ANNEX B

PC for HCIs
April 2020
MUNICIPALITY OF BARILI
PROVINCE OF CEBU
BARILI RURAL HEALTH UNIT II

APRIL 25, 2023

PHILIPPINE HEALTH INSURANCE CORPORATION
17th Flr., City State Centre Bldg.,
Shaw Blvd., Pasig City

SUBJECT : Performance Commitment for HCI (Rev 4)

Sir/Madam:
To guarantee our commitment to the National Health Insurance Program
(NHIP), we respectfully submit this Performance Commitment.
And for the purposes of this Performance Commitment, we hereby warrant
the following representations:

A. REPRESENTATION OF ELIGIBILITIES

1. That we are a duly DOH certified health care facility capable of

delivering the services expected from the type of healthcare provider
that we are applying for.
2. That we are owned by BARILI LOCAL GOVERNMENT UNIT
and managed by BARILI RURAL HEALTH UNIT II and doing
business under the name of DR. MICHELLE ANNE R. DAGOY with
License/Certificate No. 012-33-06 .
3. That all professional health care providers in our facility, as
applicable, are PhilHealth accredited, possess proper credentials and
given appropriate privileges in accordance with our policies and
procedures.

B. COMPLIANCE TO PERTINENT LAWS/RULES & REGULATIONS/

POLICIES/ADMINISTRATIVE ORDERS AND ISSUANCES
Further, we hereby commit ourselves to the following:
3. That our officers, employees, and other personnel are members in
good standing of the NHIP.
4. That, as responsible owner(s) and/or manager(s) of the institution, we
shall be jointly and severally liable for all violations committed
against the provisions of Rep. Act No. 7875, as amended, including
its Implementing Rules and Regulations (IRR) and PhilHealth policies
issued pursuant thereto.
5. That we shall promptly inform PhilHealth prior to any change in the
ownership and/or management of our institution.
6. That any change in ownership and/or management of our institution
shall not operate to exempt the previous and/or present owner and/or
manager from liabilities for violations of Rep. Act No. 7875, as
amended, and its IRR

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 7. That we shall maintain active membership in the NHIP as an
employer not only during the entire validity of our participation in the
NHIP as a Health Care Institution (HCI) but also during the corporate
existence of our institution.
8. That we shall abide with all the implementing rules and regulations,
memorandum circulars, special orders, advisories and other
administrative issuances by PhilHealth affecting us.
9. That we shall abide with all administrative orders, circulars and such
other policies, rules and regulations issued by the Department of
Health and all other related government agencies and
instrumentalities governing the operations of HCIs in participating in
the NHIP.
10. That we shall adhere to pertinent statutory laws affecting the
operations of HCIs including but not limited to the Senior Citizens
Act (R.A10645), the Breastfeeding Act (R.A. 7600), the Newborn
Screening Act (R.A. 9288), the Cheaper Medicines Act (R.A. 9502),
the Pharmacy Law (R.A. 5921), the Magna Carta for Disabled Persons
(R.A. 9442), and all other laws, rules and regulations that may
hereafter be passed by the Congress of the Philippines or any other
authorized instrumentalities of the government.
11. That we shall promptly submit reports as may be required by
PhilHealth, DOH and all other government agencies and
instrumentalities governing the operations of HCIs.
12. That we shall facilitate distribution of the professional fee
component of the PhilHealth payment/reimbursement to the
concerned professionals not exceeding thirty (30) calendar days upon
receipt of the reimbursement or at a time frame as agreed upon by
the HCI and their professionals.
13. That being a government-owned (for public-owned facilities
only) health care institution, we shall maintain a trust fund for the
PhilHealth reimbursements in compliance to Section 34-A of Republic
Act 10606 which provides that "revenues shall be used to defray
operating costs other than salaries, to maintain or upgrade
equipment, plant or facility, and to maintain or improve the quality of
care.

C. CONDUCT OF CLINICAL SERVICES, RECORDS, PREPARATION

OF CLAIMS AND UNDERTAKINGS OF PARTICIPATION IN THE
NHIP

14. That we are duly capable of delivering the CCIBP services for
the duration of the validity of this commitment.
15. That we shall provide and charge to the PhilHealth benefit of
the client the necessary services including but not limited to drugs,
medicines, supplies, devices, and diagnostic and treatment
procedures for our PhilHealth clients.
16. That we, being an accredited government hospital or
infirmary/ASC/FDC/MCP/TB DOTS/ Animal Bite package/ DRTC/PCB
and/or contracted provider for the Z benefit package provider, as
applicable, shall provide the necessary drugs, supplies and services
with no out-of-pocket expenses on the part of the qualified PhilHealth
member and their
dependents admitted or who consulted in the HCI, as mandated by
the PhilHealth “No Balance Billing (NBB) Policy”

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 17. That we, being an accredited provider, shall abide by the rules
set in the CCIBP, including the prescribed disposition of the
PhilHealth reimbursements, as stated in the current guidelines,
which shall be used by the HCI to be able to provide the mandatory
services and ensure better health outcomes.
18. That we shall maintain a high level of service satisfaction among
PhilHealth clients including all their qualified
dependents/beneficiaries.
19. That we shall be guided by PhilHealth-approved clinical practice
guidelines or if not available, other established and accepted
standards of practice.
20. That we shall provide a PhilHealth Bulletin Board for the
posting of updated information of the NHIP (circulars, memoranda,
IEC materials, price reference index, etc.) in conspicuous places
accessible to patients, members and dependents of the NHIP within
our health facility.
21. That we shall always make available the necessary forms for
PhilHealth member-patient’s use.
22. That we shall treat PhilHealth member-patient with utmost
courtesy and respect, assist them in availing PhilHealth benefits and
provide them with accurate information on PhilHealth policies and
guidelines.
23. That we shall ensure that PhilHealth member-patient with needs
beyond our service capability are referred to appropriate PhilHealth-
accredited health facilities.

D.MANAGEMENT INFORMATION SYSTEM

24. That we shall maintain a registry of all our PhilHealth members-
patients (including newborns) and a database of all claims filed
containing actual charges (board, drugs, labs, auxiliary, services and
professional fees), actual amount deducted by the facility as
PhilHealth reimbursement and actual PhilHealth reimbursement,
which shall be made available to PhilHealth or any of its authorized
personnel.
25. That we shall maintain and submit to PhilHealth an electronic
registry of physicians and dentists including their fields of practice,
official e-mail and mobile phone numbers.
26. That we shall, if connected with e-claims, electronically encode
the laboratory / diagnostic examinations done, drugs and supplies
used in the care of the patient in our information system which shall
be made available for PhilHealth use.
27. That we shall ensure that true and accurate data are encoded in
all patients’ records.
28. That we shall only file true and legitimate claims recognizing
the period of filing the same after the patient’s discharge as
prescribed in PhilHealth circulars.
29. That we shall submit claims in the format required by
PhilHealth for our facility.
30. That we shall regularly submit PhilHealth monitoring reports as
required in PhilHealth circulars.

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E. REGULAR SURVEYS / ADMINISTRATIVE
INVESTIGATIONS/DOMICILIARY VISITATIONS ON THE
CONDUCT OF OPERATIONS IN THE EXERCISE OF THE
PRIVILEGE OF ACCREDITATION
31. That we shall extend full cooperation with duly recognized
authorities of PhilHealth and any other authorized personnel and
instrumentalities to provide access to patient records and submit to
any orderly assessment conducted by PhilHealth relative to any
findings, adverse reports, pattern of utilization and/or any other acts
indicative of any illegal, irregular and/or unethical practices in our
operations as an accredited HCI of the NHIP that may be prejudicial
or tends to undermine the NHIP and make available all pertinent
official records and documents including the provision of copies
thereof; provided that our rights to private ownership and privacy are
respected at all times.
32. That we shall ensure that our officers, employees and personnel
extend full cooperation and due courtesy to all PhilHealth officers,
employees and staff during the conduct of
assessment/visitation/investigation/monitoring of our operations as
an accredited HCI of the NHIP.
33. That at any time during the period of our participation in the
NHIP, upon request of PhilHealth, we shall voluntarily sign and
execute a new ‘Performance Commitment’ to cover the remaining
portion of our accreditation or to renew our participation with the
NHIP as the case may be, as a sign of our good faith and continuous
commitment to support the NHIP.
34. That, unless proven to be a palpable mistake or excusable error,
we shall take full responsibility for any inaccuracies and/or falsities
entered into and/or reflected in our patients' records as well as in any
omission, addition, inaccuracies and/or falsities entered into and/or
reflected in claims submitted to PhilHealth by our institution.
35. That we shall comply with PhilHealth’s summons, subpoena,
subpoena ‘duces tecum’ and other legal or quality assurance
processes and requirements.
36. That we shall recognize the authority of PhilHealth, its Officers
and personnel and/or its duly authorized representatives to conduct
regular surveys, domiciliary visits, and/or conduct administrative
assessments at any reasonable time relative to the exercise of our
privilege and conduct of our operations as an accredited HCI of the
NHIP.
37. That we shall comply with PhilHealth corrective actions given
after monitoring activities within the prescribed period.

F. MISCELLANEOUS PROVISIONS
38. That we shall protect the NHIP against abuse, violation and/or
over-utilization of its funds and we shall not allow our institution to
be a party to any act, scheme, plan, or contract that may directly or
indirectly be prejudicial or detrimental to the NHIP.
39. That we shall not directly or indirectly engage in any form of
unethical or improper practices as an accredited health care provider
such as but not limited to solicitation of patients for purposes of
compensability under the NHIP, the purpose and/or the end
consideration of which tends unnecessary financial gain rather than
promotion of the NHIP.

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 40. That we shall immediately report to PhilHealth, its Officers
and/or to any of its personnel, any act of illegal, improper and/or
unethical practices of HCI of the NHIP that may have come to our
knowledge directly or indirectly.
41. That we shall allow PhilHealth to deduct or charge to our future
claims, all reimbursements paid to our institution under the
following, but not limited to: (a) during the period of its non-
accredited status as a result of a gap in validity of our DOH LTO,
suspension of accreditation, etc; (2)downgrading of level, loss of
license for certain services; (c)when NBB eligible PhilHealth
members and their dependents were made to pay out-of-pocket for
HCI and professional fees, if applicable; (d) validated claims of under
deduction of PhilHealth benefits.
Furthermore, recognizing and respecting its indispensable role in the
NHIP, we hereby acknowledge the power and authority of PhilHealth to
do the following:
42. After due process and in accordance with the pertinent
provisions of R.A. 7875 and its IRR, to suspend, shorten, pre-
terminate and/or revoke our privilege of participating in the NHIP
including the appurtenant benefits and opportunities at any time
during the validity of the commitment for any violation of any
provision of this Performance Commitment and of R.A. 7875, as
amended, and its IRR.
43. After due process and in accordance with the pertinent
provisions of R.A. 7875 and its IRR, to suspend, shorten, pre-
terminate and/or revoke our accreditation including the appurtenant
benefits and opportunities incident thereto at any time during the
term of the commitment due to verified adverse reports/findings of
pattern or any other similar incidents which may be indicative of any
illegal, irregular or improper and/or unethical conduct of our
operations.
We commit to extend our full support in sharing PhilHealth’s vision in
achieving this noble objective of providing accessible quality health
insurance coverage for all Filipinos.

Very truly yours,

Head of Facility/Medical Director/ Chief of

Hospital/ Medical Center Chief

With my express conformity,

Local Chief Executive (if LGU-owned)/Owner

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