Adopted: 03 March 2014
Date Filed: 02 April 2014

1. RATIONALE:

Pursuant to the new policies issued by the Corporation including the Implementing Rules and Regulations of Republic Act (RA) 10606, an act amending the National Health Insurance Act of 1995 (RA 7875, as amended) and the All Case Rates Policy No. 1 - Governing Policies in the Shift of Provider Payment Mechanism from Fee for Service to Case-Payment Mechanism (PhilHealth Circular No. 31 s. 2013), it is imperative that reforms in accrediting Health Care Professionals must be established as the Corporation pursues the aspirations of KaIusugan Pangkalahatan or Universal Health Care. Moreover, it is also the responsibility of the Corporation to render fast and efficient service to its stakeholders by adopting simplified procedures and requirements consistent with the Anti-Red Tape Act of 2007 (RA 9485). This directive has guided the Corporation in updating its procedures in engaging the Health Care Institutions in 2012.

In view of the foregoing, the Corporation endeavors to improve the accreditation process for health care professionals to ensure that members of the National Health Insurance Program (NHIP) and their dependents have better access to quality and cost-effective health care services.

II. OBJECTIVES

The new accreditation process for professionals aims to:

1. Establish a streamlined and effective process in accrediting health care professionals for the NHIP
2. Strengthen the monitoring system for PhilHealth accredited health care professionals
3. Recommend guidelines for health care institutions in its credentialing and privileging of its health care professionals

III. COVERAGE

This Circular shall apply to all health care professionals that are currently participating as well as those with intention to participate in the NHIP. These include:

1. Physicians
2. Dentists
3. Midwives
4. Other health care professionals as determined by PhilHealth

This Circular shall also apply to the health care institutions where these health care professionals are affiliated.

IV. DEFINITION OF TERMS

1. Affiliation - Is a process by which a health care institution accepts a health care professional as part of their health human resource and in so doing provides the health care professional practice privileges in their health care institution.
2. Continuous accreditation - given to accredited health care providers under basic participation provided that they comply with the requirements annually as prescribed by the Corporation. Continuous accreditation provides them uninterrupted participation to the Program but this privilege may be withdrawn at any time based on rules set by the Corporation.
3. Credentialing - the process established by a health care institution to obtain, verify, and assess the qualifications of a health care professional who applies for affiliation with their Institution.
4. Performance Commitment (PC) - a document signed by health care professionals who intend to participate In the Program, which stipulates their undertakings to provide complete and quality health services to PhilHealth members and their dependents. This document also reflects the willingness of health care provider to comply with PhilHealth policies on benefits payment, information technology, data management and reporting and referral, among others
5. Privileging - the process of giving appropriate practice privileges or benefits to health care professionals affiliated with the health care institution based on certain status, credentials or qualifications

V. GENERAL GUIDELINES

1. The following professionals, who are licensed by the Professional Regulation Commission, are automatically accredited and could participate in the NHIP provided that they submit the required documents (Annex A) that includes, among others, the signed Performance Commitment (PC), to the nearest PhilHealth office:
   1. Physicians
   2. Midwives
   3. Dentists
   4. Other professionals as determined by the Corporation
2. The accreditation process for health care professionals shall be streamlined through the following mechanisms:
   1. Delegating the authority to PhilHealth Regional Offices (PROs) to process all applications for accreditation of health care professionals and to update their profiles in PhilHealth database.
   2. Delegating the authority to the Chairperson of the Accreditation Committee to approve or deny the Motions for Reconsideration, including the authority to act on unresolved accreditation issues of health care professionals referred by the PROs to the Committee.
   3. Institutionalizing the continuous accreditation, until withdrawn, for health care professionals
3. Health Care Professionals may submit their application for initial accreditation and re-accreditation at any time of the year. These professionals may opt to pay the premium contribution of the remaining applicable quarter/s of the current year plus one year OR pay the remaining applicable quarter/s of the current year plus 2 years. The validity of accreditation of these professionals shall start from the day of submission of complete requirements and ends one day prior to the professional ™s birth date.
4. All HCPs must declare their membership in a national association, which is an Accredited Professional Organization by the Professional Regulation Commission (PRC). Physicians, likewise, must declare their membership in a specialty society recognized by the Philippine Medical Association. Health care professionals must recognize that their association/society plays a role in their continuing education and in regulating their profession.
5. All health care professionals shall undergo credentialing and privileging by its affiliated health care institution/s.
6. All currently accredited professionals shall sign and submit the PC (Annex B) on their subsequent application for continuous accreditation. The Warranties of Accreditation that they have signed shall remain valid until they renew their accreditation. Professionals who apply for re-accreditation and initial accreditation however, shall submit and sign the PC upon the effectivity of this Circular.
7. Payment of accreditation fee and certificate of good standing from the national association of professionals and/or specialty society of physicians are no longer required for application for accreditation. However, the names of the professionals must be reflected in the database of their respective national association and/or specialty society declared in their PC.
8. The validity period of accreditation of all professionals applying for continuous accreditation shall be a minimum of 1 year and maximum of 3 years. They may opt to pay their premium contributions equivalent for 1 year, 2 or 3 years, which shall be the basis of the accreditation validity to be granted for the professional.
9. Currently accredited health care professionals shall submit the documentary requirements not later than 45 days prior to their birthday to ensure their continuous accreditation to NHIP. Failure to submit the requirements within the prescribed period shall result in the withdrawal of their continuous accreditation. Accredited professionals shall inform PhilHealth immediately of any changes in their Personal Data Record (Annex C) to allow PhilHealth to update their record in the Corporation ™s database.
10. A Manual of Procedures and implementing guidelines shall be issued to facilitate the implementation of this Circular.

VI. GUIDELINES ON CREDENTIALING AND PRIVILEGING OF
PROFESSIONALS

Credentialing and privileging of health care professionals shall be done by the health care institutions where they are affiliated. Thus, all health care institutions must establish the mechanism to verify the capabilities, qualifications and competence of a health care professional. If done properly, this system ensures that quality services are rendered to the members and dependents of the NHIP. The following are the roles of the professionals, health care institutions and PhilHealth to ensure proper implementation of credentialing and privileging.

A. Roles of Professionals

1. Health Care Professionals shall submit their credentials to the health care institutions they are affiliated with.
2. Health Care Professionals must ensure that all their credentials are legitimate, valid and updated.
3. Health Care Professionals must ensure that they maintain their good standing with PRC-recognized professional organization.

B. Roles of Health Care Institutions

1. All accredited health care institutions shall develop their own set of policies and guidelines for credentialing and privileging their affiliated health care professionals. They may adopt from existing policies endorsed by recognized accrediting bodies. The following shall be considered by the HCIs in formulating their policy in credentialing and privileging health care professionals:
   1. Verify the credentials of health care professionals from the primary source(s). These credentials encompass professional education, internship, residency, and fellowship programs and other relevant trainings and work experience.
   2. The recognized primary sources of information for credentialing and privileging include, among others:
      • Medical Schools/Professional school accredited by the Commission on Higher Education
      • Professional Regulatory Commission
      • Training Hospital or Institution
      • Specialty Board
      • National Association of Health Care Professionals
      • Other hospital affiliations of Health Care Professional
   3. The critical credentialing parameters that must be verified are as follows:
      • Current license
      • Education and training
      • Experience, ability and current competence
2. The HCI shall conduct credentialing and privileging of all its affiliated health professionals.
3. The HCI shall set the validity period for conferred privileges consistent with the license of health care professionals unless such privileges are suspended.
4. The HCIs shall mandate their affiliated health care professionals to update their PhilHealth accreditation as part of their credentialing and privileging policy. Further, the HCIs shall enjoin their resident-physicians and contracted physicians to become PhilHealth member and encourage them to get accredited.
5. The HCI shall keep a record, contracts or its equivalent (MOA, etc.) of all PRC-registered health care professionals who have undergone credentialing and privileging, including the practice privileges conferred to them.
6. The HCI shall allow PhilHealth to review all submitted documents related to credentialing and privileging during the conduct of their monitoring of the HCI surveys and whenever deemed necessary by the Corporation.
7. HCIs shall recognize the role of PRC-recognized national association/ specialty society of health care professionals in ensuring their continuous professional education and overseeing their practice standards.
8. The accredited HCI, having conferred the privilege to their healthcare professionals, shall be held accountable to PhilHealth for any reports of noncompliance to PhilHealth policies, including those related to the quality of health delivery.
9. Violations of the Performance Commitment committed by the healthcare professional may be counted against the HCI where such practice was noted. After due process, the HCI shall be issued offense warnings and subsequently suffer the corresponding penalties or sanctions in accordance with PhilHealth implementing rules and regulations and other pertinent issuances.
10. In case the health care professionals are also members of the credentialing and privileging committee/authority, an additional provision of the Performance Commitment shall be signed by the said professionals to declare such arrangements from which may arise conflict of interest.

C. Roles of PhilHealth

1. PhilHealth shall verify the credentials and privileges of affiliated professionals of HCIs during healthcare provider performance monitoring and other quality assurance activities.
2. The Corporation shall validate with the issuing office the authenticity of documents submitted for accreditation as deemed necessary.
3. PhilHealth reserves the right to withdraw the accreditation of any HCI which does not conduct credentialing and privileging of its professionals.

VII. GROUNDS FOR WITHDRAWAL OF CONTINUOUS ACCREDITATION OF
PROFESSIONALS

Accreditation is a privilege granted by PhilHealth to health care professionals that apply for accreditation. These accredited professionals may continuously participate until such accreditation is withdrawn by PhilHealth on the following grounds:

1. Non-submission of all the required documents on the prescribed filing period
2. Official declaration on quality/ethical issues endorsed by the national association governing the practice of the professional after due process
3. Official declaration on quality/ethical issues endorsed by tile specialty society governing the practice of the physician after due process
4. Other reasons as determined by the Corporation

VIII. MONITORING AND EVALUATION OF PERFORMANCE OF
PROFESSIONALS

All accredited HCIs having committed to comply with all PhilHealth rules and regulations shall assist PhilHealth in monitoring the practices of their affiliated health care professionals. Any monitoring findings related to the practice of the professional, good or otherwise, shall also be reflected in the HCI profile and shall be used as one of the bases for the facility ™s continuous accreditation and performance assessment.

All accredited professionals shall be subjected to the same monitoring criteria already stipulated in Section 47 item e. of the new IRR that includes, among others, the following:

• Over-utilization of services;
• Unnecessary diagnostic and therapeutic procedures and interventions;
• Irrational medication and prescriptions;
• Inappropriate referral practices
• Grossly unjustified deviations from currently accepted standards of practice and/or guidelines or treatment protocols
• Use of fake, adulterated or misbranded pharmaceuticals or unregistered drugs;
• Use of drugs other than those prescribed in the latest PNF and those for which exemptions were granted by the Board

Other violations include:

• Unsafe practices (e. g. use of unsterilized instruments)
• Unethical/ Questionable practice patterns

A feedback mechanism shall be established by PhilHealth to inform the health care professional of the monitoring findings. Health care professionals with negative monitoring findings shall be subjected to a peer review through the QAC, the results of which may constitute an offense or violation of their performance commitment. Upon the recommendation of the Committee, such results shall also be reported to their affiliate national association/specialty society, PMA and PRC for other appropriate action. Moreover, the HCI where such practice was observed shall be tagged for the same offense. Three (3) offenses shall trigger sanctions, consistent with the provisions stipulated in PC 54 s. 2012. Sanctions and penalties as provided in the Performance Commitment for professionals shall also be applied as determined by the Corporation.

All other violations of the Performance Commitment shall also be dealt with accordingly. Such findings of violations by the concerned PRO shall be directly reported to their legal unit for appropriate action. Professionals and HCIs, where the violation was committed, shall be meted the same penalties as provided by existing laws, rules and regulations, particularly those provided by Rep. Act No. 7875, as Amended, and its Implementing Rules and Regulations.

VIII. SANCTIONS AND PENALTIES

Any violation of this Circular, the terms and conditions of the Performance Commitment and all existing related PhilHealth circulars, office orders and directives shall be dealt with in accordance with the pertinent provisions of RA 7875, as amended by RA 10606 and its Implementing Rules and Regulations.

IX. REPEALING CLAUSE

All previous PhilHealth issuance inconsistent or contrary to the provisions of this Circular are hereby revised, modified, repealed or rescinded accordingly. All provisions of existing issuances which are not affected by this Circular shall remain valid and in effect.

X. EFFECTIVITY

This Circular shall take effect fifteen (15) days after publication in a newspaper of general circulation and shall thereafter deposited with the Office of the National Administrative Register, University of the Philippines Law Center. This shall cover all applications for accreditation beginning on the effectivity of this Circular.

(SGD) ALEXANDER A. PADILLA
President and CEO