Commitment Form

PC for Priv.
HSP
Revised August 2013
(Letterhead of Healthcare Provider)

(Date)
PHILIPPINE HEALTH INSURANCE CORPORATION
17th Flr., City State Centre Bldg.,
Shaw Blvd., Pasig City
SUBJECT
Performance Commitment for Single HCI
Sir/Madam:
To guarantee our commitment to the National Health Insurance Program (NHIP),
we respectfully submit this Performance Commitment.
And for the purposes of this Performance Commitment, we hereby warrant the
following representations:
1.
That we are a duly registered/licensed/certified health care facility capable
of delivering the services expected from the type of healthcare provider that we
are applying for.
2.
That we are owned by
__________________________________________________________ and managed by
_______________________________________________________________ and doing business
under the name of ______________________________________________ with
License/Certificate No. _____________________ .
3.
That all professional health care providers in our facility have proper
credentials and given appropriate privileges in accordance with our policies and
procedures.
4.
That our officers, employees, and other personnel are members in good
standing of the NHIP. Further, we hereby commit ourselves to the following:
5.
That, as responsible owner(s) and/or manager(s) of the institution, we shall
be jointly and severally liable for all violations committed against the provisions of
Rep. Act No. 7875 including its Implementing Rules and Regulations (IRR) and
PhilHealth policies issued pursuant thereto.
6.
That we shall promptly inform PhilHealth prior to any change in the
ownership and/or management of our institution.
7.
That any change in ownership and/or management of our institution shall
not operate to exempt the previous and/or present owner and/or manager from
liabilities for violations of Rep. Act No. 7875, and its IRR
8.
That we shall maintain active membership in the NHIP as an employer not
only during the entire validity of our participation in the NHIP as a Health Care
Institution (HCI) but also during the corporate existence of our institution.
9.
That we shall abide with all the implementing rules and regulations,
memorandum circulars, office orders, special orders, and other administrative
issuances by PhilHealth affecting us.
10. That we shall abide with all administrative orders, circulars and such other
policies, rules and regulations issued by the Department of Health and all other
related government agencies and instrumentalities governing the operations of
HCIs in participating in the NHIP.
11. That we shall adhere to pertinent statutory laws affecting the operations of
HCIs including but not limited to the Expanded Senior Citizens Act of 2010 (R.A.
9994), 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.
12. That we shall promptly submit reports as may be required by PhilHealth, DOH
and all other government agencies and instrumentalities governing the operations
of HCIs.
13. That we are duly capable of delivering the following services for the duration
of the validity of this commitment (please check appropriate boxes):
Primary Care Facility
Level 1 hospital services
Specialized services
Radiotherapy
Hemodialysis/Peritoneal Dialysis
Others (please specify)
___________________________________
_________________________________________________
Benefit package and other services
Tuberculosis Directly Observed Treatment Shortcourse

(TB DOTS)
Maternity Care Package
Newborn Care Package
Malaria Package
Primary Care Benefit Package 1
Outpatient HIV/AIDS Package (for DOH identified
hospitals only)
Animal Bite Package
Others(please
specify)____________________________________
________________________________________________
14. That we shall provide and charge to the PhilHealth benefit of the client the
necessary services including but not limited to drugs, medicines, supplies, devices,
and diagnostic and treatment procedures for our PhilHealth clients.
15. That we, being accredited government/MCP facility, shall provide the
necessary drugs, supplies and services with no out-of-pocket expenses on the part
of the sponsored member in the NBB bed/all types of members in the MCP
provider as mandated by the PhilHealths No Balance Billing (NBB) Policy.
16. That we shall maintain a high level of service satisfaction among PhilHealth
clients including all their qualified dependents/beneficiaries.
17. That we shall be guided by PhilHealth-approved clinical practice guidelines
or if not available, other established and accepted standards of practice.
18. That we shall provide a PhilHealth Bulletin Board for the posting of updated
information of the NHIP (circulars, memoranda, IEC materials, price reference
index, etc.) in conspicuous places accessible to patients, members and dependents
of the NHIP within our health facility.
19. That we shall always make available the necessary forms for PhilHealth
member-patients use.
20. That we shall treat PhilHealth member-patient with utmost courtesy and
respect, assist them in availing PhilHealth benefits and provide them with accurate
information on PhilHealth policies and guidelines.
21. That we shall ensure that PhilHealth member-patient with needs beyond our
service capability are referred to appropriate PhilHealth-accredited health
facilities.
22. That we shall maintain a registry of all our PhilHealth members-patients
(including newborns) and a database of all claims filed containing actual charges
(board, drugs, labs, auxiliary, services and professional fees), actual amount
deducted by the facility as PhilHealth reimbursement and actual PhilHealth
reimbursement, which shall be made available to PhilHealth or any of its
authorized personnel.
23. That we shall maintain and submit to PhilHealth an electronic registry of
physicians including their fields of practice, official e-mail and mobile phone
numbers.
24. That we shall, if connected with e-claims, electronically encode the drugs and
supplies used in the care of the patient in our information system which shall be
made available for PhilHealth use.
25. That we shall ensure that true and accurate data are encoded in all patients
records.
26. That we shall only file true and legitimate claims recognizing the period of
filing the same after the patients discharge as prescribed in PhilHealth circulars.
27. That we shall submit claims in the format required by PhilHealth for our
facility.
28. That we shall regularly submit PhilHealth monitoring reports as required in
PhilHealth circulars and the PhilHealth Benchbook.
29. That we shall annually submit to PhilHealth a copy of our audited financial
statement/report.
30. That we shall extend full cooperation with duly recognized authorities of
PhilHealth and any other authorized personnel and instrumentalities to provide
access to patient records and submit to any orderly assessment conducted by
PhilHealth relative to any findings, adverse reports, pattern of utilization and/or
any other acts indicative of any illegal, irregular and/or unethical practices in our
operations as an accredited HCI of the NHIP that may be prejudicial or tends to
undermine the NHIP and make available all pertinent official records and
documents including the provision of copies thereof; provided that our rights to
private ownership and privacy are respected at all times.
31. That we shall ensure that our officers, employees and personnel extend full
cooperation and due courtesy to all PhilHealth officers, employees and staff during
the conduct of assessment/visitation/investigation/monitoring of our operations as
an accredited HCI of the NHIP.
32. That at any time during the period of our participation in the NHIP, upon
request of PhilHealth, we shall voluntarily sign and execute a new Performance
Commitment to cover the remaining portion of our accreditation or to renew our
participation with the NHIP as the case may be, as a sign of our good faith and
continuous commitment to support the NHIP.
33. That, unless proven to be a palpable mistake or excusable error, we shall take
full responsibility for any inaccuracies and/or falsities entered into and/or reflected
in our patients' records as well as in any omission, addition, inaccuracies and/or
falsities entered into and/or reflected in claims submitted to PhilHealth by our
institution.
34. That we shall comply with PhilHealths summons, subpoena, subpoena duces
tecum and other legal or quality assurance processes and requirements.
35. That we shall recognize the authority of PhilHealth, its Officers and personnel
and/or its duly authorized representatives to conduct regular surveys, domiciliary
visits, and/or conduct administrative assessments at any reasonable time relative
to the exercise of our privilege and conduct of our operations as an accredited HCI
of the NHIP.
36. That we shall comply with PhilHealth corrective actions given after
monitoring activities within the prescribed period.
37. That we shall protect the NHIP against abuse, violation and/or over-utilization
of its funds and we shall not allow our institution to be a party to any act, scheme,
plan, or contract that may directly or indirectly be prejudicial or detrimental to the
NHIP.
38. That we shall not directly or indirectly engage in any form of unethical or
improper practices as an accredited health care provider such as but not limited to
solicitation of patients for purposes of compensability under the NHIP, the purpose
and/or the end consideration of which tends unnecessary financial gain rather than
promotion of the NHIP.
39. That we shall immediately report to PhilHealth, its Officers and/or to any of its
personnel, any act of illegal, improper and/or unethical practices of HCI of the
NHIP that may have come to our knowledge directly or indirectly.
40. That we shall allow PhilHealth to deduct from our future claims, all
reimbursements paid to our institution during the period of its non-accredited
status as a result of a gap in validity of our DOH LTO, suspension of accreditation,
etc; downgrading of level, loss of license for certain services including any and all
other fees due to be paid to PhilHealth.
Furthermore, recognizing and respecting its indispensable role in the NHIP, we
hereby acknowledge the power and authority of PhilHealth to do the following:
41. After due process and in accordance with the pertinent provisions of R.A. 7875
and its IRR, to suspend, shorten, pre-terminate and/or revoke our privilege of
participating in the NHIP including the appurtenant benefits and opportunities at

any time during the validity of the commitment for any violation of any provision of
this Performance Commitment and of R.A. 7875 and its IRR.
42. After due process and in accordance with the pertinent provisions of R.A.
7875 and its IRR, to suspend, shorten, pre-terminate and/or revoke our
accreditation including the appurtenant benefits and opportunities incident thereto
at any time during the term of the commitment due to verified adverse
reports/findings of pattern or any other similar incidents which may be indicative
of any illegal, irregular or improper and/or unethical conduct of our operations.
We commit to extend our full support in sharing PhilHealths vision in achieving
this noble objective of providing accessible quality health insurance coverage for
all Filipinos.
Very truly yours,
Local Chief Executive
Chief of Hospital/Head of Facility/

Manager

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PC for Priv.

Revised August 2013

(Letterhead of Healthcare Provider)

Performance Commitment for Single HCI

Tuberculosis Directly Observed Treatment Shortcourse

participating in the NHIP including the appurtenant benefits and opportunities at

Local Chief Executive

Chief of Hospital/Head of Facility/

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