R epublic of the Philippines

PHILIPPINE HEALT H INSURANCE CORPORATION

Citystate Centre, 709 Shaw Boulevard, Pasig City
Call Center: (02) 8441 -7442 I Trunkline: (02) 84417444
www.philhealth .gov.ph U N IV ! RSAl HEAlTH CA RE
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PHILHEALT H CIRCULAR
No. 2o 2o ,./ 0021
TO ALL FILIPINOS, ACCREDITED H EALTH CARE
INSTITUTIONS/ PROVIDE RS, PHILHEALTH REGIONAL
OFFICES, BRANCHES, LOCAL HEALTH INSURANCE
--------------eF-F-IeES-1\ND-~Tti-Eits-CONCER'N'El)

SUBJE CT Imp le m e nting Guidelines for the PhiiHealth Konsultasyong Sulit a t

T am a (PhiiHealth Konsulta) P ackage

I. RATIONALE

As an initial step towards adopting a comprehensive approach to delivering primary care,

PhilHealth has corrunitted through PhilHealth Board Resolution No. 2479 to expand the
primary care benefit to cover all Filipinos. The resolution mandated the issuance of
PhilHealth Circular (PC) No. 2020-0002 entitled "Governing Policies of the PhilHealth
Konsultasyong Sulit at T ama (I<:.onsulta) P ackage: Expansion of the Primary Care Benefit to
cover all Filipinos". Section IV. B. of the aforementioned Circular requires the issuance of
applicable rules for member registration and assessment, service package, benefit availment,
provider payment mechanism and provider performance assessment.

II. OBJECTIVE

T he Circular aims to enable access to primaty care by adopting a responsive financing

mechanism for the delivery of .quality primary care services and commodities. Likewise, it
aims to define the PhilHealth K on sulta benefit package and to provide specific guidelines
~ on registration to a primary care provider, benefit availment, applicable payment
mechanism, reporting rules and performance assessment.
~ III. SCOPE
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This Circular covers the implementing guidelines of the PhilH ealth Konsulta in its
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transitional phase towards a comprehensive outpatient benefit as mandated by the
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c.;_ T he rules on accreditation of H ealth Care Providers shall be issued on a separate Circular.

IV. D EFINIT ION OF TERMS

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A Active p atient seeking - refers to the selective, coercive, and/ or exploitative
engagement of unwilling and / or ill-informed individuals in order to collect payments
from Phi!H ealth. This can refer to either provider inducement where the provider
delivers unnecessary health services to a patient to flie a claim, the involuntary
registration of unconsenting individuals to a provider, and/ or deliberately targeting the
registration of mostly healthy and/or low-risk individuals to maximize profit.

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 B. Catchment Population - all registered eligible beneficiaries to a Phill-Iealth Konsulta
Provider.

c. Balance Billing/Co-payment cap - refers to the maximum amount set by PhilHealth

that a Konsul ta Provider can charge a patient at any given year.

D. Balance Billing/Co-payment schedule- the amount charged by a Phill-Iealth Konsulta

Provider for each visit/service delivered to the eligible beneficiary. The amount should
not exceed the balance billing/co-pay cap set for the year.

E Electronic Konsulta (eKonsulta) - a PhilHealth developed web-based stand-alone

application which may be used by the Konsulta facility as an interim electronic
reporting system. This can be used for encoding of encounter data records to include
diagnosis, diagnostic tests done with corresponding results and prescribed/ dispensed
medicines.

F. Electronic Medical Record (EMR) - is the electronic record system or the electronic
document o f a patient's encounter in one health facility. In this case, the patient's
medical or health record at a health facility is being received, recorded, transmitted,
stored, processed, retrieved or produced electronically through computers or other
electronic devices.

G. Eligible Beneficiary - refers to all Filipinos given immediate eligibility in accordance

with Republic Act No. 11223 and its IRR.

H First patient encounter - initial episode of care whereby a primary care worker takes
and/ or updates the basic health data of an eligible beneficiary to identify their health
risks.

I Individual-based health services - services which can be accessed within a health facility
or remotely that can be definitively traced back to one (1) recipient. T hese include the
provision of consultation services, diagnostics, and commodities (RA 11223)

J. Maximum catchment population - the maximum number of registered beneficiaries in an area

that can be served by a facility based on the doctor to population ratio as defined by the
Department of Health.

K. Navigation - refers to the function of coordinating and directing the individual to

obtain h ealth services needed to manage a wide range of health needs.

L Patient encounter - individual episodes of care provided by a primary care provider

which are then duly reported to PhilHealth on a regular basis.

M Updating of registration - refers to the retention or transfer of an eligible beneficiary

from one PhilHealth Konsulta Provider to another.

v. POLICY STATEMENTS

A Eligibility and registration of Filipinos to an accredited PhilHealth Konsulta Provider

1. All Filipinos shall be eligible to avail of the PhilHealth Konsul ta benefit.

2 Each Filipino shall register with an accredited Phill-Iealth Konsulta Provider of their
choice with consideration to the maximum catchment population.

3. Registration to a PhilHealth Konsulta Provider shall be done yearly and fiXed for one

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 calendar year. The registration period shall be defined by PhilHealth and shall be
announced to the public through an advisory or any other official issuance.

4. Registration of eligible beneficiaries to an accredited PhilHealth Konsulta Provider

shall be guided by the following:
a. All accredited PhilHealth Konsulta Providers shall be published in the PhilHealth
website;
b. Eligible beneficiaries may check the Phil.H.ealth website for information on their
preferred Konsulta Provider including but not limited to their location, balance
billing/ co-payment schedule, and balance billing/ co-pay cap;
c. Every Filipino shall register with the National Health Insurance Program (NHIP)
as administered by PhilHealth prior to registration with a Konsulta Provider.
Filipinos not yet registered with the NHIP can register in accordance with existing,_ _ __ __
PhilHealth policies and procedures;
d. Filipinos registered with the NHIP may self-register to an accredited PhilHealth
Konsulta Provider through the PhilHealth's online Konsulta registration system
(see Annex A, "Registration to a PhilHealth Konsulta Provider");
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e. In cases where assistance is needed, such as in registering minors, persons with
disabilities (PWDs) and beneficiaries with no internet access or have difficulty
using information technology (IT), they may go to the nearest Local Health
Insurance Office (LHIO), PhilHealth Express, or PCARES whichever is available.
PhilHealth shall also conduct events with select partners to facilitate registration to
a PhilHealth Konsulta Provider; and,
f. PhilHealth may also authorize third-party agencies/ organizations to facilitate
registration to an accredited PhilHealth Konsulta Provider. These would include
the following but not limited to, local government units for citizens within their
jurisdiction, Office for Senior Citizens Affairs (OSCA) for senior citizens in their
area, employers for their employees, and PhilH ealth Konsulta Provider;
f.l Specific processes and procedures on registering through a third party agency/
organization is detailed in the manual of procedure on PhilHealth Konsulta
Assisted Registration (see Annex B. PhilHealth Konsulta Assis ted Registration
Manual);
f.2 All authorized third-party agencies/ organizations shall be responsible for
ensuring the ~ghts of the eligible beneficiary, including but not limited to the
right of choice of a primary care provider, nondiscrimination, privacy, and in
terms of ensuring the integrity of the data that they have submitted; and,
f.3 Each eligible beneficiary registered by a third-party agency/ organization shall
receive either a digital or printed confirmation slip as proof of registration. In
dses where releasing a digital confirmation slip is not possible, eligible
beneficiaries shall be required to accomplish the PhilHealth Konsulta
registration form (see Annex C, "PhilHealth Konsulta Registration Form") .
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i-~ LL a 5. The conduct of the first patient encounter within the year of registration shall be the
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<:'( (_) I shared responsibility of the accredited PhilHealth Konsulta Providers and all newly
registered eligible beneficiaries.

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6. Eligible beneficiaries have the responsibility to update PhilHealth with their

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,::s a. Updating of registration to PhilHealth Konsulta Provider of choice ·will be done in
the last quarter of the year;
b. Eligible beneficiaries who fail to update their PhilHealth Konsulta Provider of
choice shall be automatically re-registered to their last declared Konsulta Provider;
c. Eligible beneficiaries who have not used their benefit for at least 18 months,

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 rendering them as inactive, shall be given advance notice by PhilHealth to update
their registration;
d . Likewise, PhilHealth shall n otify the Konsulta Provider within six (6) months
prior to the removal of an eligible beneficiary in their catchment population due to
inactivity;
e. E ligible beneficiaries who have not utilized their primary care benefit for two (2)
years shall be removed from the registration list of that PhilHealth Konsulta Provider and
shall enable them to register to another Provider.

7. Transfer from one PhilHealth Konsulta Provider to another shall only be allowed for
the following calendar year excep t in the following cases:
a. Withdrawal, non-renewal or suspension of accreditation of the PhilHealth
Konsulta Provider;
b. Closure of the PhilHealth Konsulta Provider; and,
c. Any other 1nstances 1clentified by the Corporation.

8 In case of withdrawal, non-renewal, suspension of accreditation, or closure of the

Konsulta Provider, PhilHealth shall inform the eligible beneficiary and facilitate
transfer to another accredited Konsulta Provider. (see Annex A, "Registration to a
PhilHealth Konsulta Provider")

9. P hilHealth K onsulta Provider shall be allowed to market the benefit in ethical and
non-discriminatory means. Marketing activities include but are not limited to verbal
presentations, media campaigns, and posting and distribution of written information,
education, and communication materials. These are subject to the following
considerations:
a. The PhilHealth Kon sulta Provider shall submit their marketing plans and materials
for clearance, and approval of PhilHealth ,
b. PhilHealth Konsulta Provider shall not engage in "active patient seeking" or the
practice of hiring seekers/recruiters for the purpose of populating the registration
registry to meet the maximum catchment population.

10. The maximum catchment population shall be subject to PhilHealth assessment, and
approval based on the health human resource to population ratio as stipulated in the
accreditation policy of PhilHealth Konsulta Provider.

11. PhilHealth Konsulta Provider shall regularly check the H CI Portal for updates on the
registration list. In areas where there is slow or no internet connectivity, Phi!Health
Konsulta registration shall be done through the Updated Primary Care Module
(UP CM) at the Local Health Insurance Office (LHIO), and the encrypted softcopy of
registrati6~ list shall be fotwarded by the LI-IIO to the PhilHealth Konsulta Provider
on a weekly basis.

.,.....ro B. PhilHealth Konsulta Benefit Package Content

a 1. The PhilHealth Konsulta package covers individual-based health services including

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initial and follow-up primary care consultations, health screening and assessment and
access to selected diagnostic services, and medicines (See Annex D, "Phi!Health
Konsulta Benefit Table").
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! f.:) 2 Access to select diagnostic services and medicines will be based on the health needs of
L __. ___.~~-- the patients subject to rules of the Corporation on benefit availment.

3. PhilHealth Konsulta Provider may implement innovations such as integration and use
of telemedicine in the delivery of the services to ensure that their catchment
population has access to all services. These innovations must be lawful and not

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 contrary to existing policies of the DOH and PhilHealth. The adopted innovations
shall not replace accreditation standards stipulated in the PhiU-lealth Konsulta
accreditation policy and shall be subjected to the same benefit availment process, and
provider payment scheme provided for in this policy.

4 PhilHealth K onsulta Provider shall continually serve as the initial point of contact for
the eligible beneficiary in accessing health services. They shall perform navigation and
referral functions for patients depending on their health needs in accordance with
accepted norms and ethical practice.

5. PhilHealth Konsulta Providers shall perform preventive health services such as health
screening and assessment according to life stage and health risks of individuals in their
catchment population (see Annex E, "List of Preventive Health Services based on
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6. T he services included 1n this package will be reviewed and improved periodically

based on PhilHealth's benefit prioritization process and upon positive
recommendation of the Health Technology Assessment Council.

C. Phi!Health Konsulta Benefit Availment Process

1. PhilHealth Konsulta Providers and all eligible beneficiaries shall follow the benefit
availment process set forth by the Corporation (see Annex F, "PhilHealth Konsulta
Benefit Availment Process").

2 PhilHealth Konsulta Provider shall generate the Electronic Konsulta Availment Slip
(eKAS) and/ or Electronic Prescription Slip (ePresS) for each patient encounter (see
Annex G, "eKAS and ePresS").

3. All eligible beneficiaries availing of the benefit shall provide feedback and sign the
eKAS and/ or ePresS after every transaction.

4 The duly signed eKAS and ePresS shall be submitted to PhilHealth by the Konsulta
Provider.

D. Provider Paym ent Mechanism

1. The benefit shall be paid as an annual capitation released based on performance.

2 Capitation rates shall be set by the Corporation and shall be paid in tranches (see
Annex H , "Approved Benefit Payment and balance billing/Co-payment Schedule") .
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3. The capitation rate, tranches, and performance targets shall be periodically reviewed
by the Corporation for modification and adjustments.
cr .,._ 4. PhilHealth shall pay using the Auto-credit payment scheme (ACPS) .
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'" J 5. Phill-Iealth Konsulta Provider may charge fees for services and commodities not
'~U included in the benefit package. Provision of services and commodities outside the
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package with their corresponding rates shall still be encoded in the E11R.
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u 6. Accredited PhilHealth Konsulta Provider shall comply with the obligations identified
...____? _.1 in the HCPs' performance commitments and balance billing/ co-payment rules
stipulated in this issuance, its annexes, and all other applicable issuances.

a. Private facilities shall be allowed to charge up to the balance billing/ co-payment

cap (See Annex H, "Approved Benefit Payment and Balance Billing/Co-payment
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 Schedule") for services in the PhilHealth Konsulta package;
b. Private facilities are allowed to design their own balance billing/ co-payment
schedule. The balance billing/ co-payment schedule should be agreed upon with
PhilHealth and shall be included in their performance commitment;
c. PhilHealth Konsulta Providers shall inform their catchment population of the
balance billing/ co-payment cap and balance billing/ co-payment schedule and post the
balance billing/ co-payment schedule at visible areas on their facility; and,
d. The no balance billing/no co-payment policy shall apply to all eligible
beneficiaries registered in a government PhilHealth Konsulta Provider.

7. In cases where eligible beneficiaries are transferred by a PhilHealth Konsulta Facility

to another facility for reasons including but not limited to the inability to provide
services due to staffing shortages within the period of accreditation or change of
residency, the referring facility shall cover the cost of care to the referral facility for
the period of the transfer. Proof of transfer of residence from the original to the new
address shall be presented. Payment arrangements shall be defined and resolved
between the referring and referral facilities and shall be at no added cost to the
eligible beneficiary and to PhilHealth in covering for services included in the package.

8 In case of any disagreement with the computed reimbursement, existing guidelines

on appeal and motion for reconsideration (MR) shall apply.

9. Existing legislations and regulations that endow privileges and discounts to specific
segments of the population, including senior citizens and PWDs, shall be applied to
the balance billing/ co-payment for PhilHealth Konsulta services.

E D isposition and allocation of the capitation

1. Capitation reimbursements in government ·health care facilities shall be utilized to
cover all essential services, medicines provided for in this Circular and other operating
expenses to support delivery of care including hiring of additional physician, internet
subscription, service provider subscription fee and IT hardware. Any remaining fund
may be utilized as performance ·incentives for primary care workers and shalt be
governed and determined by the internal guidelines of the PhilHealth Konsulta
Provider. PhilHealth shall not prescribe how performance incentives will be disbursed.
If applicable, the share of performance incentives can be defined through an approved
Sanggunian resolution or any similar issuance.

2 Government Konsulta facilities shalt create a ledger to account for the utilization of
PhilHealth Konsulta funds.
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3. For private PhilHealth Konsulta facilities, capitation reimbursements shall be utilized
to cover provider fees including professional fees, reading and interpretation of
laboratory/ diagnostic results, and essential services and medicines .
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4. For capitation reimbursements, existing PhilHealth policy on late filing of claims shall
\ apply in handling submissions of patient encounters beyond the prescribed period.

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F. Handling Health data
1. All health data shall be encoded in the Konsulta compliant EtvfR system for electronic
I C) j transmission to PhilHealth (see Annex I, "Submission of Reports"). These data shall
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include but not limited to diagnosis, diagnostic tests done with corresponding results
and prescribed/ dispensed medicines, other services and commodities not currently
covered by the Package. This system shall be periodically upgraded to address
operational issues such as but not limited to portability, the overloaded iClinicSys, etc.

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 2 PhilHealth Konsulta Providers shall submit the electronic p atient record data to
PhilH ealth as soon as the record is available up to one week and in accordance with
the prescribed format. Submissions shall include all records of encounters with
eligible beneficiaries (see Annex I, "Submission of Reports").

3. Incomplete patient encounter reports shall be automatically denied by the system.

4. PhilHealth Konsulta Provider shall host and safeguard electronic patient records in
accordance with existing rules and regulations in managing health information and
data privacy. PhilHealth Konsulta Provider and all its staff and all affiliated facilities
and individuals shall commit to keep the members' personal information confidential,
secure, private and affirm the fundamental right of all persons, natural or juridical,
with particular emphasis on its members and their dependents, to privacy in
compliance with the Data Privacy Act of 2012 (R..A. 10173)

G. Monitoring and Evaluation

PhilHealth, through its Healthcare Provider Performance Assessment System (HCP-
PAS) shall employ mechanisms to assure members of the guaranteed quality healthcare
they deserve. Performance targets shall be identified to guide all concerned stakeholders
of their accountability towards providing essential primary care services especially to the
poor and marginalized families.

PhilHealth shall utilize electronic systems to facilitate the implementation of the Konsulta
Package including building a system to connect Konsulta with inpatient availment for
monitoring purposes, an application for immediate feedback and documentation of actual
patient encounter transactions, mechanisms enabling access to primary care services such
as the feedback application, biometrics kiosk, eKAS and ePresS.

H Annexes
Annex A: Registration to a PhilHealth Konsulta Provider
Annex B: PhilHealth Konsulta Assisted Registration Manual
Annex C: PhilHealth Konsulta Registration Form
Annex D: PhilHealth Konsulta Benefit Table
Annex E: List of Preventive Health Services based on Lifestage Guarantees
Annex F: PhilHealth Konsulta Benefit Availment Process
Annex G: eKAS and ePresS
Annex H: Approved Benefit Paym ent and Balance Billing/ Co-payment Schedule
Annex I: Submission of Reports
Annex J: List of Minimum Personal Information for the First Patient Encounter
/',/

VI. PENALTY CLAUSE

Failure to meet any of the performance targets (see Annex H , "Approved Benefit Payment
and Balance Billing/Co-payment Schedule") shall be a ground for close monitoring, and
subsequent sanctions and penalties.

.,...... Any violation of this Circular, terms and conditions of the Performance Commitment and
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0 all existing related PhilHealth circulars, Corporate Office Orders and directives shall be

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dealt with accordingly.

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 VII. TRANSITORY CLAUSE

Due to and in consideration of the effects of the pandemic which partly led to the
refocusing of the health system towards COVID-19 response in 2020, the PhilHealth
Konsulta package may be initially implemented in pilot areas for the first two quarters of
CY 2021. Pilot sites shall be determined based on selection criteria as defined in the
Accreditation guidelines.

Further, expansion of the implementation to other interested primary care providers shall
start on Yd quarter of CY 2021 following the PhilHealth Konsulta accreditation guidelines.

VIII. SEPARABILITY CLAUSE

In the event that any part or P-rovision of this Circular is declared unauthorized or rendered
invalid by any Court of Law or competent authority, those provisions not affected by such
declaration shall remain valid and effective.

IX. REPEALING CLAUSE

The following issuances that are inconsistent with any provision of this Circular are hereby
amended, modified, or repealed accordingly:

A. PhilHealth Circular 2019-0003: Expansion of the Primary Care Benefit (EPCB) to

Cover Formal Economy, Lifetime Members and Senior Citizens (Revision 1)

B. PhilHealth Circular 2019-0007: Per Family Payment (PFP) Processing using the
Automated Payment Utility in the PhilHealth HCI Portal (UPCM) and other Certified
E lectronic Medical Records (EMR) Revision 2

C. PhilHealth Circular No. 010 s. 2012: Implementing Guidelines for Universal Health
Care Primary Care Benefit 1 (PCB1) Package for Transition Period CY 2012-2013

D. PhilHealth Circular No. 015 s. 2014: Primary Care Benefit 1 (PCB1) now called
"Tsekap" Package Guidelines for CY 2014

X. DATE OF EFFECTIVITY

This Circular shall be published in any newspaper of general circulation and shall take effect
immediately upon publication. Further, this Circular shall also be deposited thereafter with

~ the Office of the National Administrative Register at the University of the Philippines Law
Center.

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