Patient-Centered Community Care
(PCCC)
Benefit Program Requirements
October 2014
Contents
Overview ...4
Provider Tools ...6
Requirements for Maintaining Accurate Information ... 6
Online at www.hnfs.com ... 6
Important Provider Information ...7
General Requirements ... 7
Fraud, Waste and Abuse ... 7
Privacy or Security Incidents ... 7
Office and Appointment Access Standards ... 7
Veteran ID Cards ... 7
Covered Services ... 7
Accreditation and Certification ... 7
Credentialing... 8
Privileging ... 8
Licensing ... 8
Additional Requirements for Specific PCCC Services ... 8
Audiology ... 8
Laboratory Services ... 8
Radiology Services ... 9
Radiation Oncology ... 9
Rehabilitation Medicine ... 9
Labor, Delivery and OB/GYN Prenatal Care ... 9
Surgery... 10
Cardiology ... 10
Skilled Home Health ... 10
Office-Based Diagnostic and Therapeutic Tests and Procedures ... 10
Additional Requirements for Behavioral Health Providers ... 10
Primary Care Requirements ...11
Eligibility and Authorization ... 11
Routine Diagnostic Services ... 12
Appointments ... 12
Medical Records and Documentation ... 12
Prior Authorizations ...13
General Process ... 13
Authorizations ... 13
Provider Notification Packets ... 13
Appointment Scheduling ... 14
Inpatient Authorization Process and Discharge Planning ... 14
Pharmacy and Durable Medical Equipment ... 16
Home Infusion ... 16
Claims Procedures ...16
Provider Claims Process ... 17
Claims for Labor an Delivery Services ... 17
Claims for Pharmacy Costs ... 17
Remittance Advice and Claims Payment ... 17
Rejected Claims ... 17
Denied Claims and Resubmissions ... 17
Claims Questions and Status Updates ... 17
Office Procedures ...18
Return of Medical Documentation ... 18
Content of Medical Documentation to be Transmitted to Health Net ... 18
Additional Requirements for Medical Documentation ... 19
Critical Findings... 19 Pathology ... 19 Radiology ... 19 Surgery... 20 Oncology ... 20 Gastoenterology ... 20
Skilled Home Health ... 20
Inpatient Rehabilitation ... 20
Blind/Low Vision Rehabilitation ... 20
Mental Health ... 20
Inpatient Mental Health ... 21
Complaint and Grievance Process ...21
Health Care Management and Administration ... 21
Clinical Quality and Veteran Safety Measures ... 21
Questions or Comments ...22
Overview
Participating providers in the Patient-Centered Community Care (PCCC) network agree to
comply with all Health Net Federal Services, LLC, (Health Net) and Department of Veteran
Affair’s (VA) program rules, policies and procedures including, the Health Net Preferred
Provider Network Provider Manual and this PCCC Benefit Program Requirements document.
The current versions of both the PPN Provider Manual and the PCCC Benefit Program
Requirements can be found on www.hnfs.com.
About PCCC:
Patient-Centered Community Care (PCCC) is a new Department of Veterans Affairs (VA) program to provide eligible Veterans access to health care through a comprehensive network of community-based, non-VA medical professionals who meet VA quality standards when VA must supplement care outside its own facilities. Such access is especially critical in instances when the local VA medical center lacks the needed specialists, has extended wait times or is located an extraordinary distance from the Veteran’s home. The program will augment VA’s ability to provide specialty inpatient and outpatient health care services to their enrolled Veterans.
Health Net supports VA in providing care to Veterans in three PCCC regions. These three regions – Regions 1, 2 and 4 – encompass all or portions of 37 states, plus
the District of Columbia, Puerto Rico and the U.S. Virgin Islands.
Under the PCCC program, VA is responsible for determining eligibility and for authorizing care. Eligibility for VA health care is based on Veteran status, service-connected disabilities or exposures, income and other factors.
Health Net provides VA a network of providers accredited in accordance with URAC Health Network Accreditation standards that meet all of the requirements of the PCCC program. Health Net uses systematic and integrated processes to coordinate care between VA and local community providers. Health Net is responsible for scheduling appointments, collecting and submitting required medical documentation from the rendering providers, and paying claims.
The Purpose of this Document: Health Net
PCCC Benefit Program Requirements define provider roles and responsibilities including appointment access standards; patient safety and safety events; health care services and prescriptions; authorization and care coordination requirements; clinical training components; medical documentation and report coordination with VA; and claims processing, patient billing and reimbursement information. This document is a supplement to the Preferred Provider Network Provider Manual, available at www.hnfs.com.
Responsibility for Provision of Services:
Providers and Health Net do not have an employer-employee, principal-agent, partnership, joint venture, or similar
arrangement. Providers make all independent health care treatment decisions and are responsible for the costs, damages, claims, and liabilities that result from their own actions. Health Net does not endorse or control the clinical judgment or treatment recommendations made by providers and not all services are contracted or covered services.
Key Requirements: The following items are
key aspects specific to the PCCC program. Please review this document in its entirety for complete program details and requirements. • Providers must meet all credentialing /
accreditation / certification to participate in the PCCC program and be activated by Health Net as a PCCC network provider to provide services under this program. • Providers must be currently credentialed
by Health Net in accordance with the requirements of the Preferred Provider Network Provider Manual.
• Providers must be Medicare-certified and meet all Medicare Conditions of
Participation and Conditions for
Coverage without exception, where such conditions exist.
• Certain services have additional accreditation / certification / reporting requirements as provided in the section entitled “Additional Requirements for Specific PCCC Services.”
• Provider must continuously maintain all licenses, accreditations, certifications, and professional liability insurance and must report any lapse immediately to Health Net. • Providers must make appointments available
for Veterans within 14 days of a request by Health Net.
• Office wait times for appointments must not exceed 20 minutes beyond their scheduled appointment time.
• Health Net will issue all authorizations to the provider for PCCC services upon request from VA for a specific Veteran.
• A provider notification packet will be sent with each authorization after the appointment has been scheduled with the provider which outlines the specific clinical and other requirements for the authorized care.
• Providers will render only those services listed on an authorization provided by Health Net.
• Providers must contact Health Net for authorization to provide any services in addition to those listed on the authorization. • The episode of care authorized by Health
Net is not considered complete and payable until complete medical documentation is returned to Health Net.
• Providers will be paid for all authorized services according to their PCCC
Compensation Exhibit of their Participating Provider Agreement.
• Providers collect no copayments/cost-shares/ deductibles from Veterans.
• Providers must not bill the Veteran for any services, including no-show, missed or cancelled appointments.
• Medical documentation must be faxed to Health Net (855-300-1705) within 10 days of the appointment.
• All medical documentation must be returned before claims will be paid. • Providers must report critical findings,
adverse events, close calls, and unintentional unsafe acts to VA and Health Net.
• Hospitals must report admissions within 24 hours.
• Providers of skilled home health and home infusion therapy must comply with the Service Contract Act.
Provider Tools
Requirements for Maintaining
Accurate Information
It is important network providers keep their demographic information up-to-date to ensure Health Net provides accurate information to Veterans and to speed accurate claims adjudication. Providers should use the Provider Demographic Update Form to submit any changes electronically.
To ensure continuity of care, any provider leaving a network group must notify Health Net 90 days prior to his or her departure.
During this time the provider is placed on a no referral status to ensure no additional cases are referred. This window is intended to allow sufficient time for the provider to complete authorized care or, if the care needs to be transitioned, to notify Health Net of a need to continue services with another provider.
Note: Participating providers are responsible for updating their contact information with Health Net. Go to www.hnfs.com for the Provider Demographic Update Form.
www.hnfs.com
Health Net’s website provides information about the PCCC benefits, processes,
requirements, and operations, as well as access to business tools and forms. Visit
www.hnfs.com > Department of Veterans Affairs Programs > I’m a Provider for more program details and important updates.
Important Provider
Information
General Administrative
Requirements
All services, facilities, and providers must be in compliance with all applicable federal and state regulatory requirements. Any provider on the Centers for Medicare and Medicaid Services (CMS) exclusionary list will be prohibited from network participation. See www.oig.hhs.gov/exclusions/index.asp for further detail.
Participating providers are required to immediately (within 24 hours) report in writing, but not later than three days, the loss of or other adverse impact to a provider’s certification, credentialing, privileging, or licensing.
Loss of facility accreditation status is required to be reported as soon as the facility is notified. The report is to contain information detailing the reasons for and circumstances related to the loss or adverse impact. Health Net will immediately cease to refer Veterans to the impacted provider until such time as the circumstances contributing to the event or loss have been resolved.
Fraud, Waste and Abuse
Refer to Health Net’s Preferred Provider Network Provider Manual for definitions, details and reporting processes. The document is available online at www.hnfs.com >
Department of Veterans Affairs Programs >
I’m a Provider.
Privacy or Security Incidents
Providers must report to Health Net any privacy or security breaches containing Veteran information within 24 hours. Contact Health Net at hngss_incidents@healthnet.com.
Office and Appointment Access
Standards
Providers must comply with the Office and Appointment Access Standards of the Preferred Provider Network Provider Manual. However, providers must also comply with these specific PCCC Benefit Program Requirements:
• Specialty care appointments must be made within 14 calendar days.
• Preventive care appointments must be made within 14 calendar days.
• Office wait time for appointments must not exceed 20 minutes.
Beneficiary Identification (ID)
Card
The PCCC program will not issue identification (ID) cards to Veterans for this program. It is suggested the provider verify the identity of the Veteran through a government-issued identification card (for example,driver’s license, military card, or passport). The authorization received from Health Net is the provider’s authorization to provide the specific services to a particular Veteran. Only eligible Veterans who have been authorized by VA will be referred for care by Health Net.
Covered Services
Covered services under the PCCC program are limited to the health care services set forth on the authorization received from Health Net. Any services that have not been authorized by Health Net and VA will not be paid for under the PCCC program.
Accreditation and Certification
Participating providers must meet all Medicare Conditions of Participation (CoP) and Conditions for Coverage (CfC), where such conditions exist subject to The
Centers for Medicare & Medicaid Services (CMS) modification, as required by the U.S. Department of Health and Human Services. These conditions may be met through CMS certification or accreditation by organizations deemed by CMS to meet or exceed the CMS Medicare standards set forth in the CoP/CfC.
Credentialing
Health Net and its subcontractors ensure that providers comply with the credentialing requirements of the Preferred Provider Network Provider Manual. The PCCC program has additional benefit program requirements that include Medicare
credentialing, accreditations, certifications, and provider privileging. All participating providers must be credentialed in accordance with the requirements of CoP and CfC, where such conditions exist subject to CMS modification. In accordance with requirements outlined in the Office of the Inspector General’s Compliance Program Guidance for Hospitals (https://oig.hhs.gov/compliance/ compliance-guidance/index.asp and USSC Sentencing Guidelines (http://www.ussc.gov/ Guidelines/2011_Guidelines/index.cfm), all services, facilities and providers must have a compliance program in place that includes the seven elements of an effective compliance program.
Privileging
Every procedure, test or other aspect of clinical care must be performed by providers with demonstrated current competence, either though current unrestricted privileges to provide the care as required by Medicare CoP and CfC, or other measures of demonstrated competency. Participating providers are required to make available all evidence of current credentialing and competency upon written request by Health Net.
Licensing
All participating providers and clinicians are required to have a full, current and unrestricted license in the state where the service(s) are delivered.
Additional Requirements for
Specific PCCC Services
Audiology
Initial testing results relating to potential hearing aids needs must be submitted directly to VA within two business days. All hearing aids will be ordered by the VA through the its national hearing aid contract When hearing aids are issued, medical documentation for follow up appointments such a fittings and adjustments must be returned
Laboratory Services
Clinical laboratories must meet requirements of the Clinical Laboratory Improvement Amendments (CLIA’88) of the Public Health Services Act (Title 42 United States Code (U.S.C.) 263a), per HHS’ implementing regulations under Title 42, Code of Federal Regulations Part 493.
Radiology Services
Outpatient facilities providing advanced diagnostic imaging procedures are required to be accredited in accordance with Medicare Improvements for Patients and Providers Act (MIPPA 2008), currently applicable to all providers of computed tomography, magnetic resonance imaging (MRI), breast MRI, nuclear medicine, and positron emission tomography exams. American College of Radiology and the Intersocietal Accreditation Commission have been deemed by CMS to provide this accreditation.
Facilities providing mammography are required to meet Food and Drug Administration requirements per the Mammography Quality Standards Reauthorization Act of 1998, as amended
by H.R.4382. Clinicians performing interventional radiology procedures are required to have both General Diagnostic American College of Radiology certification as well as specific current Boards in
interventional radiology.
All radiologic technologists are required to be certified by the American Registry of Radiologic Technologists (AART). Mammography
technologists must have advanced ARRT certification in mammography.
Radiation Oncology
Radiation oncology practices are required to be accredited by the American College of Radiology or the American College of Radiation Oncology. Exceptions may be submitted to Health Net for written approval for National Cancer Institute-participating programs. Medical directors for radiation oncology practices are required to be board-certified in radiation oncology or therapeutic radiology by the American Board of Radiology, the American Osteopathic Board of Radiology, or the Royal College of Physicians and Surgeons of Canada.
A full-time medical physicist is required to be part of each radiation oncology practice. These medical physicists are required to be certified by the American Board of Radiology in therapeutic radiological physics or
radiological physics.
Rehabilitation Medicine
All inpatient rehabilitation facilities are required to be accredited by the Commission on Accreditation of Rehabilitation Facilities. A rehabilitation physician is required to be a licensed doctor of medicine or osteopathy who is a board-certified or board-eligible physical medicine and rehabilitation physician, and otherwise appropriately provides rehabilitation physician services under Medicare policies.
All speech language pathologists are required to have a full, current and unrestricted license in the state in which services are provided. In states without licensure requirements for speech pathologist (Colorado and South Dakota), American Speech-Language-Hearing Association certification may be substituted for licensure.
Unless otherwise authorized by Health Net, providers of blind or low vision rehabilitation are required to be certified by the Academy for Certification of Vision Rehabilitation & Education Professionals.
All rehabilitation services are required to conform to Medicare benefits policy rules for certification and re-certification of treatment plans and content of treatment plans.
Labor, Delivery and OB/GYN
Prenatal Care
Participating providers must review the VA / DoD Clinical Practice Guidelines for Pregnancy Management found at
www.healthquality.va.gov. These are baseline criteria and do not replace clinical judgment.
Surgery
Facilities performing cancer surgery are required to be accredited by the Commission on Cancer of the American College of Surgeons, unless authorization to a non-accredited facility is authorized by referring the VA facility and approved in writing by Health Net.
Facilities performing cardiac surgery are required to report to the Society for Thoracic Surgery National Adult Cardiac Surgery Database, unless an exception is authorized by the referring VA facility and approved in writing by Health Net.
Cardiology
Facilities performing cardiac catheterizations and / or percutaneous coronary interventions
are required to participate in the National Cardiovascular Data Registry (NCDR)
CathPCI Registry, unless otherwise authorized by the referring VA facility and approved in writing by Health Net.
Facilities implanting cardioverter defibrillators (ICDs) are required to participate in the NCDR ICD Registry, unless otherwise authorized by the referring VA facility and approved in writing by Health Net.
Skilled Home Health and Home
Infusion Therapy
Unless otherwise authorized by the referring VA facility and approved in writing by Health Net, skilled home health providers are required to perform better than the state average on at least 50 percent of CMS quality measures for home care. Health Net will monitor CMS reporting databases for compliance.
Providers supplying skilled home health or home infusion therapy must comply with the requirements of the Service Contract Act, including wage and benefit requirements for applicable workers. The Department of Labor determines the levels of wages and benefits based on location of services. These can be found at www.wdol.gov. Annually in September, participating providers must review the current and applicable wage
determination to assure they remain compliant with it and the Service Contract Act.
Office-Based Diagnostic and
Therapeutic Tests and
Procedures
Diagnostic and therapeutic procedures performed in a setting other than an inpatient facility, hospital clinic or ambulatory surgery center are required to be performed in a safe manner by qualified physicians within their licensed scope of practice. Physicians
are required to be appropriately trained and proficient in performing any such procedures. The same credentialing requirements
are required for office-based procedures. Processes for using sedation during a procedure are required to conform to the requirements in Medicare CoP for medical centers or ambulatory surgical centers.
Additional Requirements for
Behavioral Health Providers
Providers of evidence-based psychotherapies (EBPs) are required to have specialized training and experience in EBPs. This includes foundational instruction on the theoretical and applied components of the therapy and ongoing supervision or expert consultation on the implementation of the therapy. For example, a Veteran being referred for cognitive processing therapy is required to be seen by a provider who has specialized training and experience in that treatment modality. The following is a list of EBPs VA currently uses: • cognitive processing therapy for post-traumatic stress disorder (PTSD) • prolonged exposure therapy for PTSD • cognitive behavioral therapy (CBT) for depression • acceptance and commitment therapy for depression • interpersonal psychotherapy for depression • behavioral family therapy for serious mental illness • multiple family group therapy for serious mental illness • social skills training for serious mental illness • integrated behavioral couples therapy for relationship distress
• CBT for insomnia • CBT for chronic pain
• motivational interviewing for motivation, engagement, and adherence
• motivational enhancement therapy for substance use disorders
• contingency management for substance use disorders
• behavioral couples therapy for substance use disorders
• CBT for substance use disorders
Veterans with a history of military sexual trauma (MST), and being treated for a behavioral health problem related to MST, may receive care from a provider of the gender of their choice.
For both inpatient and outpatient behavioral health care, participating providers are advised of Veterans Affairs / Department of Defense (VA / DoD) Clinical Practice Guidelines (CPGs) for the diagnosed behavioral health diagnosis found at www.healthquality.va.gov. These are baseline criteria and do not replace clinical judgment.
Primary Care
Requirements
The following sections identify the key requirements that differ from the PCCC specialty providers, and are specific to primary care providers within the PCCC program. Primary care is defined as “any care in scope of licensure, which can be performed in the provider’s office, without conscious sedation.” Primary care is directed toward health promotion and disease prevention and includes the management of acute and chronic medical conditions. Ancillary services
such as labs, radiology and pathology that cannot be performed within the primary care provider’s office setting must be referred to a network provider or VA facility (no new VA pre-authorization is required). Diagnostic and treatment such as MRI, CT, or any procedure that requires conscious sedation or to be performed outside the provider’s office must be preauthorized by VA. If it is determined that these or other additional services are required, complete the Request for Additional Services and submit to Health Net. The form is available on www.hnfs.com: www.hnfs.com/go/forms.
Authorizations
Covered services under the PCCC program are limited to those services listed in the authorization. Providers must contact Health Net for authorization to provide any services in addition to those listed on the authorization.
Primary care services may be authorized for one fiscal year up to 24 visits. If
additional visits are necessary, beyond what is indicated in the authorization, providers must complete the PCCC Request for Additional Services form found on Health Net website, www.hnfs.com/go/forms. Primary care authorizations are inclusive of initial visits; follow up visits; and acute primary care services. These include, but is not limited to:
• Routine diagnostic tests • Routine diagnostic radiology • Preventative services
Primary care providers must have (24) hour on-call coverage.
Routine Diagnostic Testing
• Complete Blood Count Prothrombin Time/ International Normalized Ration
• Standard 12-lead electrocardiogram • Fecal Occult Blood Test
• Urinalysis
• Routine chemistry tests • Partial Thromboplastic Time
Routine diagnostic laboratory test must be completed within five business days of the initial appointment.
Routine Diagnostic Radiology
Routine diagnostic testing includes: • Chest x-rays (Antero Posterior/Lateral) • Extremity x-rays
• Abdomen • Spine
• Bones and joints
Routine diagnostic testing excludes MRI, CT or any procedure that requires conscious sedation. Routine diagnostic radiology test must be complete within five business days of the initial appointment.
Routine Diagnostic Services
If diagnostic testing and / or radiology and preventative services can not be preformed within the primary care practice, please notify Health Net immediately.
Appointments
Health Net is responsible for coordinating the Veteran’s initial appointment with a primary care provider’s office. Providers are strongly encouraged to contact Veterans with a courtesy appointment reminder. Notify Health Net of any no show, missed, cancelled or rescheduled appointments. Contact Health
Net at 1-800- 979-9620 or fax 804-622-3559.
Medical Records and
Documentation
Providers must return medical
documentation of the initial visit within 10 days. Medical documentation for all subsequent visits must be maintained within the office. Medical records shall should always be maintained up-to-date and comply with the medical community standards. The record must include required veteran demographics and clinical information as needed to support the care provided provide care, treatment, and services performed.
Note:
• A single comprehensive medical primary care record must be immediately accessible to VA. • Complete medical records must be submitted
to Health Net at the end of the authorization, or after visit 24.
• Claims will not be paid until medical documentation is returned.
Prior Authorization
General Process
Health Net provides coordination and oversight to support orders of authorized care by VA. Providers will receive the VA Authorization Form, which includes all health care services authorized and contains the following information:
• VA authorization
• Veteran’s name and contact information • purpose of authorization and relevant
diagnoses and other medical documentation • type and amount of service requested (for
example, number of visits / procedures / treatments)
• preferred appointment date, if specified by the Veteran
• date by which return of information is needed • preferred gender of provider
• VA point of contact for emergency situations or additional information / authorization needs • where to submit required medical
documentation
• station and authorization number
Authorizations
All services will be authorized by VA and the care request will be submitted to Health Net. Health Net will coordinate with the provider and Veteran to obtain an acceptable appointment date and time while considering appointment wait time and Veteran
commute times to ensure compliance with VA requirements. Health Net will prepare a provider notification packet containing specific requirements for the services covered in the authorization. All services must be performed by PCCC participating providers and facilities. Requests for additional services not contained in the authorization(s) must be submitted to Health Net. Refer to the provider notification packet for more information and instructions. Health Net will work directly with the VA to obtain new authorizations for the requested services.
Note: Authorizations alone do not guarantee payment. The provision of health care services is to be limited to that set forth in the authorization form. All claims must correlate with authorizations and returned medical documentation. Only the authorized practitioner may render and bill for services.
For questions regarding an authorization, contact Health Net’s PCCC Call Center at 1-800-979-9620.
Provider Notification Packets
After an appointment is scheduled, Health Net will send the provider notification packets to each scheduled facility or provider. These provider notification packets provide case-specific clinical requirements, VA standards and guidelines of the PCCC authorized care. Packets may include, but are not limited to: • VA’s authorization, and any clinical notes
or medical documentation provided with the authorization.
• The Veteran’s name and demographics, diagnosis, specific services authorized, date and time of appointment already arranged, and authorization begin and end dates. • Comprehensive information about provider
options for completing and returning medical documentation.
• Instructions for communicating kept and no-show appointments.
• Reminder instructions that the Veteran should be seen within 20 minutes of the scheduled appointment time.
• Instructions and due dates for returning the required medical documentation as a pre-condition of payment and a reminder that claims for services rendered will not be considered until the return of accurate medical documentation is complete.
• Service-specific checklist(s). For example, customized to correspond to the services authorized by VA.
• Instructions for ongoing treatment and/or extended service requests for VA approval. • Instructions for reporting critical findings. • Instructions for notifying the Veteran of test results. • Instructions for submitting claims. • Information on how to handle emergent situations.
• Information on the VA National Formulary. • Instructions for reporting suicide risk.
• Information about the Suicide Prevention Safety Plan found at, www.mentalhealth.va.gov/docs/ VA_Safety_planning_manual.pdf, including the Veterans Crisis Line telephone number.
Appointment Scheduling
Health Net is responsible for coordinating all appointments with a provider’s office or facility, however, providers are strongly encouraged to contact Veterans with a courtesy appointment reminder. Providers must comply with the following access care standards for care: • Urgent care appointments must be within 48
hours.
• Office wait time for appointments must not exceed 20 minutes.
Providers must report all no-show, missed or cancelled appointments to Health Net at 1-800-979-9620 or by fax at 804-622-3559.
Note: Providers must not bill Veterans, or request reimbursement from VA or Health Net for no-show, missed or cancelled appointments.
Be aware, Veterans will not provide an ID card for the PCCC program. All information needed by the provider or the facility will be included on the authorization form and provider notification packet.
Authorizations containing the notation of “urgent” require the Veteran be scheduled for care within 48 hours. Return of medical documentation is the same as for routine care, unless the authorization also specifies “urgent with oral report” or “urgent with written report.” Urgent care is defined as care considered essential to evaluate and stabilize conditions. Urgent care is care that if not provided will likely result in unacceptable morbidity/pain when there is a significant delay in evaluation or treatment.
Urgent care is not the same as a medical
emergency. Urgent medical care does not threaten life, limb or vision, but needs attention to prevent it from becoming a serious risk to health.
Furthermore:
• Urgent with oral report must be provided to point of contact as designated on the authori-zation within 48 hours of finding. The follow-ing will be written on the authorization:
o Urgent scheduling.
o Oral report plus written report per con-tract performance standards.
• Urgent with written report must be provided to point of contact as designated on the authorization within 48 hours of finding. The following will be written on the authorization:
o Urgent scheduling.
o Written report per contract performance standards. No oral report required.
Inpatient Authorization
Process and Discharge
Planning
Providers are responsible for notifying Health Net of Veteran inpatient admissions and discharges. Health Net will coordinate and communicate admissions and discharges from an inpatient facility whenever inpatient health care is ordered. Inpatient facilities are responsible for providing status updates directly to the authorizing VA and Health Net. Provider notification packets will instruct inpatient facilities how to handle post-inpatient coordination.
For discharges, Health Net coordinates with the authorizing VA facility, as necessary, to facilitate the transfer of the Veteran back to a VA facility and / or for other services, such as home health services.
To notify Health Net of an inpatient admission or discharge call 1-800-979-9620 or fax a notification to 804-622-3559.
Note: Participating providers are required to provide immediate (within 24 hours) notification to Health Net of discharges against medical advice;
notification is to be by fax or telephone, using the fax / telephone numbers provided on the authorization.
Emergency Health Care Services
Veterans seeking emergency care may self-present to an emergency facility for serious conditions. If the Veteran’s condition is life threatening, the facility must contact VA at 1-877-222-VETS (8387) within 24 hours. If 24 hour notification is not made, the facility should contact the Veteran’s assigned Veterans Affairs Medical Center (VAMC) within 72 hours. The VAMC can be identified by the Veteran or a family member. If unknown, search the VA Directory (www. va.gov/directory) and notify the VAMC in closest proximity to the facility.
As an alternative to contacting the VA or VAMC directly, the emergency facility may notify Health Net by calling 1-800-979-9620 or faxing at 804-622-3559 within 72 hours of the Veteran’s self-presenting. Health Net will notify VA with the required information. All notifications must include:
• Veteran’s full name
• last four digits of Social Security number • the condition for which the Veteran is being
seen
• the mode of transportation by which the Veteran arrived, and if by ambulance, a copy of the trip report, if possible
If a Veteran’s condition is non life threatening, the network facility must contact Health Net for authorization before admitting or treating the Veteran.
Notify Health Net by one of the following methods, within HIPPA guidelines: • call 1-800-979-9620
• fax admitting sheet to (804) 622-3559
Note: If the emergency facility does not notify either VA or Health Net within 72 hours, the facility must submit the claim directly to VA within 90 days of the emergency encounter for the claim to be considered. Contact VA at 1-877-222-VETS (8387) for more information.
Emergency Health Care Services
During an Authorized
Appointment
When a provider determines the Veteran requires emergency health care services during an authorized appointment, he or she will seek immediate treatment at a facility or via local emergency medical services. The facility will follow the above guidelines for notifying VA or Health Net. If the treating provider or facility is able to stabilize the Veteran and still requires additional medical services in a facility, the treating provider or facility will notify VA or Health Net (see above for contact information) prior to transport or admission.
Pharmacy and Durable
Medical Equipment
VA is primarily responsible for supplying the Veteran with all prescribed non-urgent/emergent medications, medical / surgical supplies and nutritional products. Participating providers must prescribe in accordance with the VA National Formulary (http://www.pbm.va.gov/PBM/ nationalformulary.asp), which includes provisions for requesting non-formulary drugs. Prescriptions must be transmitted by fax to VA for processing. Incomplete prescriptions will not be processed and will be returned to the prescribing provider.
If there is an urgent need for a Veteran to start a medication and it is not possible for the Veteran to obtain the medication from a VA pharmacy, a provider may prescribe a prescription for up to a 14-day supply,
without refills. The Veteran should be informed the prescription can be dispensed by a network pharmacy, without charge to the Veteran, or from a non-contracted source and the VA will reimburse the Veteran directly. If the medication is needed on an ongoing basis, the prescribing provider must send the VA pharmacy or Consolidated Mail Outpatient Pharmacy the following information: • provider’s name • address • personal DEA number (not a generic facility number) • telephone number • fax number • National Provider Identifier
Health Net will coordinate requests for durable medical equipment (DME) with the ordering VA facility. Most DME products and medical supplies will be provided by VA. Requests for exceptions to this
requirement may be considered under special circumstances. Exceptions to this requirement, such as DME for surgeries, require provider coordination with the ordering VA facility for approval in advance.
Home Infusion
Referral for home infusion services will be communicated directly by a Veteran Affairs Medical Center Community (VAMC) referral nurse. Referral will be by phone or fax to the home infusion provider. This process constitutes the “referral” for care and allows the provider to deliver care and ensure accuracy and timing of orders. The authorization is generated by VA and issued to Health Net. Health Net forwards an authorization by fax to the home infusion provider for submittal with their claim. Medical
documentation for home infusion includes the nursing notes and treatment plan. The Home Infusion Therapy provider completes the PCCC Home Infusion Form and it to the VAMC referral nurse. Health Net will send the 10-7079, with sections 4(a), 4(b) and 4(c) in the Authorization Remarks, to the provider.
Claims Procedures
Provider Claims Process
Health Net’s process for receiving and paying providers is designed to ensure the medical claims received by VA are complete and accurate. A “clean claim” is a claim that complies with billing
guidelines and requirements, has no defects or improprieties, includes substantiating medical documentation as defined by the provider notification packet and does not require special processing that would prevent timely payment. Clean claims will be processed within 30 days. Claims aged more than 30 days will be paid interest in addition to the payable amount.
Before preparing a claim, remember
participating providers must not bill Veterans, VA or Health Net for:
• no-show, missed or cancelled appointments • rendered care not included on the
authorization form
Note: Authorizations alone do not guarantee payment. The provision of health care services is to be limited to that set forth in the authorization form. All claims must correlate with the care specified on the authorization. Only the authorized practitioner may render and bill for services.
Participating providers are encouraged to submit health care claims via HIPAA-compliant electronic data interchange
transaction sets through Health Net’s
designated clearinghouse, Emdeon. Visit http:// www.emdeon.com/physicians/ to register. If already registered, providers may submit claims using the following information.
Payer Name: Health Net – VA Patient Centered Community Care Program
Payer ID: 68021
Note: The provider notification packet will contain detailed information on how to submit a claim.
Claims for Labor and Delivery
Services
For labor and delivery services, the provider must submit separate inpatient claims for the mother and newborn.
Claims for Pharmacy Costs
The provider must include the following with their claim:
• an 11-digit National Drug Code (NDC) number
• the corresponding Current Procedural Terminology and Health Care Procedure Coding System codes
• the quantity (package or unit) for each NDC number
Remittance Advice and
Claims Payment
The remittance advice includes notification to the provider that there is no Veteran liability and the provider must not bill the Veteran for any amount not allowed for payment. The remittance advice also includes instructions for the provider on filing an allowable charge review or dispute of payment, should the provider not agree with the provider claims payment.
Allowable Charge Reviews
An allowable charge review is a written notice from the provider to Health Net that:
• Challenges, appeals or requests
reconsideration of a claim (including a bundled group of similar claims) which has been denied or adjusted.
• Challenges a request for reimbursement for an overpayment of a claim.
• Seeks resolution of a billing determination or other contractual dispute.
Health Net accepts allowable charge reviews from providers if they are submitted within 90 days of receipt of the decision, for example, health remittance advice indicating a claim was denied or adjusted.
The allowable charge review must include: • provider’s name
• provider’s ID number
• providers contact information including telephone number, and
• number assigned to the original claim Additionally, the allowable charge review request must include a clear identification of the item, date of service and a clear explanation as to why the provider believes the payment amount, request for additional information, request for reimbursement of an overpayment, or other action is incorrect.
Claims Questions and Status
Updates
For questions about a claim or to inquire about a status update, contact Health Net at 1-800-979-9620.
Office Procedures
Return of Medical
Documentation
Health Net must deliver medical documentation to VA within 14 days. To fulfill our requirement for a thorough review and deliver in this timeframe, providers are requested to deliver medical documentation to Health Net within 10 days of the appointment. If additional appointments are conducted, medical documentation must be submitted to Health Net within 14 calendar days upon completion of the episode of care. Medical documentation recording an authorized episode of inpatient care must be submitted to Health Net within 30 days after discharge.
Using the cover sheet provided by Health Net, fax the complete documentation to 1-855-300-1705.
Tips for returning medical documentation: Deliver medical documentation or a no show notification immediately following the first appointment.
Use the provided checklist to ensure all elements of the medical documentation are complete. Return medical documentation to Health Net, even if VA has also requested a copy.
The cover sheet provided includes a bar code which is specific to a single episode of care for an individual Veteran. Using the cover sheet expedites processing of medical documentation and delivery to the Veteran’s file.
Note: Do not combine documentation for multiple authorizations when using the provided cover sheet, as this will delay processing of the documents.
Do not submit claims with medical documentation.
Please refrain from copying the cover sheet, as this may degrade the copy quality and delay processing of documents.
The Veteran must be notified of test results within 14 calendar days of the authorized episode of care.
Participating providers must not bill Health Net until they have submitted medical
documentation for both inpatient and outpatient care to Health Net. Health Net will consider exceptions for highly unusual circumstances. This process will be audited on a regular basis.
Content of Medical
Documentation to be
Transmitted to Health Net
At the completion of the authorized episode of care, participating providers must submit medical documentation to Health Net that includes: • Veteran identification; to include name, sex,
last four digits of Social Security number, and date of birth
• initial assessment and reassessments
appropriate for clinical condition, including, but not limited to:
o relevant medical history and physical examination, including inventory of body systems
o vital signs
o pain assessment (using 0–10 scale) • initial and final diagnoses / diagnostic
impressions • therapeutic goals
• care plans and rationale, including rationale for diagnostic and therapeutic procedures • diagnostic and therapeutic procedures,
treatments, and tests and their results • specific care / services provided, including
medication use and medication allergies or sensitivities
• Veteran’s response to care / services • safety measures required to protect the
Veteran from injury
• Veteran’s functional limitations and activity restrictions related to the care or services provided
• list of all medications and recommended / ordered durable medical equipment / prosthetics
• instructions given to Veteran • recommended follow-up
Additional Requirements for
Medical Documentation
Critical Findings
Critical findings on outpatient imaging or laboratory testing, or during evaluation and treatment, must be transmitted to VA and Health Net by phone within 24 hours upon completion of the test / evaluation / treatment. Contact with VA and Health Net (for example, name of person contacted, date and time of contact) must be documented in the impression section of the diagnostic imaging report, or elsewhere in the medical documentation for non-imaging-related critical findings. Any initial findings must be followed up by submission of complete
medical documentation within 10 days. To report a critical finding to Health Net, contact Health Net at 1-800-979-9620.
Newly identified suicide risk in a Veteran not referred for inpatient behavioral health treatment is considered a critical finding. A new diagnosis of cancer must be reported to VA and Health Net within 48 hours of diagnosis.
Immediate notification (within 24 hours) to the authorizing VA facility and Health Net is necessary if the provider determines the Veteran requires:
• urgent follow up after completion of authorized episode of care
• urgent additional care during the authorized episode of care
Note: Refer to the provider notification packet for contact information to the authorizing VA Medical Center.
Pathology
Participating providers are not normally required to return pathology slides to the authorizing VA facility. However, providers must ensure pathology slides for biopsies performed under the PCCC program are made available to VA within five (5) business days of Health Net’s receipt of a VA request for the slides.
Radiology
Films and reports must each be identified by Veteran name, date of birth, last four digits of the Social Security number and date of procedure. The name of the procedure, description and interpretation results of the exam must also be listed on each report. Interpreted radiology results must be communicated as oral reports submitted to VA and Health Net within 48 hours of the
examination, and the written report returned within 14 calendar days. Participating
providers are required to make films available upon request from the authorizing VA facility within five business days of Health Net’s receipt of a VA request.
Surgery
Upon the Veteran’s discharge after an authorized surgical procedure, participating providers are required to complete and return to Health Net the VA Purchased Surgical Care Patient Outcome form, along with the other required clinical feedback.
Oncology
Medical documentation submitted to Health Net for Veterans referred for medical / radiation oncology services must include information stated in the Additional Medical Documentation for Medical / Radiation Oncology Form.
All newly diagnosed cancer / carcinomas identified during test or treatment must be reported to VA and Health Net within 48 hours, as critical findings.
Gastroenterology
Medical documentation submitted to Health Net for Veterans referred for gastroenterology procedures (for example, colonoscopy, sigmoidoscopy, esophagogastroduodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography must include information stated in the Additional Medical Documentation for Gastroenterology Procedures Form.
Skilled Home Health
The initial plan of care must be submitted to VA and Health Net within three business days of authorization. Discharge summary must be submitted within five days of completion of authorized episode of care.
Inpatient Rehabilitation
Functional status and functional status change from onset of treatment through discharge documented using CMS Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) must be documented and reported to VA and Health Net. The IRF-PAI example can be found at: https:// www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS10036.pdf.
Blind / Low Vision Rehabilitation
The VA Low Vision Visual Functioning (VA LV VFQ 20) Survey is to be administered at baseline, and again within two to four weeks post-discharge or end of treatment. Since many respondents would be visually impaired or blind, a mail-out version of this survey should be used only when it is certain the respondent has appropriate assistance, as described in the instructions contained within the Instructions for the VA Low Vision Visual Functioning (VA LV VFQ 20) Survey.
Behavioral Health
The following information should be provided in the medical documentation and does not require Veteran authorization for disclosure: • medication prescription and monitoring (as appropriate) • counseling session start and stop times • modalities and frequencies of treatment • results of clinical tests and any summary of diagnosis • functional status • treatment plans • symptoms • prognosis or progress
Inpatient Behavioral Health
If suicide risk is a clinical issue, the Veteran is to be provided a written copy of the Veteran’s personal Suicide Prevention Safety Plan, located at www.mentalhealth.va.gov/docs/ VA_Safety_planning_manual.pdf. The plan must include the Veterans Crisis Line telephone number 1-800-273-8255.
Complaint and
Grievance Process
The Health Net Customer Service Center performs customer service functions with knowledgeable, courteous and responsive staff, with support available from 7:00 a.m.– 7:00 p.m., Monday through Friday, in each time zone. Telephone support is available through the toll-free number, 1-800-979-9620. Provider may also fax the Customer Service Center at 1-804-622-3559.
All Veteran complaints about any aspect of care are required to be submitted to Health Net within one business day of receipt. Health Net and VA reserve the right to audit oral and written complaints and handling of complaints.
Health Net is required to temporarily refrain from referring Veterans to participating providers where VA has notified Health Net of concerns or issues with a provider until such time when the concern has been resolved.
Health Care Management
and Administration
Participating providers are required to report to Health Net via secure means within 24 hours of discovery of Veteran safety events that are sentinel events, adverse events (including adverse drug events) or intentionally unsafe acts. Adverse events involving administration of drugs are
required to be reported to Health Net using FDA Form 3500, and a copy of the completed form submitted to FDA online must also be submitted to Health Net. The FDA reporting form can be found at www.fda.gov/Safety/ MedWatch/HowToReport/default.htm. All reported Veteran safety events will be investigated, confirmed and resolved by Health Net.
VA and Health Net may perform random onsite visits to provider locations to inspect physical operations and / or review records of VA enrolled Veterans, speak with Veterans, and review the quality and completeness of accreditation, certification and credentialing, as well as privileging and licensing documentation.
Participating providers agree to participate and comply with Health Net policies, including, but not limited to Health Net’s credentialing and re-credentialing, quality improvement, peer review, medical and other record reviews, prior authorization, and other policies related to the rendition by participating providers of covered services to Veterans.
Clinical Quality and Veteran
Safety Measures
Participating providers are required to provide Health Net with all CMS-reported data not later than time of publication of the data on the CMS website. In addition, The Joint Commission’s (JC) ORYX measures results will be provided to Health Net not later than the date of publication by the JC. The CMS and ORYX metrics must be reported to Health Net regardless of whether the data is published on existing JC or CMS websites.
Furthermore, participating providers are required to report on those measures of
focus in the CMS Partnership for Veterans Campaign that are not already covered in the CMS or ORXY measures.
In addition, participating providers are required to furnish the following Executive Summary PDFs from each of the clinical registry programs (STS and NCDR) at least annually for those facilities performing cardiac surgery, cardiac
catheterizations/percutaneous coronary interventions (PCI), and / or implantation of cardioverter defibrillators:
• STS National Adult Cardiac Surgery Database annual report – data for previous year at start of health care delivery, then annually
• NCDR annual database reports for CathPCI (for cardiac catheterization and PCI) and ICD Data Registry (for implanted cardioverter defibrillators) – data for previous year at start of health care delivery, then annually
Questions or
Comments
Questions, comments or suggestions regarding this document or its contents should be directed to: HNFSProviderRelations@ HealthNet.com
Definitions and
Acronyms
Here are some helpful definitions and frequently used acronyms used within the PCCC program.
Adverse events: Untoward incidents,
therapeutic misadventures, iatrogenic
injuries, or other adverse occurrences directly associated with care or services provided within the jurisdiction of a medical facility, outpatient clinic or other VHA facility.
Adverse drug event (ADE): An injury
resulting from the use of a drug. This includes harm caused by the drug as a result of adverse drug reactions, drug-drug interactions, product quality problems, or drug overdoses (whether accidental or intentional).
Authorization: Prior approval by Health Net
or the applicable payor, or payor’s designee, for the rendition of covered services that may be required under a benefit program or a Health Net policy. Also known as prior authorization.
Clinician: A health professional whose
practice is based on direct observation and treatment of a Veteran, as distinguished from other types of health workers, such as laboratory technicians and those employed in research.
Completed authorization: A completed
authorization is one for which the Veteran was scheduled, health care services provided and the authorization was not returned to VA as unscheduled.
Covered services: Specific services for which
the VA has provided an authorization to pay.
CPG: clinical practice guidelines.
test result): A critical finding or test result
is defined as those values or interpretations that, if left untreated, could be life threatening or place the Veteran at serious risk. Critical values are those results from laboratory, cardiology, radiology departments and other diagnostic areas that upon analysis are determined to be critical, regardless of the ordering priority. This conforms to Joint Commission National Patient Safety Goal NPSG.02.03.01. (Definition from “Critical Value or Result” in VHA Directive 2009-019).
Episode of care: A set of clinically related
health care services for a specific unique illness or medical condition (diagnosis and / or procedure) provided by an authorized provider during a defined authorized period of time.
Intentionally unsafe acts: As pertaining to
Veterans, these are any events that result from a criminal act, a purposefully unsafe act, an act related to alcohol or substance abuse by an impaired provider and / or staff, or events involving alleged or suspected Veteran abuse of any kind.
Higher level of care: Specialized consultative
health care, usually for inpatients and in a facility that has personnel and facilities for advanced medical investigation and treatment, such as a tertiary referral hospital. Examples of tertiary care services are cancer management, neurosurgery, cardiac surgery, plastic surgery, treatment for severe burns, advanced
neonatology services, palliative, and other complex medical and surgical interventions.
Immediate: Within 24 hours.
IRF/PAI: Inpatient Rehabilitation Facility
Patient Assessment Instrument.
LIP: Licensed independent practitioner.
Any practitioner permitted by law to provide care and services, without direction
or supervision, within the scope of the practitioner license and consistent with individually assigned clinical responsibilities. When standards reference the term “licensed independent practitioner” this language is not to be construed to limit the authority of a licensed independent practitioner to delegate tasks to other qualified health care personnel (for example, physician assistants and advance practice registered nurses) to the extent authorized by state law or a state’s regulatory mechanism or federal guidelines, and organizational policy
Network provider: A hospital, clinic, health
care institution, health care professional, or group of health care professionals who provide health care services to Veterans in performance of the PCCC contract through Health Net’s network.
PCCC: Patient-Centered Community Care. Pharmacy services: Provision of medicines,
supplies and nutritional supplements.
Primary care: Health care provided by a medical
professional (such as a general practitioner or a pediatrician) with whom a Veteran has initial contact and by whom the Veteran may be referred to a specialist for further treatment. Also, called primary health care.
Privileging: also referred to as clinical
privileging. The process by which a practitioner, licensed for independent
practice (in other words, without supervision, direction, required sponsor, preceptor,
mandatory collaboration), is permitted by law and the facility to practice independently, to provide specific medical or other Veteran care services within the scope of the individual’s license, based upon the individual’s clinical competence as determined by peer references, professional experience, health status,
Clinical privileges must be facility-specific and provider-specific.
Provider: A hospital, clinic, health care
institution, health care professional, or group of health care professionals who provide a service to Veterans.
Sentinel events: A sentinel event is an
unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase ‘or the risk thereof’ includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called sentinel because they signal the need for immediate investigation and response. These include, but are not limited to: suicide of any Veteran receiving care, treatment and services in a staffed around-the-clock care setting or within 72 hours of discharge; unanticipated death of a full-term infant; abduction of any Veteran receiving care, treatment and services; discharge of an infant to the wrong family; rape; hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities; surgery on the wrong Veteran or wrong body part; unintended retention of a foreign object in a Veteran after surgery or other procedure, and prolonged fluoroscopy with cumulative dose >1500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25 percent above the planned radiotherapy dose.
Service location: Any location at which
a Veteran obtains any health care service covered by Health Net.
Third party: Any entity or funding source,
other than the enrolled Veteran or his/her responsible party, which is, or may be, liable to pay for all or part of the cost of medical care of the Veteran.
Urgent care: Urgent care is defined as care
considered essential to evaluate and stabilize conditions. Urgent care is care that if not provided will likely result in unacceptable morbidity/pain when there is a significant delay in evaluation or treatment. Urgent care is not the same as a medical emergency. Urgent medical care does not threaten life, limb or vision, but needs attention to prevent it from becoming a serious risk to health.
VA: Veterans Affairs.
VAHCS: Veterans Affairs Health Care System VAMC: VA Medical Center.
VHA: Veterans Health Administration. The
central office for administration of the VA Medical Centers throughout the United States. The VHA is located in Washington, D.C.
VISN: Veterans Integrated Service Network. The
