PC 2023-0024: Omnibus Guidelines on Accreditation of Health Facilities to NHIP

IJAOI>HQ Pil.tPtHA$ Republic of the Philippines PHILIPPINE HEALTH INSURANCE CORPORATION 9 Citystate Centre, 709 Shaw Boulevard, Pasig City '- (02) 8441·7442 (!j)www.philhealth.gov.ph 0 PhiiHealthOfficial 'Ill' teamphilhealth PHILIJjQliH CIRCU!+J-ll No._ 3 ~ dc)_k-1 TO ALL HEALTH CARE PROVIDERS AND ALL OTHERS CONCERNED SUBJECT Accreditation of Health Care Professionals (HCProfs) (Revision 1) I. RATIONALE II. Republic Act (R.A.) No. 11223 or the Universal Health Care Act provides that the State shall adopt a people-oriented approach for the delivery of health services that is centered on people's needs and well-being and cognizant ofthe differences in culture, values and beliefs. Pursuant to Article IV, Section 16.l of R.A. No. 10606 or the National Health Insurance Act of 2013, the Corporation has the power to determine the requirements and issue guidelines for the accreditation of health care providers (HCPs) for the Program. The revised Implementing Rules and Regulations (IRR) of the same law provides that the Corporation shall verifY, through the accreditation process, the qualifications and capabilities of HCPs for the purpose of conferring upon them the privilege of participating in the Program and assuring that the health care services they render meet the desired and expected quality. Consistent with R.A. No. 11032 or the Ease of Doing Business (EODB) Act of 2018, R.A. No. 10173 or the Data Privacy Act of 2012 and PhilHealth Board Resolution (PBR) No. 2728 s. 2022, the guidelines on the process for accreditation of health care professionals (HCProfs) are hereby amended. The PhilHealth Board also approved these guidelines on April 26, 2023. OBJECTIVES To provide updated guidelines on the accreditation process for HCProfs, simplifYing the requirements and streamlining the process of accreditation in the National Health Insurance Program (NHIP). SCOPE This PhilHealth Circular shall apply to all currently accredited HCProfs, those with pending applications, and appeals or motions for reconsideration on their applications for accreditation and those with intent to participate in the National Health Insurance Program (NHIP). Page 1 of15

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IV. DEFINITION OF TERMS A. Accreditation Appeals and Review Committee (AARC) - formerly known as the Accreditation Committee, is a collegial body composed of PhilHealth management, representatives from the Department of Health (DOH), presidents or heads of different HCP organizations and patient groups that deliberates on appeals and motions for reconsideration. The Committee is recommendatory to the President and CEO of the Corporation. B. Affiliation - relation by which a health facility (HF) accepts HCProfs as part of their health human resource and in so doing provides the HCProfs practice privileges in their HF. C. Continuous Accreditation - continuous participation granted by the Corporation to HCPs that/who complied with all the requirements for accreditation prescribed by the Corporation within the prescribed period that qualify them for uninterrupted participation in the Program, until such participation is withdrawn or terminated based on the rules set by the Corporation. D. Direct Contributors - members of PhilHealth who have the capacity to pay premiums, are gainfully employed and are bound by an employee- employer relationship, and/ or are self-earning professional practitioners, migrant workers, including their qualified dependents, and lifetime members.' E. Foreign Health Care Professionals- HCProfs (doctors, nurses, etc.) who are registered/licensed under the laws of their country and whose registration/licensed to practice their profession has not been suspended or revoked, may apply for accreditation provided that they secure a Professional Regulation Commission (PRC) license. 2 ··!:<'\· ... "'' ---..::. ! F. Fraudulent Acts - any act of misrepresentation or deception resulting in undue benefit or advantage on the part of the doer or any means that deviate from normal procedure and is undertaken for personal gain, resulting thereafter to damage and prejudice which may be capable of pecuniary estimation.3 ~~· ~ G. Gap in Accreditation - period where the HCProfs is not accredited and cannot participate in the NHIP. H. Health Care Professional (HCProf) - doctor of medicine, nurse, midwife, dentist or other allied professional or practitioner duly licensed to practice in the Philippines.4 I. Health Facility (HF) -which may be public or private, devoted primarily to provision of services for health promotion, prevention, diagnosis, 'RA 11223: Universal Health Care Act, Section 4, letter f. 2 RA 8981: Professional Regulation Commission Act, Section 7, letter 1. 3 RA 11223: Universal Health Care Act, Section 4, letter j. 4 Ibid, letter k (2). Page 2 ofls

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treatment, rehabilitation and palliation of individuals suffering from illness, disease, injury, disability or deformity or in need of obstetrical or other medical and nursing care.s J. Performance Commitment (PC) - a notarized document signed by the HCProf who intends to participate in the Program, which stipulates their undertakings to provide complete and quality health services to PhilHealth beneficiaries. This document also reflects the commitment of the HCP to comply with PhilHealth policies on benefits payment, information technology, data management and reporting and referral, among others. K. Provisional Accreditation (P A) - accreditation granted by the Corporation, for a specified period of time (full or partial accreditation validity) to an HCP, institution or professional, for conditions as stated in this policy. L. Regional Accreditation Committee (RAC) - formerly known as the Accreditation Subcommittee (ASc), is a collegial body composed of the heads of the different organizational offices of the PhilHealth Regional Office (PRO), representative from the Center for Health Development (CHD) of the DOH, representatives of HCP organizations and patient advocate group, that deliberates on the applications and certain motions for reconsideration on accreditation of HCPs in the PRO. M. Temporary Withdrawal of Accreditation (TWA) - a measure instituted by the Corporation for the temporary cessation of a valid accreditation that was previously granted to an HCProjfor a specific period due to conditions as provided for in this issuance. V. POLICY STATEMENTS A. PhilHealth accredits the following HCProfs subject to full compliance with the requirements and conditions set by the Corporation:

1. Physicians a. General Practitioner (GP) b. GP with training c. Medical Specialist (MS) d. Primary Care Physician as Konsulta Package Provider
2. Dentists a. General Dentist b. Dental Specialist 3· Nurses 4· Midwives s. Other professionals as deemed necessary by the Corporation s RA 11223: Universal Health Care Act, Section 4, letter k (1). Page 3 ofls

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B. Types of Accreditation

1. Initial- the accreditation given to a qualified HCProfwho is applying for the first time andjor granted accreditation for the first time.
2. Renewal - the accreditation given to a qualified HCProf who filed an application for accreditation before the expiration of a previous accreditation in accordance with the provisions of these rules.
3. Re-accreditation - accreditation given to a qualified HCProfs due to the following conditions: a. whose previous accreditation has lapsed; b. whose subsequent application was denied; c. whose accreditation was temporarily withdrawn; or d. whose professional classification is for upgrading with existing accreditation. C. Requirements for Accreditation
4. All accredited HCProfs shall have a valid license from the Professional Regulation Commission (PRC).
5. For renewal of accreditation, in lieu of a valid PRC ID, an HCProf may submit a copy of the any document issued by PRC as proof of renewal of professional license with updated validity.
6. For cases mentioned above (Sec V.C.2), the HCProf shall submit a photocopy of the updated PRC ID to the same Phi/Health office where the HCProf submitted the application, within thirty (30) days upon receipt of the HCProf PRC ID either through email, walk-in or courier, to ensure continuous accreditation. 4· All accredited HCProfs shall have the applicable training/s andjor competency/ies required based on the servicejs they are providing. s. The prescribed accreditation requirements are provided in Annex A: "Documentary Requirements for Accreditation of Health Care Professionals".
7. All accredited HCProfs shall submit a fully accomplished and signed Provider Data Record for Health Care Professionals (Annex B) for updating of any information in the accreditation database such as change in name, address, affiliation, marital status, contact information including mobile number and email address, etc., with suppmting documents as applicable, as outlined in Annex C (Supporting Documents for Updating of Records of Health Care Professionals).
8. All accredited HCProfs shall submit a fully accomplished, signed and notarized Performance Commitment for Health Care Professionals (Annex D) as part of the documentary requirements.

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8. A primary care physician shall have defined competencies in providing efficient and quality promotive, preventive, curative, rehabilitative, and palliative health services as defined in Section 4.(s) of the UHC Act, through the competency-based certification and provision of appropriate learning interventions.6 g. Philippine Medical Association (PMA) Certificate of Good Standing (CGS) valid up to May 3181 of the current year shall be accepted for applications received on June 1 up to July 31.Ajter this date, an updated CGS is required when application is submitted. D. Premium Contributions
9. All accredited HCProfs shall be registered members of Phi!Health. They shall pay at least one (1) month premium contribution during the month the application was filed.
10. Applicant HCProfs with missed premium contribution shall be referred to the Collection Section of Local Health Insurance Offices (LHIOs)jPROs for appropriate action.
11. All accredited HCProfs shall continue to pay the required monthly premium contributions regularly. This includes the Phi!Health Lifetime members who obtain a regular source of income from employment, practice of profession and other means as per Phi!Health Circular Nos. 2019-0009 "Premium Contribution Schedule In The National Health Insurance Program (NHIP) Pursuant To R.A. No. 11223 Known As "Universal Health Care Act" and 2019-0010 "Guidelines On The Granting of Immediate Eligibility To Members" and its subsequent amendments.
12. Premium payment is neither an application fee nor an accreditation fee. E. Decisions regarding status of membership of HCProfs in their respective accredited professional organizations (APO) of the PRC shall be given due consideration in assessing the continued accreditation of such professionals. F. Accreditation Process
13. Filing of Application a. The applicant HCProfs shall submit two (2) sets of complete application as required in Annex A, during the prescribed filing period. A receiving copy of the submitted requirements shall be returned to the applicant or to his/her representative. 6 RA 11223: Universal Health Care Act, Section 4, letters. Pages ohs

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b. Only complete applications shall be accepted. Incomplete applications shall be returned to the applicants with the list of deficiencyjies noted during evaluation. c. Application for initial accreditation and re-accreditation may be submitted anytime. d. For renewal/continuous accreditation, the HCProf shall submit the application documents one hundred and twenty (120) days to twenty (20) days prior to the expiration of the current accreditation. d.1 Applications filed before 120 days prior to expiration shall not be accepted and shall be returned to applicant HCProf with advice to file the application within the prescribed period. d.2 Applications filed within the prescribed period shall be processed accordingly and shall be granted continuous accreditation, as applicable. d.3 Applications filed from the 19th day prior to and up to the expiration date of the current accreditation shall be considered late filing and shall be granted continuous accreditation but may result to late updating of accreditation records. d.4 If the last working day falls on a weekend, or a legal holiday, the deadline for the filing of the said application would be on the succeeding working day. e. Applications filed beyond the expiration of the current accreditation (lapsed) shall be considered re-accreditation and may incur gap in accreditation. f All HCProfs shall submit the complete documentary requirements for accreditation electronically or manually to their respective LHIOs/PROs. If sent via email, the original documents shall be submitted to the LHIO/PRO within thirty (30) days after submission to ensure continuous accreditation. g. The mailing address of the HCProf shall determine to which PRO the HCProf will submit the application. For the contact information of Phi!Health Regional Office's, please refer to https:/ jwww.philhealth.gov.phjabout_usjmapjregional.htm. 2. Decisions on the Applications a. Applications fully compliant with all the requirements for accreditation, as established by the Corporation, shall be granted accreditation. b. The applications for renewal of accreditation of HCProfs shall be granted continuous accreditation as applicable, until denied/withdrawn based on the rules set by the Corporation. Page 6 ofls

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c. The applications compliant with ALL of the following shall not be subject to deliberation by the RAC: c.1 Submitted complete and updated documentary requirements; c.2 Filed within the prescribed period; c.3 No pending casejs for infraction/sand/or violation/s of any PhilHealth rules, regulations and other issuances; and c.4 HCProfs not currently under P A. d. The following applications shall be subject to deliberation by the RAC: d.1 Initial accreditation, and d.2 Renewal or re-accreditation with pending case/s for infraction/s and/or violation/s of any PhilHealth rules and regulations, and other issuances. e. The decision on the applications is delegated to the head of the PRO by the President and CEO of the Corporation. f. Decisions are subject to an appeal or motion for reconsideration (MR), as applicable, within thirty (30) calendar days from receipt of the letter of the decision on the application. Otherwise, the decision becomes final and executory. g. In case the HCProf is not in agreement with the decision on the application, an appeal/motion for reconsideration may be filed addressed to the Chairperson of the RAC or the AARC accordingly, within thirty (30) calendar days from the receipt ofthe decision. The options/remedies on the denied application are provided in Table 1, "Remedies of the HCProf on the Decision of the RAC and AARC". h. A letter of approval and an electronic ID card, once eiD module is available, shall be emailed to all HCProfs with approved applications within three (3) working days upon approval of the Regional Vice- President (RVP) or by President and Chief Executive Officer (PCEO), as applicable. Receipt of such shall be acknowledged by the HCProfs immediately. The printed copy of the said letter shall be mailed thereafter. i. A letter of denial of application shall be emailed to the HCProfs with denied accreditation within three (3) working days upon approval of the decision for denial of their application for accreditation by the concerned RVP or by PCEO, as applicable. Receipt of such shall be acknowledged by the HCProf immediately. The printed copy of the said letter shall be mailed thereafter.

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j. All HCProfs whose applications for accreditation were denied may re-apply for accreditation any time after the receipt of the letter of denial of accreditation ensuring that the reason/ s for denial has/have been resolved. k. All HCProfs whose accreditation are temporarily withdrawn may apply for re-accreditation if they intend to continue to participate in theNHIP. 3· Remedies of the HCProf on the Decision on the application, Appeal or MR. a. An HCProf with an application denied by the RAC may undertake any of the following actions: a.1 Submit a motion for reconsideration, addressed to the PRO VP/RVP, when the basis of the denial is any of the conditions below: a.1.1 Compliance with requirements/minimum standards for accreditation that caused the denial of applications. i.e., HCProf settled arrears or premium contributions, submitted updated CGS, etc.; a.1.2 Delay in filing of applications due to late issuance of PRC licenses; a.1.3 Removal of gap in accreditation a.1.3.1 Due to late filing; and a.1.3.2 Due to fortuitous events, including disasters, distress, epidemics, pandemics, i.e.: a.1.3.2.1 Events that are '~cts of God" such as floods or typhoons or earthquakes; and a.1.3.2.2 Events that are '~cts of Man" such as pandemics, rebellion, insurgencies, and wars. a.2 If the above-mentioned MR is denied by the RAC, the HCProf may file an appeal with the AARC (Table 1 - Remedy of the HCProf in the Decision of the RAC and AARC) within 30 calendar days from receipt of the decision on the MR. a.3 Submit an appeal addressed to the President and CEO of the Corporation within thirty (30) calendar days from receipt of the notice ofRAC decision, when the basis for denial is/are not among the conditions from a.1.1 to a.1.3.2.2. b. HCProfwithAppeals/MR before theAARC Page 8 ofls

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b.1 When the MR of the HCProf in Section V, item F.3.a.1 is denied by the RAC, the concerned HCProf may still file an appeal with the AARC. However, HCProf shall no longer file an MR once the appeal is denied by the AARC. b.2 HCProf with denied applications for reasons not mentioned in Section V, itemF.3.a.1 may file an appeal with theAARC. When the appeal is denied, the HCProf may file an MR. reasons Section V, item F.3.a.1 was denied the RAC MR for reasons stated in Section V, item F.3.a.1 was denied by the RAC MRfor reasons not stated in Section V, item F.3 as denied theAARC Table 1: Remedies of the HCProf on the Decision of the RAC andAARC 4· Validity of the Accreditation a. The accreditation shall be valid for three (3) years, subject to PRC guidelines on validity of issued PRC licenses, unless earlier terminated, temporarily withdrawn, suspended or revoked by the Corporation. This applies for complete applications received starting January 14, 2023 onwards. b. The accreditation of HCProfs who filed the applications for renewal of accreditation during the prescribed filing period shall remain valid until the Corporation has acted on the application/appeal/ MR on accreditation. c. The denial of an application for renewal/continuous accreditation shall take effect thirty (30) days from the HCProfs receipt of the notice of denial of accreditation. d. Start date of accreditation. Page 9 ofls

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d.1. For initial accreditation and re-accreditation, the validity shall start from the date of compliance/submission of application with complete requirements. d.2. For renewal of accreditation, the validity of continuous accreditation shall start on the day after the expiry of the previous accreditation. e. The end date of accreditation shall be in consonance with the expiry of the HCProfs PRC license unless earlier terminated, temporarily withdrawn, suspended or revoked by the Corporation. To illustrate, Table 2 below shows the scenarios of an HCProf with birthdate of October 1, 1990 whose PRC card expiration date is October 1, 2022. Type of Filing Application Accreditation Validity Application Period Date Current New Remarks Start date of accreditation is 11/01/19 NA 11/01/19 the date of to submission of Initial, 10/01/22 complete Per Section requirements. V.F.1.c of this Anytime policy. 09/01/19 End date of to accreditation is 10/01/22 the expiry date 09/01/19 NA (3years& ofthePRC 30days) license. sdays early submission, Renewal, Per 11/01/19 application Section o6jo3/22 shall not be V.F.1.d.1 of 05/29/22 NA accepted. this policy to to Advise to file within the 09/10/22 10/01/22 prescribed period. On time submission, entitled to continuous Renewal, Per accreditation. Section 10/02/22 V.F.1.d.2 of 06/30/22 to End date of this policy. 10/01/25 accreditation is the expiry date ofthePRC license. Page 10 ofls

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Q.J , .. (,'• '"·lt. c, U<() I (.) ~I Type of Filing Application Accreditation Validity Application Period Date Current New Remarks 19 days late submission but prior to expiration of accreditation Renewal, Per 10/02/22 shall be entitled Section to continuous V.F.1.d.3 of 10/01/22 to accreditation. this policy. 10/01/25 End date of accreditation is the expiry date of the PRC license. 4 days late submission after expiration of accreditation, Re- not entitled to continuous accreditation, 10/05/22 accreditation, Per Section 10/05/22 to will incur gap. V.F.1.e of this 10/01/25 policy. End date of accreditation is the expiry date ofthe PRC license. Table 2: Accreditation validity based on type of application of HCProf with birth date of October 1, 1990 and PRC license expiration on October 1, 2022 or new PRC validity. f. Revocation of the license issued by the PRC or other government regulatory office/s shall also take effect on the validity of accreditation upon receipt of the said decision by the concerned HCProf or the effectivity stated in the decision. G. Provisional Accreditation (P A)

1. The following are grounds for granting provisional accreditation: a. Submitted an application, appeal or motion for reconsideration (MR) during a period of national or local calamity, whether natural or manmade; armed conflict or epidemic/ pandemic during which time there is an urgent need for health care services, unless attended by fraud; b. Pending cases that are non-fraudulent in nature before the Arbitration Office; c. Pending cases that are fraudulent in nature before the Arbitration Office for more than six (6) months; Page 11 of 15

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d. Pending casejs that are fraudulent in nature before the Prosecution Department, FFIED or PRO Legal Unit; and e. Other situations/conditions as determined by the Corporation, during which time there is an urgent need for health care services. 2. The grant of the PA shall only be for a maximum of 24 months inclusive of the PA period granted initially; 3. A HCProf granted PA shall be continuously reimbursed during the period ofPA, based on the existing rules on claims reimbursements. 4. Phi/Health shall review the applications granted PA within a prescribed period. s. Regular accreditation shall be granted once the reasonjsfor granting PAis/are resolved. H. Denial of Accreditation Any of the following conditions shall be a basis for denial of accreditation.

1. Non-compliance with any or all of the requirements for accreditation;
2. Revocation, non-issuance or non-renewal of the license issued by the PRC or other government regulatory office;
3. Conviction either by Arbitration Office, if final and executory, or by the Board 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; 4· HCProfs with fraudulent cases docketed with the Arbitration Office within six ( 6) months prior to the submission of a complete application for accreditation; and s. Such other grounds that the Corporation may determine. I. Temporary Withdrawal of Accreditation (TWA)
4. Accreditation is a privilege. The Corporation may impose TWA on HCProfs based on the rules set in this Phi/Health Circular.
5. The following are grounds for TWA: a. Non-compliance with any or all of the accreditation requirements within the prescribed filing period; b. Conviction either by the Arbitration Office, if final and executory, or by the Phi/Health Board, due to fraudulent acts as determined by the Corporation within the validity of accreditation until such Page 12 ofls

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' ,. time that the decision was 1·eversed by the appellate court or the penalty has been .fully served; c. Formal communication of the accredited HCProfs with intention to withdraw the same for whatever reason; and/ or d. Such other grounds as the Corporation may determine. 3. The President and CEO of the Corporation shall issue the order for TWA and lifting of TWA, if applicable, upon the recommendation of the VP / RVP and Area VP, based on the grounds stated in the existing guidelines. 4· The TWA shall take effect on the next day after receipt of the letter by the concerned HCProf or hisjher representative. J. Lifting of Temporary Withdrawal of Accreditation (TWA)

1. The TWA shall be lifted once the ground for the imposition of temporary withdrawal has been resolved or upon expiration of the regular accreditation period, whichever comes earlier.
2. The President and CEO of the Corporation shall issue the order oflifting of TWA once the condition for the imposition of temporary withdrawal has been resolved or until expiration of the regular accreditation, whichever comes earlier. 3· The following are conditions for lifting of TWA: a. Compliance, during the period of temporary withdrawal of accreditation, with the accreditation requirements which caused the imposition of temporary withdrawal; b. Reversal of the revocation of the license/certification of training of the HCProf by the DOH, Professional Regulations Commission (PRC) or other government regulatory office during the period of temporary withdrawn accreditation; c. Reversal by the appellate court of the conviction either by Arbitration Office or by the PhilH ealth Board due to fmudulent acts, or the penalty has been .fully served; and d. Such other grounds as the Corporation may determine. 4· If the date of effectivity of the order to lift the TWA is still within the accreditation period, the HCProf shall no longer apply for re- accreditation. The accreditation shall be reinstated for the remainder of the accreditation cycle. Page 13 ofls

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K. Suspension of Accreditation

1. The Corporation shall effect the final order of execution or Writ of Execution issued by Phi!Health against the HCProf. L. If the penalty of suspension imposed upon the HCProf exceeds the validity of the current accreditation, the unserved suspension period shall be in effect upon approval of the succeeding accreditation cycle until it is fully served. The start date of the accreditation shall be after the suspension has been fully served. M. Accreditation of the Heads of the Facilities
2. The Medical Director/Chief or Head of hospitals and infirmaries shall serve full time and shall be allowed to handle one (1) health facility only.
3. Heads of Free-Standing Dialysis Clinics (FDCs), Ambulatory Surgical Clinics (ASCs) and non-hospital facilities for the Maternity Care Package (MCPs)/Normal Spontaneous Delivery (NSD) package shall be allowed to handle a maximum of three (3) analogous facilities at a time. N. Credentialing and Privileging ofHCProfs HCProfs shall be subject to credentialing and privileging by their affiliated HFs. HCProfs shall submit their legitimate, valid and updated credentials to the HF and ensure that they maintain good standing with their PRC recognized organization.
4. Monitoring and Evaluation

All accredited HCProfs shall be subject to the existing Phi!Health rules on the HCP performance monitoring. 2. These guidelines on the Accreditation of HCProf shall be regularly reviewed and enhanced as necessary. P. Annexes

1. Annex A: Documentary Requirements for Accreditation of Health Care Professionals
2. Annex B: Provider Data Record for Health Care Professionals
3. Annex C: Supporting Documents for Updating of Records of Health Care Professionals
4. Annex D: Performance Commitment for Health Care Professionals VI. PENALTY CLAUSE Any violation of this Phi!Health Circular, terms and conditions of the Performance Commitment and all existing Phi!Health circulars, Corporate Page 14 ofls

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Orders and directives shall be dealt with in accordance with the pertinent provisions of R.A. No. 11223 and R.A. No. 7875, as amended by R.A. No. 9241 and R.A. No. 10606, and their IRRs. VII. SEPARABILITY ClAUSE If any provision of this PhilHealth Circular shall be declared invalid, unconstitutional or unenforceable, the validity of the remaining provisions shall not in any way be affected and shall remain enforceable. VIII. REPEALING ClAUSE a '"~ ___ ,,..,.. ... ,_..,,...=.,,"'"'""1 This PhilHealth Circular repeals the following: A. PhilHealth Circular No. 10 s. 2014 entitled "The New Accreditation Process for Health Care Professionals and Guidelines for Credentialing and Privileging of Professionals." B. PhilHealth Circular No. 2020-0013 entitled "Provisional Accreditation of Health Care Providers." C. PhilHealth Circular No. 2020-0006 entitled "Premium Contributions of Accredited Health Care Professionals as Direct Contributors." D. PhilHealth Circular No. 2017-0013 entitled "Guidelines on Filing of Appeal and Motion for Reconsideration on the Denied Application I Other Accreditation Transactions of Health Care Providers"; E. PhilHealth Circular No.2022 - 0029, entitled "Accreditation of Health Care Professionals (HCProfs). All other issuances that are inconsistent with this PhilHealth Circular are hereby modified, amended and repealed accordingly. IX. DATE OF EFFECTIVITY This PhilHealth Circular shall take immediately after its publication in a newspaper of general circulation. A copy of this PhilHealth Circular shall thereafter be deposited at the Office of the National Administrative Register (ONAR) of the University of the Philippines Law Center. J.LEDESMA, JR. President and Chief Executive Officer Date Signed: _ Lf i'--,!,v,s'+,f«:_:o,-"3 ___ _ Accreditation of Health Care Professionals (HCProfs) (Revision l) Page 15 ohs

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Annex A: Documentary Requirements for Accreditation of Health Care Professionals I. GENERAL REQUIREMENTS FOR ALL PROFESSIONALS (as of CY 2023)

1. Provider Data Record (PDR)
2. Performance Commitment (PC)
3. Updated PRC License or a copy of any document issued by PRC as proof of renewal of the PRC license.
4. 35mm width x 45mm height (Passport size) photo (2pcs) II. SPECIFIC REQUIREMENTS FOR APPLICATION FOR ACCREDITATION OF PROFESSIONALS (as ofCY 2023) n\ctitioner 'S:-. tpt) """' (1) <t"· t:\ C:.' b. General Practitioner (GP) with training c. Care Physician as Konsulta Package d. Specialist (MS)
5. Certificate (CGS) from its Local Component Society
6. Certificate of Good Standing from PMA or its Local Component Society
7. Certificate of Completed Residency Training
8. Certificate Good Standing from PMA or its Local Component Society
9. Certification as Primary Care Worker for UHC from DOH

of Standing from PMA or its Local Component Society 2. Specialty Board Certificate 3. Certificate of Good Standing from Specialty Society I Good Standing from PMA or its Local Component Society 2. Certificate of Good Standing from Specialty Society I Subspecialty Society toGPT

1. Certificate of Good Standing from PMA or its Local Component Society
2. Certificate of Completed GPtoMS
3. Certificate of Good Standing from PMA or its Local Component Society
4. Specialty Board Certificate
5. Certificate of Good Standing from Society I GP with Training toMS
6. Certificate of Good Standing from PMA or its Local Component Society
7. Specialty Board Certificate
8. Certificate of Good Standing from Specialty Society I Page 1 of 3 of Annex A

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Note: • For emeritus members of PMA or Specialty Societies, the professional shall submit a copy of proof of emeritus standing from the society in lieu of the CGS. a. Dentist (GD) Dental Association (PDA) 1. Specialist 2. (DS) 3. 3· Midwife Any of the following evidences of Competency on the Expanded Functions of Midwives (not required for graduates from school year 1995 and onwards):

1. Certificate of Training from a program accredited by the Continuing Professional Education ( CPE) Council of the Board ofthe Professional Regulation Commission (PRC); or
2. Training Certificate from an accredited DOH-PRC training provider /institution; or 3· Certificate of Apprenticeship for one or more years with a PHIC accredited 0 bstetrician- Gynecologists or an accredited midwife General requirements as specified. Standing from PDA
3. Specialty Board Certificate 3· Certificate of Good Standing from Specialty Society IUD Insertion:
4. Certificate on Family Planning Competency Based Training (FPCBT) Level 2/Comprehensive Family Planning Course; or
5. Post-Pactum Training Course Subdermal Contraceptive Implant Package:
6. Certificate of Training on Subdermal Implant Insertion and Removal Post-partum IUD insertion:
7. Post-Pactum IUD Training Course Page 2 of 3 of Annex A

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done in an accredited facility 4.Nurse

1. Certificate of Training on the Basic Emergency Obstetric and Newborn Care (BEmONC) for nurses from a DOH- recognized training center for BEmONC skills; and
2. Certificate of work experience for at least two ( 2) years in the labor and delivery room of at least a level one (1) hospital *Note: Midwives/Nurses may be providers ofFP without being an MCP or NCP provider Page 3 of 3 of Annex A

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lmnex B: Prmider Data Record fo:r Health Care f>rofess:ionals PROVIDER DATA RECORD HEALTH CARE PROFESSIONALS PH!C·ACCRE·AI'-5 V.2023 4.5cm x 3.5 em (Passport Size) Photo ·-----------------------------------------------------------------------------------------------------------, i INSTRUCTIONS : ' ' ' 1. Please read each sections carefully and check applicable boxes. 2. All information should be written in UPPER CASE/ CAPITAL LETTERS. If the information is not applicable, write "N I A" 3· All fields are mandatory. By affixing your signature, you certify the truthfulness and accuracy of all information provided. 4· For profile updating, fill up item no. 3 and check the appropriate box to be updated. Proceed to item no. 19 and indicate the correct data. 5· Indicate all affiliated health facilities. Use separate sheet if necessary. ' ------------------------------------------------------------------------------------------------------------1 THE PRESIDENT &CEO Philippine Health Insurance Corporation Pasig City Philippines Sir/Madam: PHILHEALTH ACCREDITATION NUMBER I I I I 1-1 I I I I I I 1-1 I Not applicable for initial applical'ion I, of legal age, hereby applies for accreditation under Sec. 61 of RA. 7875 as amended by RA. 10606 and its Implementing Rules and Regulations thereto. For this purpose, I hereby submit the following pertinent information and documentary requirements. PHILYSYS NUMBER: I I I I 1-1 I I

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• I I TAX IDENTIFICATION NO.I I PHIJ .. HEALTH IDENTIFICATION NO. I I -I I I -I I

1. CLASSIFICATION
2. TYPE OF APPLICATION 3· PROFILE UPDATE D General Practitioner (G') D General Dentist D Initial D Update of civil status D GP w J Training D Dental Specialist D Renewal D Update of name Training: Specialty: D Re-accreditation D Update of health facility affiliations D Medical Specialist D Update of Family Planning Training Specialty: 0 Midwife D Primary Care Physician (as Konsulta D Nurse D Others: Package Provider) 4- PERSONAL INFORMATION LAST NAME FIRST NAME Name MIDDLE NAME NO MIDDLE Extcnr;lon (Jr./Sr./111) N~" HEALTH CARE PROFESSIONAL D MOTHER'S MAIDEN NAME , .. ...... -·-······~ .. -~, ,n; D SPOUSE (if Married) ~ D "' s.SEX
3. CIVIL STATUS f..li:' j) D Male D Female D Single [, *hir ..... J Widowjer D Annulled D Legally Separated r;:· 7-BIR~DATE(Mr/DD/YYYY)
4. E-MAILADDRES (n·o 19· LANDLINE NO.
5. MOBILE NO. ;,;; '
6. MAILING/ BILLING ADDRESS ,;;;;:-.,. ~ ,, No./St./Brgy. \" fS City/Municipality Province Q Zip Code Contact No. e:.;~" This form may be reproduced and is not for sale Continue at the back Page 1 of 2 of Annex B

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-;;-(;oLLlluii7iiir~:Eil-;Ji1;;.::··-··-----------------·-···-····-·-·-------------- --------f· YEARGiADu;i:iiln--] 14. PRCNO. ··-·---·--r5· DATE ISSUED (MM/DD/Y:YY)------T6. VALID UP TO (MM/DD/YYYY) ·-··-·-··--· 17. RESIDENCYTRAINING (ForMS/ GP with Training) Address of Health Facility Year Started Year Ended Name of Health Facility 18. HOSPO"AL/CLINIC AFFILIATION(S) ADDRESS 1

2 3 4 5 Continue in a separate sheet if necessary 19. PROFILE UPDATE Check all applicab]e: FROM TO D Change/correction of Name (Last Name, First Name, Name extension, Middle Name) D Upgrading or Downgrading D Correction of Date of Birth D Correction of Sex D Change of Civil Status D Updating of Personal Information/ Address/ Tele- phone Number/ Mobile Number/ Email address D .. Others: Under penalty of law, I hereby attest that the information provided, including the documents I have attached to this form, are true and accurate to the best of my knowledge. I agree and authorize Phi!Health for the subsequent validation, verifica- tion and for other data sharing purposes only under the following circumstances: • As necessary for the proper execution of processes related to the legitimate and declared purpose; • The use or disclosure is reasonably necessary, required or authorized by or under thelaw; • Adequate security measures are employed to protect my information; and • I am allowing Phi!Health to access my PRC details to verify status of my professional license . Health Care Professional's Signature over Printed Name Date FORPHIUIEALTHUSEONLY Date Evaluated LHIO By: LHIO tX· i PRO PRO ~ iPAS Generated Conh·olNo. By: Date Received: LHIO LH!O LC : t.v By: -lH'),.., 'i':'· PRO PRO 1···, 0 Ul' Date Encoded: LHIO /PRO (Receiving Module) LHIO ;;o ~ PRO(DataEntJy) PRO 'f fS 1l'.·5 Page 2 of 2 of Annex B ',

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Annex C: Supporting Documents for Profile Update/Updating of Records ofHCProfs status 2. Correction of Name 3· of Sex 4· Updating 5· personal information to (from married to single) address, Telephone/mobile numbers, and e-mail address • • Properly accomplished and signed PDR • Properly accomplished and signed PDR • Copy of Birth • Properly accomplished and signed PDR • Copy of Birth • • Properly accomplished and signed PDR • Letter of Request to add hospital affiliation • Properly accomplished and signedPDR • Letter of Request to delete hospital affiliation Page 1 of 1 of Annex C

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Annex D: Performance Commitment for Health Care Professionals Performance Commitment for Health Care Professionals (Date) PHILIPPINE HEALTH INSURANCE CORPORATION 17:h Fir., City State Centre Bldg., Shaw Blvd., Pasig City SUBJECT: Performance Commitment for Health Care Professionals (Rev. 3) Sir/Madam: To guarantee our commitment to the National Health Insurance Program ("NHIP"), I respectfully submit this Performance Commitment. And for the purposes of this Performance Commitment, I hereby commit the following representations: A. REPRESENTATION OF ELIGIBILITIES it!".-, ,-- I I ~~; I ::::,I ' .I -. , ;z .. ~ ! 1 UJ)= ·~ I It;~ II l<o~,~ l 'S I '= . i ~ 1 ! ; ! ) i if-... -. I r:; i \ .......,, .==.o.. ......

1. lam ,a Doctor of Medicine/ Dentist/ Midwife/ Pharmacist/ Nurse duly registered and licensed to practice my profession by the Professional Regulation Commission (PRC) with PRC No. _____________________ ,
2. As a licensed professional, it is my responsibility that my license is updated and valid all the time;
3. I am a member in good standing of the NHIP with an active membership in the NHIP by regularly paying my PhilHealth premium contributions during the entire validity of my accreditation as a health care professional;
4. Membership in professional organization (choose one) a. D I am a member in good standing of _______ ____c ________ _ (name of the national association/ specialty society) regulating my profession; b. DI am not a member in good standing of any national association/ specialty society regulating my profession; 5· I am affiliated with (enumerate here the name/s of accredited health facility /ies, or on a separate sheet of paper, if needed.) and have undergone credentialing and given appropriate privileges in the said health facility /ies (HF / s) in accordance with its/their policies and procedures. B. COMPLIANCE TO PERTINENT LAWS/ RULES AND REGULATIONS/ POLICIES/ ADMINISTRATIVE ORDERS AND ISSUANCES
5. I am fully aware of, I have read and understood, and I shall conduct myself strictly and faithfully in accordance with the provisions of Republic Act (R.A.) 11223, R.A No. 7875, as amended, including their respective Implementing Rules & Regulations (IRRs ), particularly that pertaining to and governing the extent and limits of the grant of my privilege to be an accredited health care professional of the NHIP administered Page 1 of 4 of Annex D

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by PhilHealth, with full knowledge of the consequences of my non-compliance and violations; 7· I shall abide by all lawful, reasonable and fair administrative orders, circulars and such other policies, rules and regulations issued by the Department of Health (DOH) and all other related government agencies and instrumentalities governing the practice of my profession and affecting my accreditation in the NHIP; 8. I shall abide by all the implementing rules and regulations, circulars, advisories, and other administrative issuances issued by the PhilHealth governing my accreditation; 9. I understand, that as a health care professional of the said institutionjs, I will follow the policies of the said facility as long as it does not violate Statutory laws, Orders, Circulars and such other policies, rules and regulations issued by the DOH and all other government agencies and instrumentalities governing the practice of my profession. C. CONDUCT AND UNDERTAKINGS OF PARTICIPATION IN THE NHIP "'>;<·· ··--... ··--·--?f).·=r ~!I

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Further, I hereby commit myself to the following: 
10. I am fully aware and I hereby acknowledge that accreditation administered by the 
PhilHealth is not a right but a mere privilege as provided under Section 31, Article 
VIII of R.A. 7875, as amended on the 'Authority to Grant Accreditation' by PhilHealth; 
11. I am fully aware and I hereby acknowledge that my accreditation being a mere 
privilege extended by the NHIP, the grant of which may be continuous for as long as 
I comply with the requirements within a particular period as may be determined by 
the PhilHealth. I further acknowledge and accept that my accreditation including the 
appurtenant benefits and opportunities incident thereto, being a mere privilege, may 
be temporarily withdrawn, suspended and/ or revoked at any time during the term of 
my accreditation as may be determined by PhilHealth to protect the interests of the 
NHIP; 
12. I am fully aware and I unconditionally acknowledge and agree that non-adherence to 
guidelines or any violation of any provision of my commitment whether directly or 
indirectly, shall constitute 'Breach of the Performance Commitment' and shall be a 
ground at the discretion of PhilHealth, to suspend, shorten, temporarily withdraw 
and/ or revoke my accreditation including the appurtenant benefits and opportunities 
incident thereto at any time during tlle term of my accreditation as may be determined 
by PhilHealtll to protect the interests of the NHIP; 
13. I undertake that all qualified NHIP beneficiaries shall be given high quality of healtll 
care service due them witllout delay and tllat I shall deduct without delay tlle correct 
amount of chargeable benefits due to qualified beneficiaries upon discharge; 
14. I am fully aware and I unconditionally acknowledge and agree tllat any indicationjs, 
adverse reports/findings of pattern/s or any oilier similar incident which may be 
indicative of any illegal, irregular, improper and/or unetllical conduct or practice of 
my profession may be a ground at tlle discretion of PhilHealtll, to suspend, shorten, 
temporarily witlldraw and/or revoke my accreditation including the appurtenant 
benefits and opportunities incident thereto at any time during the term of my 
accreditation as may be determined by PhilHealtll to protect the interests of tlle 
NHIP; 
15. I am fully aware, knowledgeable and hereby agree to strictly conduct myself in 
accordance with and in compliance to all the basic precepts and tenets of my 
profession including all the laws, guidelines, policies and regulations regulating my 
profession including all the etllical standards required and governing the exercise of 
my profession; 
16. I shall promote and protect the NHIP against abuse, violation and/ or over-utilization 
of its Funds and I will not allow our institution to be a party to any act, scheme, plan 
or contract that may directly or indirectly be prejudicial to tlle NHIP; 
17. I shall not directly or indirectly engage in any form of unethical or improper practices 
as an accredited provider such as but not limited to solicitation of patients for 
Page 2 of 4 of Annex D 


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purposes of compensability under the NHIP the purpose and/or the end 
consideration of which tends unnecessary financial gain rather than promotion of the 
NHIP thereby ultimately undermining the greater interests and noble purpose of the 
NHIP; 
18. I hereby undertake that I shall immediately report to PhilHealth, its Officers and/or 
to any of its personnel, any act/s of illegal, improper and/or unethical practices of 
institutional or professional health care providers of the NHIP that may have come to 
our knowledge directly or indirectly; 
19. I shall immediately and promptly make available upon request for PhilHealth 
purposes, a listing of my schedule of professional fees readily available to PhilHealth 
Officers and authorized personnel, members, dependents and/or representatives; 
D. ADMINISTRATIVE INVESTIGATIONS IN THE EXERCISE OF THE 
PRIVILEGE OF ACCREDITATION 
20.I unconditionally recognize the authority of PhilHealth, its Officers and personnel 
and/or its duly authorized representatives to conduct administrative investigation 
relative to the exercise of my privilege and conduct of my profession as an accredited 
health care professional of the NHIP, and knowing the diversity of my profession, I 
fully welcome and understand if the investigation shall be done beyond the normal 
business/ operating hours; 
21. I undertake that I shall fully cooperate and submit myself to any assessment to be 
conducted by PhilHealth relative to any findings, adverse reports, quality issues, 
pattern/ s of utilization and/ or any other acts indicative of any illegal, irregular and/ or 
unethical practice of my profession as an accredited healthcare professional of the 
NHIP that may be prejudicial or tends to undermine the noble purpose of the NHIP; 
22. I undertake that I shall comply without delay any and all PhilHealth's summons, 
subpoena, and other legal processes; 
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23. I undertake that at any time during the period of my accreditation, upon request of 
PhilHealth, I shall voluntarily and unconditionally sign and execute a new 
'Performance Commitment' to continue my accreditation as the case may be, as a sign 
of my good faith and continuous dedication and sincerity to comply with my 
Performance Commitment, to support and promote the NHIP being administered by 
PhilHealth; 
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24. That I shall allow PhilHealth to deduct or charge to my future claims, all 
reimbursements paid to me during the following, but not limited to: (a) period of the 
gap in my accreditation status or suspension of accreditation; (b) when NEB-eligible 
PhilHealth members and their dependents were made to pay out-of-pocket for 
professional fees, and; (c) validated claims of under deduction ofPhilHealth benefits 
or overpayments to HF; 
25. Finally, I hereby declare under penalties of perjury that my above-stated statements 
are true and correct without any conditions and free from misrepresentations. 
Very truly yours, 
Signature of Health Care Professional 
PRC License Number: __________ _ 
Expiry Date: ____________ _ 
Page 3 of 4 of Annex D 


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SUBSCRIBED AND SWORN to before me this 
affiant exhibiting his/her 
validly issued government ID. 
Doc. No. __ _ 
Page No. __ _ 
Book No. __ _ 
Series of 20 __ 
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NOTARY PUBLIC 
Page 4 of 4 of Annex D