Circ2022 0023

Republic of the Philippines
PHILIPPINE HEALTH INSURANCE CORPORATION

Citystate Centre, 709 Shaw Boulevard, Pasig City
Call Center: (02) 8441-7442 1 Tnmkline: (02) 8441-7444
www .philhealth.gov .ph UNIVfRSAl 1-IEALTH CARE
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PHILH!ALTH CIRCULA~
No. 0]1,--QQZ...
TO ALL PHILHEALTH MEMBERS, ACCREDITED HEALTH CARE

PROVIDERS/NETWORKS, PHILHEALTH REGIONAL
OFFICES, AND ALL OTHERS CONCERNED
SUBJECT Implementation of a Primary Care Provider Network (PCPN)

Contracting Arrangement through the Konsulta Package in Sandbox
Sites/Networks
I. RATIONALE
The progressive realization of Universal Health Care (UHC) needs an integrated approach in
the planning, development, and implementation of health policies and programs. Section
18(a) of Republic Act (RA) No.11223, otherwise known as the Universal Health Care (UHC)
Act, mandates the Philippine Health Insurance Corporation (PhilHealth) to contract public,
private, or mixed health care provider networks for the delivery of individual-based health
services. Meanwhile, Chapter V Sections 19-22 of the UHC Act provides for the
organization of the Local Health System (LHS) into Province/City-Wide Health System
(P /CWHS), and the establishment of a Special Health Fund (SHF) for pooling of resources
(i.e., from the National Government, PhilHealth, and from Development Organizations and
Other Sources) for the delivery of health services. Furthermore, the Joint Memorandum
Circular QMC) No. 2021-001 dated January 13, 2021 signed by the Department of Health
(DOH), Department of Budget and Management (DBM), Department of Finance (DOF),
Department of Interior and Local Government (DILG) and PhilHealth allows the latter to
commence the payment to the SHF once the P/CWHS was able to meet the minimum
standards set by the Corporation. At present, provinces and cities are in various stages of
integration and have yet to demonstrate the full integration (i.e., managerial, technical, and
financial) prescribed by the UHC Act.
As an initial step to comply with its mandates, the Corporation issued PhilHealth Board
Resolution (PBR) No. 2746 Series of 2022 to implement a network contracting arrangement
of Konsulta providers within the framework of the local health system under a sandbox
setting. PhilHealth aims to begin with Konsulta services delivery as a model for the primary
care provider network (PCPN) as the core for the formation of health care primary networks
(HCPNs).
II. OBJECTIVES
This PhilHealth Circular aims to enable the Corporation to contract participating Local
Government Units (LGUs) and private healthcare providers to test PCPN innovations and
model(s) to promote effective and efficient delivery of Konsulta benefits. This issuance
includes the guiding principles and requirements for testing interventions/innovations,
( ) PhiiHealthofflcial ()Oteamphilhealth (i}ac:[email protected]

network standards, contracting templates, and financing mechanisms within which primary
care benefits or PhilHealth Konsulta benefit package can be delivered that alms to:
a. Test network contracting models in implementing and improving utilization and

delivery of Konsulta services to determine operational and financial sustalnability in
selected sites;
b. Promote formation of Primary Care Provider Networks;
1. Increase registration of PhilHealth members to Konsulta providers;
2. Improve utilization of Konsulta services;
c. Establish standards for contracting of provider networks;
d. Establish and manage a SHF for LGUs or pooled fund for private health sectors, as
applicable, to sustain and improve health systems opetations;
e. Assess the readiness of the LGUs, private health care facilities and PhilHealth in the
adoption of network contracting mechanisms; and
f. Provide guidance to the Commission on Audit (COA), Bureau of Local Government
Finance (BLGF), Bureau of Internal Revenue (BIR) and other concerned agencies
on the issuance of respective guidelines on the implementation of health care
provider network contracting.
III. SCOPE
This PhilHealth Circular shall only apply to selected provinces, cities, and private health
sectors '-Vith interest to engage or contract with PhilHealth to test
interventions/innovations/ initiatives in improving Konsulta service delivery and utilization.
Interventions/ innovations from LGUs, particularly those from UHC Implementation Sites
(UIS) shall be prioritized. Private-sector-driven initiatives shall be likewise included. The
interventions/ innovations shall encompass the following:
A. The formation of a network of providers, public, private or mixed, for Konsulta services
with established administrative and clinical referral systems; and
B. The establishment of financial arrangements with the creation of SHF or pooled fund to
support funding requirements of the intervention/innovation.
t.J IV. DEFINITION OF TERMS

~-- . ~-
/ A. Capitation1 -a type of prospective payment by which a provider receives a fixed fee for
each enrollee to cover a defined set of health care services wid1in a specified period of
time.
B. Contractin~- refers to a process where providers and networks are engaged through a
Service Level Agreement (SLA) to commit and deliver quality health services at agreed
cost, cost sharing and quantity in compliance with prescribed standards.
C. Innovation - refers to variations in elements of Konsulta service delivery, consistent

with the UHC law-prescribed managerial, technical, and financial integration as well as
existing PhilHealth and DOH guidelines, that can be tested for implementation, subject
to approval of PhilHealth.
' Palladium. (2022, March 9). USAID's ProtectHealth Technical Advisory on Payment Mechanisms.
2
Pet Republic Act N o. 11223 or the UHC Act
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D. Konsulta 3 - refers to the primary care benefit package of PhilHealth. It is paid per capita
and covers a defined set of primary care health services based on their life-stage, health
risks, and needs for which all Filipinos are entitled to.
E. Local Health Board (LHB) 3 - refers to the provincial or city government body
responsible for setting the overall health policy directions and strategic thrusts including
the development and implementation of the integrated strategic and investment plans of
the province-wide and city-wide health system, overseeing and coordinating the
integration and delivery of health services across the health care continuum for province-
wide and city-wide health systems, managing the special health fund, and exercising
administrative and technical supervision over health facilities and health human
resources within their respective territorial jurisdiction.
F. Pdmary Care Provider Network (PCPN) - refers to a group of Konsulta Providers,

whether public, private, or mixed, with established interoperable system for efficient
provision of Konsulta services.
G. Prospective payment3 - refers to a method of reimbursement in which payment is

based on a predetermined, fixed amount. The payment amount for a particular service is
based on disease or diagnosis-related groupings and validated costing methodologies.
H. Prospective provider payment4•5 - defined as the allocation of resources to a healthcare

provider to deliver the covered package of healthcare goods, services, and interventiones
to the covered population in which rates are set in advance and/ or providers are paid
before services are delivered.
I. Sandbox - a strategy for small-scale, live testing of innovations in a controlled

environment under the PhilHealth's supervision of UHC reforms intended to acquire
lessons and experience on its implementation, generate additional evidence, and flag
policy or regulatory gaps from existing policies.
J. Service Level Agreement (SLA) - refers to the contract that is executed between
PhilHealth and PCPN. The SLA identifies the services required and the expected level of
service between PhilHealth and the PCPN.
K Special Health Fund (SHF) 6 - refers to the pooled fund of the province-wide or city-
wide resources intended for health services to finance population-based and individual-
based health services, health system operating costs, capital investments, and
remuneration of additional health workers and incentives for all health workers.
L. UHC Integration Site (UIS)7- refers to DOH-supported pilot areas that shall lead the
' implementation of technical, managerial, and financial integration and UHC reforms
i.3 such as but not limited to eliminating redundancies, simplifying PhilHealth membership,
t_ 0
pooling of funds, crafting of national Human Resource for Health Master Plan,
3 Per PhilHealth Circular No. 2020-0021: Accreditation ofHCPs for Konsulta Package
4
Per PhilHealth Circular No. 2020-0020: Governing Policies on PhilHealth Costing and Costing Methodology
5
Per DOH-PhilHealth-DBM-DOF-DILG JMC 2021-001 on the SHF: https: / /www.dbm.gov.ph/wp-
content/ uploads /Issuances/ 2021/J oint-Memorandum-Circular/JMC-2021-0001_Guid elines-on-SHF. pdf
6
Ibid.
7
Per DOH AO No. 2021-0006: Guidelines on Integration of the Local Health Systems into Province-wide and City-
wide Health Systems (P /CWHS) (https:/ /doh.gov.ph/node/33697)
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regulating coverage for co-payment, transparent pricing, setting standards, licensing and
registries, health promotion, data management and health technology assessment.
V. POLICYSTATEMENTS
A. Areas of Intervention/Innovation
Different LGUs/private providers have initiated or are already implementing strategies

to improve health care delivery. Such intetventions or innovations for testing can be any
one ot a combination of the following aspects of Konsulta implementation:
1. Establishment of network of providers to deliver K.onsulta services to beneficiaries

in a coordinated and integrated manner. The different types of networks as
described in the DOH AO No. 2020-0021 or t..'-le "Guidelines on Integration of the
Local Health Systems into Province-wide and City-wide Health Systems
(P /CWHS)."
a. Public network formed by province or cities composed of purely public
providers.
b. Private network composed of private providers may also be considered subject
to approval of the Corporation. This shall enable comparative testing of
engagement mechanisms with private provider network since Phill-Iealth is also
mandated to engage the health care providers in general. The engagement of
private network can augment the services of the public network in the LGUs in
terms of population coverage.
c. Mixed network composed of public and private entities capable of delivering
primary care services.
2. Application of capitation as prospective payment mechanism prescribed in PC No.

2022-0005 shall be retained with modified payment schedule described under
Section V.F. herein (Benefit Payment) and Annex C (Benefit Payment Arrangement)
of this policy.
3. The payment arrangement allows for the frontloading of the capitation amount
based on declared physical targets per payment periods, subject to liquidation based
on accomplishments with reconciliations being reflected in the succeeding payment
periods. The money value of the Actual Physical Accomplishment is computed
based on the actual number of beneficiaries registered in a Konsulta provider with
first patient encounter and fraction of the total number of beneficiaries identified by
the network in need of primary care services and the actual physical accomplishment
of the network within a given period.
4. Computation of PCPN physical targets and contract amounts, within prescribed

limits, to be stipulated in the SLA.
5. Integration of K.onsulta providers into a network with patient records accessible on

a real-time basis throughout the network and PhilHealth.
6. Release of PhilHealth funds for this program shall accrue to the SHF for the purely
public and public-led networks and to the pooled fund for the purely private and
private-led networks. The network shall come-up with the guideline on its financial
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management which includes the payment arrangement for the facilities, suppliers
and health personnel.
7. Enhancement of Konsulta benefit implementation and utilization. This may include

but not be limited to mechanisms to facilitate registration process in PhilHealth or in
a Konsulta provider, improve beneficiary access to services, and ensure availability
of resources across providers in the network.
B. Selection Criteria
A PCPN implementing any of the above stated interventions/innovations may be

considered as a Sandbox site when it meets the following criteria:
1. In the case of purely public and public-led PCPN, at most four (4) sites, one (1)
Sandbox site shall be identified per PhilHealth Cluster Area (North Luzon, South
Luzon and NCR, Visayas and Mindanao).
a. A site shall be considered only when they meet the criteria and the standards as
prescribed in Annex A - Primary Care Provider Network Standards. Sites with
reforms that are already operational and showing initial success are of primary
interest. Operational reforms shall include facilitated PhilHealth membership
and Konsulta registration process. A Geographically Isolated and
Disadvantaged Area (GIDA) may be considered.
b. Has Konsulta accredited facilities to serve at least 20% of the 2020 Philippine
Statistics Authority [PSA] projected population. For the province, this shall
mean 20% of total population distributed among participating component
LGUs with at least one accredited Konsulta provider as of September 30,
2022.
2. In the case of a purely private or private-led network, at most two (2) networks
shall be considered when it meets the following criteria:
a. Has at least five (5) accredited private Konsulta facilities with a maximum of
20,000 enrolled population per PhilHealth accredited doctor/physician as of
September 30, 2022 within the same Province or City or may not be limited
to defined geo-political boundaries.
b. Committed to establish at least one (1) facility within six (6) months, in the
identified public network sandbox sites.
3. The Area Vice Presidents, UHC Team and the COO/EVP shall determine the
possible public sandbox sites based on the number of the accredited Konsulta
providers mentioned above, the number of registered beneficiaries, the availability
of the development partner/ consultant that will assist the public network and the
commitment to adopt the Special Health Fund (SHF). Upon evaluation of the
regional office and recommendation of the Area Office and the Taskforce PCPN
Sandbox, the PhilHealth Executive Committee shall approve the sandbox
sites/ networks. The identified public net\~ork sandbox sites shall be coordinated
with DOH for their confirmation.
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4. PhilHealth Regional Office shall orient the possible network on the mechanics of
the PCPN Contracting implementation.
C. Application Processes and Requirements
1. Cities/Provinces, private or mixed public-private networks interested to participate

as Sandbox site shall submit a letter of intent (LOI) addressed to the President and
Chief Executive Officer (PCEO) thru the Regional Vice-President (RVP) of the
PhilHealth Regional Office (PRO) not later than November 25, 2022.
a. For cities/provinces, a copy of tripartite memorandum of agreement (110A)

among LGUs, PhilHealth and DOH on UHC Implementation Site shall be
submitted.
b. For private networks, copies of the following supporting documents shall be

submitted along with LOI:
b.l. Security Exchange Commission (SEC) Registration or any document as

proof oflegal entity of a network (e.g. Joint Venture Agreement);
b.2. Bureau of Internal Revenue (BIR) Certificate of Registration;
b.3. Updated LGU business permit; and
b.4. Certified network list of accredited Konsulta providers with corresponding:
b.4.1. List of PhilHealth-accredited physician/ s per Konsulta facility
b.4.2. Number of target beneficiaries per Konsulta facility
2. Complete documents shall be submitted to the PRO Accreditation and Quality

Assurance Section (AQAS) via email or directly submitted to the said office on or
before November 25, 2022 for initial assessment, recommendation and endorsement
to the Task Force PCPN Sandbox through the concerned Regional Vice
President/VP and Area Office. The Task Force shall review and recommend to the
PhilHealth Executive Committee (ExeCom) for deliberation and approval.
3. The letter of confirmation as Sandbox site shall be sent to the applying network.
This letter shall indicate the next steps - contracting process including the draft copy
of the SLA with PhilHealth.
If the application is denied, PhilHealth shall inform the network of its

deficiency/ ies /ground for denial.
D. Contracting Process
1. The applicant Network shall prepare and submit the requirements as provided in the
PCPN Standards (Annex A) together with the baseline data on the demography and
epidemiological profile. The data shall include population distribution per
municipality disaggregated by age and sex, number of accredited Konsulta providers
and corresponding number of registered beneficiaries, and common disease
conditions in the catchment area.
2. The PRO shall conduct the assessment and review of the submitted documents in
compliance with the PCPN Standards.
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3. Should the assessment/ review yield satisfactory results, PhilHealth shall issue a
Konsulta Network Contracting Certificate with the following information:
a. N arne of the Primary Care Provider Network
b. Service Area
c. Contracting Certificate Reference Number
d. Address of the Konsulta Network
4. Should the assessment/ review yield unsatisfactory results, PhilHealth shall inform
the network applicant of its deficiencies.
E. Contract arrangement
As provided in the UHC Act, PhllHealth, through the PRO shall contract health care
providers that form networks. Below are contract considerations with details described
in the Service Level Agreement (SLA) template (Annex B).
1. Network shall execute the SLA with PhilHealth to indicate its benefit payment
agreements, targets, commitments, deliverables and contract amount in Konsulta
implementation.
2. Network shall be accountable and responsible for negotiating the contracts and
commitments with individual providers, including compensation and fees.
3. As baseline, the covered services are outlined in PC No. 2022-0005 and its
subsequent revisions or amendments. Additional services may be provided under
different arrangements with individual providers within the network and proper
information to Konsulta beneficiaries.
4. The setting of Konsulta implementation targets shall consider:

a. The number of target registered beneficiaries per facility; and
b. An adequate number of participating Konsulta-accredited health facilities and
physicians to serve the target registered beneficiaries and to provide the
Konsulta services.
5. Payments shall be computed based on per capita amount prescribed in PC No.

2022-0005, and on payment arrangement as provided herein in Section V.F.
"Benefit Payment" of this Circular.
6. The network shall commit to achieve the target of Konsulta beneficiaries,

considering its absorptive capacity, between 10,000 to 20,000 beneficiaties per
physician and 100% for each of the following performance indicators:
a. Number of registered Konsulta members
b. Number of Konsulta members with first patient encounter
7. Other performance indicators that are linked to payment shall be based on the
indicators outlined in PC No. 2022-0005, which are as follows:
a. Provision of consultation services
b. Provision of diagnostic services
c. Dispensing of medicines (Antibiotics and maintenance medications for Non-
Communicable Diseases (NCDs)
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All beneficiaries shall be given the necessary Konsulta services based on their health
proflles/First Patient Encounter (FPE) and/ or results of their consultations. The
FPE/ consultation shall be used to identify the beneficiaries for the consultation
services> diagnostic services and NCD Meds while the Antibiotics-Meds recipients
shall be determined through doctors' consultation.
8. Other performance indicators and corresponding targets that are not linked to
payment may be prescribed by the Corporation and shall be stipulated in the SLA.
9. The network shall secure a surety bond with the Government Service Insurance
System (GSIS), callable upon demand based on the 30% of the contract amount.
The network shall submit the documents as required by the GSIS in application for
the same.
10. The network shall comply with other reportorial and monitoring requirements for
the assessment of the intervention/ innovation.
11. The period of agreement shall be year 2023, subject to regular monitoring and
assessment. The testing period · may be subject to pre-termination by either
contracting parties (PhilHealth and/ or LGU /Private Network) with due cause and
notice to the other party on any of the following grounds:
a. PhilHealth may pre-terminate the agreement in the event of poor/non-
performance or indication of abuse or fraud committed by the network and/ or
other valid grounds determined by the Corporation.
b. Network may request for pre-termination if the implementation of the
intervention/innovation is proven unsustainable or not feasible.
F. Benefit Payment
1. Benefit Payment under UHC Act
Section 18 of the UHC Act mandates PhilHealth to shift to performance-driven,

close-end, prospective provider payment mechanisms and to incentivize pro·viders
that form networks. The former is partly implemented by PhilHealth through the
capitation payment scheme of the Konsulta Benefit Package, with pre-determined
amounts of Php500 per capita for public providers and Php750 per capita for
. private providers. In this regard, PhilHealth shall continue the implementation of
capitation payment but shall revise the payment mechanism to simplify the process
and to promote network formation for the improvement of Konsulta
implementation.
2. Payment Arrangement for the PCPN (Financial aspect of the Konsulta

service delivery)
The arrangement allows for the frontloading of the capitation amount based on
declared physical targets per payment periods, subject to liquidation based on
accomplishments with reconciliations being reflected in the succeeding payment
periods. As a result of the reconciliation, the network shall refund to PhilHealth or
be entitled to additional capitation corresponding to its actual accomplishments
above targets.
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The prov1s1on on Key Performance Indicators (I<J>Is), and its corresponding
percentage and computation for the contract amount shall depend on the target
number of beneficiaries per type of accredited Konsulta provider (government-
owned and privately owned) of PC No. 2022-0005 shall be adopted.
The benefit payment arrangement is summarized below:
Parameters Payment Arrangement

No. of payment 3 Releases; 1 reconciliation:
tranches Condition: based on the Number of target Konsulta
beneficiaries to be provided services for the 1st Quarter
(Maximum Release 1: 30%, Release 2: 50%, Release 3:
20%)
Computation for Whichever is lowest among:
Frontloaded • 3-month cash program by d1e network
Capitation 1 • Money value of physical targets for months 1-3
• 30% of the contract amount
Frontloaded • Cash program by the network for months 4-9
Capitation 2
• Money value of physical targets for months 4-9
With + /- variance of the money value of actual
accomplishments versus amount frontloaded in Quarter 1.
Frontloaded • Cash program by the network for months 10-12
Capitation 3 • Money value of physical targets for months 10-12
With + /- variance of the money value of actual
accomplishments versus amount frontloaded in Quarter 2
and 3.
Computation for Annual review (Money value of the total members
Annualized registered with FPE and provided primary care services VS
~ Capitation Total capitation frontloaded)
N
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--
Incentive- automatic contract renewal for the next year
Table 1: Benefit Payment Arrangement
3. The following shall be described and included in the network contract with selected
sites:
a. Selected LGUs/PCPNs with intent to join the Sandbox approach shall be
entitled to the same capitation rate, with prospective payment scheme described
in Annex C.
b. Provision of other services not covered under the Konsulta package, but are
covered by PhilHealth through other benefit packages may be reimbursed,
subject to existing applicable PhilHealth guidelines.
c. Computation and release of benefits shall consider the registered members,
frontloaded payments, accomplishment of targets, deliverables, results of
indicators and cash programming as stipulated in the SLA.
d. Public Konsulta providers shall not be allowed to charge co-payments. Private
facilities may charge co-payment for Konsulta services rendered subject to the
rules stipulated in PC No. 2022-0005 and its subsequent revisions.
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e. The network may refer and pay for a registered beneficiary to another
net\Vork/ single health facility not part of the network in the instance of
unavailability of Konsulta services within its network. Co-payment may be
charged to a registered beneficiary who avails the Konsulta services outside of
the network without a referral from an accredited healthcare provider from the
network in which the beneficiary is registered.
f. Purely private networks may charge co-payment to beneficiaries registered in
any of its accredited Konsulta providers subject to the limitations under PC No.
2022-0005. Government-owned facility under a private-led network shall not be
allowed to charge any co-payment.
g. Releases made to the pooled fund of the private PCPN account shall be
subjected to applicable taxes.
h. The network shall issue and submit a guideline to PhilHealth on the allocation
or disposition of fund collected from PhilHealth, especially on. the distribution
of individual provider incentives and fees.
i. Both public and private networks may charge for services not covered by
Konsulta Package or any other benefit packages, subject to the No-Balance
Billing policy of PhilHealth.
J· All payments to the network are subject to reconciliation at the end of the
testing period. If the computed actual physical accomplishment is less than the
frontloaded capitation released, the succeeding release of the remaining
capitation amount shall be subject to payment recovery, pursuant to PC No.
2021-0011 or the PhilHealth Payment Recovery (PPR) Policy.
k. PhilHealth shall pay using the Auto-Credit Payment Scheme (ACPS).
G. Sandbox Operationalization
1. Eligibility and Registration of Filipinos to a Primary Care Provider Network (PCPN):
a. All Filipinos shall be eligible to avail of Konsulta benefit.
b. Each Filipino shall register to an accredited Konsulta provider of their choice.
-
Registered beneficiaries can avail Konsulta benefits within the network in which
. their Konsulta provider of choice is included .
c. The PCPNs, in coordination with PhilHealth, may adopt strategies to fast-track

registration of beneficiaries including but not limited to batch registration in the
enlistment of beneficiaries. PhilHealth may also adopt a batch uploading of First
Patient Encounter data to PhilHealth Konsulta System.
d. The PCPN may also develop innovations to increase their registered

beneficiaries, as approved by the PhilHealth Regional Office having jurisdiction
over the network.
ij
0
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e. Only Accredited Konsulta Providers (AKPs) that have signified their inclusion
and participation in the Primary Care Provider Network (PCPN) Sandbox shall
be considered in the management and monitoring of the PCPN contracting.
Meanwhile, PhilHealth Circular (PC) No. 2022-0005 or the Implementing
Guidelines for The PhilHealth Konsultasyong Sulit at Tama (PhilHealth
Konsulta) Package (Revision 1) and its subsequent amendments/revisions, if
any, shall continue to be applied to non-PCPN AI<Ps.
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f. PhilHealth Konsulta beneficiaries of the selected PCPN-AKPs registered as of
December 31, 2022 shall be automatically renewed and migrated to the January
2023 PCPN Sandbox database.
g. All registered beneficiaries (existing and new) of the PCPN-AI<Ps shall be

required to update their health-assessment profiles (HAPs) and sign a Data
Privacy Consent Form with their respective AKPs. Updating of HAPs is
essential as it shall serve as the basis for determining the Konsulta services
indicated for the beneficiaries including consultation schedules and the
provision of laboratory services and drugs/medicines for the entire
implementation period.
2. Receipts, Allocation, Disbursements and Reporting of Capitation Fund through

the SHF
a. This Section shall be applicable to Public PCPNs only and the allocation,
utilization and monitoring of the SHF shall be in accordance with DOH-DBM-
DOF-DILG-PhilHealth JMC No.2021-001.
b. PCPN shall use the SHF bank account in accordance with the Department of
Finance (DOF)-Bureau of Local Government Finance (BLGF) Guidelines on
Authorized Government Depository Banks and other relevant
issuances. Likewise, Province/HOC/ICC shall maintain/ create separate books
of accounts with complete financial reporting, pursuant to the COA Accounting
Guidelines. For component cities and municipalities, all financial resources for
health shall be deposited under the health fund bank account and its financial
transactions with corresponding subsidiary ledger shall be recorded under the
existing Trust Fund.
c. The Local Health Board (LHB), in coordination with the P /C Health Officer/ s
and Management Support Unit (MSU) staff, shall formulate its plans, resource
allocation in support of the P / CWHS strategic and financial goals and
operational targets.
d. Based on the locality's epidemiological proftle and extstlng service delivery

network, the LHBs shall identify specific activities in the implementation of
the Konsulta program guided by the five (5) KPis on the provision of primary
care services (registration of members with first patient encounter data,
provision of consultation, provision of laboratory/ diagnostic services and
provision of medicines -antibiotics/ NCD medicines) to their registered
Konsulta beneficiaries .
. ··-----.... . . ... e. The Public PCPN may contract PhilHealth-accredited private primary care
providers in order to augment the current service delivery capacities of existing
facilities, including the licensed laboratories and pharmacy providers.
f. PCPN shall draft policies and procedures on charging, including menu of

charges containing professional fees, bills and statement of accounts.
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g. The disposition of the Konsulta capitation payment to SHF shall be based on
Section VI.C of the DOH-DBM-DOF-DILG-PhilHealthJMC No.2021-001.
h. Likewise, the PCPN Network shall formulate its Monthly Physical Targets and
Cash Programming for a year's implementation of Konsulta, based on the Total
Contract Amount negotiated with PhilHealth.
1. LHB shall pass a Board Resolution on proposed utilization of the funds for
the Konsulta implementation, to contain specific guidelines on resource
sharing and fund distribution to component LGUs and approving the budget
for the same. 8
j. Amendment of the Local Investment Plan for Health/ Annual Operational Plan
(LIPH/ AOP) to contain provisions on the K.onsulta implementation shall be
done at the Province/HOC/ICC level.
k. Upon signing the contract with PhilHealth, the PCPN, with the assistance of
the Management Support Unit (M:SU), shall prepare a SHF Budget Preparation
Form No. 19, Project Procurement Management Plan (PPMP) and Annual
Procurement Plan (APP) to support the requirements and/ or cost estimate of
the different expenditure items identified. The said reports shall be approved
by the LHB.
l. Once the flrst capitation payment is released by PhiiHealth, the Local Treasurer
and Accountant shall certify Availability of Funds and shall facilitate transfer of
funds to component LGUs, as applicable.
m. The P /C Budget Officer shall release the Allotment and obligate funds, based
on the plans and Board-approved budget. 10
n. The P /C Accountant, upon setting up of separate books of account and ledgers

0.
~--
specifically for SHF, shall record and disburse funds. 11
~
I' o. Receipts, disbursements, recording and reporting shall be in accordance with
the COA Accounting and Auditing guidelines and shall be issued separately.
i:J
p. Reports on actual utilization of funds (SHF Budget Utilization and Report
and SHF Financial Performance Report (for both cash and income) shall be
submitted not later than the 10th day at the end of each quarter. Please refer to
Annex D-11 to D-13 for the template of the reports.
3. Network Performance Monitoring and Assessment of the Intervention/Innovation
All approved interventions/innovations and sandbox sites should have a

monitoring, recording, and reporting system that shall track financing, operations,
and services delivery performance.
8
DOH-PhilHealth-DBM-DOF-DILG JMC 2021-001 on the SHF (Section VII)
9
Ibid, Annex A: SHF Budget Preparation Form No.1
10
Ibid, Section VIII
Page 12of1 6
0 PhiiHealthofficlal OC)teamphilhea!th e [email protected]

a. The network may use the refined version of the eKonsulta system, an equivalent
PhilHealth system designed for Konsulta Sandbox, or its own
developed/ contracted PhilHealth-certified electronic medical record system as
its recording, reporting, and monitoring system, preferably connected or linked
to each provider within the network for automatic patient record updating. An
alternative data recording and generation system may also be used by the
network in cases of constraints in IT inftastruchue, internet connection, and
interoperability issues within the network and PhilHealth systems.
b. Monthly submission of reports on indicators as prescribed in Annex D shall be

required prior to succeeding payments as these reports serve as the basis for the
computation of the amount to be released as part of capitation releases. The
same indicators shall also determine the level of performance of the network in
relation to commitments and targets.
c. Mechanism and tracking system for individual provider performance within the
network shall be the responsibility of the network as they shall input into the
deliverables of the network. This, however, does not preclude PhiJHealth from
conducting individual provider performance monitoring.
d. The Network shall submit to PhilHealth the following reports on or before the
10'h day after the end of the quarter, including Annex D11-13):
a. Statement of Revenue Targets and Acrual Collections - For Public

Networks only
b. Statement of Appropriations, Allotment, Obligations, Disbursement
and Balances- For Public Networks Only
c. SHF /Network Financial Statements
e. Routine reports and level of performance based on commitments and targets

shall input into the over-all assessment of the intervention/innovation being
tested, with the addition of indicators that include measures of effectiveness,
operational, and financial sustainability of the intervention/innovation being
tested.
---...!'-
f. A random on-site assessment may also be conducted by PhilHealth for the

validation of reports and outcomes of the intervention/innovation.
g. PhilHealth shall conduct the over-all assessment of each

intervention/innovation and consolidate these results at the end of the first
semester and of the test period. Findings and lessons learned shall be an input
into the development of appropriate guidelines for nationwide implementation.
PhilHealth shall issue a separate guideline on the monitoring and evaluation of
0 , the Network Contracting arrangement under a sandbox approach.
0
h. The Bureau of Local Government Finance (BLGF) may issue a guideline on

the submission of financial reports and financial analysis by the province/ city
while the Bureau of Internal Revenue (BIR) may issue a taxation guideline on
the Network and Provider transactions.
Page 13 of 16
0 PhiiHealthofficial ()Oteamphil health e actioncenter@phllhealth .gov.ph

1. PhilHealth and COA shall exercise independent jurisdiction over the results
and findings of their respective monitoring and evaluation, and audits. A
written and/ or face to face inquiry on results and findings may be requested by
either agency.
j. PhilHeald1 and the network shall provide their utmost cooperation and
assistance to COA to ensure timely completion of the mandatory external audit
of the operation of the prospective payments by the COA, pursuant to its
visitorial power under Section 29 (1) of Presidential Decree No. 1445 in
accordance to the appropriate and responsive accounting and auditing
guidelines for prospective provider payment.
k. The LGU Resident COA may undertake the necessary audit of the complete
process of Konsulta Benefits.
H. Monitoring and Evaluation
PhilHealth shall conduct a periodic review of this policy and specific provisions shall be
revised as needed.
I. Annexes (posted on the Official PhilHealth website at www.philhealth.gov.ph)
A. Annex A: Primary Care Provider Network Standards

B. Annex B-1: Service Level Agreement Template (Purely Public and Public-led
Network)
C. Annex B-2: Service Level Agreement Template (Purely Private and Private-led
Network)
D. Annex C: Benefit Payment Arrangement
E. Annex D-1: Monthly Physical Target and Cash Programming
F. Annex D-2: Analysis Worksheet for Frontloaded Capitation 1
G. Annex D-3: Analysis Worksheet for Frontloaded Capitation 2
H. Annex D-4: Analysis Worksheet for Frontloaded Capitation 3
I. Annex D-5: Capitation Fund Annual Performance Review
]. Annex D -6: Performance Factor Computation Form
K. Annex D-7: Summary List of Beneficiaries Needing/Providing Konsulta Services
L. Annex D-8: Detailed List of Beneficiaries Needing/Providing Konsulta Services
M. Annex D-9: Quarterly Physical Accomplishment Rep01't
N. Annex D -10: Recapitulation on Membership Category Report
0. Annex D-11: SHF Financial Performance Report (Target vs. Actual
Income/Expenditures)
P. Annex D-12: SHF Financial Performance Report (Target vs. Actual Cash
0 Receipts/Disbursements)
0
Q. Annex D-13: SHF Budget and Utilization Report
VI. PENALTY CLAUSE
Any violation of this PhilHealth Circular shall be dealt with and penalized in accordance with
pertinent provisions of RA No. 7875, as amended by RA Nos. 9241, 10606, and 11223, and
their respective Implementing Rules and Regulations, and other relevant laws.
Page 14 of 16
0 PhiiHealthofficial (')Oteamphllhealth [email protected]

VII. TRANSITORY CLAUSE
The implementation of this PhilHealth Circular is subject to the issuance of the Commission
on Audit (COA's) Accounting guidelines on the prospective payment mechanism and
enabling policies in the establishment and implementation of the Special Health Fund (SHF)
and its accounting guidelines.
VIII. SEPARABILITY CLAUSE
If any provision of this PhilHealth Circular shall be declared invalid, unconstitutional or

unenforceable, the validity of the remaining provisions shall not in any way be affected and
shall remain enforceable.
IX. DATE OF EFFECTIVITY
This PhilHealth Circular shall be published in any newspaper of general circulation and shall
take effect after fifteen (15) days from date of publication. Further, this policy shall also be
deposited thereafter with the Office of the National Administrative Register at the
Unive!Sity of ~hilippines Law Center.
ATTY. EU s:::: SANTOS

Officer-In-Charge, Office of the President and Chief Executive Officer
Date signed:
'' Ifr of~
I
~
~
·····----- -
(.j
0
Page 15 of 16
0 PhiiHealthofficial Q c;)teamphilhealth iDactlo [email protected]

Implementation of a Primary Care Provider Network (PCPN) Contracting Arrangement through the Konsulta
Package in a Sandbox Setting
Page 16 of 16
(}Phil Health official OQteamphilhealth [email protected]

Annex: A: Primary Care Provider Network Standards
Primary Care Provider Network (PCPN)

(Contracting Standard)
Introduction
Section 18 of the Universal Health Care (UHC) Act endeavors PhilHealth to contract health care
provider networks (HCPN) for the delivery of individual-based services. The HCPN, as
described in the law, refers to a group of prima1y to tertiary care providers, whether public or
private, offering people-centered and comprehensive care in an integrated and coordinated
manner, with the primary care provider acting ~s the navigator and coordinator of health care
within the network. This provision of the law is the key to addressing the limited capacity of the
health care system in the country. To date, however, there is still no existing HCPN formed for
PhilHealth to contract with.
To promote network formation, PhilHealth shall be adopting a Sandbox approach to test

initiatives in the formation and contracting of provider network, starting with Konsulta services
delivery as a model for primary care network as the core for the formation of HCPN. The
Konsulta package consists of defined primary care services planned to evolve into the
Comprehensive Outpatient Benefit Package. Since the services are primarily for Konsulta
package, d1e initial network perspective is in the context of the capability to provide covered
services in a network setting, hence identified as Primary Care Provider Network.
This document sets the standards and evidence required by which formed Primary Care Provider
Networks may be contracted by PhilHealth, building on the prescribed minimum components
under the UHC Act Implementing Rules and Regulation Section 18,4; Since a Konsulta network
has yet to be established, suggested criteria were made flexible to enable network formation that
can eventually transition to a primary care provider network (PCPN) moving toward HCPN
standards.
Definition
The Primary Care Provider Network (PCPN) is a group of health cate providers that provide
-- - - N - select services to ensure complete delivery of Konsulta covered services. The PCPN may be
composed of physicians/navigators, diagnostics/laboratories facilities, pharmaceutical facilities,
X-ray laboratories, etc. Participating networks may be purely public or purely private providers
or mixed public and private providers. This section provides a description of the network with
details on the criteria for the Primary Care Provider N etwork.
Types of PCPN
Depending on the ownership/management of the providers, the network can be:
Public/LGU
• The local government unit or LGU (province/ city) may organize a network of
primary care providers which shall be composed of purely public providers
either LGU -owned or D epartment of Health (DOH)-supported facilities such
as health centers or rural health units, laboratories, etc.
• Private primary care providers or private practitioners may be engaged by the
LGU to provide services that are not available in the network. The manner of
engagement shall be left to the discretion of the LGU.
Page 1 of 9 of Annex A
• The LGU maintains direct operational and administrative supervision of the
activities and the performance of the providers, individually and collectively,
within the network.
Private
• Private providers may group together and organize a network for the provision
of the PhilHealth Konsulta benefits.
• The lead organizer or the network management should have direct operational
and administrative supervision of the activities and performance of the
providers, individually and collectively, within the network.
• Private-led network target population and services may be coordinated with the
LGU specifically on the delineation of covered population.
Mixed Public and Private-Owned Netwo.tk

• Both public and private providers may group and organize as a network for the
provision of Konsulta benefits and services.
• This can either be joindy led by the public and private sector or either one.
Network Model
PhilHealth shall contract a PCPN with Accredited Konsulta Facility /Providers.
Contn~ct
Accreditation
i3 ·gure 1. -Network to contract accredited Konsulta providers only
0
-.... - -~-~
NETWORK STANDARD
One of the primary objectives of PhilHealth as a purchaser of health services is to ensure that
the members and beneficiaries have accessible quality health care. In this regard, providers to be
contracted need to demonstrate corresponding qualifications and capabilities to provide specified
health care services, in this case Konsulta. In the context of a network of providers for Konsulta,
coordination in some level of integration needs to be in place. Please refer to the attached
PCPN Contracting Standard listed as Table 1. Core key features are characteristics the PCPN
should comply in order to be contracted by PhilHealth. The other key features may be complied
by the PCPN immediately along with the cote key features or before the release of the second
frontloaded capitation the PCPN providing monthly reports on milestones for the non-core key
features compliance.
Management
In order to ensure that the network shall be able to function in an organized, well- coordinated
manner, it needs to have an established leadership with the network having a common goal.
Proof as Leii:·al Entity
The network to be contracted by Phi1Healtl1 has to show documents as proof that it has legal
rights and responsibilities to enter into agreement and receive payment from PhilHealth.
1. Public or Public-led network

• Sanggunian Resolution (SR) authorizing the province or city to contract with
PhilHealth and other health care providers, and to open an account for the
pooled fund for health services.
2. Private or Mixed private-led network
• Copy of Securities and Exchange Commission (SEC)-approved Articles of
Incorporation or Partnership or any proof/ document of legal entity indicating
the name/ s of Incorporators or Partners
• Updated LGU Business Permit
• Bureau of Internal Revenue (BIR) Certificate of Registration
Organizational Structure
The organizational structure illustrates how the health system and/ or network shall be managed
and how coordinated operations shall be executed. This shall indicate the leadership and
interrelated functions of each office/unit in the organization and the corresponding persons
responsible.
1. Administration/Management
The health system/ network should be able to demonstrate the capability to support the
implementation and operationalization of the intervention/innovation. Establishing the
over-all supervision of the health system or network operations, the administrative
responsibilities shall include, among others:
• Ensuring consistent and sufficient availability of resources (supplies,

commodities, etc.)
• Ensuring sufficient and competent human resources for health (HRH) to render
services to patients/beneficiaries across providers within the network
• Institutionalization of a monitoring mechanism to determine the services
rendered, the performance of providers, and the status of pooled fund collection
·7!'-------·-' and utilization
• Institutionalization of protocols/mechanisms to facilitate beneficiary registration
to PhilHealth and to Konsulta provider
• Installation of a patient record system, preferably electronic, to facilitate data and
report generation
• Negotiating or contracting with other qualified providers to fill in the gaps in
services; and
Page 3 of 9 of AnneK A
• Issuance of guidelines or protocols on patient navigation and referrals to be
observed by service units
2. Service Delivery
Activities within the network should be coordinated to ensure smooth operations of the
system for efficient delivery of services to beneficiaries. The lead office/unit shall ensure
the contracted/participant providers in the network are able to render services and that
the beneficiaries receive appropriate and quality services. Specifically, the lead office/unit
for service delivery shall:
• Establish navigation protocols or procedures including a clinical referral system

that is patient-centered and value-based approached.
• Ensure Konsulta service provision
• Ensure availability and accessibility of services including supplies, commodities
and drugs and medicines (i.e., supply chain management) to patients
• Establish a monitoring mechanism to determine compliance of individual
providers to acceptable and recommended clinical practice guidelines or clinical
pathways
3. Finance
• Monitor funds received from PhilHealth and other funding agencies

• Ensure availability of funds and resources to support and sustain operations and
continued provision of quality services.
• Maintain records of fund allocation and utilization across individual providers in
the network
Qualified Individual Providers and Health Workers
~ Since the network must ensure that the engaged providers are adequate in number and are
~ capable to render corresponding services, only those with appropriate licenses or accreditation
-----...--:·from DOH/Phill-:Iealth, as applicable, must be part of the network. These can be verified by:
a:
~!
-~
Qj
. A list of all providers and respective services including appropriate licenses and status of
accreditation in PhilHealth, if applicable.
w>-
~
~
0 • The number of providers by type of services matched with the number of target
beneficiaries for each service type based on the HRH Manual.
• The network engagement of providers outside of LGU supervision can be supported by
a contract or a memorandum of agreement (MOA) with deliverable. Providers under
LGU supervision can be engaged through a memorandum of instruction from the local
i3 chief executive (LCE) or the network management.
0
'
- . ·- - -~------I~ternal Monitoring Mechanism
• An established monitoring mechanism for individual provider performance within the
network needs to be in place to ensure that all required services are provided at expected
quality and quantity. Indicators for monitoring may be indicated in individual provider
contract. Data and reports that can be used as reference for monitoring and assessment
of performance may be sourced from an established database or record of network
issuance/ s. The patient record system shall keep track of baseline health profiles of
individual beneficiaries and shall be used in monitoting of conditions. While an electronic
patient record is recommended, an alternative system may be considered in case of poor
connectivity and interoperability issues with the PhilHealth system.
o Patient consent on record-keeping and other procedures, as appropriate, must be
secured.
o Referral to other providers for services and the type/ description of services, must
also be recorded.
o Services rendered and prescribed but not provided to individual patients must
also be part of the patient record system.
• The internal monitoring mechanism shall also help the network detect and prevent over-
referral or under-provision of services through the following provider record/ .report:
o First patient encounter and follow-up care
o Patients provided with completed services
o Referral practice based on records, type of services referred, and reasons for
referral
o Patient satisfaction survey (e.g., exit survey) to rate the providers' knowledge,
attitude, and practices (KAP) in treating patients
• The internal monitoring mechanism can also provide information that shall better aid the
network in ensuring consistent operational support. The monitoring mechanism can help
ensure:
o Consistent adequate supply of resources
o Adequate number of trained providers/ staff
o Incentives for performing providers are awarded
o Reports are generated/uploaded for transmission to PhilHealth
Technical Coordination
This aspect of the network should be able to demonstrate how beneficiaries are able to access
and provided needed health services under Konsulta. Network of providers should be able to
~ facilitate beneficiary availment of all the services. On the other hand, such facilitation should also
~ be able to prevent overlaps in service provision and to ensure efficient delivery of services.
i~-- - . - - ..... -
1 ~ !' The target beneficiaries for each provider in the network needs to be dearly defined and
identified.
;:r:>- ~ I • The providers within the net\:vork needs to be collectively capable of providing required
~a..~ services under Konsulta.
• Navigation and referral protocols must be in place to direct patients/beneficiaries to the
required services within the network. This should include referral-back protocol to the
primary care provider where the beneficiary is registered and referral to other providers
outside of the network, as needed.
One of the prescribed elements in organizing the province/ city wide health system under the
UHC is fmancial integration. This shall support the operations of the network and shall ensure
sustained adequate availability of resources for the provision of Konsulta services. The funding
allocation for Konsulta or primary care related activities and commodities can be verified from
the following LGU documents:
• Local investment plan for health (LIP H) /Investment Plan and Annual Operations Plan
(AOP)
• Health Board approved guideline on compensation, incentives and fees for contracted
services within the network including the disbursement and procurement transactions.
These can be verified or supported by signed contracts with other providers.
Table 1 summarizes the standards for contracting a PCPN to be used as assessment tool by both
the network and PhilHealth.
Pnge 5 of 9 of Annex A
~j;'I ' "l ' i:C '>,i'_G,;: .,"tii' ·,· ···:~,.,C,,I· ··
I Legal Personality Has legal rights and Document review all as applicable:
Evidence
l (core key responsibilities to For purely public or public-led network: '

I feature) enter into agreement 0 Province: Sanggunian Resolution authorizing
and receive payment the province to contract with PhilHealth and
I from PhilHealth other health care providers, and to open an
I account for the SHF for health services and
signed MOA between governor and
participating component city and municipal
I mayors or private/ public Konsulta providers
in the case of province
0 City: Resolution authorizing the highly
urbanized city or independent component city
to contract with PhilHealth and other health
care providers, and to open an accoru1t for the
SHF for health services
Document review all:

D SHF Bank account
0 Evidence of book of accounts
Document review all:
For purely private or private-led network:
0 Copy of SEC-approved Articles of
Incorporation or Partnership or any
proof/ document of legal entity indicating the
name/ s oflncorporators or Partners
i 0
Updated LGU Business Permit
("'.~
- \ il
0 BIR Certificate of Registration
Nl
---~---[.
~ structure
~~--
o l · ualified
------ -··---------
Has DOH license
~~----·---------------
Document review:
and/ or PhilHealth D
Primary care certification from DOH or
accreditation for all PhilHealth accreditation as applicable
core key involved facilities (as
. .~~.~~~)_ __. · -·- ·-··--·..
1
?.:PJ>.~_<:.?.:!>}~.------····--------·--·- ·--···--------.. -.......,_______................._____,_ . .____ . ._.._....._, ____ . ...........-.......... _._,
i..3 Has a capacity to meet Document review:
0
--- . the defined minimum D
List of providers by type of services matched
health care with the number of target beneficiaries for
professional to patient each service type based on the HRH Manual
tT::~~:':~o~-,---~~'krer:;;;:r -crPhllHe;ithrrr~,;;;~;-,___________,
System information system 1. Adoption of enhanced eKonsulta system, an
I (core
1 feature)
key among all facilities in
the network that
equivalent PhilHealth system for Konsulta Sandbox,
or its own developed/ contracted PhilHealth-certified
ensures that privacy electronic medical record system as its recording,
I- ·-- and confidenti~ty re.Eortin~:._.~1d ___:nonitoring syste~....:_efe,:_ably _,
I
r~--- -- -- --- ~~-----··
laws are followed

----- --- - --------~----- --- -----:-1
connected or linked to each provider within the I
network for automatic patient record updating.
i
2. Software: (choose one option)
a. XAMPP V1.8.3-3
b. Apache v2 4.7, MySQL 5.6 and PHPv5.5
Support Browsers: Best used in updated versions of
Google Chrome, Mozilla Firefox and Microsoft Edge
OS Supported: Windows 7x64, Windows 7x 32,

Windows 1OX32, Windows 1Ox64
Hardware Requirements
a. Memory: min of 2GB RAM
b. Storage: 500GB HD
c. Processor: min of lGHz

Data Privacy Observes and upholds Document review:
Compliance patient's privacy and D Consent forms
(core key confidentiality at all Interview with IT:
feature) times during exchange D Demonstration ofiT security and 1
of data between confidentiality of records '

j facilities within the
network
-------- ----
~ ~::~:~t;;,~~~~al records ~arl~:~l
Records Keeping Maintains a detailed, Interview/ system demonstration with IT /health
efficient, and workers:
complete medical 0Patient recording system showing
records management o Record of first patient encounter and
follow-up care
o Record of patients provided with
completed services
o Record of referrals to other providers
for services and the type/ description
of services
o Record of services rendered and
-~~l'
dministrative
ervice
_ _____
Has a capacity to Document review:
ensure adequacy of
prescribed but not provided to
individ~l pati~---------
D Record of available supplies
j .. resources to deliver D
Record of trained providers/ staff
·~~~::::~----_L~r~;:~~~~~~l-+·-~----~c-~--·7·-:·~~~::~:~:::,~st~.) o;~~;7n~ormant
I
network-wide results- interview (KII):

I based performance 0
Policies and procedures on performance
monitoring & monitoring
evaluation 0
Quality assurance program
0
~
f Patient satisfaction survey
0
Participant provider satisfaction survey
0
Facility performance evaluation/ scorecard
___ ______D__~~twOE~~aluatj~~~~~-rd -- -----j
LPerfom1ance--- ~:__a_£_ra_m_e_w~rk __£o_r_D_o~:_m_e_~~~ev_ie_':_~may -~~so~-ef_ou_n_d ~ _ ..J
I Monitoring incentivizing hlgh-~ MOAlco;tract~ m~mos, etc.): --·- -- -- --
performing facilities D Policies and procedures on performance
__
1
r··- ~-------- :::~:::k j__~l:;J~~;;~~:~::~~fo~=. ~~~-

1Technical Fuhction
1 -~~t~;~;;- --- ·r::;:~::·tl~~~~~~~l ~~=:,:·,~~~-<;,;ay -~r;o' b~- ·f;;~d ·;n-;,;~;no;~

. , · _ .· · . _ _
I
;
1
I
serve D Mechanism
catchment
to register evetyone in the I
IrServices
e~------- --~ Databa~ of_~ed !?di::idu~~---·--
Has a capacity . to l Document review any of the following:
deliver all Konsulta D List of all providers and respective services
services prescribed in including appropriate licenses and status of
PC No. 2022-0005 accreditation in Ph.ilHealth I
I
1
D List of providers by type of services matched
with the number of target beneficiaries for
each service type based on the HRH Manual
1
1 D Contract or MOA with providers outside of
J LGU supervision, for outsourced services
I D Memorandum of instruction from the LCE or
l
the network management engaging providers
under LGU supervision, for services within
the network.
I
Patient navigation Imple~ents- policies Document r~~e;- (~~y--b-;;;--fo~d-- 1n
II
and coordinated an? procedures on memos/issuances) :
care 1
p111nary care D Network's policies and procedtues on
I providers as initial navigation and coordination/Patient Pathway
contact Interview with health worker:
I I D Demonstration of patient navigation
~
~ j
L _ ·---L-----------j' ___P!~~edure/Ea.tien!_£ath~---·-----
Has provisions on Document review (may be found in
---...,.,·.,. . l navigation of patient memos/issuances):
~--~ during emergencies D Network's policies and procedures on
and special situations navigation and coordination with specific
0:
~
w>- ~
0
iii
l provisions on emergencies and special
situations/patient pathway for emergencies
and special situations
I
Interview with health worker:
. D Demonstration of patient navigation
I proc~du~e s~ecifically during emergencies and
~ !i
l
i.... .------------------------ -------+-·- · ---------··----------- -·-- --- --------------~!:-~~~-~~~~~<?_1?-..S..______________________ ______ _________________
I
Has a Document review and/ or KII:
-------..·--- .. · mechanism/ system D Network's referral protocols including
· for coordination of referral-back protocol to the primary care
care provider where the beneficiary is registered
and referral to other providers outside of the
net\vork
Interview with health worker:
D Demonstration of mechanism/ system for
~hi~MiDM. aii~k~ih~fit!~n;>~':· ~· n:c~):: ' \Lj· : ' • '
Fiscal authoritY~~~.T Pools funds at the] Document review all:
: · ~il)vb~?~~i~~~·~==- :··: ·: 7
~ ·TL~L.· -. ,lcl
(core -~ne~?_r_k_ __ _ leve! _ _.D_Ne~ork aNeen;en_!__X.zr the u~_:__of ba~___.J
I
·-----;~~-;;;;t~/~idenc~ of b-;ok~-;T~Zco~trt~-~
~-~---·-- ··~- ~-~~ ------~--
) feature) (network-wide
j accounting) and has a financial reporting and sub-ledgers
i mechaolsm for 0 LGU's investment plan for health/ Annual
J dividing funds fairly Operations Plan/work and financial plan
I
Document review /interview with Finance Officer:
I
0 Network's policies and procedures on
handling of capitation payments from
I
r---- w--- Pbi1Health
Has a network-wide Document review:
investment plan and 0 LIPH / AOP or Investment Plan
1
resource allocation 1 D Health Board approved guideline on
Ii
supporting the compensation, incentives and fees for
PCPN's strategic and contracted services within the network
I financial goals, and I including the disbursement and procurement
operational targets transactions. These can be verified or
l supported by signed contracts with other
~----- - - - - --1------.t:r.oviders._ _ _ ______ _ _ _ _ _
Has a tnenu of Document review:
charges which
implemented across 1
is 0 Network's policies and procedures on
charging and co-payment
I
I the network, which ! 0 Network's publicized menu of charges
I
J
1 1 includes professional Interview with Finance Officer: !

I ' fees 0 Demonstration of implementation of menu of 1
L____ _ __,_ __._l_ ________ __ .l1 ~~~:ce~;t th~-~~tw-ork -~ills ~d stat~~e:_j
--
....... _. ,
d
0
Annex B.l: Service Level Agreement Template
(Purely Public and Public-led Network)
Republic of the Philippines ) s.s.

Contract No. - - - - - - - -
SERVICE LEVEL AGREEMENT
KNOW ALL MEN BY THESE PRESENT:

This Agreement made and entered into by and between:
PHIUPPINE HEALTH INSURANCE CORPORATION, a government-owned

and controlled corporation created and existing by virtue of R.A. 7875, otherwise known
as the "National Insurance Act of 1995", as amended, with office address at [Address],
represented herein by its Regional Vice President (RVP), [NAME], (hereinafter called
"PHILHEALTH'').
-and-
[PRIMARY CARE PROVIDER NETWORK NAME], a (LGU/Province/City-
owned network, authorized through a Sanggunian Resolution No. _ _) issued on
_ _ _ _ _ and existing under the laws of the Republic of the Philippines, with
principal address at [Address] represented herein by its [Position of Representative],
[NAME], (hereinafter called "NETWORK")
(each a "Party'', and collectively, the "Parties").
WITNESSETH THAT:
~
.. .
1-
~
WHEREAS, in response to the need to implement reforms stipulated in R.A. No. 11223 or the
Universal Health Care (UHC) Act and as an initial step towards adopting a comprehensive
pproach to delivering primary care, PHILHEALTH has committed to expand the primary
II (/)
, ffi )-
lj-.:
..:...... are benefit to cover all Filipinos through the issuance of PhilHealth Circular (PC) No. 2022-
P1
Q
~
005, which prescribes the implementation of the PhilHeald1 Konsulta.ryong Sulit at Tama
onsulta) benefit package;
REAS, the UHC Act requires PHILHEALTH to endeavor to contract public, private,
: ~ or mixed health care provider networks for the delivery of individual-based health services;
WHEREAS, the UHC Act requires the Department of Health (DOl-I) and the local
(:) government units (LGUs) to endeavor to provide a health care delivery system that shall afford
--~-=:.. , every Filipino a primary care provider that would act as the navigator, coordinator, and initial
and continuing point of contact in the health care delivety system;
WHEREAS, the UHC Act mandates province-wide or city-wide health system to pool and
manage, through a special health fund, all resources intended for health services to finance
population-based and individual-based health services, health system operating costs, capital
investments, and remuneration of additional health workers and incentives for all health workers;
WHEREAS, the NETWORK is a group of health care providers, facilities and professionals,
with defined competencies and organized to deliver health care services in a coordinated and
integrated manner;
Page 1 of 9 of Annex B.l

WHEREAS, PHILHEALTH enjoins provinces, highly urbanized cities and private providers
to integrate their resources and services in a net\vork and test local interventions/initiatives
under Sandbox setting for the implementation of the Konsulta package;
WHEREAS, the (name of LGU network) is willing to participate as Sandbox site to test
innovations and interventions, such as the implementation of prospective payment mechanisms;
the establishment of the Special Health Fund or pooled fund in the delivery of Konsulta benefit
package, and under the terms and conditions contained in this Agreement;
WHEREAS, the (name of LGU network) is willing to sign an indemnity agreement with
PHILHEALTH and GSIS thereby securing surety bond with the GSIS and comply with the
requirement;
NOW THEREFORE, for and in consideration of the foregoing premises, and of the mutual
covenants and stipulations hereinafter set forth, the Parties hereby agree, and by these presents,
bind themselves, to wit:
1. PRIMARY CARE PROVIDER NETWORK OBLIGATIONS
1.1 Acceptance of contract amount.
The NETWORK accepts the contract amount of [AMOUNT IN WORDS]

(Php ) stipulated in this Agreement, including the corresponding
schedule of payment and conditions for payment releases specified in the payment
schedule in Attachment 1.
1.1.1. The NETWORK agrees that it shall register and provide Konsulta services
to a maximum of number of Konsulta beneficiaries,
considering its absorptive capacity betw"een 10,000 to 20,000 per physician.
PhilHealth shall not provide payment for the number of registered
r-J beneficiaries in excess of the prescribed limits. Any Konsulta services
·~-· rendered to beneficiaries not included in this maximum number shall
I . likewise not be paid by PHILHEALTH, unless an appeal for payment is
- filed and approved.
1.1.2. The NETWORK may add new certified primary care physicians and/or
accredited Konsulta providers in its operations during the validity of this
Agreement. The NETWORK may then renegotiate with PHILHEALTH
to increase or decrease its targets given the expanded absorptive capacity.
An addendum to this Agreement may be executed to reflect the updated
targets and contract amount up to the end of the 1" semester.
1.1.3. The NETWORK agrees to fully comply with mechanisms set by
PhilHealth to recover amount in excess of released capitation payments
after due reconciliation and evaluation of targets and performance
accomplishment.
1.1.4. The NETWORK agrees to secure a surety bond with the Government
Service Insurance System (GSIS) after signing the contract and before the
release of the initial capitation, callable upon demand based on the 30% of
the contract amount.
1.2 Provision of covered PhilHealth Konsulta services.
The NETWORK agrees to
Page 2 of 9 of Annex B.1

1.2.1. Render Konsulta services stipulated in PC No. 2022-0005 Section V-B and
the Benefit Table indicated in PC No. 2022-0005 Annex D to its registered
Konsulta members.
1.2.2. Ensure beneficiary access to Konsulta services during [prescribed schedule
of clinics].
1.2.3. Commit to achieve the targets of Konsulta beneficiaries of not more than
20,000 beneficiaries per physician and for each of the performance
indicators specified in this table:
All beneficiaries shall be given the following necessary Konsulta services

based on their health profiles/FPE and/ or results of their consultations:

c. Dispensing of medicines (Antibiotics and maintenance medications for
NCDs)
The Konsulta registered members of the PCPN-AKP as of December 2022

shall be automatically renewed and forwarded to the January 2023 database.
The PCPN-AKP shall assist their registered Konsulta beneficiaries (existing

and new) to update their health-assessment profiles (HAPs) and sign a Data
Privacy Consent Form with their respective AKPs. Updating of HAPs is
The PCPN-AKP shall provide the necessary Konsulta services based on

the health profiles/First Patient Encmmter (FPE) and/ or results of their
consultations of their beneficiaries. The FPE/ consultation shall be used to
identify the beneficiaries for the consultation services, diagnostic services
and NCD Meds while the Antibiotics-Meds recipients shall be determined
through doctors' consultation.
1.2.4. Maintain a high level of service satisfaction among Konsulta registered

beneficiaries as evidenced by result of patient feedback or satisfaction
survey, treat Konsulta beneficiaries with utmost courtesy and respect, assist
them in availing PHILHEALTH benefits and provide them with accurate
information on PHILHEALTH policies and guidelines in all
facilities/providers within the network.
1.2.5. Establish and institutionalize a functional referral system, which shall

ensure that PHILHEALTH member-patients are managed by competent
health workers in appropriate facilities while those with needs beyond the

service capability of the NETWORK are referred to appropriate
PHILHEALTH-accredited health facilities primarily within or if necessary
outside the network of providers.
1.2.6. Ensure that portability of Konsulta services is available to all
1 PHILHEALTH members and dependents within its network of
providers.
1.3 Assurance of service delivery capacity of member providers.
The NETWORK guarantees that:

1.3.1 Its member providers (facilities and professionals) are collectively capable
of managing the total target beneficiaries registered in Konsulta and shall
deliver services within acceptable standards of care (e.g., clinical practice
guidelines) and follows clinical pathways.
1.3.2 All its member health care providers/workers, as applicable, have the
required competencies and are PHILHEALTH-accredited or with signed
performance commitment, possess proper credentials and certifications,
and given appropriate privileges in accordance with its policies and
procedures.
1.3.3 In the event of partial or core compliance to the contracting standards, the
network shall subsequently comply with the non-core key features as
specified in the PC No. _before the release of the second frontloaded
capitation.
1.4 Assurance of frontloaded payment to member providers.
The NETWORK shall ensure prompt payments (not later than 10th day after the
receipt of PhilHealth capitation) to its member Konsulta providers listed in
..,., ,,....,_, ___,,_,, Attachment 2. In the event that the Konsulta provider has entered into a contract
with other service providers to ensure complete delivery of Konsulta services, the
NETWORK shall ensure that provider agreements specify a prompt payment
requil:ement, the terms and conditions of which are developed and agreed to by the
member Konsulta providers and other service providers.
1.5 Maintenance of a management information system.
The NETWORK shall:

1.5.1 Maintain a registry of all its Konsulta beneficiaries (including newborns)
- ........... __ ~
and a database of all services rendered (drugs, labs, auxiliary, services and
professional fees), which shall be made available to PHILHEALTH or
any of its authorized personnel upon request.
1.5.2 Maintain registry of all health workers (e.g., navigators, physicians, nurses,
midwives and dentists) including their fields of practice, PRC license, DOH
Certification, official e-mail addresses, and mobile phone numbers and
make available to PHILHEALTH upon request.
1.5.3 Ensure that true and accurate data are electronically encoded to update
patient's record in the e-Konsulta or its own network electronic medical
regisuy, to include the laboratory/ diagnostic examinations done, drugs and
supplies used in the care of the patient in its information system which shall
be made available for PHILHEALTH use.

1.5.4 Only transmit true and legitimate records and reports recogruZl!lg the
period of submission and report format as prescribed in PHILHEALTH
circulars.
1.6 Compliance to pertinent laws/policies and miscellaneous provisions and full

cooperation during regular surveys/administrative investigations/
domiciliary visitations.
The NETWORK commits that
1.6.1 As responsible owner(s) and/or manager(s) of the NETWORK, they shall
be jointly and severally liable for all violations committed against the
provisions of R.A. No. 7875, as amended, and UHC Act including its
Implementing Rules and Regulations (IRR) and PHILHEALTH policies
issued pursuant thereto.
1.6.2 It shall promptly inform PHILHEALTH prior to any change in the
ownership and/ or management of the NETWORK or any of its member
provider with signed performance commitment with PHILHEALTH.
1.6.3 Any change in ownership and/or management of the NETWORK or any
of its member provider with signed performance commitment with
PhilHealth shall immediately inform the PhilHealth within ten (1 0) working
days and does not operate to exempt the owner and/ or manager when the
offense was committed from liabilities for violations of R.A. No. 7875, as
amended, and its IRR and policies.
1.6.4 It shall maintain active membership in the NHIP as an employer (as
applicable) during the entire validity of its contract with PhilHealth as a
Primary Care Provider Network.
1.6.5 It shall abide with all the implementing rules and regulations, memorandum
circulars, special orders, advisories, and other administrative issuances by
PHILHEALTH affecting the NETWORK.
1.6.6 It 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 a Primary Care Provider. Network in contracting with
Phill-Iealth.
1.6.7 It shall adhere to pertinent statutory laws affecting the operations of a
Primary Care Provider Network including but not limited to the Senior
Citizens Act (R.A. 10645), 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
______
i.i
0 )
by the Congress of the Philippines or any other authorized instrumentalities
of the government.
1.6.8 It shall promptly submit reports as may be required by PHILHEALTH,
DOH and all other government agencies and instrumentalities governing
the operations of the networks.
1.6.9 It 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 its operations as contracted NETWORK of
the NHIP that may be prejudicial or tends to undermine the NHIP and
make available all pertinent official records and documents including the

prov1s1on of copies thereof; provided that the NETWORK's rights to
private ownership, if applicable, and ptivacy are respected at all times.
1.6.10 It shall ensure that its officers, employees, and personnel extend full
cooperation and due courtesy to all PHILHEALTH and
COMMISSION ON AUDIT (COA) officers, employees, and staff
during the conduct of assessment/visitation/investigation/monitoring of
the NETWORK's operations as an accredited NETWORK of the NHIP.
1.6.11 It shall take full responsibility for any inaccuracies and/ or falsities entered
into and/ or reflected in its patients' records as well as in any omission,
addition, inaccuracies and/ or falsities entered into and/ or reflected in
claims it submitted to PHILHEALTH, unless proven to be a palpable
mistake or excusable error.
1.6.12 It shall comply with PHILHEALTH's summons, subpoena, subpoena
'duces tecum' and other legal or quality assurance processes and
requirements.
1.6.13 It 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 its privilege and conduct of
our operations as an accredited network of d1e NHIP.
1.6.14 It shall comply with PHILHEALTH corrective actions given after
monitoring activities within the prescribed period.
1.6.15 It shall agree to return 100% of the overpayment of Capitation through
payment recovery mechanism implemented by PhilHealth.
1.6.16 It shall protect the NHIP against abuse, violation and/or over-utilization of
its funds and not allow itself or any of its membet providers to be a party
to any act, scheme, plan, or contract that may directly or indirectly be
prejudicial or detrimental to the NHIP.
1.6.17 It shall not directly or indirectly engage in any form of unethical or
improper practices as contracted NETWORK 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 ftnancial
gain rather than promotion of the NHIP.
1.6.18 It shall immediately report to PHILHEALTH, its officers and/or to any
of its personnel, any act of illegal, imptoper and/ or unethical practices of
networks and HCis of the NHIP that may have come to its knowledge
directly or indirectly.
1.6.19 It shall recognize PHILHEALTH's authority to suspend release of
payments under the following circumstances, but not limited to: (a) during
the period of its non-contracted status as a result of suspension of contract,
etc.; (b) loss of license for certain services that results to lack of access to
these services; and (c) when "No Balance Billing'' (NBB) eligible
PHILHEALTH members and their dependents were made to pay out-of-
pocket for HCI and professional fees, if applicable.
1.6.20 It shall recognize PHILHEALTH's authority, after due process and in
accotdance with the pertinent provisions of R.A. 7875 and its IRR, to
suspend, shorten, pre-terminate and/or revoke the NETWORK's privilege
of participating in the NHIP including the appurtenant benefits and
opportunities at any time during the validity of the contract for any
violation of any pwvision of this Service Agreement and of R.A. 7875, as
amended, and its IRR.

2. PHILHEALTH'S OBUGATIONS
2.1. For and in consideration of the Konsulta services rendered to its registered
members, PHILHEALTH shall pay the NETWORK a total of [AMOUNT IN
WORDS] (Php ), inclusive of all applicable taxes, upon satisfactory
completion of all milestones and submission of all the requirements specified in
this section of this Agreement and the payment schedule in Attachment 1, as
certified by the PhilHealth Regional Vice President. The releases of the capitation
frontload 2 and 3 shall require at least 60% liquidation of the 1"/2"d capitation
releases thru the money value of the Actual Physical Accomplishment (APA).
2.1.1. PHILHEALTH shall be responsible for computing the money value of
the monthly, quarterly, and annual performance targets and actual physical
accomplishment of the network.
2.1.2. PHILHEALTH shall process appeals for payment of capitation for
registered Konsulta beneficiaries in excess of [number of beneficiaries used
in calculating the contract amount], provided that all required documents
are submitted.
2.2. PHILHEALTH shall ensure timely release of payments to the network within ten
(10) days upon submission of complete requirements.
2.3. PHILHEALTH shall address the concerns of the NETWORK and issue
clarifications as needed to facilitate Konsulta implementation.
2.4. PHILHEALTH shall provide the NETWORK with regular updates and
orientation on PHILHEALTH policies and guidelines.
2.5. PHrLHEALTH shall assist the NETWORK to ensU1'e interoperability and

connectivity with PhilHealth databases to support innovations and EMR initiatives.
2.6. PHILHEALTH, through its [Office/Department Name], shall conduct random

on-site or virtual validation visits to observe the actual implementation of the
NETWORK of its innovation. PHILHEALTH shall provide the results of the
monitoring and assessment to the !Representative of the Network] fifteen (15) days
after the conduct of the assessment.
AMENDMENTS AND MODIFICATIONS
No amendment or modification of any of the terms and conditions of this Agreement

shall be valid unless evidenced by a written agreement executed by the authorized
representatives of both Parties.
EFFECTIVE DATE
This Agreement shall become effective upon the signing of all the parties to the
____
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0
agreement. The Agreement shall remain binding until terminated pursuant to the
termination provisions of this Agreement.
5. TERM AND TERMINATION
The Term of this Agreement shall be valid from January 1 to December 31, 2023.

The Parties may agree to pre-terminate this Agreement prior to its expiration in the event
of:
• Any proven cases of abuse in the operations of the Network

• Any proven fraud committed by the Network
• Request from the Network to pre-terminate the testing due to w1sustainable and/or
unfeasible implementation
All pre-terminations shall be subject to a 30-day prior notice, except when a shorter
period is agreed upon by the Parties.
6. SEPARABILITY CLAUSE
If any part of this Agreement is declared unenforceable or void, the rest of the
Agreement shall nevertheless remain in full force and effect.
7. ASSIGNABILITY
No assignment of rights, duties or obligations under this Agreement shall be made by

eid1er Party without the written approval of the other Party.
8. WAIVER
Neither the failure nor any delay on the part of either party to exercise any right, power,
or privilege hereunder shall operate as a waiver.
9. PROPRIETARY INFORMATION
The Parties agree that the terms and conditions of this Agreement and its Attachments
are proprietary, and agree to take all reasonable precautions to prevent the unauthorized
disclosure of the terms.
10. NON- DISCLOSURE AGREEMENT (NDA)
The Network shall comply with the submission of the NDA to PhilHealth in compliance
to the Data Privacy Law and rules.
ETHICS
The NETWORK shall comply with the policy on ethical and non-discriminatory
marketing ofKonsulta benefit package as stipulated in PC N o. 2022-0005 Section V-A-9.
2. EXCLUSIVE AGREEMENT
_______
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.,:
The provision of Konsulta service requires the Konsulta provider facility to engage only
in one network.
13. GOVERNING LAW AND VENUE OF ACTION
This Agreement shall be governed and construed in accordance with the laws of the
Republic of the Philippines, all PhilHealth circulars and issuances on Konsulta shall form
an integral part of this agreement. Venue of all actions arising from this Agreement shall
be brought exclusively to the jurisdiction of the appropriate courts of the Philippines,

without prejudice to the settlement of dispute through amicable settlement or alternative
dispute resolution mechanisms under existing laws.
14. ENTIRE AGREEMENT
Both Parties acknowledge that this Agreement and its Attachments constitute the entire
agreement between them and shall completely supersede all other prior understandings,
previous communications or contracts, oral or written, betvJeen the Parties relating to the
subject matter hereof.
Regional Vice-President Governor /Mayor

PhilHealth LGU _ _ _ _ _ __
WITNESSES:
IN WITNESS WHEREOF, the Parties hereto have caused these presents to be signed this_
day of at the , Philippines.
Doc No.
· Page No.
~ BookNo.--
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--~----- .

Annex B.2: Service Level Agreement Template
(Purely Private and Private-led Network)
Republic of the Philippines ) s.s.

Contract No. - - - - - - - -
SERVICE LEVEL AGREEMENT
KNOW ALL MEN BY THESE PRESENT:

This Agreement made and entered into by and between:
PHILIPPINE HEALTH INSURANCE CORPORATION, a government-owned

and controlled corporation created and existing by virtue of R.A. 7875, otherwise known
as the "National Insurance Act of 1995", as amended, with office address at [Address],
represented herein by its Regional Vice-President (RVP), [NAME], (hereinafter called
1
'PHILHEALTH").
-and-
(PRIMARY CARE PROVIDER NETWORK NAME], a private network, organized
and registered with the Securities and Exchange Commission under Company Reg. No .
_ _ _ and/or Joint Venture Agreement No. ,)] issued on and
existing under the laws of the Republic of the Philippines, with principal address at
[Address] represented herein by its [Position of Representative], [NAME], (hereinafter
called ''NETWORK")
(each a "Party'', and collectively, the "Parties").
WITNESSETH THAT:
WHEREAS, in response to the need to implement reforms stipulated in R.A. No. 11223 or the
Universal Health Care (UHC) Act and as an initial step towards adopting a comprehensive
approach to delivering primary care, PHILHEALTH has committed to expand the primary
~ care benefit to cover all Filipinos through the issuance of PhilHealth Circular (PC) No. 2022-
~ 0005, which prescribes the implementation of the PhilHealth Konsulta.ryong Stt!it at Tatna
r---..::::.::
(Konsulta) benefit package;
. 4-kEREAS, the UHC Act requires PHILHEALTH to endeavor to contract public, private,
ffi )- ,~or mixed health care provider networks for the delivery of individual-based health services;
~A. d' .
EREAS, the UHC Act requ1res the Department of Heald1 (DOH) and the local
g vernment units (LGUs) to endeavor to provide a health care delivery system that shall afford
e ery Filipino a primary care provider that would act as the navigator, coordinator, and initial
a d continuing point of contact in the health care delivery system;
- - - -. EREAS, the NETWORK is a group of health care providers, facilities, and professionals
with defined competencies and organized to deliver health care services in a coordinated and
integrated manner;
WHEREAS, PHILHEALTH enjoins provinces, highly urbanized cities, and private providers
to integrate th~ resources and services in a network and test local interventions/initiatives
under a sandbox setting for the implementation of the Konsulta package;

WHEREAS, the (private network) is willing to participate as sandbox site to test innovations
and interventions, such as the implementation of prospective payment mechanisms; the
establishment of the pooled fund in the delivery of Konsulta benefit package, and under the
terms and conditions contained in this Agreement; ·
WHEREAS, the (private network) is willing to sign an indemnity agreement with

PHILHEALTH and GSIS thereby securing surety bond with the GSIS and comply with the
requirement;
NOW THEREFORE, for and in consideration of the foregoing premises, and of the mutual
covenants and stipulations hereinafter set forth, the Parties hereby agree, and by these presents,
bind themselves, to wit:
1. PRIMARY CARE PROVIDER NETWORK OBUGATIONS
1.1. Acceptance of contract amount
The NETWORK accepts the contract amount of [AMOUNT IN WORDS]

(Php ) stipulated in this Agreement, including the corresponding
schedule of payment and conditions for payment releases specified in the payment
schedule in Attachment 1.
1.1.1. The NETWORK agrees that it shall register and provide Konsulta services
to a maximum of number of Konsulta beneficiaries,
considering its absorptive capacity benveen 10,000 to 20,000 per physician.
PHILHEALTH shall not provide paytnent for the nutnber of registered
beneficiaries in excess of the prescribed limits. Any Konsulta services
rendered to beneficiaries not included in this maximum number shall
likewise not be paid by PHILHEALTH, unless an appeal for payment is
filed and approved.
1.1.2. The NETWORK may add new certified primary care physicians and/or
accredited Konsulta providers in its operations during the validity of this
Agreement. The NETWORK may then renegotiate with PHILHEALTH
-.... __. ...,._
--. ...... until the end of the sixth month of the sandbox period to increase or
- · decrease its targets given the expanded or reduced absorptive capacity. An
r.c ~J addendum to this Agreement may be executed to reflect the updated

targets and contract amount.
~[ £ 1.1.3. The NETWORK agrees to fully comply with mechanisms set by

PHILHEALTH to recover amount in excess of released capitation
c( payments after due reconciliation and evaluation of targets and
~ performance accomplishment.
1.1.4. The NETWORK agrees to secure a surety bond with the Government
Service Insurance System (GSIS) after signing the contract and before the
release of the initial capitation, callable upon demand based on the 30% of
the contract atnount.
1.2. Provision of covered PhilHealth Konsulta setvices
The NETWORK agrees to

1.2.1. Render Konsulta services stipulated in PC No. 2022-0005 Section V-B and
the Benefit Table indicated in PC No. 2022-0005 Annex D to its registered
Konsulta members.

1.2.2. Ensure beneficiary access to Konsulta services during [prescribed schedule
of clinics].
1.2.3. Commit to achieve the targets of Konsulta beneficiaries of not more than
20,000 beneficiaries per physician and for each of the performance
indicators specified in this table:
Performance Indicators
Number of registered Konsulta
1
Targets
ene ctanes
. OO%- - - -·-
!_
_
---·---·-·--···--·----·--·---·--·..-·-·-··--..................... ~··· -· - -· - -· -.. -·-·-·-·-·-·-·· ·--·-···-·--·-.. .................... ..................... N'~-~b~;-~r --1
B fi . . i
:
I
1
members i
N~mber of Konsulta members ------~ ~- I
, with first patient 100% I
U!:r?l______________ _____ __ . _ _j__ __ _ ____-.1
AJl beneficiaries shall be given the following necessary Konsulta services
based on their health profiles/FPE and/ or results of their consultations:

c. Dispensing of medicines (Antibiotics and maintenance medications for
NCDs)
The Konsulta registered members of the PCPN-AKP as of December 2022

shall be automatically renewed and forwarded to the January 2023 database.
The PCPN-AKP shall assist their registered Konsulta beneficiaries (existing

and new) to update their health-assessment profiles (HAPs) and sign a Data
Privacy Consent Form with their respective AK.Ps. Updating of HAPs is
The PCPN-AKP shall provide the necessary Konsulta services based on

the health profiles/First Patient Encounter (FPE) and/ or results of their
- consultations of their beneficiaries. The FPE/ consultation shall be used to

identify the beneficiaries for the consultation services, diagnostic services
and NCD Meds while the .Antibiotics-Meds recipients shall be determined
through doctors' consultation.
1.2.4. Maintain a high level of service satisfaction among Konsulta registered

beneficiaries as evidenced by result of patient feedback or satisfaction
survey, treat Konsulta beneficiaries with utmost courtesy and respect, assist
them in availing PHILHEALTH benefits and provide them with accurate
information on PHILHEALTH policies and guidelines in all
facilities/providers within the network.
1.2.5. Establish and institutionalize a functional referral system, which shall

ensure that PHILHEALTH member-patients are managed by competent
health workers in appropriate facilities while those with needs beyond the
service capability of the NETWORK are referred to appropriate
PHILHEALTH-accredited health facilities primarily within or if
necessary, outside the network of providers.

1.2.6. Ensure that portability of Konsulta services 1s available to all
PHILHEALTH members and dependents within its network of
providers.
1.3. Assurance of service delivery capacity of member providers.
The NETWORK gufttantees that

1.3.1. Its member providers (facilities and professionals) are collectively capable
of managing the total target beneficiaries registered in Konsulta and shall
deliver services within acceptable standards of care (e.g., clinical practice
guidelines) and follows clinical pathways.
1.3.2. All its member health care providers/workers, as applicable, have the
required competencies and are PHILHEALTH-accredited or with signed
performance commitment, possess proper credentials and certifications,
and given appropriate privileges in accordance with its policies and
procedures.
1.3.3. In tl1e event of partial or core compliance to the contracting standards, the
network shall subsequently comply with the non-core key features as
specified in the PC No. _ before the release of the second frontloaded
capitation.
1.4. Ensure sufficient allocation and timely release of fund provision to member
providers.
The NETWORK concurs that all Konsulta capitation payments shall be paid
directly to the NETWORK and that claims of its individual member providers
shall be between the NETWORK and the individual member provider. Moreover,
the NETWORK and its individual member providers agree that individual
member providers shall not file claims directly to PHILHEALTH for services
rendered under Konsulta.
1.5. Maintenance of a management information system.
The NETWORK shall

1.5.1. Maintain a registry of all its Konsulta beneficiaries (including newborns)
and a database of all services rendered (drugs, labs, auxiliary, services and
professional fees), which shall be made available to PHILHEALTH or
any of its authorized personnel upon request.
1.5.2. Maintain a registry of all health workers (e.g., navigators, physicians, nurses,
midwives and dentists) including their fields of practice, official e-mail
addresses, and mobile phone numbers and make available to
PHILHEALTH upon request.
-----~ ... 1.5.3. Ensure that true and accurate data are electronically encoded to update
patient's record in the e~Konsulta or its own network electronic registry, to
include the laboratory/ diagnostic examinations done, drugs and supplies
used in the care of the patient in its information system which shall be
made available for PHILHEALTH use.
1.5.4. Only transmit true and legitimate records and reports recognizing the
period of submission and report format as prescribed in PHILHEALTH
circulars.

1.6. Compliance to pertinent laws/policies and miscellaneous provisions and full
cooperation during regular surveys/administrative
investigations/ domiciliary visitations.
The NETWORK commits that

1.6.1. As responsible owner(s) and/or manager(s) of the NETWORK, they shall
be jointly and severally liable for all violations committed against the
provisions of R.A. No. 7875, as amended, and UHC Act including its
Implementing Rules and Regulations (IRR) and PHILHEALTH policies
issued pursuant thereto.
1.6.2. It shall promptly inform PHILHEALTH prior to any change in the
ownership and/ or management of the NETWORK or any of its member
provider with signed performance commitment with PHILHEALTH.
1.6.3. Any change in ownership and/or management of the NETWORK or any
of its member provider with signed performance commitment with
PhilHealth shall immediately inform the PhilHealth within ten (1 0) working
days and does not operate to exempt the owner and/ or manager when the
offense was committed from liabilities for violations of R.A. No. 7875, as
amended, and its IRR and policies.
1.6.4. It shall maintain active membership in the NHIP as an employer (as
applicable) during the entire validity of its contract with PHILHEALTH
as a Primary Care Provider Network.
1.6.5. It shall abide with all the implementing rules and regulations, memorandum
circulars, special orders, advisories, and other administrative issuances by
PHILHEALTH affecting the NETWORK.
1.6.6. It 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 a Primary Care Provider N et\vork in contracting with
PHILHEALTH. .
1.6.7. It shall adhere to pertinent statutory laws affecting the operations of a
Primary Care Provider Network including but not limited to the Senior
Citizens Act (R.A. 10645), 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. ·
1.6.8. It shall promptly submit reports as may be required by PHILHEALTH,
DOH and all other government agencies and instrumentalities governing
the operations of the networks.
1.6.9. It 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 its operations as contracted NETWORK 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 the NETWORK's rights to
private ownership, if applicable, and privacy are respected at all times.
1.6.10. It shall ensure that its officers, employees, and personnel extend full
cooperation and due courtesy to all PHILHEALTH and

COMMISSION ON AUDIT (COA) officers, employees, and staff
during the conduct of assessment/visitation/investigation/monitoring of
the NETWORK's operations as an accredited NETWORK of the NHIP.
1.6.11. It shall take full responsibility for any inaccuracies and/ or falsities entered
into and/ or reflected in its patients' records as well as in any omission,
addition, inaccuracies and/ or falsities entered into and/ or reflected in
claims it submitted to PHILHEALTH, unless proven to be a palpable
mistake or excusable error.
1.6.12. It shall comply with PHILHEALTH's summons, subpoena, subpoena
'duces tecum' and other legal or quality assurance processes and
requirements.
1.6.13. It 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 its privilege and conduct of
our operations as an accredited network of the NHIP.
1.6.14. It shall comply with PHILHEALTH corrective actions given after
monitoring activities within the prescribed period.
1.6.15. It shall agree to return 100% of the overpayment of Capitation through
payment recovery mechanism implemented by PhilHealth.
1.6.16. It shall protect the NHIP against abuse, violation and/ or over-utilization of
its funds and not allow itself or any of its member providers to be a party
to any act, scheme, plan, or contract that may directly or indirectly be
prejudicial or detrimental to the NHIP.
1.6.17. It shall not directly or indirectly engage in any form of unethical or
improper practices as contracted NETWORK such as but not limited to
solicitation of patients for purposes of compensability under the NHIP, the
putpose and/ or the end consideration of which tends unnecessary fmancial
gain rather than promotion of the NHIP.
1.6.18. It shall immediately report to PHILHEALTH, its officers and/or to any
of its personnel, any act of illegal, improper and/ or unethical practices of
networks and HCis of the NHIP that may have come to its knowledge
I 1.6.19.
directly or indirectly.
It shall recognize PHILHEALTH's authority to suspend release of
payments under the following circwnstances, but not limited to: (a) during
the period of its non-contracted status as a result of suspension of contract,
etc.; (b) loss of license for certain services that results to lack of access to
these services; and (c) when "No Balance Billing" (NBB) eligible
PHILHEALTH members and their dependents were made to pay out-of-
pocket for HCI and professional fees, if applicable.
i.:5 1.6.20. It shall recognize PHILHEALTH's authority, after due process and in
o __l accordance with the pertinent provisions of R.A. 7875 and its IRR, to
suspend, shorten, pre-terminate and/or revoke the NETWORK's privilege
of participating in the NHIP including the appurtenant benefits and
opportunities at any time during the validity of the contract for any
violation of any provision of this Service Agreement and of R.A. 7875 and
its IRR.
2. PHILHEALTH'S OBLIGATIONS
2.1. For and in consideration of the Konsulta services rendered to its registered
members, PHILHEALTH shall pay the NETWORK a total of [AMOUNT IN

WORDS] (Php ), inclusive of all applicable taxes, upon satisfactory
completion of all milestones and submission of all the requitements specified in
this section of this Agreement and the payment schedule in Attachment 1, as
certified by the PhilHealth Regional Vice President. The releases of the capitation
frontload 2 and 3 shall require at least 60% liquidation of the 1"/2nd capitation
releases thru the money value of the Actual Physical Accomplishment (APA).
2.1.1. PHILHEALTH shall be responsible for computing the money value of
the monthly, quarterly, and annual performance targets and actual physical
accomplishment of the network.
2.1.2. PHILHEALTH shall process appeals for payment of capitation for
registered Konsulta beneficiaties in excess of [number of beneficiaries used
in calculating the contract amount}, provided that all required documents
are submitted.
2.2. PHILHEALTH shall ensure timely release of payments to the NETWORK

within ten (10) days upon submission of complete requirements.
2.3. PHILHEALTH shall address the concerns of the NETWORK and 1ssue
clarifications as needed to facilitate Konsulta implementation.
2.4. PHILHEALTH shall provide the NETWORK with regular updates and
orientation on PHILHEALTH policies and guidelines.
2.5. PHILHEALTH shall assist the NETWORK to ensure intetoperability and

connectivity with PhilHealth databases to support innovations and EJ\ffi initiatives.
2.6. PHILHEALTH, through its [Office/Department Name], shall conduct random

on-site or virtual validation visits to observe the actual implementation of the
NETWORK of its innovation. PHILHEALTH shall provide the results of the
monitoring and assessment to the [Representative of the Network) fifteen (15) days
after the conduct of the assessment.
I
' 3. AMENDMENTS AND MODIFICATIONS
I
I
No amendment or modification of any of the terms and conditions of this Agreement
I shall be valid unless evidenced by a written agreement executed by the authorized
I representatives of both Parties.
4. EFFECTIVE DATE
This Agreement shall become effective upon the signing of all the parties to the
agreement. The Agreement shall remain binding until terminated pursuant to the
termination provisions of this Agreement.
5. TERM AND TERMINATION
The Term of this Agreement shall be valid from January 1 to December 31,2023.
The Parties may agree to pre-terminate this Agreement prior to its expiration in the event
of:
• Any proven cases of abuse in the operations of the Network

• Any proven fraud committed by the Network
• Request from the Network to pre-terminate the testing due to unsustainable
and/ or unfeasible implementation
All pre-terminations shall be subject to a 30-day prior notice, except when a shorter
period is agreed upon by the Parties.
6. SEPARABILITY CLAUSE
If any part of this Agteement is declared unenforceable or void, the rest of the
Agreement shall nevertheless remain in full force and effect.
7. ASSIGNABILITY
No assignment of rights, duties or obligations under this Agreement shall be made by

either Party without the written approval of the other Party.
8. WAIVER
Neither the failure nor any delay on the part of either party to exercise any right, power,
or privilege hereunder shall operate as a waiver.
9. PROPRIETARY INFORMATION
The Parties agree that the terms and conditions of this Agreement and its Attachments
~ are proprietary, and agree to take all reasonable precautions to prevent the unauthorized
~ disclosure of the terms.
~---~~ 10. NON~ DISCLOSURE AGREEMENT (NDA)

0: a; The Network shall comply with the submission of the NDA to PhilHealth in compliance
W>-
1~...
~
Q
to the Data Privacy Law and rules.
<( 1. ETHICAL
2
Comply with the policy on ethical and non-discriminatory marketing of Konsulta benefit
package as stipulated in PC No. 2022-0005 Section V-A-9.
i.3
01
12. EXCLUSIVE AGREEMENT
The provision of K.onsulta service requires the Konsulta provider facility to engage only
in one network.
13. GOVERNING LAW AND VENUE OF ACTION
This Agreement shall be governed and construed in accordance with the laws of the
Republic of the Philippines, all PhilHealth circulars and issuances on K.onsulta shall form
an integral part of this agreement. Venue of all actions arising from this Agreement shall
be brought exclusively to the jurisdiction of the appropriate courts of the Philippines,
without prejudice to the settlement of dispute tl1rough amicable settlement or alternative
dispute resolution mechanisms under existing laws.
Page 8 of9 of Annex B.2

14. ENTIREAGREEMENT
Both Patties acknowledge that this Agreement and its Attachments constitute the entire
agreement between them and shall completely supersede all other prior understandings,
previous communications or contracts, oral or written, between the Parties relating to the
subject matter hereof.
Regional Vice-President Principal

PhilHealth Network: ------------------
WITNESSES:
IN WITNESS WHEREOF, the Parties hereto have caused these presents to be signed this_
day of at the , Philippines.
Doc No.
Page No. _ _
Book No.
Series of
-· ~ ·

Annex C: Benefit Payment Arrangement
Benefit Payment Arrangement
Section 18 of the UHC law mandates PhilHealth to shift to performance-driven, close-end,

prospective provider payments mechanism and to incentivize providers that form networks. In
this regard, the provider payment mechanism shall remain based on capitation but with
modifications in the payment schedule to facilitate frontloaded capitation and promote
efficiency in the delivery of Konsulta services.
1. Selected sites shall be entitled to the same capitation rate with modified payment
schedule described herein.
2. The capitation rate for the current Konsulta services as provided in PhilHealth Circular
2022-0005 shall remain applicable.
3. Benefit payment schedule shall be in tranches or portion of capitation to be released as
provided in the SLA. The revised schedule for the release of capitation tranches is to
ensure availability of funds to sustain uninterrupted delivery of health care.
4. For Konsulta registration, the total number of beneficiaries registered should not exceed
the DOH-recommended ratio for provider to patients, which is at 1 accredited Konsulta
doctor/provider per 20,000 population. The number of beneficiaries in excess of the
recommended ratio shall not be included in the computation for payment.
5. The provider payment is performance-based capitation as this shall ensure that intended
services for beneficiaries needing the provision of primaty care services are rendered
within the payment period.
6. In the computation of money value of the actual physical performance (2nd release to 3rd
release, as applicable), the resultant score of each key performance indicator shall in no
case exceed the prescribed percentage score.
Payment Arrangement for Konsulta Networks
This section describes the payment arrangement focus on the financial aspect of the Konsulta
service delivery. The arrangement allows for the frontloading of the full capitation amount based
on declared physical targets per payment periods, subject to liquidation based on
accomplishments with reconciliations being reflected in the succeeding payment periods. As a
result of the reconciliation, the network may refund PhilHealth or be entitled to additional
capitation corresponding to its actual accomplishments above targets.
The provision on Key Performance Indicators (I<Pls), and its corresponding percentage and
computation for the contract amount shall depend on the target number of beneficiaries per type
of accredited Konsulta provider, i.e., Php 500 for each enrolled Konsulta member in a public
provider and Php 750 for those enrolled in a private provider of PC 2022-0005 shall be adopted.
A. Capitation Variance - refers to the difference between the money value of the Actual
Physical Accomplishment and the frontloaded capitation.
B. Cash Programming - refers to the Primary Care Provider Network's estimate
monthly cash requirements to deliver registration and provision of primary care
services to beneficiaries.
C. Contract Amount - refers to the amount indicated in the Service Level Agreement
(SLA). It is computed based on the number of the performance target x capitation
u
c
rate depending on the type of Konsulta accredited facility; government-owned at
i -:<'r-., ••...,J PSOO; privately-owned at P750.
Page 1 of 8 of Ann~x C
D. Contracting - refers to a process where PhilHealth and networks or network and
provider are engaged to commit and deliver quality health services at agreed cost,
cost sharing and quantity in compliance v.cith prescribed standards.
E. Contract Reference Number - unique reference number issued by Phi1Health to the
contracted Konsulta network.
F. First Patient Encounter - refers to 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.
G. Frontloaded capitation - refers to an approach in the purchase of health services by
which health care providers are paid before the services are provided for a specific
package of health benefits based solely on a pre-determined and fixed budget.
H. Konsulta Eligible Beneficiary - refers to all Filipinos given inunediate eligibility to
register in an accredited Konsulta-provider in accordance with Republic Act No.
11223 and its IRR.
H. Konsulta Network Contracting Certificate - Certifi.cation issued by Ph.ilHealth to the
contracted Konsulta Network that passed/ qualified the network criteria.
I. Primary Care Provider Network (PCPN) -refers to a group of Konsulta Providers,
whether public, private, or mixed, with established interoperable system for efficient
provision of Konsulta services.
]. Money Value of the Actual Physical Accomplishment (APA)- computed by adding
the money value of the actual physical accomplishment on the registration of
Konsulta members with first patient encounter and the money value of the actual
physical accomplishment of the provision of Konsulta services.
K. Money Value of the Physical Targets - computed at performance targets and
capitation rate per facility ownership.
L. Monthly Performance Targets and Cash Programming - refers to the report to be
prepared by the network showing the physical target and cash requirement on a
monthly basis.
M. Negative Variance- money value of the Actual Physical Accomplishment is less than
the frontloaded capitation released.
N. Performance Factor- is d1e cumulative resultant score based on the performance of
the provider adjusted using weights set by the Corporation.
0. Performance Targets - absolute number of proposed by the network to be
accomplished in a given year, pursuant to the operational guidelines of Konsulta
Network contracting implementation.
P. Positive Variance- money value of the Actual Physical Accomplishment exceeds the
frontloaded capitation released.
Q. Service Level Agreement - refers to tl1e Contract between PhilHealth and the
network in the implementation of network contracting.
Description of the Payment Arrangement
target
Konsulta 1. 30% of contract amount: Php _ __
beneficiaries 2. Cash programming of LGU for months 1-3: Php
--·--·-····--·--·- - -- ..... .......-.......-.........----·---·'·---. --..------'"-'"'--..........-...........______ ...............__ ..........____.................................-....--------.....-. ........_....- ---··-- ·-·"'""""'---"'-------·
._ ,._
Page 2 of 8 of Annex C
to be grven
l.... . . . . . .._ _ _..... . ... - . . . . . . . . . . .......-.. - --.- -·-- ... . . . . . . ... ........ _ _ ..... ._... . ... - -·--·--- -.- - - - -·
r·······--·--····--···-··. ··---·l·-··········--···· ·7----···-----.. .........
(please refer to Annex D -1 for the !
Konsulta report format) !
setvices fot 3. Money value of the physical targets for months 1-3: i
months 1-3 Php [(Capitation amount x. Physical Targets for i
per facility months 1 to 3] :
·--- -- +------- · -··---
Month 4 Number of Lowest value of the following: 2
target 1. 50% of contract amount: Php _ __
Konsulta 2. Cash ptogramming of LGU for months 4-9: Php i
beneficiaries
for months 4- 3. Money value of the physical targets for months 4-9:
II 9 per facility Php [(Capitation amount x Physical Targets for
months 4 to 9]
I
Plus/minus the capitation variance between the money ;
values of APA from the months 1 to 3 vs frontloaded l
capitation 1" release. The money value of the AP A is the !
sum of:
• Money value of AP A of registered beneficiaries with !
first patient encounter (FPE) = Php [Capitation i
amount x. 40% x Registered Beneficiaries with FPEml- i
3], and j
I
• Money value of APA-Konsulta services Php !
[(Capitation amount x 60% x Performance Factorm,_3 i
x Registered Beneficiaries with FPErn 1. 3) ] ;
Computation of Performance Factor:
Performance Factor =R.Sc + RSl + R.Sa + R.Sn

I
I Computation of Resultant Score:
RSc = Resultant Score Consultation
RSl . = Resultant Score Laboratory
=
RSa Resultant Score Antibiotics
RSn = Resultant Score NCDs Meds
I Consultation:
No. of actual beneficiaries consulted_
I RSc = ·-·-------------------- x 30%

No. of beneficiaries needing consultation
Laboratory:
No. of actual beneficiaries provided diagnostic services

RSI::: - - - - - x30%
No. of beneficiaries needing diagnostic serv"ices
Antibiotics:
No. of actual beneficiaries provided with antibiotics

RSa = --------------------------- x 10%
No. of beneficiaries needing antibiotics
NCDs:
----·--.. ·--..--..- . _______ _______. _________ -----------··--------·-----·----------...--------······--·----.--...-......_....__________________.___....___ ;_______ __________ _
._ ,.,. ,
. . . . . . . . . . . . . . ... · ··1--··-·-··-·-·-· ·- -··-·······- ·---·-·-·--·"f-4o:··ar-aciuar6a·ri·efiCiaries.P"rovictea-wiihNcDt:ieas·····-····----··---- ----- -·, ··-· - --
Rsn = -------------------------------------- x 30%
i No. of beneficiaries needing NCD Meds
-----~------------+----~-~---~-----~------~---~--·~-~-~---------~-.-;_.
Month Number of j'Lowest value of the following:
1
..~---·----·
3 i
10 target ! 1. Cash programming of LGU for months 10-12: Php !

j Konsulta
i beneficiaries 1 2. Money value of the physical targets for months 10- !
!for months 1
1 12: Php [(Capitation amount x Physical Targets for I

!i~~1~ per I months 10 to 12J t
! IIPlus/minus the capitation variance between the money '

! values of APA from the months 4 to 9 vs frontloaded
i 1 capitation 2, net of capitation variance. The money value
I ' of the AP A is the sum of:
I • Money value of APA on registered beneficiaries with
· FPE == Php [Capitation amount x 40% x (Registered i
J J Beneficiaries with FPEm+9)], and ·
i.< I•
!
Money value of APA Konsulta services Php i
[(Capitation amount x 60% x Resultant scorem4-9 x !
!! ! Performance Factor tn4-9)] x Registered Beneficiaries J
, with FPEm+9)] l
iI 1
I! Computation of Performance Factor;

!
l I Performance Factor = RSc + RSl + RSa + RSn
Computation of Resultant Score:
RSc =
Resultant Score Consultation
I
I
I
!
RSl ==Resultant Score Laboratory
RSa = Resultant Score Antibiotics
I
i
I
! =
RSn Resultant Score NCDs Meds
l Consultation:
I I
1
RSc "
No. of actual beneficiaries consulted
~~;b~;;~~~-~-~~di~~-~~~~i~t~~~- x30%
li Laboratory:
I I No. of actual beneficiaries provided diagnostic services
I RSI = ~~cl·b;~;~;i~~~-;~;~di~;-;~;~~~~~~~~-;s------ x30%
I !I An t1"b"1ot1cs:
.
I
l No. of actual beneficiaries provided with antibiotics
RSa =-------------------------- x 10%
No. of beneficiaries needing antibiotics
Within Money value of actual physical accomplishments for n/
the first months 1 to 12, less released frontloaded capitation for
month months 1 to 12 = Php {[(Capitation amount x 40% x
after the Actual number of Konsulta beneficiaries with FPE for
v alidity months 1 to 12) + (Capitation amount x 60% x
of the 1 Performance Factor for months 1 to 12 x Actual number
SLA I 1 of Konsulta registered beneficiaries with FPE for
-- I j months 1 to 12)] -Released frontloaded capitation 1 to
L____l_______~~-12-}--·----------·-------------~----~
Illustrative computation per Scenario for both public and private networks
% 28% 27% 28% 27%
30
% 20% 27% 20% 27%
actual % w / Antibiotics 10
meds % 9% 9% 9% 9%
30
actual % w NCD meds % 25% 23% 25% 23%
ACTUALM4-9
30
% 26% 26% 26% 26%
30
% 16% 23% 16% 23%
10
% 8% 6% 8% 6%
30
% 30% 21% 30% 21%
Puge 6 of 8 of Annex C
number needing NCS meds 6,000 9,000 6,000 9,000
..
number w I consultation .
,iJ~[Q~g6()1
.f: ;:t
numb er w/ lab & diagnostics ri .-. ~l~Zo~oorH
- ·~:i~~'~tf~r~:~~f~f;l~fui;~~:Oti~:
number wl Antibiotics m eds {
;~J5,f• ~;fru;~,~vh1~id~~l
.
n umber w I N CD meds . Q \~:
30
actual % w I consultation % 28% 27% 28% 27%
actual % w I lab & 30
diagnostics % 20% 27% 20% 27%
actual % w I Antibiotics 10
m eds % 9% 6% 9% 6%
30
actual % w I N CD meds % 25% 17% 25% 17%
ACTUAL M1~12
number of excess/ short of target -15,000 -15,000 -1 5,000 -15,000
number of registered 100,000 100,000 100,000 100,000
numb er w / FPE 85,000 125,000 85,000 125,000
% needin_g co nsultation 100% 100% 100% 100%
% needing lab & diagnostics 57% 57% 57% 57%
% n eeding Antibiotics m eds 14% 14% 14% 14%
% needing NCS meds 20% 20% 20% 20%
number needing consultation 85,000 125,000 85,000 125,000
number needing lab & diagnostics 48,750 71,250 48,750 71,250
number needing Antibiotics m eds 11,500 17,000 11 ,500 17,000
numb er needing N CS meds 17,000 25,000 17,000 25,000
n umber w I consultation 77,000 110,000 77,000 11 0,000
n umber w I lab & diagnostics 30,000 60,000 30,000 60,000
number w I Antibiotics m eds 10,000 12,000 10,000 12,000
~'
n umber wl NCD meds 15,000 17,000 15,000 17,000
~ 30
-== actual %wl consultation % 27% 26% 27% 26%
·!a11tual % w I lab & 30
= dihgnostics % 18% 25% 18% 25%
rr. j a< tual % w I Antibiotics 10
~
) rr ed s % 9% 7% 9% 7%
'
30
~ a tual % w / N CD meds % 26% 20% 26% 20%
~ ~AYMENT
1 rondoad Capitation 1 actual
i~ I ayment 17,250,000 17,250,000 25,875,000 25,875,000
a
--Mo n ey_ V alue - A ctual FPE ml-3 6,000,000 9,000,000 9,000,000 13,500,000
Money Valu e- Performance m1-3 7,325,000 11 ,550,000 10,987,500 17,325,000
T o tal Mo ney Value 13,325,000 20,550,000 19,987,500 30,825,000
F rontload Capitation 1 adjusted -3,925,000 3,300,000 -5,887,500 4,950,000
F rontload Ca.Qitatio n 2 target 25,000,000 25,000,000 37,500,000 37,500,000
Frontload Capitation 2 actual

payment 21,075,000 28,300,000 31,612,500 42,450,000
Money_ V alue - A ctual FP E m4-9 5,000,000 7,000,000 7,500,000 10,500,000
Money Value- Performance m4-9 6,030,000 7,950,000 9,045,000 11,925,000
Total Money Value 11,030,000 14,950,000 16,545,000 22,425,000
Frontload Capitation 2 adjusted -10,045,000 -13,350,000 -15,067,500 -20,025,000
Frontload Capitation 3 target 10,000,000 10,000,000 15,000,000 15,000,000
Frontload Capitation 3 actual

_payment -45,000 -3,350,000 -67,500 -5,025,000
Total Frontloaded Capitation 38,280,000 42,200,000 57,420,000 63,300,000
Total Beneficiaries w / FPE 85,000 125,000 85,000 125 000

Money_ Value- Actual FPE ml-12 17,000,000 25,000,000 25,500,000 37,500,000
Money Value- Performance m1-12 20,605,084 29,670,743 30,907,625 44,506,115
Total Money Value 37,605,084 54,670,743 56,407,625 82,006,115
Annualized adjusted -674,916 12,470,743 -1,012,375 18,706,115
Annex D-1: Monthly Physical Target and Cash Programming
MONTHLY PHYSICAL TARGET AND CASH PROGRAMMING
NETWORK
Address:
Contract Reference
Nwnher:
TOTAL CASH FOR THE

NETWORK
P(epared by:
'"'
Page 1 of 1 of Annex D-1

'
i3
0
Annex D-2: Analysis Worksheet for Frontloaded Capitation 1
ANALYSIS WORKSHEET FOR FRONTLOADED CAPITATION 1
NETWORK
Address:
Contract Reference
Number:
Comparison among the 1st Quarter Cash Program. Money Value ofthe Physical Target and 30% ofthe Contract Amount
1. Olsh Program January XXX

February XXX
March XXX
Total
Z. Money Value ofthe Physical Target

Government-Owned FacT!ty XXX
P!ivately-Owned Faa1ity XXX
Total
N
cl,_
3_ 30%ofthecapltationCon!ractAmount
cantract Amount PXXXX

Multiply by
i3
0
RECOMMENDED FOR RElEASE

ANALYSIS' WORKSHEET FOR FRONTLOADED CAPITATION 3

NETWORK
Address:
Contract Reference
Number:
1. Compute for tfle Money Value of Actual Physical Accomplishment

No. af Senafklllries
INDICATORS needing Primary Care WEIGHTS Total Physical Resultant Score I
Services M4-9 Peri<lrma~~Ce Faclor
1. REGJSTRATlON OF MEMBERS TO THE
KONSULTA PROVIDER (1>200)
Na. Ko11sulta Rel!lsteo.d M<>mbet'l IIIIth FIBt P;llent ~counl&r 23,0011

l'tu:form;mr;o; fllt1or 90%
~o" af llle C!ll>ll;;lllo n f<lnd IPS<! OJ 300
KP112 Man~y Value
No. of BtMfic!arles
INDICATORS needing Primary Catfl
Servlcea
WI<IGHT$
..
Total Ptlyafcal
~
Rasultant Score I
PerfOrmance Factor
FIMIK':Ia(
GRAND TOTAL
Qlmputc:~tlon of kP111.2 ~(mmpl[shm!:!nt:
No. af lran•ulta Reg[5fl!"'d Memb~rs with Fl,.t pilllent &larunlcr 11\,000
l'~rformanee factDr 91"
eo$ aflhe t;pltllllcm Fund fP7$Dl ~ 50
I(]>J 12 MoO!fyV;llue i~r:wri§rq;~'0~f:5_4Z:;I·B:O:r1
RClCIIp:
Governl11t!nt.owned Fadllty 10,822,.800
Prlvat~ly.OWned Fadlity 16,142,880
Total, Money Value of Ad:ual Pbyslcal Ao:ompl!shment
2. Compute ·for the 11arlance of the fl'()ntloaded Capitation and tile Money Value of the Actual Performance Acwm p11shment
Money V.alue of the Ad~l f'hyslml Atmcripllshment

frontloaded Capitation 2
Capitation Variance
3, Cgmpansa" omonglbe 4111 Quorl>orC""h Pra1131n ""d Money Value gf1!Je Attuill Physical At<clmplbhmen~ whl<ho~~<~rh lo'""'
1. Cash Progr•m (derived from tile Monthly Physical Targets and Cash Programming)
Odob!!r )00(
lOCX
lOO!
XXX (October· December No. of ptwsltlll target x PSOO)

XXX (October· December No. of physical target x 1'750)
Ius or minus the Capltllion Variance

ECDMMEN DOD m BE 1\ELJ:ASED TO THHI EIWORK
Page 1 of 1 of Ann ex D-4

~~AN..&JYSIS WORKSHEET FORFRONTLOADED CAPITATION 2

NETWORK:
Address:
Contract Reference Number:
I.
No. Qf s.n.rltll!'l..
INDICATORS ..-nil PII!My Cue WEIGI«S Total PI\ pi cal RNullllnt Soom r
Fln[ll)elol
Servl""" 1111-3 Plltfarmomto~
FIIICtor
1. REGISTRATION OF MEMBERS TO THE.

KONSULTA PROVItlER (l"liXl)
.._------1------1-----+-------1------1
No, -.l!oglot.,..."""""""'-~!rsth-£n<"""'er
,_,ormenu·~a.:tvr
IIOl'ol ti>eOiphtbnf<M (PMOJ
m n_..,.,vabo
II.
No. 'If llonofldl!'los
II'.OICATORS n60<1ln11 Primary Car<! WEIGI«S TM~ Phy.tOIII mtUlWII S<:om I
Flnt~~cl•l
s.r-1... M1-:l Pf'fOMI:IrtCII F..,tor
Ill; !:dip: :
Govm~menl-Ownro Far:lllty 5,411,41!0

Pnvatef'f{.)wned Faci!lty 11,451,15-0
Total, M<ln~v ~ue of Actual Phyolcal ~~eeampllsl>m~nt p :t:•11![86ZjiSil :
z. CC>mf'W for ltl• -tllflt;e of lh" Fmnlloaded caplt;ltlon ..,d !he Money Value of the l\tllll!! P~lfolm111ce A«;;mpll5hment
Money Value ofth~ Actual Physl.,_t Ar:~mpllshmen~
Fron~oaded QpltatiQn 1
Cipl1atloi1 Vor1a.nce
!. Comparl<oo omorctholodanc!lll'dQIIIIUniCoihl'q?am, Monoyll~luool tho AciUAI~olAccomp!!hmont, aod 50'J6olll>ecc...troct Amoon!, llhkbR.,iolowor
1. cos:h Pmvom (derived from lhe Monthly Physical Targets and c~h Pmg,.mmlng)
Ap<!l lCOt
M~ XU
Jlme XXX
~ ly X~
AUgtl$t lCOt
:iept~ be< xu
Total
2. MoMyValue afltl4 Phy,;lQ~t
Ga•emmmt-owned F•oHI.ly Physical T•'l XXX {Aprll to September No. <>f physl<:at t.arset x PSOO}
~nvateiy-Own«< Facility Physical T~ ______xxx=:.... {April to September No. <>f phy!lca! tqetx P750l
'II)TAl,
3. SU~ ofths~ntmctAmount
Contract Amount
M~IUplyby .!109i
LOWEST AMOUNT
4.1\dd/kiltractlhl Qo~V-e!Othe
lOWEST AMOUNT
Plus&tmhus the Ca;Jibtbn \l.iriartelt
RECOMMO~!>E O TO l!E RELEASED TOTH ~
-~ ..... . .
Page 1 of 1 of Annex D -3
Annex D-5: Capitation Fund Annual Performance Review
CAPITATION FUND ANNUAL PERFORMANCE REVIEW

NETWORK
Addtess:
Contract Reference
Number:
I. Compute for the Money Value of the Annual Actual Physical Accomplishment
No. of KonouU:o Rol!lstered Membecs with Fl"t P;d!ent&lcountrr 15,500

Perfllrm..,... Fatlllt 8991
60" of the Caplliltlon l'tlnd (PSDO) 300
10'1112. M""ey llolue
No. of Kon•ulla RoJism'"'d M&mbcrs with First prtl~nt Elltounbor 21,000

Pefformance F<lclt>r 9Z %
6Dlt oflh\!. c.pltatlo~ F<ond (P7sot 450
I!PIIIl Mon<)y Value
Mol'W!y V~lue of t~ Actual Phy5ltal Aa:om pllshmeflt
Ga"Yt'JT\ment.{)wned Facility 7,25G,BOO
Privately-Owned F<>cllfly 15,014,130
T¢11, Money Vallie of A«ual PhVslr.al Aalompllshment ~!1"i;164;93"i) :
Total l<onsulta ReleaSi!s: ~~~~

FJan~utded t.pltatlon 1 XI()(
fmnllollded Cljlltation 2 XXX
fmn~oiK!od t.pltojlon ~ XXX
lANCE
;
Annex D-6: Performance Factor Computation Form
PERFORMANCE FACTOR COMPUTATION FORM

Period Covered: _ _ _ _ _ _ to _ _ _ _ _ __
Name of Network:
Nework Accreditation No.:
RESULTANT SCORE Performanc

Acered e F actor
No. F acility Consultation (30%) Diagnostics (30%) Antibiotics (10%) NCD (30%)
No.
Target Actual Score T arget Actual Score T arget Actual Score Target Actual Score
Total
This form shall be collected per quarter
Prepared by:
Name/Designation / D ate

Annex D-7: Summary List of Beneficiaries Needing/Providing Konsulta Services
SUMMARY LIST OF BENEFICIARIES NEEDING/PROVIDING KONSULTA SERVICES

Period Covered: _ _ _ _ _ _ t o - - - - - - -
Name ofNetworl~:
Nework Accreditation No.:
Total
Tills fonn shall be collected per quarter
Prepared by:
N arne/Designation/ Date

Annex D-8: Detailed List of Beneficiaries Needing/Providing Konsulta Services
DETAILED LIST OF BENEFICIARIES NEEDING/PROVIDING KONSULTA SERVICES

Period Covered: _ _ _ _ _ _ to~-----
Name of Network:
NeworkAccreditation No.:
Total
This form shall be collected pet quartet
Prepared by:
N ame/Designation/Date

Annex D-9: Quarterly Physical Accomplishment Report
QUARTERLY PHYSICAL ACCOMPLISHMENT REPORT

Period Covered: to-----~-
PHILHEALTH REGIONAL OFFICE:

NETWORK:
Address:
1. GOVERNMENT-OWNED
FACILITIES
2
3
4
5
SUB-T OTAL
2. PRIVATELY-OWNED FACILITIES
2
3
4
5
SUB-TOTAL
GRAND TOTAL
Page 1 of 1 of Annex D -9
Annex D-10: Recapitulation on Membership Category Report
RECAPITULATION ON MEMBERSHIP CATEGORY REPORT

Period Covered: _ _ _ _ _ _ to _ _ _ __ _ _
PHILHEALTH REGIONAL OFF'ICE:

NETWORK:
Address:
· · ' *'' ' . •. . · .: . ~:<··· ; .
. ·. ·N o; ofRegiStered
Bellefiilicles Given
Dependent .
·.·s' .
2
3
4
5
2
3
4 Financiallj'-incapabie point-of-service
atients
SUB-TOTAL
GRAND TOTAL
Page 1 of 1 of Annex D- 10
(j
0
Annex D-11: SHF Financial Performance Report
(Target vs. Actual Income/Expenditures)
SHF FINANCIAL PERFORMANCE REPORT

(fARGET VS. ACTUAL INCOME/EXPENDITURES)
As of ________________
NETWORK
Address:
Contract Reference
Number:
REVENUE:
Financial Grants and Subsidies ftom National Government
Agencies
Income from PhilHealth Payments
Other Donations and Financial Grants
Other Fund Sources
Contribution from the LGU Health Fund (General Fund)
Cono:i.burion from the Component LGUs
Other Sources
TOTAL
LESS: EXPENDITURES
Population-Based Health Services

Individual-Based Health Services
Health Systems Oper:atirlg Costs
Capital Investments
Remuneration of Additional Health Workers
Incentives for All Health Workers
TOTAL
I
BALANCE
Prepared by: Certified Correct by:
Provincial/ City Accountant
i.3
·-- 0

Annex D-12: SHF Financial Performance Report
(Target vs. Actual Cash Receipts/Disbursements)
SHF FINANCIAL PERFORMANCE REPORT

(TARGET VS. ACTUAL CASH RECEIPTS/DISBURSEMENTS)
As of ________________
NETWORK
Address:
Contract Reference
Number:
Financial Grants and Subsidies from National Government

Agencies
Income from PhilHealth Payments
Other Donations and Financial Grants
Other Fund Sources
Contribution from the LGU Health Fund (Genera[ Fund)
Contdbution from the Component LGUs
Other Sources
TOTAL
LESS: DISBURSEMENT
Population-Based H ealth Services

Individual-Based Health Services
Health Systems Operat:inR Costs
Capital Investments
Remuneration of Additional Health Workers
Incentives for All Health Workers
TOTAL
BALANCE
Prepared by: Certified Correct by:
Provincial/City Accountant
0
0

Annex D-13: SHF Budget and Utilization Report
SHF BUDGET AND UTILIZATION REPORT
(BY USES OF FUND, EXPENSE CLASS, OBJECT OF EXPENDITURES)
As of _________________
NETWORK:
Address:
Conttact Reference Number:
MOOE
Sub-Total
2.. Individual-Based Health Services
MOOE
Sub-Total
3. Health Systems Operating Costs
MOOE
I
I
Sub-Total
4. O.pital Investments
CAPITAl. OU1LAY
I
Sub-Total
5. Remuneration of Additional Health
Workers
I PERSONAL SERVICES
Sub-Total
6. Incentives for All Health Workers
PERSONAL SERVICES
Sub-Total
,-;,:;_ ..
TOTAL ~
Certified Correct by:
Provincial/ City Accountant
Page 1 of1 of Annex D-13

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Republic of the Philippines

PHILIPPINE HEALTH INSURANCE CORPORATION

TO ALL PHILHEALTH MEMBERS, ACCREDITED HEALTH CARE

SUBJECT Implementation of a Primary Care Provider Network (PCPN)

( ) PhiiHealthofflcial ()Oteamphilhealth (i}ac:[email protected]

a. Test network contracting models in implementing and improving utilization and

t.J IV. DEFINITION OF TERMS

C. Innovation - refers to variations in elements of Konsulta service delivery, consistent

0 PhiiHealthoffidal OOteamphilhealth [email protected]

F. Pdmary Care Provider Network (PCPN) - refers to a group of Konsulta Providers,

G. Prospective payment3 - refers to a method of reimbursement in which payment is

H. Prospective provider payment4•5 - defined as the allocation of resources to a healthcare

I. Sandbox - a strategy for small-scale, live testing of innovations in a controlled

(}Phil Health official 00 teamphil health e [email protected]

Different LGUs/private providers have initiated or are already implementing strategies

1. Establishment of network of providers to deliver K.onsulta services to beneficiaries

2. Application of capitation as prospective payment mechanism prescribed in PC No.

4. Computation of PCPN physical targets and contract amounts, within prescribed

5. Integration of K.onsulta providers into a network with patient records accessible on

0 Ph11Healthofficial OOteamphllhealth [email protected]

7. Enhancement of Konsulta benefit implementation and utilization. This may include

A PCPN implementing any of the above stated interventions/innovations may be

0 Phil Health official O(!)teamphllhealth ii [email protected]

C. Application Processes and Requirements

1. Cities/Provinces, private or mixed public-private networks interested to participate

a. For cities/provinces, a copy of tripartite memorandum of agreement (110A)

b. For private networks, copies of the following supporting documents shall be

b.l. Security Exchange Commission (SEC) Registration or any document as

2. Complete documents shall be submitted to the PRO Accreditation and Quality

If the application is denied, PhilHealth shall inform the network of its

0 PhiiHealthofficial 00 teamphilhealt h ~ [email protected]

4. The setting of Konsulta implementation targets shall consider:

5. Payments shall be computed based on per capita amount prescribed in PC No.

6. The network shall commit to achieve the target of Konsulta beneficiaries,

C) PhiiHealthofficial ()c;)teamphilhealth [email protected]

1. Benefit Payment under UHC Act

Section 18 of the UHC Act mandates PhilHealth to shift to performance-driven,

2. Payment Arrangement for the PCPN (Financial aspect of the Konsulta

0Phi1Healt hoffidal OC)teamphllhealth [email protected]

The benefit payment arrangement is summarized below:

Parameters Payment Arrangement

• 0 PhlfHealthofficlal OC) teamphllhealth [email protected]

1. Eligibility and Registration of Filipinos to a Primary Care Provider Network (PCPN):

a. All Filipinos shall be eligible to avail of Konsulta benefit.

b. Each Filipino shall register to an accredited Konsulta provider of their choice.

c. The PCPNs, in coordination with PhilHealth, may adopt strategies to fast-track

d. The PCPN may also develop innovations to increase their registered

0 PhiiHealthofficial ()OteamphTihealth e [email protected]

g. All registered beneficiaries (existing and new) of the PCPN-AI<Ps shall be

2. Receipts, Allocation, Disbursements and Reporting of Capitation Fund through

d. Based on the locality's epidemiological proftle and extstlng service delivery

f. PCPN shall draft policies and procedures on charging, including menu of

0 PhiiHealthoffidal OQ teamphllhealth (i) [email protected]

n. The P /C Accountant, upon setting up of separate books of account and ledgers

3. Network Performance Monitoring and Assessment of the Intervention/Innovation

All approved interventions/innovations and sandbox sites should have a

0 PhiiHealthofficlal OC)teamphilhea!th e [email protected]

b. Monthly submission of reports on indicators as prescribed in Annex D shall be

a. Statement of Revenue Targets and Acrual Collections - For Public

r··- ~-------- :::~:::k j__~l:;J;;:~::~~fo~=. ~~~-

1 -~~t~;~;;- --- ·r::;:~::·tl~~~l =:,:·,~-<;,;ay -~r;o' b~- ·f;;~d ·;n-;,;~;no;~