Republic of the Philippines

Phil Health
Your Partner iu Jlenftll
PHILIPPINE HEALTH INSURANCE CORPORATION
9 Cltystate Centre, 709 Shaw Boulevard, Paslg City
C.. (02) 8662· 2588 @www.philhealth.gov.ph
.IJAOOHO P/Mf>ltiA$ 0 PhiiHealthOificial }( teamphllhealth

· .To ALL ·FILIPINOS, ACCREDITED HEALTHCARE

INSTITUTIONS/ .PROVIDERS, PHILHEALTH REGIONAL
OFFICES, BRANCHES, LOCAL HEALTH INSURANCE
OFFICES AND ALL OTHERS CONCERNED

SUBJECT Implementing Guidelines for the PhilHealth

. Konsultasyong Sulit at Tama (PhilHealth. Konsulta)
Package (Revision ,1)

I. RATIONALE

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

cai·e, PhilHealth has committed through PhilHealth Board Resolution No. 2479, S.
. . . 2019 to expand the primary care benefit to cover all Filipinos. The resolution
'i ! .·,,.;. ' :::· · ,~L ' mandated the···issuance··of ·PhilHealth Circular (PC) No. 2020-0002 entitled
". :·.: ,..,; .· .. , .. .~'Governing Policies of:the .PhilHealth Konsultasyong Sulit at Tama (Ko~sult~) . ....
_. . _ .. . : · · ·Package: Expansion of the Primary Care Benefit to cover all Filipinos". Section IV.B.
· .. - · .. · ·.. ··of the aforementioned policy requires the issuance of applicable rules for member . ·
. . , ·.'. ·.-, .:registration and·.assessment, service package, benefit availment, proVidei: ]?ii);rnenf. .., -· ·
· ·· , · ·, ·· mechanism and provider performance assessment.

·' "' . .. , : .·: ....~ ·.··.:. ,.., .J'.ursuantto Phill-Iealth CircUlar No. 2022-0032 entitled, "Governing Policies of the ... . ·•
Konsulta+", the current Phil Health Konsulta package shall expand its .benef1t
· · ·· , ...... ' . . . coverage to ·encompass other primary care services in preparation for Konsulhl+; ·
· · .. - PhilHealth Konsulta Package Providers (KPPs) shall also act as the chief facility . ·
among its affiliated facilities at primary care.level, respon.sible foi· patient navigation
to ensure first-contact, continuing and comprehensive care for all persons who are
either diagnosed or undiagnosed, presenting ·with any health concern. PhilHealth
Konsulta shall also be a platform, in cooperation 'VIrith DOH health promotion
pt;ograms and campaigns, to promote positive health behaviors to its community of
patients.

OBJECI'IVES

The policy aims to enable access to primary care by adopting a responsive financing
mechanism for the delivery of quality primary care services and commodities. _ ·..
Likewise, it aims to define the PhilHealth Konsulta benefit package and proVIde · ··· to
specific guidelines on registration to a primary care provider, benefit availment,
applicable payment mechanism, reporting rules and performance assessment.

An overview may be seen in Annex A: Overview of PhilHealth Konsulta Actors and

Processes. '
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 III. SCOPE

,-; This PhilHealth Circular covers the implementing guidelines of the PhilHealth
Konsulta in its transitional phase towards implementation of Konsulta+, a
1I .
comprehensive outpatient benefit as mandated by the Universal Health Care Law.

IV. DEFINITION OF TERMS

A Balance Billing/Co-Payment Cap - the maximum amount set by

PhilHealth that a KPP can charge a, patient at any given year.

B. Balance Billing/Co-Paytnent Schedule- the amount charged by a KPP

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

C. Capitation1 - a provider payment mechanism where providers are paid a fixed

amount prospectively to provide a defined set of goods and services for each
enrolled individual for a fixed period of time, regardless of the goods and
services actually provided which is influenced by particular characteristics of
individuals that influence their health as pa1t of the estimation of the payment.

D. Catchment Population- the population within a geographical area defined

and served by a healthcare provider network. For purposes of this PhilHealth
Circular, the PhilHealth Konsulta catchment population shall mean all eligible
beneficiaries who are currently registered to a KPP. ·
7
-.. . E. '-cream-Skimming ... in the context of PhilHealtb Konsulta, it is a situati~n-- .:<-::·:
.- wher.ein KPPs selectively. perform registration and/ or first patient encoi..tn:ters
~:.·::::;·.
... . (F.PE) for individuals who are at low-risk for health conditimis. This avoids lhe -·~.-~· '
-. · ·- empanelment of individuals more likely to require provision of care, which, .. · / ' ·
_. . ... _. . __. . ·\.\•hile resulting·in lower utilization of capitation provided by PhilHealth, will
, .. .. . .- ·.· ;.; ::· ·-·-.:·: defeatthemain purpose-of primary healthcare which is to improve population
· .._. ·· · ,.,_,._.· ·· , ··· · ··· ·-·· ·.. :, :·health outcomes. His sometimes referred to as "cherry picking".

.
-· r--..-~1itt
· ' ·
.:
.· . . - · ~ ·· · F. ·· .Electronic Konsulta (eKonsulta) - a PhilHealth developed web-based. _.. ·
stand-alone application which may be used by tlu~ Konsulta facility· ·as 'a n .-: · ..;:.
interim electronic reporting system. This can be used for encoding of encounter
: ~. data records to include diagnosis, diagnostic tests done with corresponding
0::: .$ results and prescribed/ dispensed medicines.
w>- 8
~;; ~ 'G. Electronic Medical Record (EMR) - the electronic record system or the
"1' f..J electronic document of a patient's encounter in one health facility. In this case,
:i the patient's medical or health · record at a health facility is being received,
· recorded, transmitted> stored, processed, retrieved or produced electronically
u through computers or other electronic devices.
0

H. ._ Eligible Beneficiaries - all Filipinos given imniediate eligibility · in ··- ·•

accordance with Republic Act No. 11223 and its Implementing Rules and ·
Regulations (IRR), as well as other qualified Phil Health beneficiaries. ·

I. Empanehnent - also referred to as "rostering", is the identification and

assignment of populations to specific healthcare facilities, teams, or -providers
I Phi!Health Circular No. 2022-0032: Governing Policies of the Konsulta +
:Page 2 of 12
 who are responsible for the health needs and delive1y of coordinated care in
that population (WHO, 2020) .

J. First Patient Encounter (FPE)- initial episode of patient contact for the
year .whereby a primary care provider takes and/ or updates the basic health
data of an eligible beneficiary to identify their health risks. The FPE is not a
medical consultation.

K. Individual~Based Health Services- services ·which cari·be accessed within

a health facility or remotely that can be definitively traced back to one (1)
recipient. These include the provision of consultation services, diagnostics, and
commodities (RA 11223).

L Maximum Catchment Population - the maximum number of registered

beneficiaries in an area that can be served by a facility based on the doctor to
population rat'io as defined by the Department of Health.

M. Patient Encounter - subsequent individual episodes of care after the first

patient encounter provided by a primary care provider which are then duly
rep01ted to PhilHealth on a regular basis.

N. Patient Navigation - the function of a primary care proVider as the first

point of contact for patients to coordinate and direct the individual to the
appropriate healthcare provider of a particular level of care, to obtain health
· services needed to manage a wide range of health needs .

.: 0; ·. ·: Performance-'Based.Payment - a method where payments to provider$ . : .: ...:.,;

..are linked to the achievement of pre-specified pmformance targets.. ·- · · · . .
~,.. , •, •· '~ . .. " ....·.. _, . .:~ ... ;: ~-~- :····.
·P. ; :Social Mai-lc.eting - in public health, this should not be ·confused with "··--·'··
· commercial marketing- activities intended to market health products ·and .
.. .services -for the profit of private shareholders (Birkinshaw, 1989). Its objective
..,. .. ,, ., ·.-,, ·, .,.,. · ··· · ···· · is to promote public health, help avoid adverse selection and its goal is improve ·
. . - ... .. . ' .. - ....
'~
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health for all. Its strategy is therefore predominantly preventive.

It is the application of principles and techniques drawn from the commercial

sector to influence a target audience to voluntarily accept, reject, modify, or
abandon a behavior for the benefits of individuals, groups, organizations, or
society as a whole (ADB).

Q. Social Mobilization - the process of bringing together all possible

intersectoral partners and allies to participate in development programs. It
aims to empower individuals and communities to identify their needs, their
rights, and their responsibilities, change their ideas and beliefs, and organize
(.) the human, material, financial arid other resources required for social economic
c
development. It is an approach that provides individuals and groups v,rith
.knowledge and skills,.and mediates betvveen different interest groups to create
environments that support and promote health (WHO, 2001).

R. Telen1edicine2 - the delive1y of healthcare services, where distance is a

critical factor, by all healthcare professionals using information and

JointAdministrative Order No ..2 o 2 1- 0 0 01: Guidelines on the Implementation of Telemedicine in the

...2
Delivery of Individual-Based Health Services ·
Page 3 of 12
 ·communication technologies for the exchange · of valid information for
diagnosis, treatment and prevention of disease and injuries, research and
evaluation; and for the continuing education of healthcare providers, all in the
interests of advancing the health of individuals and their communities. (WHO)

S. Updating of Registration - retention or transfer of an eligible beneficiary

from one PhilHealth Konsulta Provider to another.

V. POLICY STATEMENTS

A Eligibility, registration, and assignment to an accredited PhilHealth Konsulta

Package Provider (KPP)

t All Filipinos and other qualified PhilHealth beneficiaries shall be eligible to

avail of the PhilHealth Konsulta benefit.

2. Registration and assignment of beneficiaries to a Phil Health KPP of their

choice in consideration of the maximum catchment population shall be
done through the following mechanism:

a. Member-Initiated Registration

An online platform shall be provided to enable beneficiaries to register

to their preferred Konsulta facility anytime and anywhere.

b. Philfiealth-Assisted and Initiated Registration

:· ~ .. ·. ·PhilHealth shall assist in registering beneficiaries to a KPP through its
Local Health Insurance Offices (LHIOs), PhilHealth Customer
· Assistance, Relations and Empowerment-staff (PCARES), PhilHealth
Action Center and other avenues as may be determined by the ·
·Corporation.
. ..~ i

c. Third-Party Assisted Registration.

·c.1. Konsulta regish·ation partners, which include but are·not limited :."·.:~:.::
to KPP, the Local Government Units (LGUs), private and
government Health Facilities (HFs), employers, educational
institutions, Organized groups, and other government and private
. institutions, shall be authorized to assist in registering
beneficiaries to their preferred KPPs through any of the following
means:

c.1.1. Automated transmission of records using Application

Programming Inte1face (API) for partners with available
PhilHealth ce1tified application systems or databases of their
respective beneficiaries, provided that these partners;
..
o· . together with the beneficiaries, shall also · accomplish ·
0 PhilHealth Konsulta Registration Form (Annex B: PhilHealth
Konsulta Registration Form);

c.1.2. Adoption of PhilHealth registration systems intended for

external users;
Page 4 of12
 c.1.3. Submission to PhilHealth of the lists of beneficiaries in XML
or-· excel format with duly accm;nplished PKRF. The said lists
shall be processed in batches using a script or applicable
. internal application system.

c.1-4. Konsulta registration partners shall accept any and all

beneficiaries v,rho will present themselves for registration
· which, if needed, may be done in the same visit as for the first
patient encounter.

. c.2 Interested parties are required to submit a Letter of I~tent (LOI) to

the concerned PRO/LHIO for its evaluation and approval.

3- · Registration of eligible beneficiaries to an accredited KPP shall be guided by

the following:

a. All accredited KPPs shall be published. in the PhllHealth website;

b. Eligible beneficiaries may check the PhilHealth website for information
on their preferred KPP including but not limited to their location,
balance billing/co-payment schedule, and balance billing/co-pay cap;
c. Filipinos not yet registered with the National Health Insurance Program
(NHIP) can register in accordance with existing PhilHealth policies and
procedures.

· .:. ~ ·; .:.': ::·,· .. ,., ,, .,,.,·: .·.=.\: ,;,·.,- ~4 , T1·ansferto another.KPP shall be allowed subject to the following coi1ditions __ . ,
· · . . ,_. , ; ': -: , ... · and the :beneficiary shaH accomplish the PhilHealth Konsulta Registration
Form (Annex B: PhilHea1th Konsuli:a Registration Form) .. · ·. · . _..
-. . . . •. -. ·- ., :'· ;-- . -........:;: .• ·: . .•~ ., ·o:-"; . . - : ' :;, ' :.... •. . •. .••.

a. Within the cui-rent year:

,a.l.Transfer shall be allowed from one KPP to another if the . .

.... _ •• • • , · • : - ~ - ~- 0 • -. •• • • •
. ·.....beneficiary . has not yet availed. of the First Patient Encow1ter
(FPE).

a.2.In the event that a beneficiary's current KPP ceases opetation due .
to circumstances beyond its control and through no fault of its
own, the beneficiary' may transfer to a new KPP of their choice who
shall be allov,red to render a new FPE for the remainder of the year.
The new KPP is entitled to receive the capitation due it, according ·
to this PhllHealth Circular.

a.3.In the event that a beneficiary's current KPP ceases operation due
to negligence; fault; or ·withdrawal, non-renewal, or suspension of
accreditation, PhilHealth shall institute payment recovery
measures for any capitation already paid, subject to just
compensation for the time period it was operating in conipliance ·: .•
with and faithful to this PhilHealth Circular. The beneficia1y may ::.··.·..· .
transfer to a new KPP of therr choice who shall be allowed to ·
render a new FPE for the remainder of the year. The new KPP is
entitled to receive the capitation due it, according to this
PhilHealth Circular. For succeeding year, transfer or updating of

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 registration to another KPP shall be done in the last quarter of the
current year.

s. KPPs shall be allowed to conduct social mobilization and social marketing

to promote the PhilHealth Konsulta benefit. Promotional activities include,
among others, oral presentations, social marketing campaigns, and posting
and distribution of written information, education, and communication
materials. KPPs shall coordinate with PhilHealth PROs for branding and
communication guidance.
. . .
6. The maximum catchment population shall be subject to PhilHealth
assessment and approval based on the health human resource to population
ratio as stipulated in the accreditation policy of PhilHealth KPP. The
counting of the current catchment population already empaneled with the
KPP, whkh determines if a KPP can still accept additional beneficiaries,
shall be based on the actual count of FPE done.

7· KPP shall regularly check for updates on the registration master list through
appropriate application systems. The master list shall be downloaded from
the HCI Portal and then uploaded to an appropriate PhilHealth-certified
EMR System, as may be applicable. In areas where. there is slow or no
internet connectivity, the dm"7llloading of PhilHealth Konsulta registration
master list shall be. done at the Local Health Insurance Office (LHIO} and
shall be forwarded to the KPP on a regular basis.
. . . ..
:; ;- ; ., ; ~ ;
.. .. 1 ;, B. Phil Health Konsulta Benefit Package Content

., ·.-..,. .· ·' ·"" · ··· . .. ~:: ·:·. ··"·].; . :The PhilHealth Konsulta package covers individual•bascd health seivices ·.- . o,.;
. . . . .·. ... .. , . ·.: , -including health screening as part of the first patient encounter (FPE)
..·. . .. .. .. · · .... ... ... · ·· .followed by initial primruy care consultation, access to selected diagnostic· ·· ·
· ·· " ..... · · ";··:::: ·"·· ·" ·.. " .. services, and medicines (Annex C: PhilHealth Konsulta Benefit Table) as
.. ... . . . .. .. · ··· · · · ·· ·· part of the complete package, according to the KPP physician's assessment;
·· and any follow-up consultations as may be medically necessmy.

· 2. Access to -select diagnostic services (Annex C) and medicines (Annex D:

Checklist of PhilHealth Konsulta Drugs and its . Preparations ·· as of · · ·.
September 2022 and Future Iterations Thereof} will be based on the health
needs of the patients assessed by the KPP physician during consultation;
and shall be subject to rules of the Corporation on benefit availment.
~
r- .::..'"<;;: 3 KPPs may· implement innovations such as integration and use of
telemedicine in the delivery of the se1vices to ensure that their catchment

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.......
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population has access to all services. These innovations must be lawful and
not contrary to existing policies of the DOH and PhilHealth, including any
requirements for health technology · assessment (HTA), as may be
applicable, in accordance with law. The adopted innovations as may be
. ..
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· reflected in the Performance Commitment shall not replace accreditation :
standards stipulated in the PhilHealth Konsulta accreditation policy and .·...: ...

l____g.
. shall be subjected to the same benefit availment process, and provider ·
. payment scheme provided for in this policy.

.. .. - ··· . 4 KPPs shall perform patient navigation. KPPs shall continually serve as the
initial point of contact for the eligible beneficiary in accessing health
Page 6 of 12
 serviCes ·w ithin the healthcare provider network (HCPN) to which the KPP
belongs. Where there are no HCPNs yet, the KPP shall do its best to navigate
the :beneficiary to the highest quality care needed at th~ least cost possible. ·

s. KPPs shall perform preventive health services such as health screening and
assessment according to the life stage and health risks of individuals in their
catchment population (Arinex E: List of Preventive Health Services Based
on Lifestage Guarantees).

6. The services included in this package will be reviewed and improved

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

C. PhilHealth Konsulta Benefit Availment Process

1 The conduct of the FPE V1rithin the first year of registration shall be the
shared responsibility of the KPPs and all newly registered eligible
. beneficiaries.

The following may render an FPE on behalf of the KPPs:

a. Barangay health workers (BHWs) of th~ barangay health stations (BHS)

under supervision of the accredited KPP;
b. Nurses and midwives ofthe BHS and/or RHU of the accredited KPP;
-···· .,. _,_. __,.__.-..- ... ' ·' - ,,· ·:'c;·Medical clerks -or interns authorized by their training institutions and
=. • , . --·: · , ., · under supervision of the accredited KPP;
... .. -.. , < > . ~--: · ' ,--.-:-: , ,- . -· ·,--·d:· Nurses of oi1-site clinics of employers \\rith accredited KPP; or ·.
e. Physicians of accredited KPPs. --- - '· .. -· .,....... _. ,.. .

. . . . .._.: .. ,_ .. . .-.. ,.. , . , . , . : ·_._. :. :·.2. . .. KPPs and all eligible benefiCiaries shall follow_the.b enefit availinentprocess
·· ·,.···
... . . . ______ __ ..... . :-set· forth ·by the Corporation and fill-out Request for Authorization .
..,..- · ,._, : ..•~,::·..-. ,. ·-· .. - Transaction Code · (Annex F: PhilHealth Konsulta Benefit Availment
.. · · .... --. :-.-·-·.:·:: : :..-..·- ' ·. ::. ·-Process) ..If an authorization transaction code (ATC) is not available; a photo . · ·
... tal{en-on the spot may be used in lieu of the ATC. Consent to tal<:e a photo
· :· ·· .-·...· · · must be secured·from Konsulta beneficiaries (Annex G: Sample Template . ··
for Photo Consent).

In consideration of Konsulta services pmvided to the beneficiaries, FPEs

conducted from January 1, 2022 onwards may be paid; provided that the
beneficiaries were registered to that KPP within the same year. Only then,
these beneficiaries will be included in the computation of Staten1ent of
· Accounts Payable 1 (SAP1). · ·

-
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· 3- KPPs shall generate and print the Electronic Konsulta Availment Slip
(EKAS) immediately after each patient encounter and Electronic
Prescription Slip (EPRESS) for prescribed medicines (Annex H: Electronic
---Konsulta Availment Slip (EKAS) and Electronic Prescription SHp (EPRESS).-· ., _,_.

Only in situations where the system-generated EKAS and EPRESS are not
(..) available, the KPP may accomplish blank EKAS and EPRESS, in duplicate
0
copies, both to be signed by the Konsulta beneficia1y . One copy shall be
given to the Konsulta beneficiaty and the other copy shall be encoded later .
. on. -There is no need to attach a printed -EKAS and EPRESS to the generated
·Page 7 of 12
 SAPs.

4 All eligible beneficiaries.availing of the benefit shall provide feedback and

sign the EKAS and/ or EPRESS after every transaction or affix thumbmark
if the Konsulta beneficiary is unable to wTite or sign the EKAS and/ or
EPRESS. For minors, the parent-member or guardian shall sign the EKAS
and/or EPRESS.

s. The KPP shall _submit only the accomplished reply slip v.rith brief
anonymous patient satisfaction survey to PhilHealth on or before wth
working day of the succeeding month following the applicable quarter. A
secured drop box or other similar means of collection may be used at the
point of care, to be submitted to PhilHealth. KPPs shall give the rest of the
_EKAS and/ or EPRESS to the beneficiary for their record.

6. Beneficiaries who avail _of their Konsulta services where they are registered
shall be entitled to benefits herein. Should beneficiaries opt to avail from
other KPPs where they are not registered, or other primary care providers
which are not ICPPs, or laboratoryI diagnostic and/ or pharmacy service
providers not engaged by KPPs, they may be subject to out-of-pocket
charges.

D. Provider Payment Mechanism .

-:--: ...... ·- 1 · ·- T~e benefit shall be paid as an annual capitation computed and released as ·
. '· .- · . ·, '" a performance- based payment. The maximum per capita amount for ... · ·
·:.. _. ·Ko:ilsulta shall be at Php soo.oo and Php 75o".oo for gov~rnment .-and ,: .:,
private facilities, respectively. - : . . ... . .......,
.,
- ·' ·- . .. - .... ... · - .. . .·... 2. · The .- firsttranche .for the succeedii1g years of retained beneficiaries· will be '-·,>>
· · ·· .. -- - .. •paid in full without need for another FPE, provided that the KPP conducted ·· ·-- ·
-.-. ·.::;; ·· .. .. .. ,. -- ,; -· .·:·-- -·: ::·::at least one medical consultation for the beneficiary within the preVious ··- ·
·. · ·· · .. _-- _~ :·." · · ··- ··: :.... year. Ifthe KPP did not conduct at least one medical consultation within th~ .. · ''
'. :·:·:: ·.. ·. :~ :' -::· ~::.·.· -·: ···- :·:. -.-- ·-previous year, a newFPE must be performed in the succeeding year to avail .::
of the first tranche of capitation payment.

This is an incentive for the KPP to facilitate empanelment of primary care

catchment population. Retention of beneficiaries is in itself a key feature of
primary healthcare. This allows for better quality of care, as the KPP
becomes familiar with the medical history and course.
- ~
3- Relative to this, the facility shall receive the 40% capitation which serves as
an incentive for retaining its registered Konsulta beneficiaries · and
providing primary care. However, if the beneficiary opts to transfer to
another KPP the following year, the conduct of a new FPE is necessary.

c4 Capitation rates shall be set by the Corporation and shall be paid in tranches
(Annex I: Approved Benefit Payment and Balance Billing/ Co-Payment/ Cost
Sharing Schedule).

(,) s. The capitation rate, tranches, and performance targets shall be periodically
c reviewed by the Corporation for modification and adjustments. · ·

PageS of12
 6. PhilHealth shall pay using the Auto-credit payment scheme (ACPS). In the
three months after effectivity of this Phi/Health Circular, KPPs who are still
.in the · process of setting up ACPS shall be allowed check payments.
Hencefcnth, ACPS compliance shall be part of the initial activities of the
newly accredited I<PPs, not to exceed three months.

7· KPPs may charge fees for services and commodities not included in the
benefit package. Service providers contracted by the I<PPs are prohibited
from charging fees from beneficiaries directly, and shall send their bills to
the KPPs who .contracted them. Provision of services and commodities
outside the package \o\rith their corresponding rates shall still be encoded in
theEMR.

8. KPPs shall comply with the obligations identified in the KPP's performance
commitments and balance billing/co-payment/cost sharing mles stipulated
in this issuance, its annexes, and all other applicable issuances, such as
among others:

a. The number of consultations/visits to a .KPP shall be as needed by

patients according to their health risks as assessed by a KPP physician;
b. The diagnostic procedures to be performed and medications to .be
dispensed (including, among others, year-round supply of maintenance ·
medications) shall be as medically necessary to improve the health of the
patient.
,.... ····-. . -- -·· . -- ·· ..,..... c. Private KPPs shall be allowed to charge a balance billing/ co-payment
· -··- .'· . : ·,. , ; ··.: '··-. ,...; ·· · - · cap of Php -soo.oo per annum per beneficiary (Annex I :Approved
-· ·· ·· · ··Benefit · Payment and Balance Billing/ Co-payment/Cost . Sharing · ·
. . ·. , . . .Schedule) for services in the PhilHea1th Konsulta package; .. '· ·· ..
· : .. . · d. Private KPPs are allowed to design their own balance billing/co- .. ,
· - payment/ cost sharing schedule as long as it will not exceed the co- .....,·. ·
. .. payment cap. . The balance billing/co-payment schedule should-- be .-
-' . . ' . ..: . ·. . . . ...
~: .' _ . :. . · ·.- ·. ·· ·· ·.:. agreed upon with Phil Health and shill be included in their performance
commitment;
" i. · . . -·. ;·.·. ·· . , · -. ·: -e, ;Private KPPs shall inform their catchment population of the balance... .. ··--
billing/co-payment cap and balance billing/ co-payment/cost sharing - .
schedule and post the balance billing/ co-payment schedule at visible
areas on their facility; and, ·
f. Existing PhilHealth policies on balance billing/co-payment/ cost sharing
shall apply to all eligible beneficiaries registered in a government KPP.

9· In cases where eligible beneficiaries are temporarily transferred by a KPP to

another facility for reasons including but not limited to ·the inability to
provide services due to staffing shortages within the period of accreditation,
the referring facility shall cover the cost of care to the referral facility for the
period of the transfer. Payment arrangements shall be defmed and resolved
between the referring and referral facilities and shall be at no added cost to
.. the eligible beneficiaty and to PhilHealth in covering for services included ,_, _,. ;·

(.) in the pacl~ge .

0
10. In case of any disagreement vvith the computed reimbursement, existing
guidelines on appeal and motion for reconsideration (MR) shall apply .
..• ·:-.' •'• "< : .•

, .·.~' · '· :.:: :.=.:: · '.'· 11 Existing legislations and regulations that endow privileges and discounts to
Pageg ofl2 . ·
 specific segments of the ·population, including senior citizens and PWDs,
· shall be applied t6 the. balance billing/co-payment/cost sharing for
PhilHealth Konsulta services~

E. Disposition and Allocation of the Capitation

1 Capitation payments shall be utilized to cover all essential services,

. medicines provided for in this Philiiealth Circular and other operating
expenses to supp01t delivery of healthcare including but not limited to
engagement of additional personnel (e.g. physician, dentist, nurses,
pharmacist, midwives, etc.; and also non-beathcare workers such as
encoders, among others), internet subscription, IT service provider
subscription fee and hardware .. Any remaining fund may be utilized as
performance incentives for primary care workers and shall be governed and
determined by the internal guidelines of the PbilHealth KPP. PhilHealth
shall not prescribe
. how performance incentives will be shared or disbursed.
.

2. For public/government KPPs, the share of performance incentives shall be

defined through an approved Sanggunian resolution or any similar
issuance. For the Bangsamoro Autonomous Region in Muslim Mindanao
(BARMM), certification for the creation of a ledger, trust fund, or equivalent ·
shall be issued by the DOH-BARMM.

PhilHealth shall not prescribe or differentiate facility and professional fee

. . ·.:sharing, in accordance vvith Section 18(b) of R.A. 11223. Government KPPs
• • • • . .... -~ ; . • - . '! ~:- ': ; • ••
shall cieate aledger to· account for the utilization of Phil Health Konsulta . . .
funds. · . · ::

·. . - ..
. ··--··· . . · ····- .
..
·:
, · .~ .- .' 3- . For -private KPPs, the share of pe1formance incentives sha1Lbe :defined - .
· ·· · · ·. · ·· , · through their internal policies in accordance with their management. · ..· - .... ··
.. . ;. - .._ ~
-4 · For capitation ·payments, existing PhilHealth policy on late filing of claims
·shall .apply -in handling submissions of patient encounters beyond the
prescribed period.

Handling Health Data ·.· , ..·

F. . ~

1 All health data shall be encoded in the Phi1Health-certified application

systems for electronic transmission to Phil Health (Annex J : Schedule for
Submission of Reports). These application systems shall be periodically
updated by their developers, at' their own expense, to align with the latest
updates to PhilHealth Konsulta policy.

2. PhilHealth KPPs shall submit the electronic patient record · data to

PhilHealth as soon as the record is available and in accordance vv.ith the
prescribed format. Submissions shall include all records of encOtmters with
eligible beneficiaries (Annex J). ·· -- · ·

3 Incomplete patient encounter repotts shall be automatically denied by the

system.

For encoding purposes, only the following data fields shall be required for
:. FPE: PhilHealth Identification Number (PIN), Name (Last, First, Middle, ·
Page 10 of 12
 Extension), Date of Birth, Biological Sex (Male/Female), Client Type, and
Vital Signs and Anthropometries (Annex K: Sample Template for Health
Screening/FPE).

Other data including but not limited to other parts of the patient history and
physical exam, diagnosis, diagnostic tests done with corresponding results
and prescribed/dispensed medicines, other services and commodities not
currently covered by the package shall be only required for the generation
of Statement of Accounts Payable 2 (SAP2).

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

G. Monitoring and Evaluation

PhilHealth, through its Healthcare Provider Performance Assessment System

(HCPPAS), shall employ mechanisms to assure members of the guaranteed
quality healthcare they deserve. Performance targets shall be identified to guide
all concerned stakeholders of their accountability towards providing essential
~:· · . •. 1 i :: ;·,; .c ' ;; ";; ,:··,..prima.ry-care.services especially to the poor and marginalized families.

: .-. ·: PhilHealth ·shall utilize .electronic systems to facilitate the implementation of .

·the Konsulta Package inCluding builOJng a system to co1111ect Konsulta with ,· · ·~
inpatient .availment for monitoring ptirposes, an_applic.at1on ·for ·.inun~giate·:.~::; ", ;
t ;.·· . ,"- .. feedback :and :documentation of actual patient encounter transactions, ·
mechanisms enabling access to primary care services such as the feedback-. -
application, biometrics kiosk, ERAS and EPRESS. · ·· ·

H. Annexes

1. Annex A: Overview of PhilHealth Konsulta Actors and Processes

2. Annex B:PbilHealth Konsulta Regisu·ation Form
3- Annex C: PhilHealth Konsulta Benefit Table
4 Annex D: Checklist of PhilHealth Konsulta Drugs and its Preparations as of
September 2022 and Future Iterations Thereof
s. Annex E: List of Preventive Health Services Based on Lifestage Guarantees
6. Annex F: PhilHealth Konsulta Benefit Availment Process
7. Annex G: Sample Template.for Photo Consent
8. Annex H: Electronic · Konsulta Availment Slip (EKAS) and Electronic ·
c.>
0 · Prescription Slip (EPRESS)
\o----w- 9. Annex 1: Approved Benefit Payment and Balance Billing/Co-Payment/Cost
Sharing Schedule ·
10. Annex J: Schedule for Submission of Reports
11 Annex K:Sample Template for Hea1th Screening/FPE

VI. PENALTY CLAUSE

_... ·· ··· Noh-conformanceto the .performance targets (Am~ex I) shall be a ground fot close - · ""'
Page 11 of12
 .·

monitoring, and/or sanctions and penalties prescribed by pertinent la\•VS and rules.

Any violation of this Phil Health Circu,lar,-terms and conditions of the Performance
Commitment and all existing related laws and policies shall be dealt vvith
accor.dfngly.

VII. TRANSITORY CLAUSE

PhilHealth shall undergo a gradual transition from the current Konsulta Package to
the Konsulta+ pursuant to PhilHealth Circular No. 2022-0032 entiled "Governing
Policies of the Konsulta+".

The data 1·ecords affected by a new formula for computing SAP2 for services
availed beginning January 1, 20·2 2 and removal ofpro-ratafor SAP1 beginning
January 1, 2023 as provided in PhilHealth Circular No. 2023-0013, shall remain
in effect.

. PhilHealth shall issue advisories on the implementation of system enhancements-

according to the provisions of this PhilHealth Circular. Further, the use of the revised
health screening/ FPE form shall commence once the system enhancements have
been deployed and are available for use.

VIII. SEPARABILITY CLAUSE

. ... . : .·.. , In ·the.:event that· any ·.part or provision of this PhilHealth Circular is declared · ·
· ''' · ... .. . . .. . ..,. · -unauthorized or rendered invalid by any Court of Law or competent authority, those
:,,,_·.:.. ·~ :-.- ....,, ,_.; ,. ::: ~:,_:~provisions:not affected by such declaration shall remain valid and effectiye_. ·
•· ..
. . ... .
IX. REPEALING CLAUSE

· ·, .: ·.·.The ,provisions of PhilHealth Circular No. 2023-0013: Implementing Guidelines for

;. · :.....:. :the . J>hilHealtb .Konsultasyong Sulit at Tama (PhilHealth Konsulta) Padcage · · · '
..
~

: · {Revision··2) that are.inconsistent vdth any provision ofthis PhilHealth Circular are .
---~ --:- · · hereby amended, modified, or repealed accordingly.
t'\{
~ DATEOFEFFECTnnTY
~
This PhilHealth Circular shall take effect fifteen (15) days upon_publication. This
Phill-Iealth Circular shall be published in a newspaper of general circulation and
shall be deposited thereafter vvith the Office of the National Administrative Register
at the University of the Philippines Law Center. ·

u
0

.,-,,.,.
EMMANU . LEDESMA, JR.
President and hief Executive Officer .

Date signed: btlWl ~!J.A.\

• • • · -·""- ••• --- · • • u Imnlementing Guidelines for1:he PhilHealth Konsultasyong Sulit at Tama CPhilHealth
Konsulta) Package {Revision 3) · . .
Page 12 of 12 .
 AnnexA: Overview ofPhiUIealth Konsulla Actors and Processes

Scenario 1: Registration is done p1;ior to conduct offirst patient encounter (FPE)

----other __ _
PROGESS Patient
REGISTRATION & navigation levels of
ACTOR PREPARATION
ASSIGNMENT
FPE** CONSULTATION
-----!;>-
~--- -·-
carem
HCPN .

Health
assessment ·
Facilitate risk-
Health based
screening of diagnosis
catchment Prescribe and
Offer of . population dispense
services drugs,
Application Assisted Submission of administer
for Registration Health Data t reatments
accreditation {with PIN) Records for
POS URS the First Submission of
(w ithout Tranche Health Data
. PIN)* Statement of Records for the
Accounts Second
- ..·.... :~.~
Payable Tranche
(SAPl) Ledge r Statement of ..
Accounts .. ... . . , ..
. . ·· ·...
Payabl.e (SAP2)_
··: - . .. ····• ..... . . ... ,;---~

Ledger
... .. ,. ..
~ .... . .. ·.
~

Registration
c::
I.J.J
-co with a
Awareness ··- - Hea lth
~ primary care Consultation
I.J.J screening
2 provider of
choice

Target client Processing of

list (auto- Processing of
SAP2 (second
Accreditat ion registration) SAPl (first
tranche
ofKP tranche
payment)
Database payment)
:I:
management
!:i SAP2 = No. of
. <X: SAP1 =No. of
I.J.J
J: Assisted registered
=
J:
l:l..
registration
(e.g. LHIOs,
registered
beneficiaries
beneficiaries
w ith FPE x
PCARES) with FPE x
Social Performance
40%
Marketing Factor*** x
Assisted capitation
registration 60% capitation
amount
(e.g. through amount
t hird parties)

..
Page 1 of 3 of Annex A
j·

Scenario 2: Conduct ofFPE is done prior to registration

----otiiei __ _
PROCESS Patient
PREPARATION FPE,... REGISTRATION & navigation levels of
ACTOR CONSULTATION
ASSIGNMENT -----~ carem
4----- HCPN
................ ........

Healt h
assessment
Facilitate risk-
Heaith based
ii:' screening of diagnosis

-
0..
~

c.::
w
catchment
population
Prescribe and
dispense
0 Offer of
>
0 services drugs,
UJ Application Submission of administer
~ Assisted
for Health Data t reatments
;;2 Registration
u
<( accreditation Records for
0.. (with PIN)
the First Submission of
~
-.J Tranche
POS URS
Health Data
::::> {without PIN)*
Vl Statement of Records for t he
z Accou.nts
0 Second
~
Payable Tranche
(SAPl) Ledger Statement of
..
Accounts ·
Payable (SA~2) ·
Ledger .

[I]
Registration
.
. Health with a primary
Awareness .· . Consu ltation
. screening care provider
.
. of choice

Target client list Processing of

Processing of (auto- SAP2 (second
Accreditation SAPl (first registration) t ranche
ofKP tranche
payment)
payment) Database
::c
~
management
<( SAP2 =No. of
UJ
SAPl =No. of
::c registered
registered Assisted
-::c
-.J

0..
beneficia ries . registration beneficiaries
(e.g. LHIOs, with FPE x
with FPE x
I:(. Socia l PCARES) Performance
40%
~
· ' I~
Marl(eting
capitation Assisted
Factor*** x

~
1:";
amount registration 60% capitation
amount
(e.g. t hrough
0::
.;
~
~ third parties)
~-#.~
.,... o,.,
lfJQ
<(.
~u ·!

u
0 Page 2 of 3 of Anuex A
._... i .. . .. ~ _,.. ..1"'1>•••
I
I
I
I
I
.

I
I *Forthcoming
!I
I . HAn FPE is done only once. The first tranche for the succeeding years of retained
! beneficiaries is paid in full vvithout need for another FPE provided that the KPP conducted
I

at least one medical consultation for the beneficiary within the previous year. If the KPP did
not conduct at least one medical consultation V'lrithin the previous year, a new FPE must be
performed in the succeeding year to avail of the first tranche of capitation payment. This is
an incentive for the KPP to facilitate empanelment of primary care catchment population.
Retention of beneficiaries is in itself a key feature of primary health care. This allows for
better quality of care, as the KP becomes familiar with the medical history and course.

**-~<·Incentive for KPP to perform risk-based and high quality primary care sel'\rices and
. deliver indicated health goods. The performance factor is an important control versus under
provision of primary care services.

•' • • '••M

'I

Page 3 of 3 of Annex A
 Annex ·B: PhilHealth Konsulta Registration Forn1

~!m<CTMID:,_.- - - - Q)i>.'W:fNO:..
: ----

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O *~~:M'II-1\~~·lllHI)teiJ~ 0 ll(QI&mm:lol'ri~o~lllrR.~~\;llf'(~t
(F~I!Ili~~i'-l!IIIU~H¥/} · Wllml·IMi~~-1'~-

RKL~,~~--------~~------~~-----
MQ'MM< ~1>1.1' fllm.!l'~"
'IKTaiortf: t!J!'P:._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

~-----:::~
-:--:::::_=r,...,_~
=-::-:-_-----,~=~=
-:::-:_=VOJ'l!=:----::~
=-=,....­
~mcamtE~----------------------

o~mR: ·
~~s~~-~------------------------
~c~~~~-----------------

~---------~---------
lliiA~~~R'«Yll\1lllil' ' ~l'm'1/ ~llli'!-Wlf-

· · :nrem:Jn'"inm'ftlfliHOll1 IHn'AYllll"!!lF~Dliatr.QiilPmill i1iERBCBmPi1111AllDIOtmAiA!LOFRR&TOOl!maro!ll:ll'lml

• · '(A'f;}lllli.WM!EWJ~.Il.Pf'- fFPfJi~l\11 ~'!Y.Fl'lBilOlli m_

----------------------~-----·--
PflrutrAtDt.KONS!JU\!i.Rms'lmimN'mJmJJ.~nrmm~P

llmiSiiW!Illtilm:
---- - - - - -- DmBmt:ITBtm' iiWfiSI/.rilrr

awrJ<AMr. MII•N!'llMm

~--------------- ~--::::lif'iii>iWI="'n=~""'·-
~~----------------------------

· --- ---------- - - ---- --- ------------- - ---

- - -. - -- - - - - -

Page 1 of 1 of Annex B
 Annex C: PhilHealth Konsulta Benefit Table

A. Primary Care Services -first-contact, comprehensive, continuing and coordinative

care to beneficiaries including but not limited to:
1. Consultation and case inanagement for-any conditions, including individual health
education, that can be managed by a Primary Care Physician and team as
deterniined by the legal scope of practice.
2. Provision of preventive health services as listed in Annex E.
3. Assisting eligible beneficiaries in accessing services l.n subcontracted or partner
facilities
4· Referral to specialty and higher levels of care
B. Select Laboratory/Diagnostic Examinations as needed as part of case management by
PhilHealth Konsulta primary care team including: ·
1. Complete Blood Count (CBC) wf platelet count
2. Lipid profile (Total Cholesterol, HDL and LDL Cholesterol, Triglycerides)
3. Fasting Blood Sugar (FBS) ·
. 4· Oral Glucose Tolerance Test (OGTI)
5. Glycosylated Hemoglobin (HbAlc)
6. Creatinine
7· Chest X- Ray
8. Sputum Microscopy .
g. Electrocardiogram (ECG)
10. Urinalysis
11. Pap smear
12. Fecalysis
. 13. Fecal Occult Blood Test .
_..-... -. ·. .':-. ' ;;;·. · .-,;C; ·:Belect.Drugs and . Medicines as needed as part of case management by PhilHealth . ... - ~. ,
Konsulta primary care team: : ·-.:·
·· ··· .. ··· - - ·
. ··· --'··
. ---- - ..·-
.
Name Category
..

--· -. ..:.: ~
.. ... ; . ·.. --~. _. ·:::·.::
1. Amoxicillin -.- -:-- ;.' ..:.:7·'_'-"."l
-·· .,
2. Co-Amoxiclav .'
·- ... ----
..
....
3· Cotrimoxazole Anti-microbial :
:

4· Nitrofurantoin .. , -·.-. :.;

-.
5 · Ciprofloxacin
~

._. "' ' I

6. Clarithr omycin ..
'"::'··

..
i

7· Oral Rehydration Salts Fluid and Electrolytes

8. . Prednisone
g. Salbutanl.ol Anti-asthma
10. Fluticasone + Salmeterol
~
11. Paracetamol Anti-pyretics
12. Gliclazide
~ · Anti -diabetic

·-·
..
~
w>~
~fl.
VJO
<C\,.)
. :i .
'
-~
'S
t'.)
••
(Q
0

~
~
13. Metformin
14. Simvastatin
15. Enalapril
16. Metoprolol
17. Amlodipine
.

18. Hydrochlorothiazide
Anti-dyslipidemia

Anti -hypertensives ...

..
..

.... --
1g. Losartan
0
c 20. Aspirin Anti -thrombotics
21. Clilorphenamme* Anti-histamine
..:·For hospital use only, pending furth er advisory t o b e issued by PhiiHealth on its inclusion/ exclusion
from the Primary Care Formulary (PCF) to be decided on by the Health Technology Assessment
Council (HTAC). . .

Page 1 of 1 of Annex C
 Annex D: Checldist of PhilHealth Konsulta Drugs and its Preparations
as of Septe1nber 2022 and Future Iterations Thereof
!
!! .
ACTIVE INGREDIENT/MEDICINE DOSAGE FORM/ STRENGTH
Amlodipine 5 mg tablet (as besilate/camsylate)
Amlodipine 10 mg tablet (as besilatejcamsylate)
Amoxicillin (as trihydrate) 250 mg capsule
Amoxiciliin (as ttihydrate) 500 mg capsule
Amoxicillin (as trihydrate) 100 mg/rnL granules/powder for drops (suspension), 15 mL
Amoxicillin (as trihydiate) 250 mg/ 5 mL granules/powder for Suspension, 6o mL
Aspirin So mg tablet
Aspirin 100 mg tablet
Aspirin 300 mg tablet
Aspirin 325 mg tablet
Chlorphenamine (Chlopheniramine) (as maleate) 4 mgTablet
Chlorphenamine (Chlopheniramine) (as maleate) 2.5 mg/smL symp, 6o mL
Ciprofloxaciu 250 mg tablet (as hydrochloride)
Ciprofloxacin soo mg tablet (as hydrochloride)
Clarithromycin 250 mg base tablet
Clarithromycin soo mg base tablet ... ·. -~ . .
·-·- -
Clarithromycin 125 mg/s mL granules/powder for SU$pension, so mL
· l---
Clarithromycin
-- - -.. --
· :.·.: --
-- ... ·--
- - -- -- --f-2_s_o_n_lg_/_s_m
_L_ gr_a_n_u_le_s_IP_o_w_d_e_r_fo.,-r_s_us_p_e_
n_si_on _· _
-",._s_o_·m L-'-~~----"-.....,_::_-_-,__. .. ,."~---"'-'-""-1
· .. : ~·.::._~ ..
......
.. . .. Co-Amoxiclav (Amoxicillin +·Potassiwn Clavulauate) soo mg amoxicillin (as trihydrate) + 125 mg potassium-cla~an.ate p~rjablet .
. . . ... :.~

Co-Amoxiclav {Amoxicillin .+.Potassium Clavulanate) 875 mg amoxicillin (as trihydrate) +. 125 mg pot~ssium c~avulamite p~r t~biet

·Co· An . . ·, (An
- 10XIC1av . . ·.. . ·. .. . p·· .t ·. .
10XICI 11m + o assmm C1avu
. 1ana
. .t e.). .200 mg amoxicillin
d (as trihydi·ate)
. + 28.5 mg potassium clavula~ate
·· · ·- . .: . .p.er·- 5 roT
·•
· ·· · ··· · ·· ... · .. - granules/pow erforsuspenswn,7omL . ·-- . _-.: · · ·, .. _..
400 mg ·amox:icillin (as trihydrate) + 57 mg potassium elavlilanntfper 5 ri1L
granules/powder for suspension, 70 mL ' ·--:·..... -·
6oo mg amoxicillin (as tdhydrate) + 42.9 m·g potassi~~ clavu1ariate per 5 ~L
Co-Amoxiclav (Amoxicillin +Potassium Clavulanate)
granules/powder for suspension
Cotrimoxazole (sulfametlloxazole + triinethoprim) 400 mg sulfamethoxazole +So mg trimetboprim tablet/capsule (B)
Cotrimoxazole (sulfamethoxazole + trimethoprim) Boo mg sulfamethoxazole + 160 mg trimethoprim tablet (B)
Cotrimoxazole (sulfamethoxazole + trimetboprin1) 200 mg sulfamethoxazole + 4 o mg tdmethoprim/ 5 mL suspension, 70mL

Cotrimoxazole (sulfamet hoxazole + trimethoprim) 200 mg sulfamethoxazole + 40 mg trimethoprim/ 5 mL suspension, 12omL

Cotrimoxazole (sulfarnethoxazole + trimethoprim) 400 mg sulfamethoxazole + So mg trimethoprim per 5 mL suspension, 6o mL

Enalapril (as maleate) 5 mgtablet

Enalapril (as maleate) 20 mgtablet

Enalapril + Hycb'ochlorothiazide 20 mg enalapril + i2.5 mg hydrochlomthia~de tablet ·. ·· : .. .· , .... .'

..
-· ··

~ Inhalation: DPI
Fluticasone (as propionate) + Salm( terol (as ~ 100 micrograms fluticasone + 50 micrograms salmeterol x 28 doses and 6o
xinafoate) ,..,.
___ _ ;-:·-----,.~cu
,:.:.:::::::.::=:.:~--------+--Er;; .• ;.- doses--witlrappropt'iate'llcrompa:nyilllfdi, pcu""''

F~uticasone (as propionate)+ Salme tt:e.~

bd
ri.Q 0
-· Inhalation: DPI .
250 micrograms fluticasone +5o micrograms salmeterol x 2·trdose·s ~an·a 6o
. ·- -,-·

xmafoate) · . ·· ··. · · ~}""·--~~·

. s:i'~d_o_
2:: ses
_WJ_._th_a_p_p_r_op_r_ia_t_e_a_cc_o_n_lp_an_YI_·n_g_d_is_p_en_s_e_r_ _ _ _ _ _ _ _ ____,

..
(J
Page 1 of 3 of Annex D
c
 Inhalation: DPI
Fluticasone (as propionate) + Salmeterol (as
soo micrograms fluticasone + so micrograms salmeterol x 28 doses and 6o
xinafoate)
doses with appropriate accompanying dispenser
MDI:
Fluticasone (as propionate) + Salmeterol (as
50 micrograms fluticasone + 25 micrograms salmeterol x 120 actuations {with
xinafoate) dose counter*)

Fluticasone (as propionate)+ Salmeterol (as xinafoate) MDI: .

125 micrograms fluticasone + 25 micrograms salmeterol x 120 actuations (*)
MDI:
Fluticasone (as propionate) + Salmeterol (as xinafoate)
250 micrograms fluticasone + 25 micrograms salmeterol x 120 actuations(*)
Gliclazide 30 mg MR tablet
.Gliclazide 6o rng MR tablet
Gliclazide 8o rng tablet
Hydrochlorothiazide 1205 mg tablet
Hydrochlorothiazide 25mgtablet
Losartan (as potassium salt) · 50 mg tablet
Losartati. (as potassium salt) 100 mg tablet
Metformin (aS hydrochloride) 500 mg t ablet
Metformin (as hydrochloride) 500 mg film coated tablet
Metformin (as hydrochloride) Bso rng tablet
Metoprolol (as tartrate) 50 mgtablet
Metoprolol (as tartrate) 100 mg tablet o• -- ..

. ~I: · . : Nitrofurantoin so mg capsule (asmacrocrytals)

.. - . ····· Nitrofuran toin :.~ .. . 100 mg capsule (asmacrocrystals) ' ' " .. . .
v· ···
"
oo Oral Rehydration Salts (ORS) 20.5 sachet ".
•,o
"
. Paracetamol 300 mg tablet '' .. . ~--' .· . ...... ···-· ' 0

Paracetamol 500 mg tablet

...
0 • -
..... . Paracetamol : · 0 .. 0

100 mg/mL drops, 15 mL (alcohol-free)

00 ooo · ··· ·· · ··- · ..... .0 120 mg/5 mL (125 rng/5 mL) syrup/suspension, 30 inL . --- -
Paracetamol
{alcohol-free) . . ·: ~

·-' Paracetamol · --. o.O 120 mg/5 mL (125 mg/s mL) syrup/suspension, 6o mL (alcohol-free) .
Paracetamol 120 mg/5 mL (125 mg/s mL) syrupjstispensioi1, i2o mL (alcohol-free)
Paracetamol 250 mg/s mL syrup/suspension, 30 mL (alcohol-free)
Paracetamol 2so mg/s rnL syrup/suspension, 6o mL (alcohol-free)
Paracetamol 250 mg/5 mL syrup/suspension, 120 rilL (alcohol-free)
Paracetamol Rectal: 125 mg suppository
Paracetarnol Rectal: 250 mg suppository
Prednisone
-~
""':.> '•
5 mg tablet
Prednisone
-~ 'i 10 mgtablet
Prednisone ~
<:;\. 20 mg tablet
•o ..
Prednisone .tt: ~ 10 mg/s mL suspension, 6o ·m L
·-·· ',· . \

Salbutamol (as sulfate) • 0

~Ci 0 2 mg/s rnLsyrup, 6o mL

v~o -
1hoy..Fowder-Inhaler-(HPH 0
~-o-~~
"
Sa'lbutanwi-canmta:re)-
200 micrograms/dose 'v\~th appropriate accompanying dispenser

Salbutamol (as·sulfate) ' . " Metered Dose Inhaler (MDI): 100 micrograms/dose x 200 actua~ons . .. ..
o.. ··-..r
()
0

Page 2 of 3 of Annex D
Salbutamol (as.sulfate) Breath Actuated MDL• 100 micrograms/dose x 200 actuations
.. --
Salbutamol (as sulfate) Resp. Soln.: (for nebulization) I mg/ mL, 2.5 mL (unitdose)
Salbutamol (as sulfate) . Resp. Soln.: (for nebulization) 2mgjmL, 2.5 mL (unitdose)
MDI:
Ipratropium + Salbutamol 20 micrograms ipratropium (as bromide) + 100 micrograms salbutamol x 200
dosesx10mL
Resp. Soln.: (for nebulization) soo micrograms ipratropium (as bromide
Iprab·opiurn + Salbutamol
anhydrous) + 2.5 mg salbutamol (as base) x 2.5 m.L (w1it dose)
Simvastatin 20 mgtablet
Simvastatin 40 mg tablet

.· ;

.. ·:.... ::.-::

cr: ..
<1>
.....
UJ> N
}w CJ.. 0
~0
~l)
...... ~
~

..
0 .. . ..
Q . o.-:.. •

Page 3 of 3 of Annex D
 Annex R: List ofPt;eventive Health Services Based on Lifestage Guarantees
--·-- ---- -··--- ___ -- .. ----··------. ··--··--··------·--· --
,, -·-·-- - - - - --·--·---··- ·-- -----:---:--.- ~·-··· - -· --- ·-·. - -----·- ·---·~--------·-------- -··------·----- ...-.. --· - ··----.. ·-.---·---:-·

Age Targeted Diagnostics (according to risk, age and health assessment}

0-12 mos.

>1-4 y/o
-

5-9 y/o
-
10-19 y/o
-

20-39 y/o
-
40-49 y/o

SJ.__ 50-59 y/o

rt 60 and up
w>
l-0...
cno
<o
:! . :' .· : !':; J .,

Recomme~~~d~~ As applicable Ill Noi A~~i.:"~'e Q . !l ';~1\f•'d tO Waive

,.
Page 1 of i of Annex E
I
i
 Annex F: PhilHealth Konsulta Benefit Availment Process
--------------------

B
"'
'"t:
<It
Prar.tttttorrur
F"fer~dJlbi/Hrollll
Kcr.uorta Padtage
l"l'l:"lridu.
Yes-+ SerureATC

. Log-bt~the Prlilt/gpt~•rl!/writ'e
.cp
AOC'Ompllsh1h<> EltA~I
Gin! t"" ATC tD tho
til No 'hrougti
u lhe;energ•tli!JC •n~/"'~PRESS ""d
~

c
IV
_1 1)!!1"50ilel
.lnten~t? ·
Yes+! Menbet Portal
""d ~erore thl!
ATt
··• andprcce.~tu

komaltafod.lllJ
1-------------..---1'Pf>ll~lllt lton,..lra
tocirrtv
JUb:nJU.o .P.hiHR.Ilh
X'<ms>>ltllfot!llty
<l>' 1/mJorgo fltst
·ro
<U· Pat;r.nt.-£rr.t.o.unt~r

:c (fPE} +
I
F.llf"outt!te
"6i) l\eqller;1 for
I
ffi r"j.. Aut ho<itetion 1-
I Transaction COde
l.ln (RATC}

Answenhe l
~Cltrley-que~rlons r I.

..s~
- m
Cl)o · r~rateth~l!.TC SOp wh hc

a! c :r:
<II
LJ- o.n codnod print,<~< ut~a
1 ~ 1 Genemte ATC
:r::z:~.:::! 1 "1 through UPCM -II' dfgltallm•~• :l>f1he QJI codo
1-
:ET3~fl
t~e~b a.en.P.:ftciary't 'tafMr.J•
.oriilleut~ATeiSfpol'<f
a.o.EIE
_, ' 0 reTea~ il-t.D tbe: ~r:dlry
~
wro .- - · ~-
tao
.c; ...
+<'
mE~~
.a; "'

:!:2~ 2 3Q;,
::c~~.!!! o
c..U .f1;41
-
o. ll=
Ill ~

t-c
(\'1 Ett: 1
lii6
c:s
.... (I)
. if!
0!:
:.uot.l-1>•

...cum,
4.
Genera~ATC
tl~rough
I CAllES
~
Cl!fl"ttnte 'thl!. A:rc: sn·p. with.
QJtctlde:ud print, .o rtaMo
lllcl,.l lmopol'lhe Qllco4a
'thl<llJCI> btMfi'....,..J'<amii<O,
. O<fdl puttlleAJc-«pood
re.IN.sl!. it to tfu~btnefiUill'l'·
f-.

c N ~ No
f-0.. 0
.cu~
~ ~(.)
o .....
+='(.)
~. wo
i: ~u ~
('J Q.J ·-
L,. Generate 1\TC Give the ATC ro the

?
Q/ ... ....
Through ~--11' I-
6(!?~ l'h~Heallll t!trnugh CSMS beneficiary
·- 0 c
;!£ & (l:j N· CAC?
0
u .9:
...
Q r---~------~-, "
; r: Can duct p_rimary ca1'G"
Ellt~de fill
date Gl!lt~rote nnd
.J: 1 · J..;l Tak~ " photo of
m~ ~ ' S
...., "' IU ~
~ 1;:» ·' 0 ... , . 1'1 • -~ the ;ttt11He1!Jth lhsltt Be.,if.<;O.,y •l ~
ccns'-':hatfcms. health
recardsio the ~ 1 print ttt• EKAS
.ro f.~&ten.ulrTg
~
scre_C!l\I.JtG·.il ndl
:r; l<onsui11J ----~~ ~zm.e:u t iJnd'
·elettrollk -·"1 nnd{OI' El"RESS
'tile PfiifH~ciftb
= S~ E
& ::x: C>;:CI.
bencl"td!!rV ond.
Nt!Jhln>tionsy<tem '
.
'{[fspm:slnc.cJ
"'POrting and give ltto \11e
save. :: ~ .;. med fdnas, Hn•nsary
system. bene1kl'ary.

a
'Autho1ization Transaction Code (ATC) - 'system gcnemtcd 1mique code given to an eligible beneliciary p1ior to ben~fit ~v~ilwent. This can be taken by the Konsulto facility for walk-in clients.
Notes: •rfFirst f'aticnt Encounter (FPE) is not yet done; beneficiary may be assisted firnt tci register. ·.;. · '· • · ·
Procedure. details for A and B will' be defmed in .Annex J. ... · • ' · , .. : .
} . !!!;:' • .... · .. ,··
.• , J

' Page 1 of 2 of Annex F

..
'I
DATEOFAPPOINTMENT: DA1'£0FAPPOINTI\'IENT;
0MEMBER 0ME7t!BER
D DEPS'IDENT OnEPENDENT
Pltt ________ _ _ _,I>All:OFBIR'flf: --::..::::"1\·z·-~ PiN:_ ____ _______ _ DATEOFBIRllt: -·"MWlii.itrf'I'Y""
M,.. •...,.u.rr
F\JLLNAME: RJU. NA.'I-1E:
---mfiii.iiiiif___ _ i:iisriii.WF.---~ooiifNAii'
.r ~iA~w-----Rii$Y'NA'MF----~lDoi£ijiM'Ii-.

----..--·--
~fmtnUI,..(Il\fl' (lr/~ttd flf11111•l

ATC:

B£N£ftaAIIV'S CCP't

MTEOF.APPOIJii'MOO: DATEOFAPI'OINTMENT:
OMEl\,BER DMEMBER ·.· !

: QDEPENDETiT Oooorooo
PIN:___,~--·-·----·-·.DAnlOFfliRTH: - MM/lltl/l'li~'Y
- ·..,-·.--..···-· Pitt · DATE oraornt: · ··
-·--··----~--~---~ -liiwoo;r-wy---:-· :
RJU.NAI'Itt:: . RJU.NAM£:
- . mfriiiiM!i-----·'MmDiTwiM's·~
--i~fiiA'riE""--
.

ADDRESS:

' ATC:

-·-----~-·---- ----

----- ------- - -

Page 2 of 2 of AnnexF

u
.
Q
 Annex G: Sample Template for Photo Consent

Optional: Insert Facility Logo/Name

PHOTO CONSENT FORM

I , - - - - - - -- - - - - -- --' vvith address _______

Name of Konsulia Benef iciary
- - - -- - --:-:----:-- -:----------- --grant permission and give
Address of Konsulta Beneficiary
my consent to - - - - - - - -- -- -- - ------.,...---,--,..,..-:-....,...,-for the use
N ame of Konsulta l'aclw g e Provide1· (KPP) ·
of my photo or picture as one of the requirements in the availment of Konsulta benefit.

By signing below, I hereby authorize my Konsulta facility to save my photo for post-

audit monitoring purposes of PhilHealth.

-, _·:,· :Name ofKonsulta Beneficiary Signature ·. Date

--1
' ··- ·· '. .

. ~ 'lim, -~, \1!!!1\ '111!1! ~ i!!!ll' ~-·>111!1'-~ ~ iJ!':l!'· '!!!\!! '"' oJ!!IIl '""" '~ '""'!!· '.l!!il' ·~ :~ ~- ~ "-" i!ll!ll ,-_· .... ~ 1~ ""' 'lmi'• -~..,."\'~!:! ~-.· $1fo ·~ w,, :r,m, i!• I •..

Optional: lnse~TFacility LogojNome · . - :.:., . . ··· · · · ·· . ··

~
UJ>-
1- 0..
CI) Q · -~ ...
-
Cl>
~
0
PHOTO CONSENT FORM
<{ '
~u
I, --~-------------' with address _______
0 Name ofKonsulta Beneficiary
0
'-----"":'-=~---------------------grant permission and give
Address ofKonsulta BenejiC'iary
my consent to ------.,.....----------------~ for the use
NameofKonsull"a Package Provider (KPP)
of my photo or picture as one of the requirements in the availment of Konsulta benefit.

By signing below, I hereby authorize my Konsulta facility to save my photo for post-

audit monitoring purposes of Phi1Health.

'Name·of Konsulta Ben-eficiary Signature ·- Date ·

Page 1 of 1 of Annex G
 :. i~
!1
Annex H: Electronic Konsult~ Avallihenf Slip (EKAS) and Electronic Presctiption Slip (EPRESS)

.i ..

I ~~ PhilHealth ELECTRONIC .KoNsUUAAVAit~lENTSuJ {EKAS) :

~iii ~tvt'<rtotrhriTtwll' . . . - . I• pl~iJ!!~fJ!h
• ElECTRONIC PRESCRIPTION SUP (EPRESS}
To he 'fiiiH·O~t ~tile faeilitr (Pupunan :ng Jl~sil:i-llad} - '
To befilled-e11t bY.tllefa~:ilily {Pupullan ngPn!lid'a11)
Ciw.!l~ I "CI~a5anli:I.-J Tilllrictill!llib.i
I
HCIIWil£:
--. I nart~I.1E:
Tl:a;-z!lo.: ]~~~~- r~ooltt
Plll!f"t;i!HeaMI~Ifullllerj: J~{~l(~~M.~
Pli(NUI!o~M'.iittczlmffi'll!l:el): ~~~utmtlpC;ilC~: A~li11f: 0 r.!'A!Ilm
l'iiUtnilla!oo·t~BO~~lllJ: ~!Et!illij: I ~11\\(ll\lneni~;Rpooo~
PMen'JI~(Pim!;i!laA!ll:~~ , ~~ II 0 OfFI:lillOO
C<mtld:l"-lf~JIIle!OI!!ITeillr"'..,l'

r.l<iit-'iiillPfwe: 0 MEMB11! 0 Dfi'Bmtr A!~1irol raOSKH!Cr>:le(J\IG)

~
Kcnw!taSemces !Pl>!famed
:!. IS
1 ~tsMtm~l l't!lt«I!M\IIIl'f
:Jk USE GENERIC NAME

~l!t2 Bloo!1Ollrt(Ci!C)tl/ pla'.MtCO!.IIl

t!picl profile (Tot<J:Cbclomm,Iri.glyari«..,·Kot .,..,ostml, Llll<h>Jts!r!OII

I
FastingBiood SUJr;~r {FB'SJ I
I
tli:JI ~l!COSe Toluance test r
I
I
Glycos,yfaltd HemoglGbfn (filiAte) I
I
.cre.rtinint I
I
I
tlltstX-Ray I
I
I
~um Mitmco.py
.I
t
a~.moeardiogrnm (ECG) I
'I ·
~
~
Urinal)-'Sii I
n,.iciaa:
§•
-~ -
I f'I!CW:ML:

r-l!i·I
I t'll!flo;
l'zp Sll!eal llellDf.,mi<CDIIr:.~:o::==­ :SZ:rrt'.
I {Pttsaot.-r.>Oo(IJ'•t&JO•'"I.
I
f".l!cill)<sis I
I .......
I

I
FteaiOcelllt l!il<loll 'l"!-$t I· ~ -~ -- -- - --- - ----- ---- -----~~ -----~ --- - -- -- - - - -·
LY. ,..,.
""·~llo~ltlbo ....... ~
t
I
. -. t:o be filfed..out b)' tilt!-patient {Pupuaan ng Pasyente}-
,w> o ~-- -~·----- - patient
---------
(PUPilR-~n----------~ - --~- -~- - ~- --~-
I
I
~0.. ; out by the
Th be- fi!led' Jtft :Pasy-ente) I -~~=--==~;"';:::'=rt~ _tz.~l _.lto(Hi>ol~ .
C/)Q lbn!,_~fr:.ateft..~r~tll.etnndaf!micfl? :1 '
,,
.
·,;:;;;;;~·;;·;;;~;·;;;~- ··"·""'"'"''''"' ''"'''"'''"~'-'"""'"'r.:<;'" ''' ''"''t::\"'""' ""''"·' '''"
..\~.'-~~~~-~[~~~~-~!!~.~~-~~~L................~.:::.~.._,.....:...Q _ ... - ... ~..~..~
.I

<.u ~'Glid.!lm,..wfthltttn~' G ... '· G . \OJ . .· · I'

(liiJI}IO............, .{IIOI.l..nmnWfoll.r)
'R,;-J;;;; ~;;,;;,;;;;;w;;.u;;;;;:;;~· · - ·-·· ·· · · - ··-·-
0~ D~ o 'g
....- ..........................
_...,_...,.............._,.,....................- ....
~ -~;~~~:~:.;~.71i~~=~:L~-··-······-....~.....~-~;L~~-···Q;~.~.P..!~~. ...............;..~ .I

...g ) (P"aranfrtntt~UMnre,awg'Ulii•RJ!w.:aJ;
(l':trotfl l~t. -~n , I'Jilllffl~.ll«<tf:ltlao)~ ,i ; ': ·: l

~.........,._"'l(;c--
.,
.I

I:"'....-.. . . . .,~-·---
!""'~*"*'..aiwftblb--"4~=r ~~·~.,...,.,.,._
, · ·,·1. ·.'.\!j ·I. ........
'.1 _
.- ~'""•"'"'"-"'·"''"'"""~ ,.._ _ _ _.._""' I
.,.
Page 1 of 1 of Annex H
j.
 Annex 1: Approved Benefit Payment and Balance Billing/Co-Payment/
Cost Sharing Schedule

1. The maximum per capita rate amount for Konsulta shall be at Php750.00 and
Phpsoo~oo for private and public facilities, respectively.

a. ·The Konsulta Package Provider (KPP) shall receive 40% of this amount based on
the number of registered members with first patient encounter.
b. The KPP shall receive 6o% of this amount based on the number of registered
members with first patient encounter as of December that year and achieved
performance targets at the end of the year.

2. First Tranche or First Patient Encounter (FPE) (40%) Payment

a. The KPP shall receive 40% of the annual capitation rate based on the number of
registered eligible beneficiaries with first patient encounter.

Number of registered
Month beneficiaries with FPE per Calculation Sample Capitation
month
Janua1y 1,500 1,500 X 200.00 300 000.00

February 2,000 2 ,000 X 200.00 400,000.00

March 500 500X200.00 100.000.00

April 3,000 3 000 X 200.00 6oo,ooo.oo ·

May 6oo 6oox2oo.oo 120 000.00
· .- , ,.· June :· · ··1,500 . 1,500 X 2 00,00 300, 000.00

July . .1 000 1,000 X 200.00 200,000.' 00

.. ·.: August .. . ?50 750X 2 00.00 '150 ooo:oo

.September ·. ... . .- ~ 1,300 . 1,300 X 200.00 26o boo:oo
. .
October ..
8oo 8oox2oo.oo .160,000.00

.. . ~ November .. . .. ... ·1,000 1,000 X 200.00 200, 000.00

.. ..
· December '
" 900 · goo x 200.00 180 000.00 .

Total 14,850
Amount of capitation · 2 970 000.00 .
Table 1: Sample Computatwn for the Ftrst Tranche or FPE Payment for a Pubhc KPP

rt-
Number of registered Sample
Month beneficiaries with FPE per Calculation Capitation1
month
January 1500 1,500 X 300.00 450 000.00
0:': ~ February 2 000 2 000 X 3 0 0.00 6oo ooo.oo
UJ>- n)
t-O.. 0 March 5.00 5_00 X 3 00.00 150, 000.00
_,

~
{(JQ ..
April .3~000 _3 ,000 X 300.00 900 000.00
<!u
:.i May 6oo 600X300.00 180,000.00

June 1,500 i ,soci x 3oo.oo 450 .000.00

(J . . -· ..
0 July 1000 1 000 X 300.00 300 000.00
August 750 750X300 .00 225,000.00
-·- ·- •* ·-· -·
September 1300 1, 300 X 300.00 390 000 .00
October 8oo 8 0 0X300 .0 0 240,000 .00
. ' ' ..
1 2% Withholding Tax for Private Facilities will be deducted in this amount

Page 1 of 6 of Annex I
 Number of registered
Sample
Month beneficiaries with FPE per Calculation
Capitation 1
month .
November 1,000 1,000 X 300.QO 300,000.00
December 900 900 X 300.00 270 000.00
Total 1<4,850
Total 4.455,000 .00
Less: Withholdingtax 89 100.00
Amount of capita:tion . 4.365,900.00
Table 2: Sample computatwn for the F1rst Tranche or FPE payment for a Pnvate KPP

b . The first tranche for the succeeding years of retained benefi~iaries will be paid in
full without need for another FPE, provided that the KPP co1iducted at least one
medical consultation for the beneficiary ·within the previous year. If the KPP did
not conduct at least one medical consultation within the previous year, a new FPE
must be performed in the succeeding year to avail of the first tranche of capitation
payment. · ·

Assuming that the KPP started in Year 1 with 15,000 beneficiaries with FPE, and
all these beneficiaries stayed with the same KPP through the years:

PublicKPP
.. Scenario 1:.,Medical consultation is done every year; no needto repeat FPE.
Year1 Year2 Year3 Year4
.. 15; ooox Php 15, oooxPhp 15, ooo xPhp
2oo.oo =Php 3M. ····' ....,.-:-_,
-15,ooo xPhp . .. 200.00 =Php 3M 200.00 = Php 3M
.:wo.oo =. Php 3M .. {no need to repeat (no need to repeat · (no need to repeat ..
.. FPE) FPE) FPE)
Medical consultation Medical consultation Medical Medical
..
· done .: .. done consultation done consultation done
.. ; ·; ...... , . . .. Table 3: Sample computation for the Fust Tranche or FPE payment rn a Pubhc KPP

Scenario2 - Medical consultation is done in some years; need to repeat FPE after
years without medical consultation ..
Year1 Year2 Year3 Year4
g,oooxPhp
7,000 X Php 200.00 2oo.oo = Php 1.8M
= Php1.4M 15, oooxPhp
15,000xPhp 200.00 = Php 3M Remaining balance
2oo.oo = Php 3M Remaining balance (no need t o repeat to depend on actual
to depend on actual FPE) repeat FPE done
repeat FPE done for
for 6,ooo
8,ooo beneficiaries.
beneficiaries.
Medical
Medical consultation ··Medical ·-·· -
consultation · · · cortsultation·done Medical
done for 7,ooo
beneficiaries only done for all1s,ooo for9,000 consultation done
beneficiaries only . . . .

...
(.)
Table 4: Sample
. computatwn
.
for the F1rst Tranche or FPE payment m a
. Publtc KPP
0
Private KPP
.. Scenario_I-= Medical-consultation-is done every year~ -no -needto repeat-FPE;--- - -
Year1 Year2 Year3 Year4
15, 000 X Php 3 00.00 = 15, 0 0 0 X Php 3 00.00 15, 00 0 X Php 300.00 15 , 0 00 X Pb p 200.00
: I
Php 4-5M less 2% = Php 4.5 M less 2 % = Php 4 .5M Jess 2 % = Php3M
withholding tax withholding tax withholding tax (no need to repeat

Page 2 of 6 of Annex I
 Year1 Year 2 Year ·3 Yeaq
=Php4-41M .. = Php4-41M =Php4.41M FPE)
(no need to repeat (no need to repeat
FPE) FPE)
Medical consultation Medical consultation Medical Medical
done done consultation done consultation done
Tables: Sample computation for the F1rst Tranche or FPE payment m a Pnvate KPP

Scenario 2 - Medical consultation is done in some years; need to repeat FPE after
years without medical consultation
Year1 Year2 Year3 Year4
15,oooxPhp 7,000 X Php 300.00 I5,000xPhp g,oooxPhp
300.00 = Php 4.5M = Php 2.1M less 2% 300.00 = Php 4.5M 300.00 = Php 2.7M
less 2% withholding withholding tax less 2% less 2%
tax = Php2.058M withholding tax Withholding tax
= Php4-41M =Php4-41M = Php2.646M
Remaining balance
to dep.e nd on actual (no need to repeat Remaining balance
repeat FPE done for FPE) to depend on actual
B,ooo beneficiaries. repeat FPE don e
for6,ooo
beneficiaries:
Medical consultation Medical consultation Medical Medical
done for 7,000 done for all1s,ooo consultation done consultation pone
beneficiaries only for g,ooo
beneficiaries only
Table 6: Sample computatiOn for the First Tranche or FPE payment m a Pnvate KPP

· ·' · -Beginning ·J anuary 1, 2023, the pro-rata computation is hereby canceled and
-:·c ;·
.;
· :.::terminated. ··For newly-registered Konsulta beneficiaries .for ..CY . 2023 and
.... ... . succeeding years, pro-rata shall not apply for the first tranche. ·

d. To ensure that all FPE data records are successfully uploaded and patient recoi;ds~~ ..- ...
. ate updated on time, all KPPs shall submit, through HCI Portal or Local Health
Insurance Offices (LHIOs), the required XML files regulal'ly; preferably on a daily
basis (see Annex J, "Schedule for Submission of Reports").
. !
,:e:.The ,computation of the first tranche shall depend on the compl~te data uplqaded ··
as of 11:59 PM of the 7th calendar day·of the succeeding applicable month.

f The computation of SAP1 shall depend on the complete data submitted by the
KPP. PhilHealth, through the BAS, shall generate SAP1 eve1y 8thth day until the
·end of the month of the succeeding applicable month.

g. The monthly computed capitation amount shall be released as soon as possible

within 6o days after the 8 th calendar day of the succeeding applicable month,
provided that all data records are successfu1ly t~.ploaded and passed the system
vaJidation of PhilHea1th. .

3. Second Tranche (6o%) Payment

a. KPPs shall receive a maximum of Php 450.00 (private)/Php 300.00 (public) of

the per capita payment rate based on the number of FPE done amon_g_Jhe____.
·--.. · ..- .. - ·---- catchm·ent-pupulatiun-asofDecemoerlliafyeai· and-actiievea performance targets
at the end of the year.
' I

Page 3 of 6 of Aunex I
 b. The performance factor is the cumulative resultant score based on the
performance of the KPP adjusted using weights set by the Corporation. The
following are the performance targets which constitute the performance factor.

Percentage of beneficiaries
who availed Konsulta Target Weights
Perfonnance Indicators services over beneficiaries (c) (d)
withFPE (a)
Primary Care
Consultation
Number of unique
Unique
individuals who consult at
registered
1 least once/T.otal number of 100% . 30%
beneficiaries who
registered beneficiaries wid1
consulted a
validated FPE
pnrnaty care
doctoi:
Utilization of Number of unique
Laboratory individuals who received
Services laboratory service/Total
2 50% 30%
Unique nu.mber of registered
laboratory beneficiaries with validated
services done FPE
Dispensing of
Medicines
. .. . .. Number of unique .. .
Unique individuals who received .. .. i
' " registered indicated medicines for .. . .., - - .. " o N • •
" --
....
. ..
3 beneficia1ies conummicable 15% 10%'
.. who received diseases/Total number of "

.. antibiotics as . registered beneficiaries wid1 . .

prescribed by validated FPE
their prima1y ...
care doctor
Dispensing of
Medicines
Unique Number of unique
registered individuals who received
beneficiaries who indicated non-commwucable . 30%
4 20%
received NO) medicines/Total number of
medication as registered beneficiaries with
prescnbed by validated FPE
their primaly

.,
care doctor.
~·-·· . --··.. ----·- · · ··· ··- ---- --- -- -· .. . - -·- --
Sum of all Indicators x Weights 100%

ti . tfable 7:.Performance Indicators in computing for the Performance Factor ··.. .- !

ct:
~
..
.C'JQ.l..
IJJ
J-0..
>"·0 --
- - t,fi-o- - - · - -- ------ · - -- - - -
. <!c.)
~ .
~~

u
..
0 Page 4 of6 of Annex I
 The percentage of the tranche to be released will be based on the cumulative resultant
. score ofthe performance ofthe KPP. ·

Number ofbeneiiciaries "'r:ith consultation= 8,ooo ·

Number of beneficiaries with labs= 3,000
Number of beneficiaries who received antibiotics= 2,000
Number of beneficiaries who received NCD medicines = 1,500
Letx =No. ofbeneficiaries with FPE
X= 14,850
Percentage of beneficiaries
who availed Konsulta
Computation Resultant Score (in percentage)
Performance Indicators/Description services over beneficiaries
with FPE I Actual Score
a b =ale e =bxd
Primary Care Consultation 0.54 x 0.30 = 0.16 or
Unique registerec 16%
1 0.54 0.54/1 C< 0.54
beneficiaries -who consulted <
.primru.y care doctor
Utilization of Laboratory
0.20/0.50 = . 0.40 x 0.30 == 0.12 or
2 Services Unique · 020
0.40 12%
laboratory services done
Dispensing of
Medicines
Unique .. r<!gisterec 0.13/0.15
3 0.13 0.87 x .10 .. 0.09 or 9%
· beneficiaries who receivec .,.0.87
antibiotics · as prescribed b1
their primary care doctor •.

.. --· ··· l•• ... .-.

-~

Dispensing of :Medicines
..
Unique registered
4 beneficiaries who · receivec 0.10
0.10/0.20 = · 0.50 x 0.30 = 0.15 or -·-
15% . . -· ·-
NCO medication as 0.50
prescti.bed by their primar)
care doctor -

.. Performance Factor o.52 ·o r52%

Table 8: Sample computation for the Performance Factor
--~~--~i Sample computation for Second Tranche for a public KPP
Second h·anche = No. of registered beneficiaries with validated FPE x
~ Q)
Performance Factor x 6o% capitation amount
= 14,850 X 0.52 XPhp 300.00
~ = Php 2,316,6oo.oo .

Sample computation for Second Tranche for a private KPP

Second tranche = (No. of registered beneficiaries with FPE x Performance
---FactGr-x-69%-Gapita-tien-amountj-- -2%- Withholding tax ·
= (14,850 X 0.52 X Php 450.00)- 2%
= Php3,474,90o.oo - Php 69,498.00
·- Php 3,405,402.00

c. Resultant score will be multiplied to Php4so.oojPhp300.00 and to the total number

of registered beneficiaries with first p.atienLencounte.r..as_oinecemher...oLth.~:;-_ __
applicable year.

·d: To facilitate'J>'r ompfpayment, all KPPs shall submit, through HCI Poital or LHIOs, · · 1
the complete consultation data on a daily/weekly basis or until the end of January of
Page 5 of 6 of Almex I
. '

i the immediate succeeding year.

e. TI1e computation of the·second tranche and generation of SAP2 shall depend on

the complete data submitted as of 11:59 PM of the 7th calendar day of January.
PhilHealth, through th~ BAS, shall generate SAP2 on the 8th day until the end of
· January.

f. The computed 2nd tranche capitation amount shall be released as soon as possible
within 6o days after the 8th calendar of January, provided that all data records
are successfully uploaded and passed the system validation of PhilHealth.

4· SAP1 generation shall be done only once in a month. Any unpaid FPE due to additional
reports uploaded by KPPs shall be automatically included in the succeeding SAP1
computation.

s. As determined by the Corporatimi, any adjustment in the SAP1 and/ or SAP2 generated
in previous years shall be in accordance with any approved revisions _to the formulas
for the first and second tranches, as may be applicable to specific years. It shall be
processed and released during the first quarter of CY 2024.

6. In case of discrepancies between . any generated SAP ledger and the applicable
masterlists, the Local Health Insurance Office/BAS is authorized to cancel the SAP,
without prejudice to the generation of a replacement SAP.

7· Balance Billing/Co-Payment/Cost Sharing

--- . .-. ..... a. - Privat~ KPPs shall .be .allowed to charge balance billing/co-payineht cap of
Phpsoo.oo per ammm per beneficiary basis.
··-··
.. . ....
. ;

-. ~. .- : .. .:... . . ' ... -

(.)
0

Page 6 of 6 of Annex I
 I' .,

Annex J: Schedule for Submission of Reports

Tranche 1
Upload t he XML file report
~ through HCI Portal on a daily
<lJ With basis, on or before t he 7th
"'C I { A ~

With Internet? Yes ---+1 Extract the XM L

·:.; eKonsulta? calendar day of the succeeding !--
0 File
~ applicable month.
Q.
C1)
b.O Save the XML file in USB and
ra
~ email to LHIO or submit
u
l'tJ
1 No •I Extract the XML ...
personally to LHIO on a daily
c.. L--No- - I · · .·I"' I File basis, on or before the 7 th
nS cale ndar day of the
.:t:::
::l ·: 1,~· . succeeding applicable month.
V)
l';
c:
0
~
..c: With Online Yes -~1 · Direct uploading
~
ra
QJ
EMR? of data
J:
:.c
Q.

-----~ Upload the submitted XMLfile to

-
0

il-
UPCM o n a daily basis, on or
::I: before the 7th calendar day of t he
...1 .
succeeding applicable month.
~ ­ Q)
w>-.....
L _ _ 1'\ ,....
( I)
. '

en a
~

.' QJ
·u
~(.) .. ; ,: -~--'------.,.-
~
.

~ ~- :·
.;·
>(i;
,. All Konsulta data
s~all ~e'stored in ~-------------'----...,--------'--------1
.·....,roc
J.. (.)
·.
. • :. ·. Ph1IHealth
·.. · i{dnsulta Database
'- 0 ~

:
QJ ·
u
~
..
- ..

I Page 1 of 2 ofAnnex J
i
Tranche 2
Upload the XMl file
'-
,QJ through the HCI Portal on
"'0 Extract the XMl a daily basis, on or beforn
·:; Yes
File the 7'~ calendar day of
0
.... January of the Immediate
Q. succeed in ear.
QJ
b.O
1'0 Save the XML fife In USB and
..'t:: Receive the
ema II to LHIO or submit
-
•:•
u Extract the XMl accomplished EKAS
1'0 personally to LHIO on a daily
.C. File basis, on or before the 7'" and EPRESS and
:1'0 calendar day of January of the
.:!:::: ! ; Immediate succeeding year.
submitto LHIO
::;, I

V) i
s:
0
~ Contact the
..s: Service Provider ~N Yes
Directuploading
.:!::::
1'0 for data upload ing of data
ClJ
X
..r:
c..

~ Upload the submitted XML file to

Receive and
-0
:I:
....1
UPCM on a daily basis, on or
before the 7'h calendar day of
January of the immediate
forward the EI<AS
and EPRESS to PRO
succeeding year. AQAS
ct ..

-
ClJ
u
.:t:: Afi .Konsu Ita data
sh~ll be stored in
0
. ·PhiiHealth

' +'
....
1'0
0
' Konsuita Database
c: 0
:~ ..

. ;;; -~
. . ~· =· . . '.:. : :
Page 2 of 2 of An nex J
 Annex K: Sample Ten1plate for Health Screening/FPE
HEALTH SCREENING/FPE FORM

CLIENT PROFILE 1.
0 Walk-in clients with Authorization Transaction Code (ATC)
·~Authorization Transactioi1 Code:
Photo (if without ATC)

Note: ATC should be used within the Screening Date.

0 Walk-in clients without ATC

*Health Screening Date (mm/dd/yyyy2:

INDIVIDUAL HEALTH PROFILE

r=C=as::. :e:. .;N:. .:.u=m=b=
er:·:. .:. _ __ __ __ __ _ __ _ _ ...., PhilHealth Identification Number:

'~----------~''~----------~~
C1ient Details
Last Name: First Name: Middle Name: Extension Name:
~,~--~,~,~--~, ,~~--~,~~----~~
r-;A:cg.:::.;e::.. .__ _ __ _ _____, Date of Birth (mm/ddfyyyy): Sex: ,.: .C;:.lie
.:.:;.;:n;:. :.t.Typ
.;:;...........e;;.; .:_ _ __ ____,
I I I II.____ ___,
. . -~ .. . ~ -·' ..:.': :.: ··: .. 2. REVIEW OF SYSTEMS
..
1. Chief complaint (please describe) . ..
..
...
. .. .
. .. . .. . . ..
.. . . ~;. -~
..
...
. - . .
. . ... .·- ·
. .
.....
... ..... 'l.·. · ... .. ..
..
.. . ..
.. . .· . , .: .2 .·Do you experience any of the following: fever, cough, colds, or headache?
~ OYes ONo ..
.•:
. ; 1

- --·----~ If yes, please explain: ..

.. .
..

0::
'lf: ~ Do you experience any of the following: unexplained change in weight, loss of appetite, change in
w>·
1-fl 0
~ bowel movement, or abdominal pain?
OYes ONo

~
CI)C
~<.; ~fyes , please explain:

0
c
-~4-Do you experience any of the following: chest pain or difficulty in b reathing?
OYes ONo

If yes, please explain: ..

5· Do you experience any of the follovdng: frequent urination, frequent eating,_f~~q~~~! i!1_!a_~~.9i _____
·- .. .. ·· -·--nmas; ~imoking·ana drinking-alcohol?' - - - · --· ____ .. - ----· · --·---
OYes ONo ... ..

This form may b e reproduced and is.n ot for sale.

Page 1 of 2 of Annex K
 If yes, please explain

. 6. For male and female, do you experience ay of the following: pain or discomfort on urination or
frequency of ur ination?
o Yes o No

If yes, please explain:

7. For females only,

a. Last menstrual period (mrri/dd/yyyy): b. First menstrual period (mm/ddjyyyy):

Number of pregnancy: _ _ _ _ _ __

If the answer is yes to uestions 1-6, the beneficia r needs to consult a doctor.

g. PERTINENf PHYSICAL EXAMINATION FINDINGS

PERTINENT PHYSICAL EXAMINATION FINDINGS

Blood Pressure:
Heart Rate:
I
II I I mmHg
/ min
Height:
' Veight:
I
I
jccm)
l(kg)
I
I
I(in)
lob)
Respiratory Rate:
I ltmin BMI: I j
.1.•- ·Visual Acuity ' I 1" 1 I Tem:perature:
I loc
Pediab·i~ Client aged o-2a mgnths ... . ..

Length: - .. .. . . . ... .. .. Head Circumference: Skinfold Thickness:

I lccm) I I (em) I .. I·· . (em)- ·

Body Circumference:
--- Waist: Hi2: Limbs: .. .

I .. l c~t~)-1 I (em) I I (em)

Middle and U.J2J2er Arm

I Icern) .. . .

Blood ~>e (as available)

OA+ O B+ OAB+ 00+ OA- OB- O AB- 0 0-

General Survey: 0 Awake and alert 0 Altered Sensorium I I

--~
':i-1 .
. ~
..
0!:
w>-~
....<11ca

-
.

i~ (.)
-

Cl

Page 2 of 2 of Annex K