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PRIMARYCAREBENEFIT1
ManualofProcedures forProviders
A stepbystep instruction to guide the PCB Provider in the PhilHealth Circular 10, s. 2012 Implementing Guidelines for Universal Health Care Primary Benefit I (PCB1) Package for TransitionPeriodCY20122013.

Forfurtherinformation/query,pleaseemailthePCBteamat pcbteam.philhealth@gmail.com

TABLEOFCONTENTS
I.PurposeoftheManual II.RationaleandObjectivesofthePrimaryCareBenefit1 III.DefinitionofTerms IV.EngagingwithPhilHealth WhocanprovidePCBservices HowtoEngagewithPhilHealthasaPCBProvider WhataretheObligationsofaPCBProvider V.BenefitPackageDeliveryMechanism Whoaretheentitledmembers Enlistingentitledmembers Establishing/updatingtheindividualhealthprofile WhataretheservicesunderPCB1? ProvidingthePCB1services Referringtheentitledmember VI.RecordingandReporting TheIndividualHealthProfile(AnnexA.1) PCB1PatientLedger(AnnexA.3) Quarterly report of PCB services availed by PCB1 entitled members and dependents(AnnexA.5) PCBProviderClienteleProfile(AnnexA.2) QuarterlyReportForm(AnnexA.4) VII.SubmissionofReports VIII.PaymentofPCBPackage IX.RolesandResponsibilities Members LocalHealthInsuranceOffices X.MonitoringandEvaluation XI.Annexes A. PhilHealthCircular10s2012 B. ProviderDataRecord C. DOH Department Memorandum No. 20120148. Assignment of Sponsored Program Members identified through NHTSPR to their Primary Care Providers D. TemplateforMasterlistofEnlistedMembersforPCB1 E. ProvidersAgreementFormforObligatedServices F. TamangSagot 1 2 3 8

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26 27 29

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ABBREVIATIONS/ACRONYMS
AGEAcuteGastroenteritis AQASAccreditationandQualityAssuranceSection BASBenefitAdministrationSection BPBloodPressure CHTCommunityHealthTeam FBSFastingBloodSugar DMDiabetesMellitus HCDMDHealthCareDeliveryandManagementDivision HITPHealthInformationTechnologyProvider IECInformation,EducationandCommunication IHCPInstitutionalHealthCareProvider ICTInformationandCommunicationTechnology KPKalusuganPangkalahatan LCELocalChiefExecutive LGULocalGovernmentUnits LHIOLocalHealthInsuranceOffice MDRMemberDataRecord MMGMemberManagementGroup MOOEMaintenanceandOtherOperatingExpenses MOPManualofProcedures NHIPNationalHealthInsuranceProgram NHTSPRNationalHouseholdTargetingSystemforPovertyReduction OGOrganizedGroup OPBOutPatientBenefit OWPOverseasWorkersProgram PBRPhilHealthBoardResolution PCPerformanceCommitment PCBPrimaryCareBenefit PCB1PrimaryCareBenefit1 PDRProviderDataRecord PFPRPerFamilyPaymentRate PROPhilHealthRegionalOffice SPSponsoredProgram URTIUpperRespiratoryTractInfection UTIUrinaryTractInfection VIAVisualInspectionwithAceticAcid

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I.PURPOSEOFTHEMANUAL
This Manual of Procedures (MOP) for PhilHealth Circular No. 10, s. 2012 entitled, ImplementingGuidelinesforUniversalHealthCarePrimaryBenefitI(PCB1)Packagefor Transition Period CY 20122013 (Annex A), as amended, is designed for the use of PCB Providers. This MOP provides a stepbystep instruction to guide the PCB providers in participating in the NHIP, to deliver the PCB package, enlisting PCB entitled members, providePCBservicesasnecessary,submittingreports,andutilizingthePFPRaccordingly.

II.RATIONALEANDOBJECTIVESOFTHE PRIMARYCAREBENEFIT1
InsupportoftheAquinoHealthAgendatoprovideUniversalHealthCareforallFilipinos, alsoknownasKalusuganPangkalahatan(KP),andconsistentwithitsexecutionplan,the Philippine Health Insurance Corporation aims to ensure that all Filipinos have access to qualityhealthservicesthatareefficientlydelivered,equitablydistributed,fairlyfinanced andappropriatelyutilizedbyaninformedandempoweredpublic. Toachievethesegoals,theCorporationthroughPhilHealthBoardResolutionNo.1587,s. 2012 amended the implementation of the Outpatient Benefit Package and approved a PrimaryCareBenefit1(PCB1)Package,withthefollowingobjectives: 1. Expand the number of services included in the Primary Health Care benefits for PhilHealthmembers; 2.IncreasetheutilizationrateforservicesincludedinthePrimaryHealthCarebenefits forPhilHealthmembers; 3.EnhanceincentivesforPCBproviderstopromotehealthybehaviour,preventdiseases and/orassociatedcomplications,andfacilitateappropriatereferral;and 4.Ensurecompleteandtimelyreportingofhealthdataformonitoringandperformance assessmentandevaluationpurposes.

III.DEFINITIONOFTERMS
ThefollowingdefinitionsoftermshavebeenexpandedtoprovideguidancetoPCBproviders. The recommended management of the conditions defined here is based on the appropriate clinicalpracticeguidelines. Acutegastroenteritis(AGE)inflammationofthegastrointestinalsystemwithatleastoneof thefollowingsignsorsymptoms:diarrhea,nausea,vomiting,abdominalpain.Theremayalso be accompanying signs and symptoms of dehydration such as thirst, restlessness, irritability, decreasedskinturgor,sunkeneyeballs,sunkenfontanel(forinfants),diminishedconsciousness, decreased urine output, cold clammy extremities, feeble pulses, peripheral cyanosis, and low bloodpressure.Thosewithmoderatetoseveredehydrationshouldbereferredtothenearest hospital. Bodymeasurementsmeasurementoftheheight(incentimeters),weight(inkilograms),and weightandhipcircumference(incentimeters)foradults20yearsandolder.Heightandweight ismeasuredinchildren. Breastfeedingprogrameducationprovisionofinformationregardingtherightofthemother tobreastfeed,advantagesofbreastfeeding,andinformationregardingsupportprograms. Circular refers to PhilHealth Circular No.10, series 2012, Implementing Guidelines for UniversalHealthCarePrimaryBenefitI(PCB1)PackageforTransitionPeriodCY20122013,as amended. Chest Xray a radiologic examination of the chest; usually taken in posteroanterior (PA) or anteroposterior (AP) view. This is suggested for, but not limited to, patients with suspected pneumonia. Complete blood count is a test panel that gives information about the cells in the patients blood; automated(hemoglobin, hematocrit,red blood cell count, white blood cell count, and plateletcount)ormanualcellcount(erythrocyte,leukocyte,orplatelet).Thisissuggestedfor, butnotlimitedto,patientssuspectedwithanemiaanddenguehemorrhagicfever. Consultationisatypeofserviceprovidedbyaphysicianinitiatedbyapatientand/orfamily forevaluationandmanagementwhichrequiresthreekeycomponents: history physicalexamination medicaldecisionmaking

Counsellingand/orcoordinationofcarewithotherprovidersareprovidedconsistent withthenatureoftheproblem(s)andthepatientsand/orfamilysneeds.Theservicealso includesupdatingofindividualhealthprofile. Corporation refers to the Philippine Health Insurance Corporation, government owned and controlled corporation, duly organized and existing by virtue of Republic Act No. 7875 (as amendedbyRepublicActNo.9241),otherwiseknownastheNationalHealthInsuranceActof 1995.ThisreferstoPHICorPhilHealth. Counselling for lifestyle modification patient and/or family education activity during one or more visit(s) designed to encourage healthy behavior changes, including, but not limited to promotion of healthy diet and nutrition, regular and adequate physical activity, avoidance of substancesthatcanbeabusedsuchastobaccoandalcohol,andadequatestressmanagement andrelaxation. Counsellingforsmokingcessationpatientand/orfamilyeducationduringoneormorevisit(s) concerning harms of smoking, benefits of smoking cessation, benefits and adverse effects of treatmentoptions,andinformationregardingtoolsandsupportprograms. Cumulative reporting a method of recording data such that the reports from previous time periods are included in the report of the current period. For example, the report for third quartershouldcontainthesecondquarter,andthereportforfourthquartercontainsthosefor secondandthirdquarters. Dependentthelegaldependentsofamemberwhoarethe: 1. legitimatespousewhoisnotamember; 2. unmarriedandunemployedlegitimate,legitimated,acknowledgedandillegitimate childrenasappearinginthebirthcertificate,andlegallyadoptedorstepchildrenbelow twentyone(21)yearsofage; 3. childrenwhoaretwentyone(21)yearsoldorabovebutsufferingfromcongenital disability,eitherphysicalormental,oranydisabilityacquiredthatrendersthemtotally dependentonthememberforsupport; 4. parentswhoaresixty(60)yearsoldorabove,nototherwiseanenrolledmember,whose monthlyincomeisbelowanamounttobedeterminedbytheCorporationinaccordance withtheguidingprinciplessetforthintheAct.

Diarrheaisthepassageofunusuallylooseorwaterystools,usuallyatleastthreetimesina24 hour period. Frequent passing of formed stools is not diarrhea, nor is the passing of loose, "pasty"stoolsbybreastfedbabies. DigitalRectalExamisaninternalexaminationofthelowerrectumbyaphysiciantofeelthe prostatetoallowtheexaminertoestimatethesizeoftheprostateandfeelforanylumpsor otherabnormalities.Thismayalsobedonetofeelforanymassesorotherabnormalitiesinthe rectum. Electronic submission refers to submission of documents using the internet, Institutional HealthCareProvider(IHCP)portal,andothermeansasdeterminedbytheCorporation. Enlistment refers to the act of signing up by a PCBentitled member with a Primary Care Providerforaperiodofoneyear.ForSponsoredProgrammembers,thissignifiesconcurrence withthePCBProvidertowhichtheyhavebeenassigned. Fasting Blood Sugar (FBS) is a test to determine the level of glucose in plasma after an overnightfast.Fastingisdefinedasnocaloricintakeforatleast8hoursuptoamaximumof14 hours. Fecalysis a stool examination for white blood cells, red blood cells, parasites, and ova for patientswithdiarrheathatissuspectedtobeofparasiticorprotozoalorigin.Whenwarranted, testforoccultbloodmustberequestedforpatientssuspectedofhavinggastrointestinalblood loss. Hypertension is considered in a patient with BP 140/90 mmHg recorded on at least 2 occasions, or in patients with BP 140/90 mmHg and signs of endorgan damage. It may be classifiedasstage1(SBP=140159orDBP=9099)orstage2(SBP160orDBP100). Individual/ClientHealthProfileatwopageformthatassessesthegeneralhealthstatusofthe member/dependent. The profile includes basic demographic data, past medical and surgical history, family health history, personal/social history, immunizations, reproductive health history and pertinent physical examination findings. The Individual Health Profile is updated annually. Lipid Profile a fasting lipoprotein profile including major blood lipid fractions, i.e., total cholesterol,LDLcholesterol,HDLcholesterol,andtriglyceride;thisrequiresa9to12hourfast. MembersforthepurposesofthisManualofProcedures,referstotheentitledmembers underPhilHealthCircularNo.10.TheyaretheSponsoredProgram,OrganizedGroupand OverseasWorkersProgrammembers. Nonhealth professionals are workers not directly engaged in patient care such as, but not limitedto,administrative,security,sanitationandmaintenance,dietaryorfood,socialworkers,
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community, volunteer or barangay health workers, womens health teams and community healthteams. NonhypertensiveindividualwithsystolicBPof<140mmHganddiastolicBP<90mmHgin theabsenceofintakeofantihypertensivemedications. Obligated service refers to a service that must be rendered to target clients because it is medically necessary and for the purpose of determining outcome performance as basis for payment. Organized group any organization of the informal sector registered with an authorized government regulatory body with the aim of providing social protection or social health insurance to its members. These organizations may include microfinance institutions, cooperatives,nongovernmentorganizations,transportoperatorsanddriversassociations,and credit unions, among others. The eligibility of these organizations to avail of PCB1 will be determinedbytheapplicablepoliciesconcerningtheorganizedgroup. Pap smear A procedure in which cells are scraped from the cervix for examination under a microscope.Itisusedtodetectcancerandchangesthatmayleadtocancerandmaybeused as alternative for Visual Inspection with Acetic Acid. A Pap smear can also show conditions, suchasinfectionorinflammation,thatarenotcancer.ItisalsocalledPaptestandPapanicolaou test. PCB Provider refers to any health facility providing services under the Primary Care Benefit package.ItisalsoreferredasProviderinthisManual. PCB1Packagestandsforprimarycarebenefits1packagewhichincludesthefollowing3main provisions: a.primarypreventiveservices b.diagnosticexaminations c.drugsandmedicinesforcertaindiseases Periodic clinical breast examination is an examination of the patients bilateralbreasts bya physician or a nurse, which includes inspection and palpation. This should be performed at regularintervalsasspecifiedinthecircularamongthetargetedindividualsevenintheabsence ofsymptomsorsignsrelatedtothebreasts. PhilippineHealthInsuranceCorporationagovernmentownedandcontrolledcorporationduly organized and existing by virtue of Republic Act No. 7875 (as amended by Republic Act No. 9241),otherwiseknownastheNationalHealthInsuranceActof1995.Itmaybereferredtoas PHIC,PhilHealthortheCorporationinthisManual. Profilingreferstotheactofdoing/updatingtheindividualorclienthealthprofileofentitled memberanddependents.
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 Regularbloodpressure(BP)measurementsauscultatorymethodofBPmeasurementusingan aneroidorelectronicsphygmomanometeratintervalsspecifiedinthecircular. Sputum microscopy a microbiological method of sputum examination for diagnosis and followupofpatientswithpulmonarytuberculosis(TB). Suspecteddiabetesmellitusreferstoindividualswithknownriskfactorsfordiabetesmellitus (DM) such as history of impaired glucose tolerance, gestational diabetes, vascular diseases, sedentarylifestyle,obesityandfamilyhistoryofDMaswellasthoseindividualswithsignsand symptoms suggestive of it such as polyuria, polydipsia, polyphagia, unexplained weight loss, weakness,fatigueandtinglingornumbnessofextremities.Theyshouldundergolaboratorytest suchasfastingplasmaglucosefordiagnosis. Suspectedurinarytractinfection(UTI)referstoindividualswithclinicalsignsandsymptomsof infectionreferabletotheurinarytractsuchasdysuria,frequency,hematuria,fever,flankpain, lower abdominal pain, and back pain. Routine urinalysis is done for the following conditions: acute uncomplicated pyelonephritis, acute cystitis in pregnant women, and acute uncomplicatedcystitisinmenandinwomenwithgynecologicalsignsandsymptoms.Antibiotic managementdependsontheinitialanddefinitiveUTIcondition. Urinalysisisthephysical,chemical,andmicroscopicexaminationofurine Visualinspectionwithaceticacid(VIA)theprimaryscreeningtoolforcervicalcancerbasedon acetowhitening,withthecervicalintraepithelialneoplasiaturningwhitewhenexposedto35% aceticacid.

IV.ENGAGINGWITHPHILHEALTH
A.WHOCANPROVIDETHEPCBPACKAGE
Anygovernmenthealthfacilitysuchashealthcenters/ruralhealthcenters(HCs/RHUs)and the Out Patient Department (OPD) of Municipal / City / Provincial Health Offices and government hospitals, that meets the Standards as provided in Annex C.1 of PhilHealth CircularNo.10,series2012.

B.HOWTOENGAGEWITHPHILHEALTHASAPCBPROVIDER
1. 2. SecureacopyoftheTechnicalStandardsforaPCBProviderfromanyPhilHealthOffice. (AnnexC.1ofPhilHealthCircularNo.10) Conduct a selfassessment of your health facilitys human resources, equipment and supplies and available network local partners to determine if your health facility can providealltheservicesnecessaryfortheimplementationofthePCB1Package. When your selfassessment activity reveals that your facility will qualify as a PCB1 provider, secure a copy of the following from the nearest PRO or LHIO, or you may downloaditfromthelinksindicatedbelow: a. ProviderDataRecord(AnnexB): http://www.philhealth.gov.ph/circulars/2012/circ13_2012.pdf b. PerformanceCommitment(PC)forPCB1Provider(AnnexA): http://www.philhealth.gov.ph/circulars/2012/circ10_2012.pdf c. TemplatesforMOAforreferralfacilitiesifyouintendtorefersomeservicessuchas laboratoryorradiologicservicestootherhealthfacilities(AnnexA) http://www.philhealth.gov.ph/circulars/2012/circ10_2012.pdf Accomplishtheabovementionedforms RegisterwithPhilHealthbysubmittingtherequireddocuments. a.ForcurrentlyparticipatingPCB1providersfor2012 Performance Commitment shall be submitted on or before June 30, 2012 with the followingsignatories: Table1.SignatoriesforPerformanceCommitment TypeofHealthFacility Signatories 1. LocalChiefExecutive RHU/HC 2. MHO/CHO 1. LocalChiefExecutive OPDClinicsofMHO/CHO/PHO 2. MHO/CHO/PHO OPDClinicsofDOHretained 1.MedicalDirectororChiefof hospitals Clinics OPDClinicsofLGUOwnedhospitals 1.LocalChiefExecutive
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3.

4. 5.

2.MedicalDirector/ChiefofClinics oftheProvincial/district/ municipalhospitalsunderthe Province

b.Newlyengagedproviders 1. CompletelyfilledoutProviderDataRecord(PDR).Thisformmaybedownloaded fromthePhilHealthwebsite.(AnnexB) (http://www.philhealth.gov.ph/circulars/2012/circ13_2012.pdf) 2. CopyofupdatedDOHlicenseforgovernmenthospitals,and,ifapplicable,the updatedDOHlicenseofthereferrallaboratoryorradiologyserviceprovider 3. PerformanceCommitment(PC)(seeTable1forappropriatesignatories) 4. CopyofMemorandumofAgreement(MOA)withareferralfacilityfordiagnostic servicesthatarebeyondthePCBproviderscapacitytoprovide. 5. ProofofpaymentofRegistrationFee Note:FornewlyengagedgovernmentPCBprovidersthathaveassignedNHTSand reenrolledLGUSPmembers,theirPFPRcanbemaderetroactivetoJanuary1,2012, onthefollowingconditions: a.TheproviderhascertificationfromPROthattheprimarycareserviceswas providedtothemembersduringtheconcernedquarters,and, b.TheproviderhassubmittedthePerformanceCommitmentbyJune30,2012. c.ForPCB1providerwithintentiontorenewitsparticipationassuch: 1. CompletelyfilledoutProviderDataRecord(PDR).Thisformmaybedownloaded fromthePhilHealthwebsite.(AnnexB) (http://www.philhealth.gov.ph/circulars/2012/circ13_2012.pdf) 2. CopyofupdatedDOHlicenseforgovernmenthospitals,and,ifapplicable,the updatedDOHlicenseofthereferrallaboratoryorradiologyserviceprovider 3.PerformanceCommitmentifthereisachangeinmanagement(seeTable1for theappropriatesignatories) 4.CopyofMemorandumofAgreement(MOA)withareferralfacilityfordiagnostic servicesthatarebeyondthePCBproviderscapacitytoprovide,ifapplicable. 5.ProofofpaymentofRegistrationFee. 6.CompletelyfilledoutProvidersAgreementFormforObligatedServices(AnnexE) AlltheaboverequirementsshallbesubmittedbetweenAugust1andSeptember30 ofthecurrentyeartoavoidadditionalchargesorgapsinparticipation,exceptitem6, whichshallbesubmittedwithinthefirstquarterofthesucceedingyear. APCBproviderthatincurredagapinparticipationandthosethathastransferredor has changed location shall submit the same requirements as newly engaged providers.
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 6. ScheduleofRegistrationandApplicationforParticipation AProvidermayrenewitsparticipationinSeptemberofthecurrentyearofparticipation. TheProvidercanavailofa10%discountonregistrationfeeiftheapplicationforthe renewalissubmittedinAugustofthecurrentyear.Ontheotherhand,theProviderwill bechargedahigherregistrationfeeiftheapplicationisfiledfromOctobertoDecember ofthecurrentyearofparticipationasshowninTable2. PotentialPCBProvidersmayapplyanytimeoftheyearatthenearestPROorLHIObut theirparticipationshalltakeeffectonlyonthesubsequentquarteruntiltheendofthe currentyear.Forinstance,iftheProviderappliesinMaythevalidityofitsparticipation shallstartfromJuly(beginningofthethirdquarter)andendsinDecemberofthatyear. ThePFPRshallbecomputedbytheLHIOuponreceiptofcompletereportswhichshallbe submittedbytheProviderwithin15workingdaysafterthequarterthatitsparticipation becameeffectiveandeveryquarterthereafter.Inthesameexampleabove,thePFPRwill becomputeduponthesubmissionoftherequiredreportsbytheProviderwithinthefirst 15workingdaysofOctober. 7.RegistrationFees Table2.ScheduleofRegistrationFees
RENEWAL INITIALREGISTRATION
BEFORETHE PRESCRIBED PRESCRIBED FILINGPERIOD FILINGPERIOD September130 August131 900 1000

RENEWAL(LATEFILERS)
APPLICATIONSFILEDAFTERTHE PRESCRIBEDFILINGPERIOD

(additionalfee)
October1 November30 2000 December131 4000

1000

Example: 8.MonitoringandEvaluation:AsprovidedinthePerformanceCommitment,theProvider shallvoluntarilyallowPhilHealthauthorizedpersonneltoconductmonitoring/audit activitiesrelatedtoPCB1provisionandutilization.

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RegistrationFee Dateoffiling Filingperiod(September) P1,000.00 60daysbeforeexpiry(October) 30daysbeforeexpiry(December) AdditionalFee None P2,000.00 P4,000.00 Total RegistrationFee P1,000.00 P3,000.00 P5,000.00

C.WHATARETHEOBLIGATIONSOFAPCBPROVIDER?
1. RegisterasPCBProviderandaccomplishPerformanceCommitmentaccordingly. 2. Acquire from the LHIO the masterlist of SP members assigned to the facility, actively enlistthemandperformregularupdatingofenlistedmembersandtheirdependents.In addition,securefromLHIOanyadditionalentitledmemberswhohaveenrolled/become eligibleintheprecedingquarter. 3. Establish/updatethehealthprofileofthePCB1entitledmembersbyusingtheAnnex A.1ofPhilHealthCircularNo.10,s.2012,oranyothersimilardocument. 4. Provide the services for the PCB1 entitled members as described by the Circular or accordingtotheirclientshealthneeds. 5. Ensure that all diagnostic services are available to the entitled clients. This means enteringintoMemorandumofAgreement,ifapplicable,withanotherhealthfacilityfor diagnostic services that are beyond the current capacity of the participating PCB provider.FacilitiesunderthesameLGUmaynotenterintoaMOA. 6. PostthePCB1servicesinaconspicuousplaceinthehealthfacility. 7. DistributeIECmaterialsonPCB1forentitledmembersorconductIECactivities.AnnexF providestheanswerstocommonlyaskedquestions. 8. SubmitreportsasrequiredbytheCorporation. 9. Cooperate with representatives of the Corporation in terms of conducting occasional audits.Continuetoinvestontheirhealthfacilityandhealthpersonneltocompleteand maintain their capacity to deliver the PCB services, particularly those Providers who enterintoMOAwithanotherhealthfacilitytoprovidediagnosticservices. 10. EstablishasysteminthehealthfacilitythatwillprioritizePCB1entitledmembersand dependents in provision of health services. (See Box 1) Such system, however, should not affect nonNHIP/non PCB1entitled member clients from getting urgent/emergent attention.
Box1.DistinguishingtheservicesforPCB1entitledmembers:AnExample DuringtheimplementationofOPBPackage,oneHealthCenterinMetroManila establishedaFastLanefortheSponsoredProgrammembersandtheirdependentswhen theygotothehealthfacilityforconsultation.Thismeansshorterwaitingtimeforthese patients.Withthissimplesysteminplace,PhilHealthSPmembersfelttakencareof.Theyfeel thebenefitofhavingPhilHealthcoveragebeyondthehealthservicesduetothem. ThisisanexamplethatmaybeadoptedbyPCBproviderstodistinguishPCB1entitled membersfromtherestofthehealthfacilityclientele.

11. EncouragenonNHIPclientstobecomePhilHealthmembersanddirectthemtoenrollat thenearestLHIO.

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V.BENEFITPACKAGEDELIVERYMECHANISM

A.WHOARETHEENTITLEDMEMBERS?
Sponsored Program (SP) members and their qualified dependents are entitled to PCB 1 services at the PCB provider where they are assigned for the year. SP members include those members identified under the NHTSPR and those enrolled by the LGUs (municipal, cityandprovincialgovernments),Senators,HouseRepresentatives,privateinstitutionsand othernationalagencies. In addition, eligible members who enrolled under Organized Groups (OG) as well as OverseasWorkersProgram(OWP)andtheirqualifieddependentswillbeentitledtoPCB1 package. The eligibility of these members will follow the rules set by the Membership ManagementGroup.

B.ENLISTINGENTITLEDMEMBERS
1. PhilHealthwillprovidethemasterlistoftheentitledmemberstothePCBproviders.This masterlistwillincludethenamesandaddressofNHTSPRmembers,LGUsponsoredSP membersandtheeligibleOGandOWPmembersresidingintheirlocality.Alternatively, for NHTSPR, the PCB providers can search the names of the SP members from PhilHealth website. (http://www.philhealth.gov.ph/members/sponsored/nhts pr_list.html). The Department of Health as sponsor of NHTSPR to NHIP directs the assignmenttoPCBProvider(AnnexC). 2. Entitledmembersareassignedtohealthfacilitiesasfollows: a. ThefollowingentitledmembersareassignedtomunicipalRHUs SPmembersidentifiedthroughNHTSPRresidinginthemunicipality SPmembersenrolledbytheMunicipalGovernment SP members assigned by their Sponsors. For instance, the PLGU and other Sponsors (Senators, House Representatives, private institutions and other nationalgovernmentagencies)mayassigntheSPmemberstheyenrolledtothe RHUwheretheSPmemberresides

Note: For Municipalities with more than one RHU, the Municipal Health Officer will distribute the assigned entitled members to the municipalitys network of health facilities that can participate as a Provider. The distribution of SP members must be submittedtoandconcurredbytheLocalChiefExecutive.
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b. ThefollowingentitledmembersareassignedtotheCityHealthOffice SPmembersidentifiedthroughNHTSPRresidinginthecity SPmembersenrolledbytheCityGovernment SP members assigned by their Sponsors. For instance, the PLGU and other Sponsors (Senators, House Representatives, private institutions and other nationalgovernmentagencies)mayassigntheSPmemberstheyenrolledtothe RHUwheretheSPmemberresides

Note:TheCityHealthOfficerwilldistributetheassignedtheSPmemberstoitsvarious healthcenters.ThedistributionofSPmembersmustbesubmittedtoandconcurredby theLocalChiefExecutive. c. The following entitled members are assigned/may enlist at the Out Patient Department of government hospitals/Provincial Health Office (LGU hospitals, DOH hospitals) SPmembersenrolledbytheProvincialGovernment Other SP members enrolled by Senators, House Representatives, private institutionsandothernationalgovernment EligibleOrganizedGroupmembers EligibleOWPmembers

Note: The OG and OWP members enlist by themselves. PCB providers may actively encouragethemtoenlistintheirfacility. 3. Oncetheyhavethemasterlist,thePCBprovidersshouldactivelyseekouttheentitled SPmembersassignedtotheirfacility.ThePCBprovidersmaydothefollowingtoenlist theentitledmembers: a. SortthelistbybarangayandmobilizetheCommunityHealthTeams(CHTs)tolocate andenlisttheSPmembers b. PostthelistofSPmembersinthehealthfacilityorbarangayhall c. Duringtheenlistmentactivity,thePCBproviderisexpectedtodothefollowing: Informthemembers/dependentsabouttheirPCB1andotherbenefits; DistributionofIECmaterialsrelatedtoPCB1andotherbenefitsofPhilHealth AsktheSPmembertosign/thumbmarktheSPmasterlist Do/update the individual health profile of entitled members and their dependents

d. PutupIECmaterialstoencouragetheOGandOWPmemberstoenlistinthefacility 4. IfSPmembersinthelistarenotfound,thePCBproviderwillreporttotheconcerned LHIOimmediately.TheLHIOwilltheninformtheMembershipManagementGroup.

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Note: The PCB Provider is not authorized to replace the unlocated SP member in the masterlist. 5. If an eligible member entitled to PCB1 package seeks consult but is not yet assigned/enlisted with any of the PCB providers, the PCB provider should do the following: a. Providetheneededhealthservice b. Enlisttheentitledmemberandinformhim/herofthePCB1services c. Submit the details of the entitled members to LHIO using the Template for MasterlistofEnlistedMembersforPCB1(AnnexD) 6. IfaclientcomesinclaimingtobeentitledtoPCB1(e.g.NHTSPRbeneficiarywithValid PhilHealthorDSWDCardbutnotincludedinthemasterlistprovidedbyPhilHealth),the PCBprovidershouldenlistthemember. 7. UsingtheTemplateforMasterlistofEnlistedMembersforPCB1(AnnexD),theProvider shouldinformtheLHIOofthefollowingconcerns: a. Anycorrectiontothename/birthday/addressoftheenlistedmembers b. NamesofentitledmemberswhoseMembershipDataRecordsneedtobeupdated, includingnameandbirthdayoftheirdependents c. NHTSPR beneficiaries for possible revalidation due to apparent improvement in socioeconomicstatus d. If other signed in behalf of the member, the relationship to the member and the reasonforenlistingbyproxymustbenoted. 8. The PRO, through its LHIO, shall provide the PCB provider with the list of additional entitled members (newly enrolled/eligible SP, OG, OWP members) not later than 15 workingdaysbeforethesucceedingquarter. 9. For any proposal to assign SP members to PCB providers that is inconsistent with the abovearrangements,theconcernedLGUmaywritedirectlytothePresident/CEOofthe Corporation.

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C.ESTABLISHING/UPDATINGTHEINDIVIDUALHEALTHPROFILE
Using Annex A.1 of the Circular, the PCB provider should establish or update the health profileoftheentitledmembersandtheirqualifieddependents.ThePCBprovidermayalso use a similar form for individual health profile as long as the form can provide the summarized data that Annex A.2 of the Circular requires (PCB Provider Clientele Health Profile)

D.WHATARETHESERVICESUNDERPCB1?
The following services shall be provided to respond to the health needs of the entitled clientele: A. PrimaryPreventiveServices 1. Consultation the first consultation visit in a given year, which shall, at the least, include the establishment or updating of individual health profile. Consultation services should be given to all patients seeking health evaluation, advice, and/or management. 2. Visual inspection with acetic acid (VIA) Visual inspection of the cervix with acetic acid should be performed in women 2555 years of age or those who are sexually activewithanintactuterus.FornegativeVIAresult,arepeattheexaminationevery three(3)yearsisrecommended.Thismaybeprovidedtoyoungeragegroupsifthe patient is determined by the provider to be of high risk for cervical cancer. Pap smearmaybeanalternativeforVIA.Patientswithpositiveresultshouldbereferred forcolposcopy. Patients with religious and cultural barriers/prohibition may sign a waiver not to availthisservice. 3.RegularBPmeasurementsBloodpressuremeasurementsusinganeroidordigital sphygmomanometershouldbetakenateachadultpatientvisitevenifthepatient consultsforunrelatedsymptoms.PatientsfoundtohaveelevatedBP(SystolicBPof 140mmHgormoreordiastolicBPof90mmHgormore)withoutevidenceoftarget organdamageshouldhaveanotherBPmeasurementafteratleast1weekfromthe initial visit. Patients found to have hypertension should have at least monthly BP measurement. Nonhypertensive adult patients should have BP measurement at leastonceeveryyear. 4.BreastfeedingprogrameducationItdealswitheducatingandprovidingknowledge and information to pregnant and lactating mothers on the advantages of breastfeeding (lower risk of diarrhea, pneumonia, and chronic illnesses); the risks associatedwithbreastmilksubstitutesandmilkproductsnotsuitableasbreastmilk substitutes such as, but not limited to, condensed milk and evaporated milk; the
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physiologyoflactation;theestablishmentandmaintenanceoflactation;theproper care of the breasts and nipples; and such other matters that would contribute to successful breastfeeding. Mothers should be encouraged to exclusively breastfeed their babies from birth up to 6 months. Continued breast feeding along with appropriate complementary foods is recommended up to two years and beyond. Educationshouldbegivenduringtheprenatal,perinatalandpostnatalconsultations and/orconfinementsofthemothersorpregnantwomeninahealthinstitution. 5.PeriodicclinicalbreastexaminationsThisexaminationshouldbeperformedoncea year on patients 50 years old and older. This may also be offered among younger patient groups identified to have a high risk for breast cancer according to the provider. Patientswithreligiousandculturalbarriers/prohibitionmaysignawaivernottoavail thisservice. 6. Counselling for lifestyle modification This is focused on major health risk factors particularly tobacco use, unhealthy diet, physical inactivity, and alcohol use, and, include other relevant risk factors such as but not limited to the following: hypertension,highbloodsugar,overweightandobesity,andimpairedlungfunction. Allpatientsseekingconsultshouldbeadvised. 7. Counselling for smoking cessation All patients seen in the clinic should be asked about smoking and/or second hand exposure. Patients should be educated on the hazardsofsmokingandencouragedtostop. 8. Body measurements Pediatric patients should have their weight and height measured and recorded for each visit. All adult patients (20 years old and above) should have their waist circumference (at the narrowest point, usually just above the umbilicus) and hip circumference (at the widest point) measured and their waisthipratio(WHR)calculated. 9.DigitalRectalExaminationThismaybeperformedformen50yearsoldandolder afterdiscussionofthenatureandriskofprostatecancerandtherisksof,benefits of, and alternatives to screening. This may also be performed in patients 50 years oldandolderalongwithfecaloccultbloodtesttoscreenforcolorectalcancer. Patients with religious and cultural barriers/prohibition may sign a waiver not to availthisservice. B. DiagnosticExaminations Requestofthefollowingdiagnosticexaminationsstilldependsontheclinicaljudgement ofthephysicianbasedonhis/heruptodateknowledgeandcircumstanceofeachcase.
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1. Complete Blood Count (CBC) It is requested for the diagnosis or monitoring of the following conditions such as: suspected anemia; suspected bone marrow disease and blood dyscrasia; possible complications of leptospirosis, increasing severity of denguefever,prenatalcheckup,possiblesideeffectsofdrugs. 2. Urinalysis Urinalysis is not a prerequisite for treatment of acute uncomplicated cystitis.Routineposttreatmenturinalysisinacuteuncomplicatedcystitisisalsonot recommended. Urinalysis may be ordered in, but not limited to, nonpregnant womenwithsuspectedacuteuncomplicatedcystitisplusvaginalirritationorvaginal discharge to confirm the presence of urinary tract infection, acute uncomplicated pyelonephritis,allpregnantwomenontheirfirstprenatalvisitbetweenthe9thto 17th weeks to screen for asymptomatic bacteriuria in areas where urine culture is not available, suspected urinary tract infection in pregnant patients, and complicated urinary tract infection. The performance of urinalysis does not take precedenceoverappropriatereferraland/ortransferofpatientsrequiringahigher levelofcare. 3.FecalysisThisshouldbeperformedamong,butnotlimitedto,patientswithacute gastroenteritissuspectedofhavingparasiticorprotozoalinfection. 4. Sputum microscopy This should be requested for all TB syptomatics meaning all patientswhopresentwithcoughoftwoweeksormoreandallhouseholdmembers of identified TB patients. Three (3) specimens are required as specified by the guidelinesoftheNationalTuberculosisProgram. 5.FastingBloodSugartestingshouldbeconsideredinalladultsatleast40yearsold. Early testing should be considered among patients with at least one risk factor as follows:historyofimpairedglucosetolerance(IGT)orimpairedfastingglucose(IFG); historyofgestationaldiabetesmellitus(GDM)ordeliveryofababyweighing8lbsor above;polycysticovarysyndrome(PCOS);overweight:BodyMassIndex(BMI)2of 23kg/m2orObese:BMIof25kg/m2,waistcircumference80cm(females)and 90cm(males),Waisthipratio(WHR)of1formalesand0.85forfemales;first degreerelativewithtype2diabetes;sedentarylifestyle;hypertension(BP140/90 mm Hg); diagnosis or history of any vascular diseases including stroke; peripheral arterial occlusive disease; coronary artery disease; acanthosis nigricans; schizophrenia; serum HDL < 35 mg/dL (0.9 mmol/L) and/or Serum Triglycerides > 250mg/dL(2.82mmol/L). 5. LipidprofileThisissuggestedfor,butnotlimitedto,patientswithtype2diabetes mellitus and for patients with at least two (2) of the following risk factors: hypertension; family history of premature coronary heart disease (coronary heart diseaseinfirstdegreerelative<55yearsold[male]or<65years[female]);and/or age45years(male)or55years(female).Totalcholesterolmaybeprioritizedin casesoflimitedresources.
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 7. Chest xray It should be performed in patients with suspected pneumonia. They include, but not limited to, patients presenting with acute cough, abnormal vital signsoftachypnea,andfeverwithatleastoneabnormalchestfindingofdiminished breath sounds, rhonchi, crackles, or wheeze. It is also requested for patients suspectedwithTBbutwithnegativesputumAFB. C. Drugsandmedicines DrugsandmedicinesrecommendedintheClinicalPracticeGuidelinesforthefollowing conditionsshouldbeavailableinthefacility: 1.Asthmaincludingnebulisationservices inhaledshortactingbeta2agonist inhaledcorticosteroids oralcorticosteroids 2.AcuteGastroenteritis(AGE)withnoormilddehydration oralrehydrationsalts(ORS) 3.UpperRespiratoryTractInfection(URTI)/Pneumonia(minimalandlowrisk) amoxicilln(adultandpediapreparation) erythromycin(adultandpediapreparation) 4.UrinaryTractInfection(UTI) flouroquinolones

E.PROVIDINGTHEPCB1SERVICES
a. PCB1serviceswillbeprovidedbasedontheneedoftheentitledmember/dependent. Thehealthprofessionalmayusetherecommendedriskbasedapproachinmanaging patients(Box2). b. ThePCBProvidershoulduseAnnexA.3oftheCircular,oranysimilarformtodocument theconsultation/healthserviceprovidedtotheentitledmemberordependent.These servicesmustbesummarizedinAnnexA.5oftheCircular,whichwillbekeptinthe healthfacility.TheservicesprovidedmustalsobereportedquarterlyusingAnnexA.4of theCircular. c. Fortheidentifiedclientstargetedforobligatedservices,providetheservicesaccording tothetiming(e.g.monthlyforhypertensive)indicatedintheCircular. d. Scheduletheprovisionofobligatedservicesandinformthetargetmembers/ dependentsaccordingly e. AllhealthservicesdeliveredbytheProvidershallbereportedandmonitored.Targets forobligatedservicesincluderegularBPmeasurements,VIA,andperiodicclinicalbreast examinationsmustbeprovidedtotargetclients. f. TheProvidermayencourageentitledmembers/dependentstoutilizePCB1services whenneededbysettingupamechanismforfasterhealthservicesforthosewhoare entitledtoPCB1package.Thismaybedonethrough,butnotlimitedto,the
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developmentofafastlaneforentitledmembersandtheirdependentswherethey willbeprioritizedinthedeliveryofservices.However,patientswhorequire emergent/urgentattentionshallreceivepromptcareregardlessofPhilHealth membershipstatusevenwiththecreationofafastlane. Box2.ARecommendedRiskbasedApproachinmanagingpatients: 1)Classifywhetherthepatientrequiresemergent/urgentmanagementorrequires immediatetransfertoahigherlevelfacility.Proceedwiththeappropriatemanagement ortransferifwarranted. 2)Evaluatethepatientschiefcomplaint. 3)Identifyriskfactorsforcommunicableandnoncommunicablediseases. 4)Performriskassessment. 5)Counselthepatientregardinghis/herriskofhavingordeveloping(a)particular disease(s). 6)Advisethepatientregardingage,sex,andriskappropriateinterventions.These include,butarenotlimitedto,screeningprocedures,diagnostictests,smokingcessation, lifestylemodification,andintakeofmedications.

F.REFERRINGTHEENTITLEDMEMBERS
If the patient is advised to have a diagnostic examination that is not available in the PCB provider,thepatientshouldbereferredtoanotherhealthfacilityunderthesameLGUor where the PCB provider has forged a Memorandum of Agreement (MOA). The fees for diagnostic services shall be shouldered by the referring PCB provider and charged to the PFPRandthepatientshouldnotshoulderanycostfortheprocedure.Theproceduresshall bepaidaccordingtotheratesestablishedintheMOA. If the patient has health care needs that are beyond the service capability of the PCB provider, the patient shall be referred to the appropriate health facility. The referral or transfershallbecoordinatedandfacilitatedbythePCBprovider.Furthermore,thepatient shouldbetransportedbyamodeoftransportthatisappropriatefortheconditionofthe patient.

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VI.RECORDINGANDREPORTING
ThePCBprovidershallmaintainthethefollowingreports:

1.THEINDIVIDUALORCLIENTHEALTHPROFILE(ANNEXA.1)
a. Theindividualhealthprofilecontainsacomprehensivehistoryandphysical examinationofthemember/dependentandisthebasisforthefollowing: 1.Deliveringhealthcareservicesforthepatient 2.CumulativedataintheutilizationreportsforPCB1. 3.MonitoringandevaluationactivitiesofPHIC. b. Theprovidermustaccomplishtheindividualhealthprofileofallenlistedmembers anddependentslivingwiththeprimarymember.Healthprofilingmustbedoneat leastonceayear. c. TheProvidermayuseanysimilarformthatisalreadybeingusedbythehealth facilityprovidedthattheinformationitcontainscanbesummarizedintoPCB ClienteleHealthProfile(AnnexA.2) d. Thisreportshallbemaintainedinthefacilityandmayberequestedby PhilHealthpersonnelforreviewduringmonitoringactivities.

2.PCB1PATIENTLEDGER(ANNEXA.3)
a. Thisledgercontainsallrenderedhealthservices,includingthoseidentifiedinPCB1 packageandotherserviceswhicharenotpartofthePCBservices(e.g. immunization,familyplanning,etc.). b. TheProvidershallmaintainapatientledgerforallitsclientswhoseekconsult,not onlythosewhoareentitledtoPCB1services. c. TheProvidermayuseanysimilarformthatisalreadybeingusedbythehealth facilityprovidedthattheinformationitcontainscanbesummarizedintoAnnexes A.4andA.5oftheCircular. d. FillingupthePCBforms i. Table1.ObligatedservicesIndicatethedatewhentheobligatedserviceswere rendered,basedonthegivenfrequency.PutnotapplicableorNAfor members/dependentswhowerenotprovidedwithobligatedservices. ii. Table2.DiagnosticexaminationsservicesIndicatethedatethediagnostic serviceswereperformedorprovided.Writethediagnosisandtypeof diagnosticexaminationneededtobedone.Putacheck()ifitisgivenor donebythereferrallaboratorywithwhomtheProviderhasaMOA.

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iii. Table3.OtherPCB1servicesTheseincludetheprimarypreventiveservicesof PCB1andthedrugsandmedicinesprovidedtoentitledmembers/dependents. iv. Table4.OtherservicesThesearetheservicesgivenorperformedto PhilHealthmembers/dependentswhicharenotpartofthePCB1servicessuch as,butnotlimitedto,immunization,familyplanning,etc. v. PartIIconsultationforillness/wellcheckup vi. Thisreportshallbemaintainedinthefacilityandmayberequestedby PhilHealthpersonnelforreviewduringmonitoringactivities.

3.QUARTERLYREPORTOFPCBSERVICESAVAILEDBYPCB1ENTITLEDMEMBERS ANDDEPENDENTS(ANNEXA.5)
a. AnnexA.5willserveastheProviderslogbookofdailyhealthcareprovisionand consultations.Afterfillinguptheindividualpatientledger(AnnexA.3),encodethe appropriateinformationtoAnnexA.5form.Thedatafromthisreportwillbethe basisorsourceofdatafortheAnnexA.4orquarterlysummaryofPCBservices provided. b. Fillinguptheform i. Dateindicatethedatethepatient/memberconsultedorwasgiventheservices ii. PhilHealthnumberPhilHealthidentificationnumber(PIN)oftheregistered member.Ifthepatientisadependent,usethePINofthemember. iii. NameWritethecompletenameofthepatient iv. MembershipEncircleMifthepatientisamemberandDifthepatientis dependent v. SexEncircleMifthepatientismaleandFforfemale vi. AgeIndicatetheageofthepatientuponconsultation vii. DiagnosisDiagnosisofthepatientidentifiedbythephysicianupon consultation.ThiscanbeseeninAnnexA.3PartIIcolumn4 Assessment/Impression viii. BenefitsgivenPut1foranyservicesavailed/givenbythepatients.Oneormore servicesmaybeavailedorrenderedtopatients ix. MedicinesgivenWritethemedicinesgiventothepatients c. AlldataencodedonthisreportmustbetakenfromIndividualPatientLedger(Annex A.3) ThePCBprovidershallsubmitthefollowingreports:

1. UpdatedMasterlistofEnlistedMembersforPCB1(AnnexD)
a. AsoftcopyofthemasterlistofSponsoredProgrammembersshallbeprovidedby the PRO through the LHIO. The Provider retains the pertinent details such as PIN, name,addressandnumberofdependentsandaddsthecolumnsforthesignature,
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b. c.

d.

e. f.

enlistment status and remarks and other required fields such as the dates and signature(SeeAnnexDforTemplate).TheProviderwillprintthemasterlistinthis formattobeusedduringenlistment. Using this form, the Provider will ask the entitled members to enlist to the health facilitybysigningthespaceprovidedintheform. Intheeventthatthemembercannotsignthemasterlist,aqualifieddependentof legal age may sign on his/her behalf stating their relationship and the reason why the member could not sign. If the member cannot write or sign his/her name, thumb mark is acceptable but it should be witnessed by at least onedisinterested party.Thisinformationmustbewrittenonthecolumnallottedforremarks. For additional members who enlist but not included in the original masterlist provided by PhilHealth, the Provider may add them, including other details as required,atthebottomofthepage. Thehealthfacilitypersonnelwhopreparedthereportshallcertifythecorrectnessof theupdatedmasterlistandtheheadofthefacilityshallapprovethereport. Acopyoftheupdatedmasterlistwiththesignatureofmemberswillbesubmittedto LHIO.

2. PCBPROVIDERCLIENTELEPROFILE(ANNEXA.2OFCIRCULAR)
a. ThisreportisasummaryofindividualorclienthealthprofilesofallPhilHealth membersanddependentsassignedinyourfacility.Alldatainthisreportarederived fromAnnexA.1(Individual/ClientHealthProfile)andmasterlistofmembers.This reportshallbesubmittedquarterly,withinfifteen(15)workingdaysafterthe quarter. b. FillingupAnnexA.2 BoxI.PCBProviderData i.Writetheregion,provinceandcity/municipalityonthespacebelowthelabel ii.Indicatethenumberofassignedfamiliespertypeofsponsor/membershipbasedon themasterlistofwhoareenlisted. iii.Indicatethenumberoffamiliesservedunderthecatchmentareawhoarenota PhilHealtmembers. BoxII.AgeSexDistribution i. BasedonallaccomplishedAnnexA.1,distributethenumberofprofiledmembers anddependentsaccordingtoagedistributionandgender. ii. Computeforthetotalno.ofmembersanddependentsaccordingtogender.Reflect thisdataonthebottomrowdatafields. iii. Computeforthetotalno.ofmembersanddependentsaccordingtoage distribution.Reflectthisdataontheleftmostcolumndatafields.

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iv. Makesurethatthehorizontal(Totalbasedongender)andthevertical(basedon agedistribution)sumsarecorrect.WritethisvalueontherightlowerspaceofBox II. BoxIII.PrimaryPreventiveServices i. InreferencetoAnnexA.1andA.2,determinethenumberoffemaleNHIPmembers anddependents,25yearsoldandabove,thathasundergonebreastcancer screeningandreflectthisontheappropriatespace. ii. DeterminethenumberoffemaleNHIPmembersanddependents,25to55years oldwithintactuterus,thathasundergonecervicalcancerscreeningandreflectthis ontheappropriatespace. BoxIV.DiabetesMellitus i. BasedonallaccomplishedAnnexA.1,distributethenumberofprofiledmembers anddependentsaccordingtogender. ii. Graycoloredareasshouldnotcontainanydatabecausethisisnotapplicabletothe specificdatarequested. iii. Computeforthetotalnoofmembersanddependentsaccordingtogender.Reflect thisdataontheleftmostcolumndatafields. BoxV.Hypertension i. BasedonallaccomplishedAnnexA.1,distributethenumberofprofiledmembers anddependentsaccordingtogender. ii. Computeforthetotalno.ofmembersanddependentsaccordingtogender.Reflect thisdataontheleftmostcolumndatafields. c. Thenurse/midwifewhoprepared/accomplishedthereportshallcertifythe correctnessofthereportbywriting/stampinghis/hernameonthespacelocatedat theleftlowerpartofthereportandaffixinghis/hersignature. d. TheHC/RHU/facilityphysicianshallapprovethereportbywriting/stampinghis/her nameonthespacelocatedattherightlowerpartofthereportandaffixinghis/her signature.

3.

SUMMARYOFBENEFITSAVAILMENT(ANNEXA.4)

a. ThisreportprovidesthesummaryofbenefitsavailedbyentitledPhilHealthmembers and dependents assigned in your facility for a specific quarter. This report shall be submittedquarterly,withinfifteen(15)workingdaysafterthequarter. b. AccomplishingAnnexA.4 BoxI. CoveredPeriodthispertainstotheperiod/quarterwhenthebenefitwasavailed.
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BoxII. PCBParticipationNo.ThenumberassignedbyPhilHealthtothePCBproviderwhichis reflectedinitsCertificateofEligibilitytoParticipate(CEP) BoxIII. Municipality/City/Provincelocationofthehealthfacility BoxIV. ObligatedServices 1.TargetColumnplacethetotalnumberofNHIPmembersanddependentssetby PHICasthefacilitystargetforeachparticularobligatedserviceforthatquarter.The targetsmustbeconsistentwiththesubmittedProvidersAgreementFormfor ObligatedServices(AnnexE). 2.AccomplishmentColumnplacethetotalnumberofNHIPmembersanddependents thatwereprovidedtheserviceforeachpartcularobligatedserviceforthatquarter. BoxV. MembersandDependentsServed 1.InreferencetoAnnexA.2,BoxII,reflectthedataontheappropriatefieldsbasedon genderdistribution. 2.ReflectalsothetotalbasedonAnnexA2,BoxII. 3.Makesurethatthehorizontal(Totalbasedongender)andthevertical(basedonage distribution)sumsarecorrect.WritethisvalueontherightlowerspaceofBoxV. BoxVI. Benefits/ServicesProvided 1. DataforthisreportshallbethesumofeachserviceprovidedasreflectedinAnnex A.5basedongenderdistribution. 2. Dataforreferredbenefits/servicesshallcomefromconsolidateddataofAnnexA.3, PartI.ReferredColumn BoxVII. MedicinesGiven 1.BasedonallaccomplishedAnnexA.5,determinethedifferentmedicationsgivento NHIPmembersordependentsbasedongenderdistribution. 2.Themedicationsshouldbewritteninitsgenericform. BoxVIII. Top10CommonIllnesses(Morbidity) 1.Enumeratethetop10diagnosisofcommoncausesofconsultofpatientsinthe facility. 2.Tabulatetheseaccordingtothenumberofcasesseenwithintheapplicablequarter, fromhighestincidencetolowest.
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c. Thenurse/midwifewhoprepared/accomplishedthereportshallcertifythe correctnessofthereportbywriting/stampinghis/hernameonthespacelocatedat theleftlowerpartofthereportandaffixinghis/hersignature. d. TheHC/RHU/facilityphysicianshallapprovethereportbywriting/stampinghis/her nameonthespacelocatedattherightlowerpartofthereportandaffixinghis/her signature.

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VII.SUBMISSIONOFREPORTS
HOWTOSUBMITREPORTS
EachPCBfacilityisrequiredtoregistertheirofficialemailaddressandcellphonenumberwhen theyfiletheirapplicationsforregistrationandparticipation.ItshallinformPhilHealthofany changeintheirofficialcontact Thereportsmaybesubmittedintwoforms:throughastandardformatspreadsheetviaweb service or through XML/web services. Assistance for this may be provided for by endorsed HITPs by ITMD. Communications will be sent through email by default and in special circumstances,bytext.

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VIII.PAYMENTOFPCBPACKAGES
a. TheprovidershouldbeengagedwithPHICasaPCBprovider. b. TheProvidershallbepaidPerFamilyPaymentRate(PFPR)thatwillbecalculated quarterly,providedthatthefollowingreportsaresubmittednotlaterthan15daysafter eachquarter UpdatedMasterlistofEntitledMembersforPCB1(AnnexD) PCBProviderCleinteleHealthProfile(AnnexA.2oftheCircular) SummaryofPCBServicesProvided(AnnexA.4oftheCircular)

c. FortheFY2012,theQ1andQ2PFPRwillbecalculatedbasedonthenumberofSP membersassignedtothePCBprovider.ForQ3andQ4,itwillbebasedonthenumberof SPmembersenlistedandprofiledbythehealthfacility. d. Foreachenlistedmember,theprovidershallbepaid=Php50anotherForevery profiledSPmemberanddependentthatwereprofiledanother=Php75willbepaid

FY2012 Q1 assigned members enlisted members enlisted profiled members+ members+ dependents dependents 24000 38000 15000 35000 totalPFPR 875,000.00 1,187,500.00 581,250.00 1,131,250.00 3,775,000.00

7000 6000 9500

Q2 9500 Q3 Q4 TotalAnnualPFPR

e. ForFY2013,thePFPRwillbecomputedbasedonthenumberofenlistedSPmembers, thenumberofSPfamilieswithupdatedprofileandthepercentageoftheobligated servicesprovided.Foreachquarter,thePFPRwillbecalculatedasfollows: P50foreachenlistedSP/OG/OWPmember P25proportionallyforprofiledmemberanddependents. P50fortheaccomplishmentofobligatedservices.

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 FY2013 assigned members enlisted members enlisted profiled members+ members+ dependents dependents 8500 10000 10000 34000 40000 40000 20000 35000 40000 %obligated services totalPFPR

Q1 10000 Q2 Q3 Q4 TotalAnnualPFPR

1,250,000.00 0.55 783,750.00 0.8 1,118,750.00 0.95 1,225,000.00 4,377,500.00

f. ThePFPRChecksshallbeissuedtotheProvidereveryquarter.However,delaysin paymentmayhappenwhenreportsareincomplete,submittedinhardcopytotheLHIO orsubmittedlate.Checksshallbereleasedtotheproviderwithin15daysupon submissionoftherequiredreportsofthequarter. g. ThePFPRshouldbedisposedaccordingtotheprovisionsintheCircular.However,the Providermayconsiderthefollowing: Chargetheannualmembershipfeestoprofessionalsocietiesandregistrationto annualconventionsortrainingactivitiesofhealthstafftothe40%PFPR; Poolthe20%ofPFPRintendedashonorariumandredistributeaccordingtothe agreedproportionofthehealthandnonhealthstaffconcerned,provided,thatsuch agreementisinwritingandapprovedbytheLocalHealthBoard. Forthemaintainanceofinformationsystem/subscription,etc. Upgradediagnosticcapacitytoallowfullprovisionofdiagnosticservices

h. ThePFPRP100forelectronicreportingwillbecalculatedonJanuaryoftheofthe succeedingyearconsideringthefollowingfactors: 1. ThemostadvancedlevelofelectronicreportingdonebytheProviderforthelast quarteroftheyear; OnlythosePCBproviderswhohavecontractedwiththeHealthInformation TechnologyProvider(HITP)andwhohavebeensubmittingtheirreports electronicallythroughtheirHITPsduringthelastquarterofthecurrentyearshall beassessedfordaily/realtime,weeklyormonthlyreporting.Providerswhodo notsubmitelectronicreportsthroughtheirHITPscanonlysubmitthefollowing reportsbyusinganelectronicspreadsheetandsubmittingviaemailorweb services.

2. UpdatedmasterlistofenlistedmembersforPCB1 3. CircularAnnexA.2PCBProviderClienteleProfile 4. CircularAnnexA.4SummaryofBenefitsAvailment

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IX.ROLESANDRESPONSIBILITIES
MEMBERS
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. HaveinpossessionatalltimesyourPhilHealthNumberCardorIdentificationCard. UpdateyourMemberDataRecord(MDR)foranychangeinpersonalinformationsuchas changeincivilstatusoradditionofanewdependent. InformtheLocalHealthInsuranceOfficeiftherewillbesubsequentchangesinaddress. RequestforareplacementincaseoflossofPhilHealthNumberCardorIdentificationCard. Ensurethatyoupromptlyandregularlypayyourcontributions(forOrganizedGroupsand OverseasWorkersProgramMembers)toavoidsuspensionofbenefits. BefamiliarwiththeserviceswhichonecanavailofinPCB1. Cooperatewiththehealthcareproviderintermsofenlistmentandprofilingprocedure. Signawaiverifprocedurestobedoneareinconflictwithonesownpersonalbeliefs. BeawareofamendmentsandupdatesonPhilHealthpoliciesandbenefitsschedule. SeekclarificationfromanyPhilHealthofficeonanyunclearpolicyorguideline. ReportatoncetoPhilHealthanyhealthcarefacilitythatfails,withoutvalidreason,to accommodateaPhilHealthmemberwhowishestoavailofbenefits. ReportatoncetoPhilHealthanyfraudulenttransactionthatyouknowabout. ObserveandcomplywithPhilHealthrulesandregulationsasthereareoffensesinits ImplementingRulesandRegulations

LOCALHEALTHINSURANCEOFFICE(LHIO)
1.CoordinatewiththePCBProvidersintermsof: AssistingtheminpreparationofPerformanceCommitment(PC),Memorandumof Agreement(MOA)foroutsourcedservices,andotherdocumentsthatmayberequired bytheCorporationforthePCB1 SendingthehealthfacilityintheareathemasterlistofSPassignedtothem ProvidethelistofOGandOWPmembersresidingintheproviderscatchmentarea Assistingthehealthfacilitiesintermsofmembereducationandprovidingtechnical assistanceintermsofsubmittingreportsandcoordinationoftheITsystem ReceivereportsofthesehealthfacilitiesforthePCB1 ComputeandreleasePFPRofhealthfacilities Othersuchcoordinationactivitiesasrequired 2.ConsolidatereportsofeachareaforPCB1andprovidereasonableactionasmaybe requiredwithintherealmsoftheirdutiesandresponsibilities 3.CoordinatewithconcerneddepartmentatCentralOffice/PROintermsof SendingregularreportsandotherfeedbackastothePCB1 Providecooperationformonitoringandevalationactivitiesandothersuchactivities thatmaybeprovidedforbytheCentralOffice

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X.MONITORINGANDEVALUATION
The Monitoring and Evaluation of PCB will be linked with the overall M&E framework of Kalusugan Pangkalahatan and PhilHealth Balance Scorecard. PhilHealth Central Office through the Health Insurance Product Sector at the Central Office shall oversee the overall management of monitoring and evaluating the impact of PCB1 while the PhilHealth Regional Office through its Health Care Delivery Management Division shall ensure that collection and data management at the regional level. The operational details of the Monitoring and EvaluationwillbeissuedonaseparateOrder. 1. TrackingtheimplementationandutilizationofPrimaryCareBenefitsinvolvecollecting andanalyzingthefollowingindicatorsquarterly: Indicator Definition DataSource: Enlistmentand (a.1) # ofenlisted NHTSidentifiedSP members/total # of UpdatedSP healthprofiling NHTSidentifiedSPmembersassignedtothePCBprovider masterlist,PCBForm ofSponsored (a.2) # of enlisted LGUidentified SP members/total # of A.3orequivalent LGUidentifiedSPmembersassignedtothePCBprovider Program document members (a.3) # of NHTSidentified SP members with complete health profile for all family members/total # of enlisted NHTSidentifiedSPmembers (a.4) # of LGUidentified SP members with complete health profile for all family members/total # of enlisted LGUidentifiedSPmembers Structureof (b.1)#ofvisitsrelatedtoPCBservices/total#ofvisitsto PCBFormA.2,A.4and PCBprovider PCBProviderbyPCBentitledmembersanddependents PCBProviderpatient visits (b.2)#ofpreventivevisits(i.e.totalvisitstoPCBprovider logbook visits due to illness and other services like prenatal, pre marriagecounselling,etc) (b.3)#ofvisitsofPCBentitledmembersanddependents/ total # of visits of nonPCB entitled members and dependents (b.4)#ofvisitsofPHICmembersanddependents/total# ofvisitstothePCBprovider

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(c.1)#ofhospitaladmissionforhypertensionamongPCB entitledmembersanddependents/total#ofPCBentitled membersanddependentsdiagnosedwithhypertension (c.2) # of hospital admission for acute gastroenteritis among PCB entitled members and dependents/total # of visits due to AGE among PCBentitled members and dependents (c.3) # of hospital admission for pneumonia among PCB entitled members and dependents/total # of visits due toupper respiratory tract infections among PCBentitled membersanddependents Utilizationof (d.1) # of hypertensive PCBentitled members and Obligated dependentswithmonthlyBPmonitoring/totalnumberof Services hypertensivePCBentitledmembersanddependents (d.2) # of women who had VIA/total # of women eligible forVIAamongPCBentitledmembersanddependents (d.3)#ofwomenwhohadclinicalbreastexam/total#of women eligible for clinical breast exaM among PCB entitledmembersanddependents (e.1)#ofPCBentitledmembersanddependentswithlipid Diagnostic examination profile/total # of PCBentitled members and dependents and Referral withriskfactors Rate (e.2) # of PCBentitled members and dependents with FBS/total#ofPCBentitledmembersanddependentswith riskfactors (e.3)#ofPCBentitledmembersanddependentsreferred for diagnostic examinations/total # of PCBentitled membersanddependents 2. Facilityreported data will be complemented by exit interviews and discussions(FGDs)
31

Hospitalization ratesfor primarycare sensitive diagnoses

HospitalAdmission dataandPCBForm A.2

UpdatedPCB MasterlistandPCB Form4

Updatedmasterlist, PCBFormA.2,A.4

focus group

IX. ANNEXES

ANNEXA ANNEXB ANNEXC PHILHEALTHCIRCULAR10S2012 PROVIDERDATARECORD(PDR) DOHDEPARTMENTMEMORANDUMNO.2012 0148.ASSIGNMENTOFSPONSOREDPROGRAM MEMBERSIDENTIFIEDTHROUGHNHTSPRTO THEIRPRIMARYCAREPROVIDERS TEMPLATEOFMASTERLISTOFENLISTED MEMBERSFORPCB1 PROVIDERSAGREEMENTFORMFOROBLIGATED SERVICES SAMPLECALCULATIONOFPFPR PROCESSFLOWFORPAYINGTHEPROVIDERS TAMANGSAGOT

ANNEXD

ANNEXE ANNEXF ANNEXG ANNEXH

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AnnexA
PHILHEALTHCIRCULAR10S2012

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AnnexB
PROVIDERDATARECORD(PDR)

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AnnexC

DOHDEPARTMENTMEMORANDUMNO. 20120148.ASSIGNMENTOFSPONSORED PROGRAMMEMBERSIDENTIFIEDTHROUGH NHTSPRTOTHEIRPRIMARYCARE PROVIDERS

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AnnexD

SAMPLETEMPLATEOFMASTERLISTOF ENLISTEDMEMBERSFORPCB1

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AnnexE PROVIDERSAGREEMENTFORMFOR OBLIGATEDSERVICES

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Date: ProvidersAgreementFormtoProvidetheObligatedServices As PhilHealths participating Primary Care Benefit 1 (PCB1) Package Provider we agree to perform the obligatedservicestoachievethetargetsstipulatedbelow: BENEFIT/SERVICES IDENTIFIEDCLIENTS HOWTOCOMPUTE TARGET (#of clients) BPmeasurement Nonhypertensive 90%ofthetotalidentifiedtarget clientsbasedonPCBClientele _____ HealthProfile LetterheadoftheFacility

Hypertensive

Periodicclinicalbreast examination

Female,25yearsold andabove Female,2555years oldwithintactuterus

90%ofthetotalidentifiedtarget clientsbasedonPCBClientele HealthProfile 90%ofthetotalidentifiedtarget clientsbasedonPCBClientele HealthProfile 90%ofthetotalidentifiedtarget clientsbasedonPCBClientele HealthProfile

_____ _____

Visualinspectionwith aceticacid

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___________________________ PrintedName HeadoftheFacility

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AnnexF
SAMPLECALCULATIONOFPFPR

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 FY2012 enlisted members+ dependents 6000 9500 24000 38000 profiled members+ dependents

Q1 Q2 Q3 Q4

assigned members 7000 9500

enlisted members

TotalAnnualPFPR

totalPFPR (Php) 875,000.00 1,187,500.00 15000 581,250.00 35000 1,131,250.00 3,775,000.00

AssignedmembersincludeNHTSandLGUandothersponsoredmembers+OGandOWPwho signedupinthefacility

FY2013

Q1 Q2 Q3 Q4

assigned members

profiled enlisted enlisted members+ members+ members dependents dependents 8500 10000 10000 34000 40000 40000 20000 35000 40000

%obligated services

totalPFPR (Php)

10000

1,250,000.00 0.55 783,750.00 0.8 1,118,750.00 0.95 1,225,000.00 4,377,600.00

TotalAnnualPFPR

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AnnexG
FLOWCHARTOFPAYINGTHEPROVIDERS

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Note:PaymentforPCB1 packageshould bepaidwithinthirtydays afterthereceiptofcompletereports

AnnexH TAMANGSAGOTPARASAPCB1

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1. WhatisthePrimaryCareBenefitI(PCBI)Package? The Primary Care Benefit (PCB) 1 is an enhanced OutPatient Benefit (OPB) package to ensurethatallFilipinoshaveaccesstoqualityhealthservicesthatareefficientlydelivered, equitably distributed, fairly financed and appropriately utilized. It has the following main provisions: 2. primarypreventiveservices 3. diagnosticexaminations 4. drugsandmedicines Underthispackage,twoadditionallaboratorytestsareprovidedattheprimaryhealth facilityorpartnerlaboratory:fastingbloodsugarandlipidprofile. Asidefromadditionalservices,theimplementationofPCB1requiresassignmentof entitledmemberstoPCBprovidersandlinksthepaymentofproviderstotheprovisionof specificservices. 2. WhatpromptedPhilHealthtointroducethePCB1? ThePCB1packageisaimedatexpandingthenumberofservicesincludedinthepreviousOPB package; increase utilization rate for services included in the Primary Health Care benefits; enhanceincentivesfor PCBproviderstopromotehealthybehaviour,preventdiseasesand/or associated complications, and facilitate appropriate referral; and ensure complete and timely reportingofhealthdataformonitoringandperformanceassessmentandevaluationpurposes. 3.WhataretheservicesincludedinthePCBIpackage? The following services shall be provided to respond to the health needs of the covered clientele: PrimaryPreventiveServices Consultation Visualinspectionwithaceticacid RegularBPmeasurements Breastfeedingprogrameducation Periodicclinicalbreastexamination Counsellingforlifestylemodification Counsellingforsmokingcessation Bodymeasurements DigitalRectalExamination
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Diagnosticexaminations Completebloodcount Urinalysis Fecalysis Sputummicroscopy Fastingbloodsugar Lipidprofile Chestxray DrugsandMedicinesforthefollowingconditions: Asthmaincludingnebulisationservices AcuteGastroenteritis(AGE)withnoormilddehydration UpperRespiratoryTractInfection(URTI)/Pneumonia(minimalandlowrisk) UrinaryTractInfection 4.WhoareentitledtothisnewPCBIpackage? Forthetransitionperiod20122013,thepackageshallbeavailabletoSponsoredProgram, OrganizedGroupsandOverseasWorkersProgrammembersandtheirqualifieddependents. 5.WherecanmembersavailthemselvesofthePCB1package? The PCB 1 package is available in all participating health centers/rural health centers (HCs/RHUs) and OutPatient Departments of Municipal Health Offices, City Health Offices, ProvincialHealthOfficesandallgovernmenthospitals. 6.WhencanmembersstartavailingthemselvesofthePCB1package? ThePCB1packageshallbemadeavailableinallparticipatingPCB1providersstartingApril1, 2012. 8.HowwillmembersavailthemselvesofthePCB1package? Forthetransitionyears(20122013),PhilHealthmemberswhocanavailofthisBenefit are limited to the Sponsored Program, Organized Group and Overseas Workers Program membersandtheirqualifieddependents. The Sponsored Program members, whether identified through the NHTSPR or by the LGUs/ other Sponsors, must know the PCB Provider (RHUs or Health Centers or OPD of governmenthospitals)wheretheyhavebeenassignedfortheyear.TheymustvisittheirPCB Provider/contacttheCommunityHealthTeamintheirareatoenlistandknowtheservices under this Package. They must allow their PCB provider to do their and their dependents
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health profile. They can also avail of other services listed in PCB1, as advised by their PCB Physician. The Organized Group and OWP members may enlist at their preferred PCB provider annually. Similar to the SP members, they must also allow health profiling. They can avail theservices,asneededandasadvisedbytheirPCBPhysician. 7. How will SP members know to which RHU/health center they are assigned for the PCB1 package? SPmembersmayasktheirBarangayHealthWorkerorCommunityhealthTeamfortheir PCB 1 Provider. They may also inquire at the nearest RHU, Health Center or Local Health InsuranceOffice. In addition, the staff members of the PCB 1 provider shall contact and inform the entitledmembersassignedtothefacilityregardingtheireligibilitytothePCB1package. 9.HowwillPhilHealthknowthatthememberisalreadyenlistedtoafacility? Once the member signs the masterlist, it signals that he is enlisted to a specific PCB1 providerfacility.ThePCBprovidershallthensubmitasoftandhardcopyofthemasterlistof enlistedmemberstotheLHIO. 10.WhatifthePCB1entitledmembersmovedtoanotherprovinceinthemiddleoftheyear? PCB1entitledmemberswhomovetoanotherprovinceinthemiddleoftheyearmay changePCBproviders.However,theymustinformthenearestLHIOintheirnewresidence aboutsuchtransfer.Theymustsubmitacertificationsignedbythebarangaychairpersonof theirnewplaceofresidencetobeabletocontinuetheirentitlementtoPCB1services. 11. What documents should the members bring with them when availing of the PCB 1 package? SP members only need to bring their PhilHealth ID cards or MDR when they avail the PCB1 package. Availment should be within the effectivity period shown on the ID card or MDR. 12.HowoftencanamemberorhisqualifieddependentavailofthePCB1packagewithina year? The member and his/her dependents may avail of any of the services as often as recommendedbythehealthcareprofessional. 13.WillmembersavailingthePCB1packageneedtopayanyamountforanyoftheservices includedinthepackage?
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 No.MembersandortheirqualifieddependentsavailingofthePCBIpackageneednot payanyamountsinceservicesincludedinthepackagearepaidtotheProviderthroughthe PFPR. If the member/dependent is referred for diagnostic services to another facility, the PCBprovidershallpayforthatserviceasprovidedintheMOAwithReferralfacility. 14.Whataremyrolesandresponsibilitiesasanentitledmember/dependent? Thefollowingareyourrolesandresponsibilitiesasanentitledmember/dependentof PCB1. BringatalltimesyourPhilHealthNumberCardorIdentificationCard. UpdateyourMemberDataRecord(MDR)foranychangeinpersonalinformationsuch aschangeincivilstatusoradditionofanewdependent. InformyourLHIOiftherewillbesubsequentchangesinyouraddress RequestforareplacementincaseoflossofPhilHealthNumberCardorIdentification Card. Ensurethatyoupromptlyandregularlypayyourcontributions(forOrganizedGroups andOverseasWorkersProgramMembers)toavoidsuspensionofbenefits. BefamiliarwiththeserviceswhichonecanavailofinPCB1 Cooperatewiththehealthcareproviderintermsofenlistmentandprofilingprocedure Signawaiverifprocedurestobedoneareinconflictwithonesownpersonalbeliefs BeawareofamendmentsandupdatesonPhilHealthpoliciesandbenefitsschedule. SeekclarificationfromanyPhilHealthofficeonanyunclearpolicyorguideline. ReportatoncetoPhilHealthanyhealthcarefacilitythatfails,withoutvalidreason,to accommodateaPhilHealthmemberwhowishestoavailofbenefits. ReportatoncetoPhilHealthanyfraudulenttransactionthatyouknowabout. ObserveandcomplywithPhilHealthrulesandregulationsasthereareoffensesinits ImplementingRulesandRegulations ONPCB1PROVIDERS 1.WhatkindofhealthcarefacilitywillqualifyasPrimaryCareBenefit(PCB)Provider? Anygovernmenthealthfacilitythathasthecapacityandhumanresourcestodeliverthe PCBIshallqualifyasPrimaryCareBenefit(PCB)provider.Theseinclude,butarenotlimited togovernmentownedhealthstations/healthcenters/ruralhealthunits(BHS/HCs/RHUs)and OutPatientdepartmentsofgovernmenthospitals,includingthosepreviouslyauthorizedas OPBProviders. 2.WhathappenstothecurrentOPBparticipatinghealthfacilities?

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 The current OPB participating RHUSs and Health Centers, as well as authorized hospitals, are considered PCB providers for CY 2012 upon submission of duly signed PerformanceCommitmentforPCBProvider. 3.WhatarethemainfunctionsofthePCBProviders? ThePCBProvidersshall: Seek out and enlist Sponsored Program members and their qualified dependents assignedtotheirfacilities; FacilitatetheenlistingofOrganizedGroupmembersandOverseasWorkersProgram membersresidingintheirlocality; Render PCB1 Package services needed by the entitled members/dependents assignedtotheirfacilities; Establish a baseline health profile of all PCB Ientitled members and qualified dependentswhichshallbekeptandupdatedatleastannually; MaintainarecordofitsPCBIclienteleandtheservicesrendered; EnsurethatPCBIclientswithhealthcareneedsbeyondtheirservicecapabilityare referredtoappropriatehealthfacilities; Ensure their continuous participation as PCB providers by complying to standards andupgradingtheircapacitytoprovideservices;and AbidebytheprovisionsembodiedinthePerformanceContracttheysigned. 4. What if the PCB Provider does not have facilities to provide diagnostic tests among members? ThesefacilitiesmayforgeaMemorandumofAgreementwithanotherhealthfacility under a different management to provide those diagnostic tests that are not available in theirownfacilities.TheMOAbetweenthePCB1providerandthefacilitythatwillprovide diagnosticserviceswillincludethepricefortheservicethatisbeingcontracted.ThePCB1 providershallpaythediagnosticservicescontractedoutfromthePFPR. 5.WhatotherservicesmustthePCB1providerdeliver? ThePCB1providermustalsorenderobligatedservicestotargetclientsbecausethese aremedicallynecessaryandforthepurposeofdeterminingoutcomeperformanceasbasis forpayment.

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6.Whataretheseobligatedservices?Whoareeligiblefortheseservicesandhowoftenare thesedone? Amongtheobligatedservicesare: Benefits/Services Primary services Preventive TargetClients(Principalmembers) Frequency

BPMeasurement

Nonhypertensive (18 years old Onceayear andabove) Hypertensive (with BP >/=140/90 Onceamonth mmHg breast Female,25yearsoldandabove Onceayear

Periodic clinical examination Visual inspection aceticacid

with Female,2555yearsoldwithintact Onceayear uterus

7.Whatifthemember/dependentwantstowaivetheavailmentofobligatedservices? Patientswithreligiousandculturalbarriersmaysignawaiverforobligatedserviceslike visualaceticacidwashandsubmitthesignedwaivertotheirPCBProvider.TheProvider shallincludethenumberofpatientswhowaivedsuchserviceswhentheysubmitAnnex A.4(SummaryofPCBServicesprovided). 8.HowwillthePCBProvidersbepaid? ThePCBProvidersshallbepaidthroughaPerFamilyPaymentRate(PFPR),whichshallbe computedandreleasedonaquarterlybasis.Throughappropriateadministrativeissuances (e.g. local ordinance, Sangguniang Bayan Resolution etc.), the LGUowned providers shall create/maintainatrustaccountperprovince/city/municipalityforthePFPRfund. 9.WhatdocumentsmustaPCBProvidersubmittofacilitatethereleaseof thePFPR?Whenandwhereshouldthesedocumentsbesubmitted?
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For 2012, the facility shall submit an updated list of its enlisted members (soft and hard copycertifiedcorrectbytheheadofhealthfacility),AnnexA.2andAnnexA.4tothe nearest LHIO within 15 working days after the end of the quarter for the 3rd and 4th tranchesfor2012. For2013,thefacilityshallsubmitalistofassignedSPandenlistedOGandOWPmembers within15workingdaysaftertheendofthefirstquarter.Fortheremaining3quarters, thefacilityshallalsosubmitanupdatedlistofenlistedmembers,AnnexA.2andAnnex A.4tothenearestLHIO,15workingdaysaftertheendofeachquarter. 10.HowmuchwillthePCB1providerbepaidforprovidingtheservicesto members? PCB1providersshallbepaidamaximumP500.00foreverymemberassignedtotheirfacility per year for the PCB 1 services and the amount shall be released in four (4) tranches, as follows: For 2012, the following tranches shall apply based on the type of membership and enrolmentmechanism:

Table2.MaximumPaymentofPFPRbytypeofPCB1entitledMembersforFY2012 PCB1EntitledMembers NHTSandSPLGUrenewal 1stTranche 125.00 2ndTranche 3rdTranche 4thTranche 125.00 125.00 125.00 125.00 125.00 125.00

SPLGUnewenrollees,Organized GroupsandOWP

Notethatforthe3rdand4thtranches,thepaymentwilldependonthenumberofenlisted membersandnumberofprofiledmembersanddependents.Therefore,thefullamountofPhp 125persponsoredprogrammemberspertranchemaynotbegiveninfull. For 2013, the PFPR will still be paid in quarterly tranches based on enlistment, profiling and accomplishmentofobligatedservices.
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11. Are there any incentives offered to PCB Providers who will submit their reports electronically? For the transition period, a maximum incentive of One Hundred Pesos (P100) PFPR per enlisted member shall be released to PCB Providers who will submit reports electronicallyaccordingtotheformatprescribedbyPhilHealth. 12.HowlongwillittakeforPhilHealthtoreleasethePFPRtothePCB1 PhilHealthshallreleasethequarterlyPFPRtoPCBproviderswithin30daysuponreceipt ofcompletereports(i.e.updatedmasterlistofenlistedmembers,A.2andA.4),providedthat thereportsA.2andA.4aresubmittedontimeandinelectronicform. IntheeventthatthePCBProvidersubmithardcopiesoftheirreports,theirPFPR500 forPCBserviceswillbecomputedaccordingtotheirreportbuttheywillnotgetanyamount fromthePFPR100intendedforelectronicreporting. 13.HowshallthePFPRbedisposedandallocated? ThePFPRshallbepaidtothePCBproviderwheretheentitledmembersareenlisted.Thisshall bedividedinto: 1.Eightypercent(80%)ofPFPRshallbespentfortheoperationsofthePCBProvideras statedintheCircular. 2.Twentypercent(20%)shallbeusedexclusivelyforthehonorariaofthehealthpersonnel, nonhealthpersonnel,andvolunteerhealthworkerssuchascommunityhealthteams andwomenshealthteamswhoareconnectedtothePCBprovider.Specifically,thisis brokendownasfollows: a. Tenpercent(10%)forthephysician; b. Fivepercent(5%)forotherhealthprofessionalstaffofthefacility;and c. Fivepercent(5%)fornonhealthprofessionals/staff,includingvolunteers andcommunitymembersofhealthteams(e.g.,Women'sHealthTeam, CommunityHealthTeam) Fordetails,pleasecontactPhilHealthsCallCenterat4417442 X.
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