In support of the United Nation ™s Millennium Development Goal Number 6 to halt or reverse the incidence of Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Virus (AIDS) by 2015, PhilHealth through Board Resolution No. 1331, series of 2009 has approved the implementation of an outpatient HIV/AIDS treatment package. This benefit aims to increase the proportion of the population having access to effective HIV/AIDS treatment and patient education measures.

A. General Rules

1. The Outpatient HIV/AIDS Treatment (OHAT) Package will be paid through a case payment scheme. Annual reimbursement is set at 30,000 pesos per year.

2. Only confirmed HIV/AIDS cases requiring treatment shall be covered by the package.

3. Package shall be based on Department of Health (DOH) guidelines on anti-retroviral theraphy among adults and adolescents with human immunodeficiency virus infection. All treatment hubs in accredited facilities are required to follow the guidelines set by the DOH.

B. Specific Rules

1. Covered items under this benefit are drugs and medicines, laboratory examinations including Cluster Difference 4 (CD4) level determination test and test for monitoring of anti-retroviral drugs (ARV) toxicity and professional fees of providers.

2. The package will be released in four (4) quarterly payments; each sub-package is worth 7,500 pesos payable to the recognized treatment hub of accredited facilities. A maximum of four (4) treatment sub-packages per year may be claimed by the treatment hub.

3. Each quarterly claim is covered by the rule on single period of confinement computed from the date of consultation. Any additional claims filed within this same period for the same reason will be denied.

4. Only the actual quarters wherein services were provided in a year will be reimbursed.

For example:

Start or treatment	October 15, 2010
Covered period of benefit entitlement	October 15, 2010 - December 31, 2010
Total amount of benefit	7,500 pesos

5. Each quarterly claim shall be charged one (1) day against the 45-day annual limit or a sum of 4 days per year.

6. In cases of transfer from one treatment hub to another, PhilHealth will still reimburse provided:

a. The facility that the patient was transferred to is also PhilHealth accredited.
b. A referral letter from the referring facility to the receiving facility is accomplished.
c. The Corporation will reimburse the facility prior to the transfer.

C. Inclusion Criteria

1. PhilHealth shall only pay for cases confirmed by STD/AIDS Central Cooperative Laboratory (SACCL) or Research Institute for Tropical Medicine (RITM).

D. Exclusion Criteria

1. Excluded in this OHAT Package are the following:

a. Diagnosis of HIV/AIDS with no laboratory confirmation
b. HIV/AIDS cases with no indication for anti-retroviral therapy
c. Management of patients with pulmonary tuberculosis co-infection. A separate package for TB-DOTS may be reimbursed in accredited TB-DOTS facilities. A member may avail of both the OHAT and TB-DOTS packages simultaneously.
d. Illness (opportunistic infections) secondary to HIV/AIDS that requires hospitalization

2. HIV/AIDS cases requiring confinement are covered under the regular inpatient benefit of PhilHealth.

E. Claims Availment and Processing

1. Claims for the OHAT Package must be submitted to PhilHealth within sixty (60) days from the first day of treatment.

2. Claims with incomplete requirements shall be returned to the facility for completion.

The following documents are required for processing of claims:

a. For all claims

    i. Duly accomplished revised PhilHealth Claim Form 1 by member and employer.
    ii. Duly accomplished revised PhilHealth Claim Form 2 by the health care providers.

Fill in all blanks and write œNA  if the information required is not applicable

a.) Part I: Items 1 to 13 should be properly filled out. The following boxes should be filled out as follows:

1.) Item No. 4, write Outpatient HIV/AIDS Treatment Package or OHAT on the Category of Facility (see Annex C).

2.) Item No. 10, write the date that corresponds to the day of consultation as seen in the Health Regimen Card as the date of admission and the date of discharge.

Write œNA  in the Time of Admission and Time of Discharge. For the item No. of Days Claimed, write œOPD. 

3.) Item No. 11, write the amount 7,500 pesos in the column provided for the Total Actual Charges and also in the column corresponding to the Total PhilHealth Benefit

4.) Item No. 13, write œNA  in the space provided.

b.) Part II: the physician must accomplish this portion

1.) Item No. 14, write HIV/AIDS in the Space for Admission Diagnosis
2.) Item No. 15, write Human Immunodeficiency Virus - Acquired Immune Deficiency Syndrome in the space for Complete Final Diagnosis
3.) Item No. 16, write œNA  in the columns provided for the Total Actual PF Charges and PhilHealth Benefit
4.) For the portion provided for drugs and medicines, write œOHAT PACKAGE 

c.) Part III: the physician must accomplish this portion by writing œOHAT PACKAGE  in the spaces provided for x-ray, laboratories, supplies and others.

d.) Part IV: the institutional health care provider accomplishes this portion by affixing the signature over printed name of the authorized representative and writing his/her official designation and the date the form was signed in the prescribed format.

e.) Part V: the patient or his/her representative accomplishes this portion by signing in the appropriate space provided together with the date the form was signed; indicate the relationship to the patient, if a representative signs in behalf of the patient; and the reason for signing on behalf of the patient.

iii. Updated Member Data Record (MDR)
iv. Proof of premium payment for individually paying members
v. PhilHealth ID card for sponsored, pensioners and overseas workers program members

b. Other documents to be submitted:

Initial Claims	Succeeding Claims
- Photocopy of the following:	1. photocopy of the health regimen booklet
1. HIV screening test result	2. waiver and consent for release of confidential information
2. confirmatory test results by SACCL or RITM	(see annex A)
3. health regimen booklet	* include referral letter in cases of transfer
- clinical abstract - waiver and consent for release of confidential information (see Annex A)

3. For previously diagnosed cases but are filing for the first time, the claimant must still submit all the necessary laboratory test results together with the other requirements. This will be considered as the initial claim.

4. To ensure patients ™ right to confidentiality, all claims for the OHAT Package shall be enclosed in a sealed envelope, marked œCONFIDENTIAL  and submitted to the PhilHealth Regional Office.

5. PhilHealth employees who will be directly involved in the processing of claims for HIV/AIDS shall sign a confidentiality agreement to further ensure patients ™ right to confidentiality.

6. All claims for the OHAT Package shall undergo regular claims processing (appropriate office order shall be provided for the guidelines)

7. To facilitate processing of this package, the Relative Value Scale (RVS) code shall be used by PhilHealth in claims evaluation:

Code	Description	RVU
99246	OUTPATIENT HIV/AIDS PACKAGE	Package

F. Accredited Providers

1. Only DOH-designated treatment hubs in accredited facilities may file for reimbursement for the OHAT package. (see Annex B)

2. No separate accreditation for treatment hubs as OHAT Package providers shall be required, as long as the hospital is currently accredited by PhilHealth. In cases where there are gaps between facility accreditation, claims for the sub-package will not be paid.

3. Accredited providers designated as treatment hubs are required to create a trust fund for reimbursement of OHAT Package.

4. The disposition of PhilHealth payment shall be:

a. 80% as revolving fund for the delivery of the required service e.g., drugs, supplies, laboratory reagents, equipment, site improvement, referral fee.

b. 20% administrative costs including staff training and incentive that shall be divided among the HIV/AIDS Core Team (HACT) and other staff directly providing the services composed of, but not limited to the following: doctors, dentists, nurses, medical social workers and medical technologists

5. All fees for the OHAT Package are payable to the provider who filed the initial claim. In cases where there is transfer of patient from one treatment hub to another, PhilHealth facility, for such claim to be processed. In cases where transfer occurred within the same quarter, PhilHealth shall pay the initial facility.

G. Eligibility Rules for Members and Dependents

1. Sponsored and Overseas Workers Program members are entitled to the package if the period of treatment falls within the validity periods of their membership as stated in the ID card.

2. Retirees and pensioners shall be entitled to avail of the package upon presentation of PhilHealth ID.

3. Employed members including KASAPI and the Individually Paying Program (IPP) members must have at least (3) months of contribution within the immediate six (6) months prior to the availment of claim.

This Circular shall take effect for all claims starting October 1, 2010.

All other provisions of previous Circulars, Office Orders and all other related issuances that are not inconsistent with any provisions of this Circular remain in full force and effect.

(SGD.) DR. REY B. AQUINO
  President and CEO