Republic of the Philippi11es

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PHILH~W
PHILIPPINE HEALTH INSURANCE CORPORATION

CIRCUW
Citystate Centre, 709 Shaw Boulevard, Pasig City
Call Center (02) 8441-7442 Trunk1ine (02) 8441-7444
www.philhealth.gov.ph
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UNIVERSAl HEALTH CARE
U.IV>•O•~ •• u"~G~ •u• •• ,..,.

No. ll.OILIL~ CJOO~

TO ACCREDITED HEALTH CARE PROVIDERS, PHILHEALTH

REGIONAL OFFICES, BRANCHES, LOCAL HEALTH
INSURANCE OFFICES, AND ALL OTHERS CONCERNED

SUBJECT Implementation ofthe Debit-Credit Payment Method Nationwide

(Revision 11

I. RATIONALE

Pursuant to its mandate under Section 16.d and 34 of Republic Act (RA) 7875, as amended by
RA 9241 and 10606, also known as the National Health Insurance Act of 2013, Phi!Health as the
administrator of the National Health Insurance Program is granted the power and function to
"formulate and implement guidelines on... payment, methods, and referral systems" and that
Phi!Health can design provider payment mechanisms including "case-based payment... " and
"other provider payment mechanisms that may be determined and adopted by the
Corporation... Subject to the approval of the Board, the Corporation may adopt other payment
mechanism that are most beneficial to the members and the Corporation." Likewise, Section
18.10 of Implementing Rules and Regulations (IRR) of RA 11223 provides that "Phi!Health shall
adopt any or a combination of closed-end, prospective provider payment mechanisms, such
as ... case-based payment... and other appropriate mechanisms".

With the staggering number of COVID-19 cases significantly burdening the Philippine Health
System and with Health Care Facilities (HCFs) requiring sufficient cash flow to continue
operating during the pandemic, there is a renewed recognition on the value of consistent and
efficient reimbursements for providers treating COVID-19 patients and facilities providing the
Phi!Health COVID-19 testing package. This, however, does not diminish the value of protecting
public interests and safeguarding public funds from misuse. In balancing these interests, the
Corporation, upon securing Board approval thro Phi/Health Board &solution No. 671 s. 2021, and as
amended and approved ry the Board during the &gular Board Meeting held on March 2, 2022, shall adopt
the application of Debit-Credit Payment Method (DCPM) to facilitate the settlement of accounts
payable to HCFs during the State of Public Health Emergency due to the COVID-19 pandemic.

II. OBJECTIVES

This Phi!Health Grcular aims to establish the guidelines in facilitating the settlement of accounts
payable to Health Care Facilities in order to ensure continuous delivery of health care services
during the COVID-19 pandemic.

Ill. SCOPE

6.> ~
This Phi!Health Circular shall apply to HCFs treating COVID-19 patients and facilities providing
the Phi!Health COVID-19 testing package with in-process claims received/refiled starting
0 Phi\Healthofficlal ()CZ) teamphilhealth (! actioncenter@philhea!th.go~.ph
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 February 1, 2020 to February 15, 2022, in-process claims are not included in the first four DCPM
implemmtation, with no unliquidated Interim Reimbursement Mechanism (IRM) Fund balances on
record, and that are not serving the penalty of suspension during the applicable period.

This will not applyto in-process claims already approved for payment for received claims starting
February 1, 2020 to Febmary 15, 2022. Likewise, this Phi!Health Circular will not apply to
received/ rejiled claims starting February 16, 2022 and onwards.

IV. DEFINITION OF TERMS

A Denied claim - a claim that has been determined to be invalid and unworthy of payment
reimbursement due to an absolute deficiencythat cannot be remedied through return to sender
or due to a finding of an unmet requirement.
B. Good claim- filed claims with complete documentary requirements that has been determined
to be valid and worthy of payment.
C Health Care Facility (HCF) - health facilities public or private, devoted primarily to the
provision of services for health promotion, prevention, diagnosis, 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
D.In-process claims- claims received for processing without final decision as to denied, return-
to-hospital (RTH}, or paid.
E. Interim Reimbursement Mechanism (IRM) - a special privilege for the provision of substantial
aid to an eligible Health Care Institution direcdy hit by fortuitous event with clear and apparent
intent to continuously operate and/ or rebuild the HQ in order to provide continuous health
!!} care services to adversely affected Filipinos.
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~lr. Received daims -all claims manually and electronically received by the Corporation. These
•, include refiled claims.
~- Re-filed claim- a claim that has been previously submitted by a HCF or member but to which
1

ffi >- ~ it is returned due to deficiency and compliance of documentary requirements.

~ 4!:1 -I.Retum-to-Hospital (RTH} claim - a deficient claim after due adjudication and validation,
~ ()\~ redirected back to HCF with instructions to comply with a certain requirement, but from
~ which the action of returning the complied claim to Phi!Health may result in the reversal of
the deficiency into a good claim for payment ornon-compliance that mayresult into the denial
iJ of the claim.
0
. __ _ __JI-. Sixty (60) days tum-around-time - the period to process, review and pay claims as provided
for under the Revised IRR of RA 7875, as amended by RA 9241 and 10606, otherwise !mown
as National Health Insurance Act of 2013.

V. POLICY STATEMENTS

A The implementation of DCJlM nationwide shall be applicable only to in-process claims

received/ refiled starting Februaty 1, 2020 to Febmary 15, 2022, wbicb are not included in the
population from the previous DCPM implementation, excluding Return-to-Hospital (RTH} and
denied claims, claims referred to legal for further investigation which includes claims under
the Temporary Suspension of Payment of daims order, and claims already approved for
payment.

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0 PhiiHea!thofficlal OOteamphllhealth ~ [email protected]

 B. Additionally, claims directly filed bythe member, claims with invalid illness codes, and initially
identified in-process claims included in the first four DCPM implemmtation that were returned-
to-hospital and has since been received by Phi!Health within the inclusive period of the fifth
implementation of DCPM shall likewise be excluded from the computation of applicable in-
process claims. Likewise, all directly filed claims regardless of received date is excluded from
the computation.

C Previous recipients from the previous DCPM implementation shall be eligible to apply for the
DCPM nationwide provided they meet the inclusion criteria.

D. HCFs should meet the following criteria to be eligible for DCPM

1. Must have no IRM Fund balance on record;
2. With claim for Phi!Health COVID-19 packages; and,
3. Was not serving the penalty of suspension during the applicable period.
4. Healthcare Facilities who already availed of ai!J or all rif the previous DCPM implementation
mqy avail regardless rif the recordedpercentage rif reconciliation.

E. Eligible HCFs that are interested to participate must submit a Letter of Intent (LOI) or
application for DCPM

F. The DCPM application shall only be processed once the HCFs have already forwarded the
undertaking (see Annex A, "Undertaking") to the concerned PRO, duly signed by the HCF
owner or MedicaVHospital Director subject to the concurrence of Phi!Health.

,.....--:~_G.. Under DCPM nationwide implementation, Phi!Health shall facilitate the settlement of
~ j accounts payable from appropriate in-process claims in compliance with the following rules:
~ 1. Pay eighty percent (80%) of the total amount of applicable HCF receivables subject to
a: e; two percent (2%) expanded withholding tax for private eligible HCFs, as applicable; and,
~ £ 2. Pay progressively the remaining twenty percent (20%) of the amount of good claims,
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~ subject to two percent (2%) expanded withholding tax for private eligible HCFs, as
~ (.) ~ applicable, following full compliance to existing claims processing requirements and full
reconciliation of the eighty percent (80%) of the total amount of applicable HCF
receivables initially paid to the HCF.
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---.:=..JH No adjustment shall be made to HO"s with payments received from any of the first four
DCPM implen:mtation in relation to the eighty (80 %) percent computation rate.

I. In the Debit-Credit Reconciliation Notice, the reconciliation shall be indicated, and the HCF
should be reflected in the subsidiary ledger.

J. The Corporation, subject to the approval of the Board, can adjust the inclusive dates of claims
applicable for DCPM Any changes to the inclusive dates shall be announced through a
separate issuance.

K. The HCF shall issue an electronic copy of the Official Receipt (OR) within five (5) days of
receipt of payment. Concurrently, the HCF shall transmit the original OR within fifteen (15)
days of receipt of payment. Failure to submit the OR shall result in the withholding of all
succeeding payments from Phi!Health.
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0 PhliHealthofficial OOteamphilhealth e [email protected]

 L. In cases where there is a need to recover unreconciled amounts under the Da>:M, including
but not limited to cases where the Ha> ceased to operate and there are insufficient unpaid
claims to be applied to paid amounts, Phi!Health shall employ the Payment Recovety Policy
and! or exhaust all legal remedies, including the filing of legal action as warranted

M Phi!Health reserves the right to suspend payments under the Da>M for recurrent non-
compliance to standards of care, presence of fraud or for any other reason deemed relevant
by Phi!Health.

N. Phi!Health shall regularly monitor the implementation of the Da>M

PENALTY CLAUSE

Violations of any provision of this Phi!Health Grcular shall be penalized under R.A No. 11223,
its Implementing Rules and Regulations and other applicable laws, rules, and regulations.
a: .(')*i
~ ~ I. SEPARABILITY CLAUSE

.. ~ (.) \~ Should any provision of this Phi!Health Grcular be declared invalid, unconstitutional or
~ unenforceable in whole or part by any competent authority, it shall not affect or invalidate the
~ remaining provisions hereof.
0
VIILREPEALING CLAUSE

Pertinmt provisions of Phi/Health Circt1/ar No. 2021-0023: Imp!ementatiOII of the Debit-Credit Pqyment
Nationwide which are inconsistmt with the foregoing are heref?y amended and modified.

IX. DATE OF EFFECTIVITY

1his Phi!Health Circular shall be effective immediately upon publication in a newspaper of

general circulation or Official Gazette. A copy of this Phi!Health Grcular shall be also deposited
with the Office of the National Administrative Register at the University of the Philippine Law
Center.

Date signed: N\Ofd" ~3

1 WW

Implementation of the Debit-Credit Payment Method Nationwide (Revision 1J

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.. 0Ph11Healthofficlal C)~teamphilhealth [email protected]

C'Or.tpl't~
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ANNEX A: Undertaking

UNDERTAKING
DQ>M Nationwide (revision 1)

KNOW ALL MEN BY THESE PRESENTS:

a health care facility duly organized and existing under and by virrue of the laws of the
Republic of the Philippines, with principal office address at
duly represented herein by
1ts President/Manager/ Chief of
Hospital/Medical Director/Owner hereinafter referred to as "HCF,"

IN COMPLIANCE WITH THE PHILHEALTH CIRCULAR ON THE

IMPLEMENTATION OF DCPM NATIONWIDE (REVISION 1)

WHEREAS, pursuant to Proclamation No. 1218, s. 2021, President Rodrigo Roa Puterte
extended the period of the State of Calamity throughout the Philippines due to COVID-19
pandemic until September 12, 2022 and mandated all government agencies to continue rendering
full assistance to and cooperation with each other and mobilize the necessary resources to
undertake critical, urgent, and appropriate disaster response aid and measures in a timely manner
to curtail and eliminate the threat of COVID-19;

WHEREAS, the HCF has been licensed by the Department of Health as a hospital or health care
facility that can provide appropriate care, supervision, and treatment of individuals who have been
confinned to be afflicted with the Covid-19 virus or conduct SARS-CoV-2 testing services;

WHEREAS, the HCF is currently an accredited health care provider who commits itself to
participate and abide with the existing rules and regulations on the implementation of the National
Health Insurance Program (NHIP); -., , _,
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WHEREAS, the HCF has pending benefit claims with the PHILHEAL1H covering packages for
COVID-19 and other illnesses/procedures;

WHEREAS, the PHILHEALTH, in recognizing the urgent necessity to institute measures to

ensure that the HO remain financially viable to enable it to continuously serve the health care
needs of affected PHILHEAL1H members in this time of public health emergency, resolved to
engage in a Debit Credit Payment Method to quickly settle its accounts or arrears to the HCF's
In-process claims to partially pay for the healthcare services provided to PHILHEAL1H
beneficiaries;

WHEREAS, the HCF has submitted documents to support its claim for reimbursement from
PHILHEAL1H;

WHEREAS, the PHILHEAL1H shall allow payment of eighty percent (80%) of the total In-
process claims of the HCF currently on board with the PHILHEAL1H, subject to reconciliation,
verification and validation of documents submitted and in compliance with the requirements of
the Phi!Health Circular on DCPM Nationwide;

WHEREAS, as an additional condition to allow payment, it has been determined that the
accreditation of the HCF is valid and that the HCF was not serving the penalty of suspension
during the applicable period (February 1, 2020 - February 15, 2022);

NOW THEREFORE, for and in consideration of the above-premises, the HCF agrees to
undertake as follows:

(a) The HCF hereby acknowledges the receipt of partial payment of its benefit claims by the
PHILHEAL1H m the amount of (state amount m words
_______________(P_____--', subject to application
of the appropriate withholding taxes, as may be applicable.

The HCF undertakes to issue an official receipt for said partial payment to be sent to the
PHILHEAL1H within five (5) days for the electronic copy, and fifteen (15) days for
original copy, from crediting of said amount in its identified account with its depository
bank.
' .

(c) The HCF undertakes that despite receipt of said payment, it shall either refund to the
PHILHEAL1H within five (5) days from receipt of notice, an amount in excess of what it
is entitled to, or corresponding to the claims eventually found to be erroneous or otherwise
not consistent with Phi!Health Circular No. 2021-0023, or allow recovery thereof through
the Phi!Health Payment Recovery Policy.

(d) The HCF undertakes that upon failure to deliver the required documents on the date
specified herein for unjustifiable reason, or that claims have been found to be not
consistent with Phi!Health Circular No. 2021-0023, the HCF agrees to submit itself to
undergo the processes under applicable Phi!Health circulars or issuances, and the
provisions of Republic Act No. 7875, as amended by the UHC Act, and its IRR

(e) In case of suits or actions arising out of or in connection with this Undertaking, actions
shall be lodged with the proper courts where the Phi!Health Regional Office is situated,
and the parties hereby waive other applicable venues.

(f) The HCF undertakes to comply with all circulars, issuances, orders, and advisories issued
by the PHILHEALTH, and to refrain from committing acts prejudicial to the interest of
the PHILHEAL1H and the National Health Insurance Program.

The duly-signed Performance Commitment of the HCF submitted to Phi!Health shall

form an integral part of this Undertaking.

This Undertaking is executed in accordance with the laws of the Philippines and is not
contrary to the same.

If any provision of this Undertaking shall be held to be invalid or unenforceable for any
reason by a court with jurisdiction over the parties to this Agreement, the remaining
provisions shall continue to be valid and enforceable.

0} This Undertaking may be executed by electronic signature. Electronic signatures shall, for
all purposes, be treated as originals.

IN WITNESS WHEREOF, the HCF through its duly authorized representative affixed its
signature this __ day of at , Philippines.
 ' .

<HEALTH CARE FACILITY>

By:

(Name)
(Authorized Representative)

Signed in the presence of:

ACKNOWLEDGEMENT

REPUBLIC OF THE PHILIPPINES)

CITY OF ) S.S.

BEFORE ME, this __ day of , personally appeared

_ _ _ _ _ _ _ _ _ _ _ _ _ _ who exhibited to me the following:

Identification Document Presented Place of Issuance and Expiry Date

Known to me to be the same person/s who executed the foregoing Undertaking consisting of
_ _ _ _ _ L_j pages including this page on which the acknowledgement is written and
they acknowledged that the same is their free act and deed and that of the cmporation being
represented.

WITNESS MY HAND AND SEAL on the date and place first above written.

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