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(NAR) VOL. 25 NO. 3 / JULY - SEPTEMBER 2014

[ PHILHEALTH CIRCULAR NO. 014, S. 2014, June 13, 2014 ]

REVISED GUIDELINES FOR THE PHILHEALTH OUTPATIENT ANTI-TUBERCULOSIS DIRECTLY OBSERVED TREATMENT SHORT-COURSE (DOTS) BENEFIT PACKAGE



Adopted: 13 June 2014
Date Filed: 07 July 2014


I. BACKGROUND

PhilHealth constantly develops its benefit packages to effectively respond to the needs of its members. Mindful of PhilHealth members afflicted with Tuberculosis (TB), the PhilHealth Board approved Resolution Nos. 485 and 490 of 2002 which established the case rate benefit for out-patient TB-DOTS package amounting to 4,000 pesos for “consultation, anti-tuberculosis medicines and necessary diagnostic services”.

Subsequently, PhilHealth issued Circular No. 17 s-2003 which provided the guidelines for the accreditation of Directly Observed Therapy Short Course (DOTS) facilities as well as Circular No. 19, s-2003 that implemented the TBDOTS Package to include new cases, pediatric and extra-pulmonary TB. Although treated under DOTS and on out-patient basis, retreatment cases are not yet covered in the said Package.

The Philippine Plan Against Tuberculosis 2010-2016 was crafted to fine tune strategic directions with a view to sustain the gains of the TB control program and achieve Millennium Development Goals (MDG) for TB. The goal is to reduce TB prevalence and mortality rates by half compared to 1990 figures. Targets were marked at 85% case detection rate and at least 90% treatment success rate.

To achieve these targets, the NTP addressed some problems that hamper access to diagnosis and treatment of TB in the DOTS facilities. Criteria for management of sputum negative TB were modified in cases when there are no TB Diagnostic Committee (TBDC) (DOH Memorandum No. 2011-0218, dated July 19, 2011). The TBDC recommendation should not be a cause of delay in initiating treatment. In the said memorandum, DOH emphasized that ALL forms of TB should be given treatment. Also, to improve case finding, diagnosis by Direct Sputum Smear Microscopy (DSSM) shall only require submission of 2 samples, as stated in DOH Memorandum No. 2013-0021, dated January 9, 2013. The NTP Manual of Procedures was likewise revised to ensure that the processes in DOTS implementation support the objectives and strategies in the Philippine Plan of Action to Control Tuberculosis (PhilPACT). In light of the said modifications, the guidelines to PhilHealth TB-DOTS benefit package should be likewise updated to reflect the overall national objectives and standards of TB control.

Furthermore, the National Health Insurance Act of 2013 strengthens the role of PhilHealth in providing means for the members to have financial access to health care and for the healthcare providers to improve their health services. The law prohibits charging additional fees to indigent patients. It also prescribes that PhilHealth reimbursements to public health facilities be retained by the individual facility and be spent on operating expenses of the facility as well as improvement of its services, while professional fees shall be pooled and distributed among the facility’s health personnel. Such measures are reflected in this revised TB DOTS package, such that public and private facilities have means to sustain the delivery of TB DOTS services, leading to better TB control.

II. OBJECTIVES

This circular is issued with the following objectives:

  1. To expand the benefit to cover other TB cases that are sensitive to first line anti-TB drugs.
  2. To align the PhilHealth TB DOTS Package with the current policies and guidelines for TB control
  3. To strengthen the financial mechanism as leverage for better performance of providers leading to desired health outcomes and sustained TB control.

III. GENERAL GUIDELINES

  1. To avail of this package, accredited TB DOTS facilities shall comply with the prescribed guidelines of the NTP on diagnosis, treatment and reporting for TB.
  2. PhilHealth TB DOTS Package shall cover TB cases that are susceptible to 1st line anti-TB drugs.
  3. It shall cover for diagnostic exams, consultation services, drugs, health education and counseling during TB DOTS treatment.
  4. PhilHealth TB DOTS Package shall cover both children and adults, with the following registration groups (whether bacteriologically confirmed or clinically diagnosed, pulmonary or extra-pulmonary):

    a. New
    b. Retreatment

  5. 1) Relapse
    2) Treatment After Failure
    3) Treatment After Lost to Follow-up (Return After Default)
    4) Previous Treatment Outcome Unknown

  6. The following cases are excluded: a. In-patient admissions b. Drug resistant TB c. Latent TB Infection
  7. HIV patients that are under treatment for 1st line drug sensitive TB and on anti-retro viral drugs may avail of TB DOTS Package in accredited TB DOTS Centers and Out-patient HIV/AIDS Treatment (OHAT) Package in accredited HIV treatment hubs at the same time. Claims shall be filed separately.
  8. The TB DOTS package shall be a fixed case rate of four thousand pesos (Php4,000.00) and to be given to health care institution in two separate payments.

    a. The first payment of two thousand five hundred pesos (Php2,500.00) shall be given after the intensive phase (package Code 89221).
    b. The second payment of one thousand five hundred pesos (Php1,500.00) shall be given after the continuation (maintenance) phase (package Code 89222).

  9. Payment for referring physicians and other expenses for some services done outside the facility (e.g. chest x-ray) shall be settled by the facility.

IV. PROVIDER ACCREDITATION

1. Accreditation of TB-DOTS providers shall be in accordance with the policy on Provider Engagement through Accreditation and Contracting of Health Services as stated in PhilHealth Circular (PC) 54 s-2012 and subsequent issuances.

2. The Health Care Institution shall submit the following requirements upon its application for initial accreditation:

  1. Performance Commitment, duly signed by both the owner or local chief executive and the head of the facility (e.g. MHO, CHO, PHO, medical director, chief of hospital, etc.);
  2. Properly accomplished provider data record;
  3. Proof of payment of accreditation fee (Php1,000.00);
  4. Electronic copies of photos (in jpg format) of the internal and external areas of the facilities;
  5. Statement of intent for those applying in the last quarter of the current year as attached in PhilHealth Circular 11, s-2013;
  6. Updated DOH-PhilCAT Certificate;
  7. Location map;

3. As provided in Section VI.C of PhilHealth Circular 54, s-2012, accredited TB DOTS Package Providers may continuously participate in the National Health Insurance Program (NHIP) until such participation is withdrawn or terminated. To ensure this, TB DOTS Facilities shall submit annually (on or before January 31st) the following:

  1. Signed performance commitment;
  2. Updated DOH - PhilCAT TB DOTS Certificate (if not submitted, the facility shall be subjected to pre-accreditation survey);
  3. Latest Financial Statement/Report for private facilities;
  4. Proof of payment of accreditation fee (Php 1,000.00).

4. In line with All Case Rates Policy stated in PhilHealth Circular 31, s-2013 Section VI.B that professional services must be provided by accredited health care professionals, PhilHealth shall accredit TB DOTS physicians who provide consultation services in the TB DOTS facility.

  1. PhilHealth shall require that TB DOTS physician/s be accredited with PhilHealth for TB DOTS facilities applying for initial and re-accreditation in 2014.
  2. Currently accredited TB DOTS facilities shall have their physicians accredited by July 31, 2014.
  3. It shall be a requirement for all continuous, initial and re-accreditation in 2015.

5. Accreditation of TB DOTS physician/s shall be according to the provisions of PhilHealth Circular 10, s-2014. They shall submit to the nearest PhilHealth Local Health Insurance Office or Regional Office the following requirements for initial application:

  1. Properly accomplished Provider Data Record for professionals;
  2. Signed Performance Commitment;
  3. Updated PRC License or its equivalent;
  4. Two (2) pieces of 1x1 photo;
  5. Proof of payment of premium contribution; and
  6. Certificate of completed residency training or specialty board certificate if applicable.

V. BENEFIT DELIVERY AND CLAIMS FILING

1. The payment shall be payable to the accredited TB DOTS facility.

2. Claims with the following treatment outcomes shall be paid:

  1. Cured
  2. Treatment completed
  3. Died
  4. Treatment failed

3. Claims with the following treatment outcomes shall be denied:

  1. Lost to follow-up
  2. Not evaluated

4. Claims of TB cases that were initially treated with 1st line anti-TB drugs but were diagnosed to have Drug Resistant TB any time during treatment even before being declared as treatment failed in the 5th month shall be paid.

5. TB DOTS Facilities must comply with the referral mechanisms prescribed by NTP. In cases when the patient is referred to another facility, the referring facility shall file the claim. Claims from receiving facility shall be denied.

6. Availing of this package shall have no corresponding deduction in the 45- days benefit limit per calendar year.

7. No Balance Billing policy as prescribed in PhilHealth Circular 03, s-2014 shall apply.

8. The following package codes shall be used for each treatment phase:


Treatment Phase
Package Code
Description
Intensive Phase
89221
Directly observed treatment short course; intensive phase
Continuation Phase
89222
Directly observed treatment short course; continuation (maintenance) phase

9. The ICD 10 Codes listed in Annex 2 shall be used for this Package.

10. For easier verification of eligibility status, all TB DOTS Facilities must have a PhilHealth Enhanced HCI Portal. Policies and guidelines of which are stated in PhilHealth Circular 02, s-2014.

11. Since there will be separate claims for each treatment phase, the following shall be considered dates of admission and discharge:

Admission Date
Discharge Date
Anti-TB Treatment Phase being claimed
Package Code
First day of intensive phase (treatment start date) Last day of intensive phase
Intensive Phase
89221
First day of continuation (maintenance) phase Last day of continuation (maintenance) phased
Continuation (maintenance) Phase
89222

12. PhilHealth members and their dependents are eligible to avail of the package if premium contributions are paid for at least three months within the six months prior to admission dates of each treatment phase.

13. For claims filing, the following documents must be submitted to PhilHealth within 60 calendar days after the last day of each treatment phase:

  1. PhilHealth Benefit Eligibility Form (PBEF) OR Other documents required by PhilHealth as proof of eligibility such as Member Data Record (MDR), proof of premium payment for individually paying program members, overseas workers program members and PhilHealth ID cards (for sponsored, lifetime members) and other secondary documents as enumerated in the PBEF or listed in PhilHealth Circulars 50, s-2012 and PC 1, s-2013 in cases when PBEF is not available.
  2. PhilHealth Claim Form 1 (CF1) duly filled up by the member and/or employer It shall no longer be required if PBEF affirmed the eligibility of patient to avail of PhilHealth benefits upon the start of treatment date.
  3. PhilHealth Claim Form 2 (CF2) - instructions and sample form of which are attached as Annex 3 and Annex 4 respectively.
  4. Copy of patient's completed NTP treatment card

14. Submission of the NTP Treatment Card prior to starting the treatment is no longer required. Also, the TBDC Recommendation Form is not a requirement anymore for sputum negative/ clinically diagnosed patients.

15. Claims with incomplete requirements and/or discrepancy/ies in the entries shall be returned to the facility or sender (RTS) for compliance within 60 days from the receipt of notice. Failure to comply shall cause denial of claim. However, as stated in PhiHealth Circular 09, s-2014, it shall only be allowed for claims with admission dates on or before June 30, 2014. Afterwards, PhilHealth shall no longer return these claims to the facility but would already deny the claims. The facility must ensure that all requirements are attached, all forms are properly accomplished and there are no discrepancies in the entries before submitting the claims.

16. TB DOTS facilities and physicians shall ensure that their PhilHealth accreditation is updated. Both must be accredited at the start of the treatment. If there is a gap in their accreditation during the course of patient's treatment, claims may still be paid provided that they are accredited on start of treatment. Claims with treatment start date when either of them are not accredited shall be denied starting August 31, 2014.

VI. ALLOCATION OF TB DOTS PACKAGE PAYMENT

1. Public TB DOTS facilities shall maintain a trust fund for reimbursements received from PhilHealth. This trust account shall be created through appropriate administrative issuances such as ordinances or resolutions from Sangguniang Panlungsod/Bayan/Lalawigan for LGU-owned facilities and executive committee resolutions or administrative memoranda for TB DOTS facilities in the government hospitals/infirmaries/other institutions. In cases when there is one trust fund for several PhilHealth benefits, a separate ledger shall be kept for TB DOTS package payment.

2. All TB DOTS facilities shall allocate reimbursement for TB DOTS Package based on their existing policies and procedures.

3. Should the TB DOTS facilities not have any policy on allocation of TB DOTS payment prior to the effectivity of this circular, they shall follow the following guidelines prescribed by DOH in the latest NTP Manual of Procedures:

  1. Forty percent (40%) for the facility fee.
  2. Twenty five percent (25%) for the referring physicians to cover for consultation services during the course of treatment. Should there be no referring physician, this portion shall also be allotted as facility fee.
  3. Thirty five percent (35%) for the services of the staff of the TB DOTS facility.

4. The facility fee shall be used for operational costs and for contingency to augment the supply of anti TB drugs and reagents; acquire equipment such as microscope, IT equipment and software; and support for TB Diagnostic Committee, advocacy activities and training of staff. This may also be used for referral fees of warranted diagnostic services that are not available in the facility and quality assurance of sputum microscopy.

5. The fee for services of the health facility staff shall be pooled and distributed among health personnel who were involved in the delivery of health services for TB including the DOTS physicians, nurses, midwives, medical technologist or sputum microscopist, barangay health workers and treatment partners.

6. Guidelines on the distribution of TB-DOTS payment for the services of the facility staff shall be set by each facility after thorough consultation among its governing body and the health staff. The guidelines shall be approved by the head of the organization (i.e. local chief executive in LGU owned TB DOTS clinic). The allocation should take into consideration the expertise, skills and time that each health care worker allotted in ensuring that the patient received quality care leading to cure or completion of TB treatment.

VII. MONITORING AND EVALUATION

1. Monitoring and evaluation (M and E) of the delivery and utilization of the benefit package shall be based on the M and E framework of PhilHealth.

2. Public DOTS facilities shall furnish PhiLHealth copies of their issuances creating the trust fund and guidelines on allocation within a year after their initial accreditation through their respective PhilHealth Regional Offices.

3. The facility is required to maintain a minimum set of information on each patient such as NTP treatment card and TB registry that shall be readily available to PhilHealth during monitoring and evaluation.

VIII. EFFECTIVITY

This Circular shall take effect 15 days after its publication in a newspaper of general circulation. New and retreatment cases with intensive treatment starting that date should follow the guidelines of this circular.

IX. REPEALING CLAUSE

All other existing issuances and provisions of previous issuances inconsistent with this circular are hereby repealed and/ or amended.

X. ANNEXES*

1. Annex 1 - Definition of Terms
2. Annex 2 - ICD-10 Codes for TB
3. Annex 3 - Instructions How to Accomplish Claim Form 2 for TB DOTS Package
4. Annex 4 - Sample Claim Form 2

(SGD) ALEXANDER A. PADILLA
President and CEO

* Text Available at the Office of the National Administrative Register, U.P. Law Complex, Diliman, Quezon City.

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