Guidelines on Filing of Appeal and Motion for Reconsideration (MR) on the Denied Application/Other Accreditation Transactions of Health Care Providers (HCPs)

May 31, 2017

PHILHEALTH CIRCULAR NO. 013-17

 

I. RATIONALE

Section 31 of the Republic Act 7875, as amended by RA 10606 or the National Health Insurance Act of 2013 provides that "the Corporation shall have the authority to grant to health care providers accreditation which confers the privilege of participating in the Program."

The revised implementing rules and regulations (RIRR) of RA 10606 further provides "The Corporation shall determine the period of accreditation within reasonable period of time from receipt of the application and reserves the right to issue, deny or withdraw the accreditation after an evaluation of the capability and integrity of the health care provider (HCP).

PhilHealth has streamlined the process of accrediting HCPs and has delegated to the respective PhilHealth Regional Offices (PROs) the processing of all applications for accreditation and other transactions related to accreditation. Denied HCPs may file an appeal/motion for reconsideration to the Accreditation Committee (AC). The decision of the Accreditation Committee shall be final and executory upon approval by the President and CEO.

II. OBJECTIVE

This Circular shall define the process in filing of appeal or motion for reconsideration (MR) on denied applications/other accreditation transactions of health care providers.

III. SCOPE

This Circular shall cover all applications for accreditation of HCPs and other accreditation transactions denied by the Accreditation Subcommittee and Accreditation Committee.

IV. GENERAL GUIDELINES

A. The Accreditation Subcommittee (ASc) in the PhilHealth Regional Office:

1. Shall deliberate all applications for accreditation (initial, continuous and re-accreditation) and other accreditation transactions of HCPs. It shall recommend the approval or denial of applications/other accreditation transactions of HCPs to the Regional Vice President/Vice President (as applicable) as delegated by the President and CEO of the Corporation.

2. The decision of the ASc on the applications/other accreditation transactions of HCPs may be appealed within fifteen (15) days from receipt of the denial letter. The appeal of the HCP shall be addressed to the Chairperson of Accreditation Committee (AC) copy furnished the RVP/VP of the concerned PRO.

B. The Accreditation Committee (AC) in the head office shall deliberate on the appeal of HCPs with denied applications and motion for reconsideration (MR) of HCPs with denied appeal: CAIHTE

1. It has the authority to grant, deny or take such other actions as are just and equitable under the circumstances, within thirty (30) calendar days from receipt of the appeal/MR provided that the complete staff work pertaining to the matter has been provided.

2. The AC may grant an appeal if any of the following grounds exists:

a. Misappreciation of material facts by the ASc;

b. Compliance/s to noted deficiency/ies after the prescribed period;

c. The recommendation of ASc is contrary to law;

d. Other grounds the Committee may deem appropriate to subserve the interest of substantial justice.

3. The decision of the AC on the appeal shall be final and executory upon approval by the President and CEO unless the HCP files a Motion for Reconsideration (MR) on the denied appeal within fifteen (15) calendar days from receipt of such decision.

a. If the last day falls on a Saturday, Sunday, holiday, or declared non-working holiday, the last day to file the MR shall be the next working day.

b. Only one (1) MR shall be filed.

4. The AC may grant the MR if newly submitted documents or discovered facts were presented that would alter the Committee's decision.

5. Failure to file an MR within the prescribed period shall result in the finality of the decision.

C. This policy shall apply to all appealed accreditation matters that were returned by the Corporate Secretary to the Accreditation Committee, as directed by the Committee on Appealed Administrative Cases against health care providers and members (CAAC).

V. PENALTY CLAUSE

Any violation of this Circular, the terms and conditions of the Performance Commitment and all existing related PhilHealth circulars, advisories and directives shall be dealt with and penalized in accordance with the pertinent provisions of RA 7875, as amended, and its Revised Implementing Rules and Regulations.

VI. REPEALING CLAUSE

All previous PhilHealth issuance/s, such as but not limited to PhilHealth Circular 54, s. 2012, inconsistent with or contrary to the provisions of this Circular are hereby revised, modified or repealed accordingly. All provisions of existing issuances that are not affected by this Circular shall remain valid and effective.

VII. EFFECTIVITY

This circular shall take effect after fifteen (15) days from publication in the Official Gazette or any newspaper of general circulation and thereafter deposited with the National Administrative Register at the University of the Philippines Law Center.

All PhilHealth Offices through the Corporate Communications Department, and Public Affairs Units and Health Care Delivery and Management Divisions (HCDMD) of the PROs shall ensure appropriate and massive information campaign efforts regarding this issuance. aScITE

 

(SGD.) DR. CELESTINA MA. JUDE P. DE LA SERNAInterim/OIC, President and CEO