paid to the
HCI.
 Credentiating and privileging of doctors (including
specialists), and other health care professionals shall be
delegated to the concerned HCI. PhilHealth shall no longer
have tiered payments according to training or specialization
of the doctors.
 HCIs shall be responsible to file the claims of PhilHealth
beneficiaries within the prescribed period of filing (60 days).
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 Direct filing by members shall only be allowed for certain
circumstances as prescribed by PhilHealth
 The No Balance Billing (NBB) policy shall apply to all
indigents and sponsored sectors.
 The Corporation shall set specific case rate guidelines for
special circumstances such as GIDA, Health Human Resource
Shortage areas , Emergency/acute care-selected emergency
department visits that are skillfully evaluated and efficiently
managed without need for further admission
INDIGENT PROGRAM
PhilHealth`s Indigent Program or Pro – Poor Program
 “Medicare para sa Masa”
 Indigent people
o Persons who have no visible means of income, or
o Whose income is insufficient for family substinence
 Formulated by the indigent sector component of National
Health Insurance Program (NHIP) to provide health
insurance coverage for these indigent people
 NHIP requires PhilHealth (in partnership with LGUs) to
o choose the poorest 25% of the population to cover,
o with an annual premium of Php 1,188 per family
shouldered by the national government through
PhilHealth, LGUs, private individuals and corporations
and the members
 General Objectives: This Joint DOH-PhilHealth Order aims to
set the governing policies and guidelines in the enrollment of
critical poor to PhilHealth in government hospitals and their
immediate availment of personal health benefits.
 Specific Objectives:
o To describe the rules and procedures in the
enrollment of critical poor admitted in government
hospitals
o To state the benefits of these critical poor members
Definition of Terms
 National Health Insurance Program (NHIP) - The social
health insurance program implemented by the Philippine
Health Insurance Corporation as mandated by RA 7875 as
amended by RA 9241 which seeks to provide universal
health insurance coverage and ensure affordable, acceptable,
available, accessible and quality health care services for all
citizens of the Philippines.
 Critical Poor - Persons assessed and identified as poor by the
hospital Medical Social Welfare Assistance Officer who are
not listed nor registered to the Sponsored Program but can
immediately avail of NHIP benefits. Their continuous
enrollment to the sponsored program in the succeeding
years shall be subject to validation of the DSWD.
 Sponsored Program (SP) - A component of the NHIP that
seeks to cover families belonging to: (1) Families identified
under the National Household Targeting System for Poverty
Reduction (NHTS - PR) of the Department of Social Welfare
and Development (DSWD); (2) Families identified by Local
Government Units (LGUs) and other sponsors; The families
enrolled under the Sponsored Program can automatically
avail of PhilHealth benefits upon enrollment;
 No Balance Billing Policy (NBB) - a privilege given to
Sponsored Program members which lets them receive
quality health care with no out-of-pocket expense incurred.
This prohibits the hospital from charging the patient for

room and board, drugs, laboratories, professional fees and
other expenses over and above the PHIC reimbursement.
This was initially introduced and implemented through
Philhealth Circular 11, s 2011 with the subject "New
Philhealth Case Rates for Selected Medical Cases and
Surgical Procedures and the No Balance Billing Policy.
 PhilHealth Member (Member) - Any person whose
premiums has been regularly paid to the National Health
Insurance Program. He may be a paying member, an indigent
member or a pensioner/ retiree member;
o Dependent child
o The unmarried and unemployed legitimate, illegitimate,
acknowledged children, legally adopted below (21)
years of age;
o Children who are 21 years old or above but suffering
from congenital disability, either physical or mental, or
any disability acquired that renders them totally
dependent to a member for support;
Pro Poor Mandate
 Republic Act 7875, National Health Insurance Act of
1995
 Signed by the former President Fidel V. Ramos on February
14, 1995
o As a safety net mechanism for the poor
 This new law had the highest priority to be able to provide
each and every Filipino with a basic minimum package of
health insurance benefits.
 Section 2 of its first article on Guiding Principles in support
of Section II, Article XIII of the 1987 Constitution of the
Philippines,
 “the State shall adopt an integrated and comprehensive
approach to health development which shall endeavor to
make essential good, health and other social services
available to all the people at affordable cost. Priority of the
needs of the underprivileged, sick, elderly, disabled,
women, and children shall be recognized. Likewise, it shall be
the policy of the State to provide free medical care to
paupers.”
 As the Universal Health Care (UHC), or Kalusugang
Pangkalahatan (KP), aspires to improve implementation of
the compulsory nature of premium payments to avoid
adverse selection and achieve social solidarity, the indigent
poor shall have their premium payments subsidized
through:
o National Government appropriations
o Sin Tax collections
o Local government sponsorship enrollment
 Invariably, despite all efforts by government to enroll all the
poor, there are still leakages that not all the poor are able to
be covered and are not protected when they need to avail of
vital health services at the point of care.
 Hence, in order to assure that none of the poor are left to
chance, it is imperative that these ''critical poor" be
accordingly enrolled by the hospital concerned and that
PhilHealth appropriately reimburses those sendees
extended to them.
GUIDING PRINCIPLES AND POLICIES
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 There are 3 guiding principles in support of the pro-poor
orientation:
o Universality
o Equity
o Care of Indigent
Universality
 The Program shall provide all citizens with the mechanism
to gain financial access to health services, in combination
with other government health programs.
 The National Health Insurance Program shall give the
highest priority to achieving coverage of the entire
population with at least a basic minimum package of
health insurance benefits.
Equity
 The Program shall provide for uniform basic benefits.
 Access to care must be a function of a person’s health needs
rather than his ability to pay.
Care of the Indigent
 The Government shall be responsible for providing a basic
package of needed personal health services to indigents
through premium subsidy, or through direct service
provision until such time that the Program is fully
implemented.
PRO-POOR ORIENTATION OF RA 7875
 The pro-poor orientation of RA 7875 can be further gleaned
in the treatment of four specific topics in various articles
and sections of the law, and their supporting IRR, released in
July 2000.
 These four specific topics are:
o Identification of the Poor
o Enrollment of indigent members
o Uniform basic package
o Premium contributions
Identification of Indigent Members
 Indigent
o As defined in the National Health Insurance Act of 1995
(RA 7875 as amended by Act 9241 and 10606)
o A person who has no visible means of income, or
whose income is insufficient for the subsistence of
his family, as identified by the Department of Social
Welfare and Development (DSWD) based on specific
criteria set for this purpose in accordance with the
guiding principles set forth in Article I of the Act 10606.
 As stated in section 22 of RA 7875 as amended by act
9241,
o The Corporation shall initiate the signing of a
Memorandum of Agreement (MOA) with LGUs and with
other concerned parties, if applicable, for the
implementation of the Indigent Program in their
areas.
 Section 23 of RA 7875 as amended by act 9241,
o Identification of Indigent members shall be
undertaken through the conduct of a social research
survey, referred to as the means test,
o To determine the current socio-economic and health
profile of the indigent sector in each LGU.

 Means Test is a
o Protocol administered at the barangay level to
determine the ability of individuals or households
to pay varying levels of contributions to the
Program,
o Ranging from the:
 Indigent in the community whose contributions
should be totally subsidized by government, to
those
 Who can afford to subsidize part but not all the
required contributions for the Program.
 Local Health Insurance Office (LHIO)
o Charged with the supervision of the conduct of means
testing in coordination with the barangay captain and
social welfare officer and community-based health care
organizations.
 Community-Based Information System – Minimum Basic
Needs (CBIS-MBN) approach
o Administered at the barangay level by the
City/Municipal Social Welfare and Development Office
(C/MSWDO) and/or the Barangay
o Shall be interphased with the means test protocol.
o The Corporation, however, reserves the right to adopt
other means test mechanisms as it may deem
appropriate
 LGU and the Corporation shall give priority to the
enrollment of the elderly, disabled, orphans and
paupers in the Program, especially when premium donors
are involved
 Once identified, indigent members can now proceed with the
enrollment.
Enrollment of Indigent Members
 The process of enrollment shall include the:
o Identification of beneficiaries
o Issuance of appropriate documentation specifying
eligibility to benefits
o Indicating how membership was obtained or is
being maintained
 The Corporation, as stated under section 7 of RA 7875
amended by Act 9241 and 10606,
o Responsible for the enrollment of beneficiaries
o In order for them to avail of benefits under this Act with
the assistance of the financial arrangements provided
by the Corporation under the following categories:
a. Members in the formal economy;
b. Members in the informal economy;
c. Indigents;
d. Sponsored members; and
e. Lifetime members
 Once enrolled, the list of indigent members shall be
evaluated every year through a procedure prescribed by
the Corporation in coordination with the concerned LGU.
 Membership in the Indigent Program can be
revoked/cancelled by the Corporation for any of the
following reasons:
o Non-compliance by the indigent member or any of the
dependents with NHIP rules and regulations; or
o Employment of the member resulting to change in
membership status, or an increase in the family
income above the poverty threshold.
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 The LGU may propose for the replacement of the indigent
member whose membership was revoked/cancelled during
the membership year.
o The “replacement member” should also be certified by
the Local SWDO and/or Barangay Official
 In case of death of the member, the dependents of the
deceased indigent member shall continue to avail of
NHIP benefits for the unexpired portion of the coverage.
 The LGU and/or the premium donor may extend
membership beyond the unexpired portion of the
coverage to orphans of deceased members until such time
that the orphans are in legal custody or guardianship of
the state.
Uniform Basic Package for Indigents
 An Indigent member of PhilHealth is privileged to enjoy the
following minimum services which are subject to the
limitations specified in the Act and as may be determined by
the Corporation:
o In-patient Hospital Care
1. Room and board;
2. Services of health care professionals;
3. Diagnostic, laboratory, and other medical
examination services;
4. Use of surgical or medical equipment and facilities;
5. Prescription drugs and biologicals, subject to the
limitations stated in section 37 of this Act; and
6. Inpatient education packages
o Out-patient Care
 Services of health care professionals;
 Diagnostic, laboratory, and other medical
examination services;
 Personal preventive services; and
 Prescription drugs and biologicals, subject to the
limitations described in section 37 of this Act;
o Emergency and Transfer Services
o Other HealthCare services
Two Phases of the Implementation of the Indigent Program
 Phase I
o Curative Care
o Regular Inpatient and Outpatient Package
 Through PhilHealth-Accredited
Hospitals/Providers
o Coverage of the following services:
 Room and Board;
 Services of health care professionals;
 Laboratory and other medical examination
services;
 Prescription drugs and biologicals;
 Surgeon’s, anesthesiologist’s and operating room
fees;
 Surgical family planning procedures; and
 Outpatient benefits for chemotherapy,
radiotherapy, hemodialysis, cataract extraction and
minor surgical procedures performed in an
operating room complex
 Phase II
o Preventive Care
o Outpatient Consultation and Diagnostic Package

 Through Accredited, LGU-Managed Rural Health
Units/Health Centers
o Coverage for the following services:
 Primary Consultation
 Laboratory examinations
 CBC, CXR, stool exam, urinalysis, sputum
microscopy
Premium Sharing Schedule
 Section 28 of RA 7875 as amended by Act 9241,
o The premium contribution subsidy for indigent families
shall be shared by the National Government and the
LGUs Online sources
 The LGU premium contribution of 4th, 5th, and 6th class
municipalities shall be progressively increased.
 However, the LGU premium contribution of 4th, 5th, and 6th
class municipalities shall be made equal to that of the
National Government only when they shall have been
upgraded to 1st, 2nd, or 3rd class municipalities
 Under the current law, it is stated that premium
contributions for indigent members as identified by the
DSWD through a means test or any other appropriate
statistical method shall be fully subsidized by the national
government
TWO PHASES OF PHILHEALTH IMPLEMENTATION
PHASE 1 ORGANIZING, MAKING A WORKING PLAN, AND
OBTAINING BASELINE INFORMATION
STEP 1 Form a PhilHealth Plus Team
STEP 2 Formulate PhilHealth Plus Work Plan and Timetable
STEP 3 Conduct rapid assessment of NHIP and collect
baseline data purpose.
PHASE 2 OTHER GROUNDWORKING ACTIVITIES WHOSE
RESULTS ARE TO BE UNDERTAKEN IN
IMPLEMENTING PHILHEALTH PLUS
STEP 4 Conduct survey to identify indigents
STEP 5 Conduct KAP survey on Health Insurance
STEP 6 Identify funding sources
STEP 7 Review local ordinances and policies
Phase 1: Organizing, Making a working plan and
Obtaining baseline information
Step 1: Form a PhilHealth Plus Team
 Different components that work for the implementation of
PhilHealth
o Head of the PhilHealth Regional Office (PRO)
 Implementation of PhilHealth Plus in a location
within his jurisdiction
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 Form a team who shall oversee and coordinate all
PhilHealth Plus related concerns
 Need not be a member of this team but he will have
to be updated with all developments
o PhilHealth Regional Office
 Convene, orient and train PhilHealth Plus team
 Prioritize the PhilHealth Plus area for the
establishment of a local service office
 Tap local as well as international
agencies/entities/individuals as donors to
premium contributions, especially for indigents
 Inspect and assess rural health units and other
health service providers, and facilitate their
accreditation
 Facilitate review and approval of PhiHealth Plus
Team-recommended policies and guidelines
 Develop database
o PhilHealth Central Office
 Orient and train PhilHealth Plus team and
PhilHealth Regional Office
 Provide assistance in capability-building activities
 Assess implementation of PhilHealth Plus in the
different PhilHealth Plus areas
 Provide overall design and direction to social
marketing and advocacy for enrolment
 Develop and implement HSP accreditation
guidelines
 Develop and implement accreditation guidelines
for Collecting Agents (including organized groups,
NGOs, etc.)
 Facilitate review and approval of PhiHealth Plus
team-recommended policies and guidelines
 Provide financial and other material resources for
the NHIP operations
 Develop database support programs
o Local Government Unit
 Designate counterpart staff to PhilHealth Plus team
 Ensure the availability of health services and
resources to NHIP members
 Improve facilities and staff capability to meet
accreditation standardsof PhilHealth Plus
 Support the Indigent Program of PhilHealth by
paying the required premium counterpart and
enact, whenever necessary, appropriate ordinance
and/or resolutions
 Seek/ensure multi-year funding for the Indigent
Program
 Facilitate the approval of local policies supportive
of the objectives of PhilHealth Plus, and the NHIP in
general
 Provide counterpart resources, i.e., office space,
personnel, budget, among others, for PhilHealth
Plus
 Mobilize social and political support for PhilHealth
Plus
 Use LGU licensing, regulatory, and policing powers
to implement mandatory enrollment to NHIP

 Provide baseline data for LGU profile
 Recommend alternative collecting agents (such as
LGU treasurers)
 Synchronize implementation of other health sector
 Reform initiatives with PhilHealth Plus
o Department of Health
 Designate counterpart staff to PhilHealth Plus team
 Advocate for adoption of the Indigent Program by
the LGU
 Advocate for enrolment of the local population to
NHIP
 Provide technical and financial support to NHIP in
the locality
 Mobilize international as well as local agencies for
technical and financial assistance
 Assist the LGU in improving health facilities and
services to meet accreditation standards of
PhilHealth
 Facilitate review and approval of PhilHealth Plus
Team – recommended policies and guidelines
within DOH
 Synchronize implementation of other health sector
 Reform initiatives with PhilHealth Plus
o NGOs
 Advocate enrollment to NHIP
 Facilitate enrollment of members
 Function as accredited collecting agents for NHIP
Step 2: Formulate PhilHealth Plus Work Plan and Timetable
Targets Indicator
1. Enrollment for  Percentage of the total population
each category belong to formal, informal and
indigent sectors
2. Accreditation of  Percentage of the total number of
health services HSPs with particular attention to
(HSPs) geographic distribution
3. Accreditation of collecting agents with particular attention to
geographic distribution
4. Information and education campaign activities to be
conducted
Step 3: Conduct rapid assessment of NHIP and
collect baseline data purpose
 This assessment of NHIP and collection of baseline data
would allow timely and pertinent information regarding
the province and their current state in the province.
 The data and information collection is done to assess the
LGU profile and the current state of NHIP in covered areas.
This process should not exceed more than 2 months.
 The most significant data that has to be gathered is the
breakdown of the population into the formal, informal, and
indigent sectors
Phase 2: Other Groundworking activities whose results are
to be undertaken in implementing PhilHealth Plus
Step 4: Conduct survey to identify indigents
 The results of this survey may be the most important
baseline information in the PhilHealth Plus implementation
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 The municipal social welfare and development office usually
has a masterlist of indigents
 If survey takes too long to complete, an estimate may be
used.
Step 5: Conduct KAP survey on Health Insurance
 The results of this survey will:
o Inform implementors of the perceptions of the local
population on health insurance
o Aid the PhilHealth Plus team in planning strategies for
expanding the membership of NHIP within the
community.
Step 6: Identify funding sources
 To cover as much of the population as possible, the team and
the LGU shall identify funding sources that can be tapped for
augmenting the premium contributions for the Indigent and
Individually paying programs, and for the upgrading of local
health facilities
o House of Representatives
o Grants from ODA and other foreign sources
o DOH health reform fund
o DOH advocacy fund
o Corporate Sponsors
o NGO Sponsors
o Individual Sponsors
Step 7: Review local ordinances and policies
 To ensure that all the aspects of PhilHealth Plus
implementation do not conflict with any existing local
ordinance and policy. If conflict arises, LGU may issue
amendatory ordinances as appropriate
HOSPITAL ACCREDITATION
Types of Accreditation
 Automatic Accreditation
o Accreditation route of health care institutions that are
licensed or certified by DOH or other certifying body
duly recognized by Philhealth. They do not undergo pre
accreditation survey
 Non-automatic Accreditation
o Applies to HCIs that are not licensed/ certified by the
DOH/CHD. They shall undergo preaccreditation survey
before being accredited
Accreditation Application Types
According to the Revised Implementing Rules and Regulations of
the National Health Insurance Act of 2013 (RA 7875 as amended
by RA 9241 and 10606), accreditation shall be of the following
types:
 Initial accreditation
o Which shall be given to qualified health care providers
that are applying for the first time after they were able
to comply with the requirements.
o Three-year operation requirement
 All licensed facilities, except Maternity Care
Providers, which apply for initial accreditation
must follow the three-year operation requirement.
 Continuous accreditation

o Which shall be given to accredited health care providers
that applied for uninterrupted participation to the
Program
o The HCI shall submit the requirements from January
1 – 31 of each year to continuously participate in the
NHIP
o The conditions for withdrawal or termination of
Continuous Participation:
 HCIs that has closed or ceased operation.
 HCIs that failed to apply for re-accreditation within
90 days after its actual transfer of location
 HCIs that failed to apply for re-accreditation within
90 days after change in ownership
 HCIs that failed to apply for continuous
accreditation within the prescribed filing period
 Other reasons as determined by the Corporation
 Reaccreditation
o Given to health care providers under any of the
following:
 Health care institutions whose previous
accreditation has lapsed or whose subsequent
application was denied;
 Health care institutions that failed to submit the
requirements for continuous participation within
the prescribed period;
 Acquisition of additional service capability that
would require change in license/certificate, as
applicable, issued by the relevant authority;
 Transfer of location.
- The health care institution must first secure a
license to operate from the DOH for the new
facility prior to the date of transfer and
- Apply for re-accreditation within ninety
(90) calendar days from the date of transfer.
- Beyond this period, the accreditation shall
automatically lapse and all claims filed with
the Corporation shall not be paid.
- The health care institution must inform the
Corporation of the planned transfer indicating
the exact date of transfer and address of the
new site.
- The ninety (90) day grace period shall not
apply to the new site if it is not licensed;
 Upgrading of facility level or category;
 Change in the classification of health care
institution;
 Change in ownership. The health care institution
in good standing must apply within the ninety (90)
calendar days from actual change of ownership;
 Resumption of operation after
closure/cessation of operation.
 Reinstatement of accreditation
o Which is the restoration of accreditation after
compliance to conditions following a suspension
imposed by the Corporation.
 The following health care institutions may apply:
- Hospitals
- Out-patient clinics
 Rural health units/health centers
 Dispensaries/infirmaries
 Birthing homes/facilities41
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 Medical Out-patient Clinics
 Other Primary Care Facilities licensed by
the DOH
- Free-Standing Dialysis Clinics
- Ambulatory Surgical Clinics
- Health Maintenance Organizations (HMOs)
- Community-Based Health Care Organizations
(CBHCOs)
- Pharmacies
- Other health care institutions licensed by the
DOH
 Accreditation Requirements
o Based on the Revised Implementing Rules and
Regulations of the National Health Insurance Act of
2013 (RA 7875 as amended by RA 9241 and 10606), the
following are the accreditation requirements for health
care institutions:
 They must have been operating for at least three
(3) years prior to initial application for
accreditation, with a good track record in the
provision of health care services.
- The following health care institutions shall
also be exempted from the three (3) year
operation requirement:
- Primary Care Benefit Providers with or
without out-patient malaria package;
- TB DOTS providers;
- Non-hospital maternity care package
providers;
- Animal bite treatment providers; and,
- Such other health facilities as may be
determined by the Corporation
o They must be licensed / certified by the DOH, as
applicable;
o They must comply with the provisions of the
performance commitment. They must have their own
ongoing formal program of quality assurance that
satisfy the Corporation’s standards;
o Any other requirements that may be determined by the
Corporation.
Accreditation Requirements
 Not included in IRR of the NHI Act of 2013 but are included
in implementing rules and regulations of the National Health
Insurance Act of 1995 (Republic Act 7875 as Amended by
Republic Act 9241):
o Health care institutions must have the human
resources, equipment, physical structure and other
requirements in conformity with the standards of the
relevant facility, as determined by the Corporation;
o All personnel of the health care institution must be
members of the NHIP
o Physicians and other health care professionals must
submit a Certificate of Good Standing from their
respective recognized national associations.
 Specialists must submit a Certificate of Good
Standing from their respective specialty societies
(duly recognized by the Corporation in accordance
with its established standards and criteria)

o Health care providers must have their own ongoing
formal program of quality assurance that satisfy the
Corporation’s standards
o They must adopt all referral protocols, practice
guidelines, payment mechanisms, health resource
sharing arrangements of the NHIP and other accepted
standards of practice;
o They must recognize and respect the rights of patients;
o Must comply with all information system requirements
including but not limited to:
 Reporting mechanisms established by the
Corporation
 Maintenance of accurate records
 All patients, services rendered and health
outcomes resulting from such services, health
expenditures on patient care and continuous
patient education
o Must accept any and all corrective actions to be
prescribed by the Corporation to ensure quality
of services
o Must allow the Corporation to inspect and secure
reproduction of certified true copies of their medical
and financial records and to visit, enter and inspect
their respective premises and facilities
o The health care professionals must be members of the
NHIP
Steps in Hospital Accreditation
 To be submitted
 Accreditation fees
 Accreditation surveys (PAS)
 Deliberation of applications and issuance of letters or
certificate of accreditation to HCIS
Accreditation Status Awards
 Centers of Safety (COS)
o DOH licensed hospitals that applied for a higher
accreditation award (COE/COQ) that are not accredited
by IAOs, while self-assessment scores do not qualify for
at least a COQ
 Higher accreditation awards
o Those granted accreditation by international
accrediting organizations (IAO) and has complied with
the specific of PhilHealth Centers of Quality (COQ) and
Centers of Excellence (COE).
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o Hospitals not granted accreditation by international
accrediting organizations (IAO) may qualify as COQ or
COE if they comply with ALL of the ff:
 Non-withholding of necessary/essential services to
patients applicable to licensed service capability
 Compliance to policies on the implementation of
case rate and/no balance billing (if applicable)
 No Writ of Execution issued against the applicant
provider by PhilHealth within 3 years prior to
application of accreditation
 No negative monitoring findings, e.g. irrational
drug use, over/underutilization of services, etc.
that remain uncorrected for the year preceding the
applicable period
 Certificate Of Eligibility To Participater (CEP)
o This shall be issued by PhilHealth upon compliance to
the preceding requirements and procedures.
DOH Hospital Classification on Service Availability
LEVEL 1 (Primary/Emergency hospital)
 An emergency hospital that provides initial clinical care and
management to patients requiring immediate treatment, as
well as primary care on prevalent diseases in the locality
 Clinical services include general medicine, pediatrics and
non-surgical gynecology and minor surgery
 General administrative service and may provide ancillary
services (primary clinical laboratory, first level radiology,
pharmacy)
 Provides nursing care for patients who require minimal
category of supervised care for 24 hours or longer
LEVEL 2 (Secondary hospital)
 Non-departmentalized hospital that provides clinical care
and management on the prevalent diseases in the locality
 Clinical services include general medicine, pediatrics,
obstetrics and
 gynecology, surgery and anesthesia
 Appropriate administrative and ancillary services
(secondary clinical
 laboratory, first level radiology, pharmacy)
 Nursing care provided in the Level I Hospital as well as
intermediate, moderate and partial category of supervised
care for 24 hours or longer
LEVEL 3 (Tertiary hospital)
 Departmentalized hospital that provides clinical care and
management on the prevalent diseases in the locality, as well
as particular forms of treatment, surgical procedure and
intensive care.
 Clinical services provided in Level 2 Hospital as well as
specialty clinical care
 Appropriate administrative and ancillary services (tertiary
clinical laboratory, second level radiology, pharmacy) 47
 Nursing care provided in Level 2 Hospital as well as total
and intensive skilled care
LEVEL 4 (Teaching and training hospital)
 Teaching and training hospital (with at least one Accredited
Residency training Program for Physicians) that provides
 PhilHealth

clinical care and management on the prevalent diseases in

the locality, as well as specialized and sub-specialized forms
of treatment, surgical procedure and intensive care.
 Clinical services provided in Level 3 Hospital as well as sub-
specialty clinical care
 Appropriate administrative and ancillary services (tertiary
clinical laboratory, third level radiology, pharmacy)
 Nursing care provided in Level 3 Hospital as well as
continuous and highly specialized critical care

Grounds for Denial/Non-Reinstatement of Accreditation

 Non-compliance with any or all of the requirements of
accreditation;
 Revocation, non-renewal or non-issuance of license/
accreditation/ clearance to operate or practice of the health
care provider by the DOH, PRC or government regulatory
office or institution;
 Conviction due to fraudulent acts as determined by the
Corporation until such time that the decision is reversed by
the Appellate Court or the penalty has been fully served;
 Change in the ownership, management or any form of
transfer either by lease, mortgage or any other transfer of a
health care institution without prior notice to the
Corporation; or,
 Such other grounds as the Corporation may determine.

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