Veterans Choice Program and Patient-Centered Community Care VAMC Scheduling Initiatives Provider Orientation Webinar

Transcription

1 Veterans Choice Program and Patient-Centered Community Care VAMC Scheduling Initiatives Provider Orientation Webinar January 2018

2 Scheduling Initiatives Introduction The U.S. Department of Veterans Affairs (VA) has implemented various scheduling initiatives for Patient-Centered Community Care (PCCC)- and/or Veterans Choice Program (VCP)-eligible veterans within the area of responsibility of specific Veterans Affairs Medical Centers (VAMCs) and for specific benefits. Under these scheduling initiatives, the care coordination and appointment scheduling responsibilities is slightly different. The following areas are included under these initiatives : Tomah, Wisconsin (supports VCP) Fort Harrison, Montana (supports VCP) Madison, Wisconsin (supports VCP) Fargo, North Dakota (supports VCP and PCCC) The following benefits are included under these initiatives : skilled home health care/home infusion therapy (supports VCP and PCCC) For all other Health Net Federal Services, LLC (HNFS) managed regions; please refer to and our general provider orientation webinar. 2

3 The Tomah, Wisconsin Scheduling Initiative is effective Dec. 5, 2017 VCP authorizations only. The Skilled Home Health Care/Home Infusion Therapy Scheduling Initiative was effective Oct. 31, 2017 VCP and PCCC authorizations. The Madison, Wisconsin Scheduling Initiative was effective Oct. 18, 2017 VCP authorizations only. The Ft. Harrison, Montana Scheduling Initiative was effective Sept. 13, 2017 VCP authorizations only. The Fargo, North Dakota Scheduling Initiative was effective Oct. 3, 2016 VCP and PCCC authorizations. Please visit for detailed information. 3

4 Introduction The U.S. Department of Veterans Affairs (VA) VCP and PCCC programs provide eligible veterans access to care through a comprehensive network of communitybased providers. These programs augment VA s ability to provide specialty inpatient and outpatient health care services to veterans. HNFS was awarded its PCCC contract in In 2014, HNFS expanded its services with VA in support of the Veterans Access, Choice and Accountability Act, which funded VCP, a subset of PCCC. 4

5 Proud to Support VA in Regions 1, 2 and 4 HNFS manages three regions which cover 13 VISNs, and encompass all or portions of 37 states. Plus the District of Columbia, Puerto Rico and the U.S. Virgin Islands. 5

6 Looking for answers? Many of the top provider inquiries can be answered online. Many of the questions providers ask over the telephone can be answered on our website. We encourage providers to check our website before calling. Our Frequently Asked Questions page is a good resource for additional information. Please visit our website for the latest news and updates on VA programs at 6

7 VCP & PCCC: Two VA Programs Supported by HNFS VA offers numerous programs for veterans to access care in the community. This chart illustrates some of the differences between the VCP and PCCC options. Veterans Choice Program (Veteran-driven) For veterans who face wait times in excess of 30 days for needed medical care, or for whom a regular VA medical center (VAMC) is inaccessible, VCP makes it possible for veterans to receive care from a non-va health care provider in their community. All veterans who were enrolled with VA as of August 1, 2014, received a Choice Card. Veterans can choose to contact the customer service number on the Choice Card to initiate care; however, they must meet VCP eligibility requirements. Veterans must seek care from providers who are part of the HNFS network or who have accepted the VCP terms of participation. All initial care requires prior authorization. Patient-Centered Community Care (VA-driven) PCCC supplements VA s ability to provide specialty inpatient and outpatient health care services, as well as behavioral health care, limited emergency care and newborn care services to enrolled veterans. VA initiates the request for care outside of its facility. Care must be provided by an HNFS PCCC network provider. All initial care requires prior authorization. 7

8 Options for Providers In order to treat veterans under PCCC or VCP, providers must join the HNFS PCCC provider network or register as a VCP participating provider. PCCC Network Sign an HNFS network contract and complete the credentialing process. Be listed in our Preferred Provider Network for all current and future VA programs. Render services to VCP- or PCCCeligible veterans upon receipt of an authorization. VCP Participation Accept terms of the VCP Participation Agreement. Complete certification when a VCPeligible veteran selects you as his/her provider for authorized care. Render services to only VCP-eligible veterans upon receipt of an authorization. 8

9 Join Our Network If you are interested in participating in this community of providers, please complete the HNFS Join Our Network form at and it to 9

10 Provider Participation If you or your organization is interested in serving veterans under VCP as a participating provider, view/agree to the VCP Participation Agreement and register online at Rendering providers must: be Medicare participating (certain exceptions apply), have an active unrestricted state license, be DEA licensed (as applicable), have no sanctions, and provide a Type 1 and/or Type 2 NPI (as applicable). 10

11 Program Requirements The following slides provide a brief overview and highlight the following important elements: eligibility appointments provider notification packets authorizations and covered services requesting additional services referring to other providers critical findings medical documentation claims procedures PCCC contracted providers are eligible to receive both PCCC and VCP authorizations. Participating VCP providers are limited to receive only VCP authorizations. 11

12 Eligibility VA is responsible for determining eligibility and authorizing care. Eligibility for VA health care is based on veteran status, service-connected disabilities or exposures, income, and other factors. 12

13 Updating Provider Demographics Has your information changed? Be sure to let us know! Veterans Choice Program Patient-Centered Community Care Send an to identifying what needs to be updated, such as updating the phone number, adding a location, deleting a practitioner, and changing the provider name or specialty. Be sure to include the following information: practice address phone number fax number (for authorizations and reminders) Tax Identification Number billing address Network providers should use this the HNFS Provider Demographic Update form at to update provider demographic information, including: practice address telephone number fax number Tax Identification Number billing address location addition or deletion practitioner deletion 13

14 Veterans Choice Program Eligibility To be eligible for VCP, veterans must be enrolled in VA health care and meet at least one of the following criteria: live more than 40 miles from a VA health care facility are unable to get a VA appointment within 30 days of their preferred date/the date determined medically necessary by their physician need to travel by air, boat or ferry to the VA medical facility closest to their home face an unusual or excessive burden in traveling to a VA medical facility based on geographic challenges, environmental factors or a medical condition have specific health care needs that warrant participation in the program live in a state or territory without a full-service VA medical facility To verify eligibility, veterans must call the Veterans Choice Call Center at

15 VAMC Scheduling Initiative: Differences in Process Old Scheduling Procedure New Scheduling Procedure Veterans called the Veterans Choice Call Center. Calls were routed to Health Net Federal Services, LLC (HNFS). HNFS scheduled the appointments. HNFS faxed the provider information concerning the appointment, including medical records. HNFS provided the authorization letter to the veteran and the provider. Provider sent required medical documentation to HNFS. Provider sent generic SAR form to HNFS. Provider contacted HNFS for all inquiries. HNFS provided care coordination for veterans under VCP/PCCC. Veterans call the Veterans Choice Call Center. Calls are routed to the VAMC. VAMC staff schedules the appointments. VAMC faxes medical documentation to the provider that includes necessary clinical information and provides appointment information to HNFS. Health Net Federal Services provides the authorization letter to the veteran and the provider. Provider sends required medical documentation to the VAMC. Provider sends secondary authorization request (SAR) when needed to the VAMC. Provider contacts the VAMC for scheduling questions and clinical issues. Questions unrelated to these will be directed to HNFS. VAMC provides care coordination for veterans under Veterans Choice Program. 15

16 Process Overview Veteran calls Veterans Choice Call Center to confirm eligibility (for VCP)/Local VA clinic refers veteran for care with a non-va community provider (for PCCC). VAMC locates HNFS network or VCP provider who can accept the veteran as a patient. VAMC schedules appointment with the provider and notifies veteran of the appointment. VAMC forwards appointment information to HNFS. VAMC faxes the provider information about the appointment, including medical records. Health Net Federal Services faxes authorization letter to the provider and veteran. Health Net Federal Services receives and processes claim. 16

17 Authorizations and Covered Services All initial care requires prior authorization from HNFS. In general, authorizations cover services related to evaluation and treatment for the episode of care, including routine clinical procedures and other necessary diagnostic services (for example, anesthesiology, radiology and pathology/laboratory services). 17

18 Appointments The VAMC is responsible for coordinating initial appointments with a provider s office or facility. Providers are strongly encouraged to contact veterans with a courtesy appointment reminder. Providers must notify the VAMC of missed, canceled or rescheduled appointments. Providers may not bill the veteran, VA or HNFS for missed or canceled appointments. Appointments must be scheduled within 30 days of the clinically indicated date. Veterans must be seen within 20 minutes of their scheduled appointment time. 18

19 Appointment and Authorization Information After the VAMC schedules an appointment, they will fax the provider information with the appointment details, authorization number and other important information. The information from the VAMC will include appointment details, veteran contact information, applicable clinical information, and a VAMC-specific Secondary Authorization Request (SAR) form. The VAMC will notify HNFS that an appointment has been scheduled and HNFS will issue an authorization letter to the veteran and the provider. In addition to the authorization details, the letter from HNFS to the provider will include instructions for returning medical documentation to the VAMC, claims information and other program details. It is important the appointment information from the VAMC and the authorization letter from HNFS be distributed to the appropriate departments within the practice/facility. Note: Please allow two business days for routine care and one business day for urgent care from when VA makes the appointment to when HNFS faxes the authorization. 19

20 Urgent Care Urgent care is coordinated through the VAMC. Providers must notify the VAMC within 24 hours when veterans require: Urgent additional care during the episode of care Urgent follow up after completion of the episode of care 20

21 Emergency Care Emergency care should be provided to any eligible veteran who self-presents to an emergency room (ER). The ER must contact the VAMC within 72 hours (either by phone or by fax). Note: The VAMC can only authorize emergency care for PCCCeligible veterans. Emergency room visits are only a covered benefit under VCP when provided as part of the authorized episode of care. 21

22 Inpatient Care Providers must: Coordinate all inpatient admissions and discharges with the VAMC. Notify the VAMC within 72 hours of an emergency admission (this also applies to weekend notifications). Coordinate discharges with the VAMC: For veterans who are to be transferred back to a VA clinic or a different facility. For veterans who require discharge planning to their home, and may require supplies, home health or equipment. 22

23 DME and Medical Supplies Most non-urgent/non-emergent durable medical equipment, prosthetics and orthotics (DMEPOS) products and medical supplies will be provided by VA. VA will allow for treating physicians and facilities, and independent suppliers to provide veterans with urgently or emergently needed DMEPOS. These items may include, but are not limited to, splints, crutches, canes, slings, and soft collars. Urgent or emergent DMEPOS will be covered under an authorized episode of care when provided by the treating physician or facility, or an independent supplier at the time of treatment, and prior to the veteran leaving the treating provider s location. Providers should submit claims for urgent or emergent DMEPOS to HNFS. Visit > Claims for submittal instructions. If the independent supplier is submitting the claim, the date of service must match that of the physician/facility treatment date. Note: Failure to plan or coordinate in advance of a scheduled procedure shall not constitute as an urgent or emergent need. 23

24 Mental Health Care Services VA and the Department of Defense offer Clinical Practice Guidelines, available at If suicide risk is identified as a clinical issue, provide the veteran with a written copy of the veteran s personal Suicide Prevention Safety Plan: Veterans Crisis Line telephone number:

25 Exclusions and Bundled Services The clinical notes on p. 2 of the authorization information from HNFS will indicate any exclusions. Please note: If the clinical notes indicate bundled service, a variety of procedures commonly associated with the type of care authorized will be covered without the need for additional approval. For a complete list of services covered under a bundled services authorization, please visit > Authorizations > Bundled Services. 25

26 Request for Additional Services Additional prior authorization from the VAMC is required when the veteran: requires care beyond the approved dates; requires care beyond the number of visits/units authorized; needs care for another medical condition or body part (including other joints); must see a different non-ancillary provider for evaluation/treatment; and/or requires an inpatient admission, when specifically excluded on the authorization. 26

27 Secondary Authorization Request Form To request an additional authorization, fax a completed VAMCspecific Secondary Authorization Request (SAR) form (provided by the VAMC and available at to the VAMC s dedicated fax number. The VAMC will review the request. To expedite the review, please include: The completed SAR form. All applicable medical documentation. Justification for the request. If approved by the VAMC, HNFS will fax new or updated authorization to the requesting provider. 27

28 Referring Veterans to Other Providers Please refer to program-specific guidelines when referring veterans for authorized care you are unable to perform at your practice, as not all services require a new authorization/secondary Authorization Request. Veterans with VCP-authorized care may use network providers or providers not in our network who meet and agree to VCP participation terms. (Veterans with PCCC-authorized care must seek care from network providers.) 28

29 Referring Veterans to Other Providers continued For care authorized under VCP, please share the authorization details provided in your provider notification packet with all providers involved in the veteran s care, as this will expedite claims processing. 29

30 Transition of Care The VAMC will coordinate all transitions of care, including those necessitated by a provider leaving the network and when a primary provider refers a veteran for specialty care. The VAMC will review all requests for additional care (see Secondary Authorization Requests slides). HNFS will issue a new authorization to the servicing provider as appropriate per program guidelines. 30

31 Critical Findings Providers must report critical findings directly to the referring/ordering provider. VA defines critical findings as a test result value or interpretation that, if left untreated, could be life threatening or place the veteran at serious health risk. Critical values/results 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. Remember to document the notification in the veteran s medical records. 31

32 Prescriptions Prescription medications must be prescribed in accordance with the VA National Formulary (VANF). Routine prescriptions VA requires veterans fill all routine (non-urgent/non-emergent) prescriptions at VA pharmacies. Veterans who fill routine prescriptions elsewhere may not be reimbursed. Please advise your veteran patients accordingly to help them avoid unexpected expenses. Fax the prescription to the local VA pharmacy or Give veteran a copy of the HNFS authorization to physically take or mail along with the prescription to a local VA pharmacy for fulfillment. Urgent prescriptions Providers may issue veterans with up to a 14-day supply of VANF prescriptions when needed urgently. Veterans may take urgent prescriptions to any non-va pharmacy to be filled at his/her own expense and seek reimbursement from the Purchased Care office at their local VA health care facility. 32

33 Prescriptions continued If a non-va provider would like to administer a prescribed medication to a veteran in his/her office (such as an injectable), that provider must purchase the medication and submit a claim to HNFS for reimbursement. VA pharmacies cannot dispense medications directly to non- VA providers. Medications must be on the VA National Formulary and be part of the treatment authorized per the terms of the provider packet. 33

34 Prescriptions continued VA pharmacies must have the prescribing provider s information on file in order to fill prescriptions. As such, VA requires the following prescribing provider information on all routine and urgent prescriptions: name address personal DEA number (not a generic facility number) telephone number date of birth Social Security number fax number National Provider Identifier (NPI) gender Incomplete prescriptions cannot be filled and will be returned to the prescribing provider. 34

35 Medical Documentation Medical documentation must be faxed to the VAMC* within the following time frames: VCP Outpatient: 60 calendar days of the first appointment and 60 calendar days upon completion of the episode of care Inpatient: 25 days after discharge PCCC Outpatient: 10 calendar days of the initial appointment and 10 calendar days from the last date of service Inpatient: 25 days after discharge Note: For PCCC only, HNFS cannot pay claims until medical documentation is received. *Skilled home health care exception: For skilled home health care/home infusion therapy services, providers are to return medical documentation to the VAMC only if that VAMC is participating in a scheduling initiative (for example, Tomah, Wisconsin). Otherwise, return medical documentation to HNFS. 35

36 Medical Documentation continued Medical documentation may include, but is not limited to: discharge summary relevant medical history and physical examination initial and final diagnoses or diagnostic impressions specific care or services provided, including medication use and medication allergies or sensitivities Veteran s response to care or services list of all medications recommended or ordered durable medical equipment (DME) or prosthetics recommended follow up Tips: Do not combine documentation for multiple authorizations. Do not submit claims with medical documentation. An electronic or written signature is required to be considered complete. 36

37 Copayments and Billing Veterans VA will invoice the veteran for any applicable copayments. You may not bill the veteran, VA or HNFS for no-show, rescheduled or canceled appointments. Providers may not seek reimbursement from or have any recourse against veterans for covered services authorized by HNFS. 37

38 Other Health Insurance All care delivered to a veteran under VCP and PCCC must be authorized by HNFS even when another health insurance is present. VA is the primary payer and will coordinate benefits should a veteran have other health insurance (OHI). As such, providers should not bill OHI carriers or collect OHI copayments from veterans receiving care through VCP or PCCC. VA will bill veterans directly for any applicable copayments. Submit all claims to HNFS as the primary payer. Do not bill a veteran s OHI carrier (as primary or secondary) or include that carrier s Explanation of Benefits with your claim to HNFS. 38

39 Reimbursement Only authorized services are eligible for reimbursement. For more information, refer to the VAMC-specific Claims Quick Reference Charts, located at Veterans Choice Program Claims must be submitted within 120 days of the date of service or upon the conclusion of a series of authorized visits. Claims Submittal Time Frames Patient-Centered Community Care Claims must be submitted within 90 days of the date of service or upon the conclusion of a series of authorized visits. 39

40 Clean Claims All claims must be submitted to HNFS, and not to VA or Medicare. A clean claim is a claim that complies with billing guidelines and requirements, has no defects or improprieties and does not require special processing that would prevent timely payment. Clean claims will be processed within 30 days, and providers will receive their payments from HNFS. 40

41 Electronic Claims Submission Health Net Federal Services accepts electronic data interchange (EDI) claims for PCCC and VCP through Change Healthcare. Visit the Change Healthcare website to register: Payer Name: Health Net VA Patient-Centered Community Care Program Payer ID: Note: This payer name and ID applies to PCCC and VCP electronic claims. 41

42 Paper Claim Submission Paper claims can be mailed to: Health Net Federal Services, LLC Veterans Choice Program VACAA PO Box 2748 Virginia Beach, VA Health Net Federal Services, LLC Patient-Centered Community Care PO Box 9110 Virginia Beach, VA ***HNFS cannot accept faxed claims for processing.*** 42

43 Online Claim Status Providers can check the status of their claims at Once registered, you can search by the veteran s information or claim number to obtain the status. Once logged in, select Claim Status Inquiry under Claims Management in the left-hand menu. Choose Patient-Centered Community Care (for VCP and PCCC claims) in the payer field. 43

44 Online Claim Status continued If you are having difficulties checking claim status online at please use the following tips to locate your claim: If you are using the Express Entry feature, try manually entering the NPI instead. When asked, "Is the provider name the same as the organization name?", answer "No." The NPI is the billing NPI from the submitted claim. The subscriber ID can be the 10-digit number from the veteran s card or his/her Social Security number. The date of service can be the exact date the service(s) were rendered or a date range (30 day maximum). Only complete the required fields that are marked with a red asterisk. If you still are having trouble, please contact Availity Client Services at

45 EFT/ERA Health Net Federal Services offers and encourages electronic options for provider remits and claims payment. Electronic Remittance Advice (ERA): Complete the ERA registration process (through Availity or Change Healthcare) to stop receiving paper remittance advices. You may only be enrolled with one clearinghouse with HNFS for VCP and PCCC claims. Electronic Funds Transfer (EFT): Complete and submit the HNFS Electronic Funds Transfer form, available at Learn more at > Claims. 45

46 Provider Resources We offer VAMC-specific online resources, including: Scheduling Initiative Quick Reference Charts Provider webinar schedules Visit Clinical resources from VA: VA offers free clinical education products on a range of mental health and substance use disorder topics. Access the complete inventory of manuals, workbooks, videos, and websites at: 46

47 Important Contact Numbers Scheduling and Clinical Inquiries Tomah, Wisconsin (VCP only) Telephone: (608) Monday Friday: 8:00 a.m. 4:00 p.m. Central time, excluding certain holidays excluding certain holidays Medical documentation fax: (608) SARs fax: (608) Madison, Wisconsin (VCP only) Telephone: (608) Monday Friday: 8:00 a.m. 4:30 p.m. Central time, excluding certain holidays excluding certain holidays All Other Inquiries (Health Net Federal Services) Veterans Choice Call Center: Monday Friday: 9:00 a.m. 5:00 p.m. Eastern time, excluding certain holidays Patient-Centered Community Care Call Center: Monday Friday: 6:00 a.m. 10:00 p.m. Eastern time, excluding certain holidays Medical documentation fax: (608) SARs fax: (608)

48 Important Contact Numbers continued Scheduling and Clinical Inquiries Ft. Harrison, Montana (VCP only) Telephone: (406) Monday Friday: 8:00 a.m. 4:00 p.m. Mountain time, excluding certain holidays Medical documentation fax: (406) SARs fax: (406) Fargo, North Dakota (PCCC/VCP) Monday Friday: 8:00 a.m. 4:30 p.m. Central time, excluding certain holidays Medical documentation fax: (612) SARs fax: (612) All Other Inquiries (Health Net Federal Services) Veterans Choice Call Center: Monday Friday: 9:00 a.m. 5:00 p.m. Eastern time, excluding certain holidays Patient-Centered Community Care Call Center: Monday Friday: 6:00 a.m. 10:00 p.m. Eastern time, excluding certain holidays Skilled Home Health Care/Home Infusion Therapy (PCCC/VCP) Medical documentation fax: For VAMCs not listed on slides 47 48, submit to HNFS at Otherwise, submit to the appropriate VAMC. SARs fax: Refer to the specific VAMC on the authorization. 48

49 Thank you for serving our nation's veterans!