Primary Care Provider Network
Implementation of PCPN Contracting
Arrangement through the KonSulTa
Package in Sandbox Sites (revision 1)
PhilHealth Circular No. 2023-0008
Effectivity: 13 May 2023
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Rationale
RA 11223 (UHC Act)
• Mandates PhilHealth to contract public, private, or mixed HCP networks
for the delivery of individual-based health services.
• As an initial step to comply with its mandates, PhilHealth issued a
resolution to implement a network contracting arrangement of Konsulta
providers within the framework of the LHS under a sandbox setting.
• PhilHealth aims to begin with Konsulta services delivery as a model for the
PCPN as the core for the formation of HCPNs.
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Sandbox – a strategy for small-scale, live testing of innovations in a
controlled environment under 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
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Objectives of
the PCPN
Sandbox Test innovations in improving
Contracting the implementation of
Konsulta benefits
Promote formation of
Network Providers
Increase member
registration
Establish Assess the readiness of LGUs, Provide guidance to
Improve utilization of Creation and COA/BLGF/BIR and other
network contracting private providers,
Konsulta services management of SHF and PhilHealth in adopting concerned agencies on the
standards issuance of respective
network contracting
guidelines on the
implementation of HCPN
contracting
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Scope
Applies only to selected provinces, cities and private health sectors with
interest to engage or contract with PhilHealth to test
interventions/innovations/initiatives in improving Konsulta delivery and
utilization.
The interventions/innovations shall encompass the following:
A. Formation of a network of providers, public, private or mixed, for Konsulta services with
established administrative and clinical referral systems
B. Establishment of financial arrangements with the creation of SHF or pooled fund to
support funding requirements of the intervention/innovation
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Policy Statements
Areas for Intervention/Innovation
1. Establishment of network of providers to deliver Konsulta services to beneficiaries in a
coordinated and integrated manner.
2. Application of capitation as prospective mechanism prescribed in PC No. 2022-0005 shall
be retained with modified payment schedule as described herein.
3. 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.
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Policy Statements
Areas for Intervention/Innovation
4. Computation of PCPN physical targets and contract amounts, within prescribed
limits, to be stipulated in the SLA.
5. Integration of KPPs 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 (public) or
pooled fund (private)
7. Enhancement of Konsulta benefit implementation and utilization.
8. PCPNs are encouraged to start to prepare and integrate services in the primary
care setting and higher levels of care, with Konsulta service as base, including
those that are already covered by existing benefit packages.
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Selection Criteria
PURELY PUBLIC/ PUBLIC-LED PURELY PRIVATE/ PRIVATE-LED
Has at least 5 accredited Konsulta facilities with a
Meets the PCPN standards maximum of 20,000 enrolled population per
PhilHealth accredited MD as of January 31, 2023
With Konsulta accredited facilities to serve at least Committed to establish at least 1 facility within 6
20% of the 2020 PSA projected population as of months in the identified public network sandbox
January 31, 2023 sites
Presence of network and referral arrangements to
accredited PhilHealth providers for other benefit
packages as applicable to their catchment
population
7 Sites recommended by the Area Office and Task Force Konsulta Sandbox Team, and approved by
the PhilHealth Executive Committee
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Application Process & Requirements
1. Letter of Intent (not later than May 15, 2023)
2. Tripartite MOA among LGUs, PhilHealth and DOH on UHC-IS
3. For Private networks
a. SEC Registration or any document as proof of legal entity of a
network
b. BIR Certificate of Registration
c. Updated LGU Business Permit
d. Certified network list of accredited Konsulta providers with list of
accredited MDs/facility and number of target beneficiaries/facility
Submitted to the AQAS for endorsement to the Task Force PCPN Sandbox Team for their
recommendation to the PhilHealth Executive Committee.
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Contracting Process
1. Preparation and submission of core requirements. Additional
requirements for public networks are baseline data on demography
and epidemiological profile.
2. Evaluation and review of the submitted documents in compliance
with the PCPN Standards.
3. Execution of SLA.
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Important Provisions of PCPN
1. The transaction is covered by a Service Level Agreement (SLA).
2. Liquidation thru physical accomplishment is a prerequisite for the
subsequent payment releases.
3. Implementation of a performance-based Konsulta program.
4. Cash programming will be strictly observed
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Important Provisions of PCPN
5. Release of funds will be based on the money value of the performance target,
cash programming, or maximum of 30%/50%/20% of the contract amount,
whichever is lower.
6. The releases will be covered by the committed target/no. of Konsulta
beneficiaries.
7. A mechanism of refund to PhilHealth is employed in case the money value of
total accomplishments is less than the total capitation advance releases at the
end of the year
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Important Provisions of PCPN
8. IT system support on performance monitoring system.
9. Capacity building programs for personnels of PhilHealth, DOH, other internal
stakeholders and participating LGUs to ensure efficiency and accuracy of
implementation.
10. Require the Network to secure GSIS Surety Bond to cover the portion of Capitation
Frontloaded. (30% of the Contract Amount)
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Important Provisions of PCPN
11. Only Accredited Konsulta Providers 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,
the existing PhilHealth Konsulta policy shall continue to be applied to non-PCPN KPPs.
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Comparison Konsulta-Facility VS PCPN Contracting Arrangement
Particulars Konsulta PCPN Sandbox
Services Primary Care Services (Konsulta Benefit Package)
Payment
Mechanism/Rate Capitation Fee: G - Php 500; P – Php 750
Coverage Nationwide implementation Selected sites (at most 5 public networks & 2
private networks)
Contracting PCPN thru SLA with absolute
Accreditation of Konsulta Facility, performance targets and contract amount
Engagement
Performance Commitment Accreditation of Konsulta Facilities through a
Performance Commitment
Mode of payment Prospective, payment after services Prospective, payment before services
rendered/ Reimbursement rendered/Frontload
Formula of Capitation PC 2023-0013, No. of Beneficiaries needing
Computation Based on PC 2023-0013 Konsulta Services will be the denominator.
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“Prospective payment is the allocation of
resources to a health care provider the deliver the
covered package of health care goods, services, and
interventions to the covered population in which
rates are set in advance and/or providers are paid
before services are delivered. ”
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