Network Provider Handbook April 2017

Transcription

1 Community Care Network Provider Handbook April 2017 VAPatient-Centered A Wholly-Owned Subsidiary of Centene Corporation

2 Table of Contents Overview 3 About PCCC 3 Veterans Choice Program 3 Document Purpose 3 Responsibility for Provision of Services 3 Key Requirements 3 Provider Tools Requirements for Maintaining Accurate 5 Information Important Provider Information 6 General Administrative Requirements 6 Privacy or Security Incidents 6 Office and Appointment Access Standards 6 Identification Cards Not Issued 6 Cost-Shares and Deductibles 6 No-Show,Canceled and Rescheduled 6 Appointments Provider Network 7 Accreditation and Certification 7 Credentialing 7 Privileging 7 Licensing 7 Additional Provider Participation Requirements 7 Laboratory Services 7 Radiology Services 7 Radiation Oncology 8 Rehabilitation Medicine 8 Labor, Delivery and OB/GYN Prenatal Care 8 Surgery 8 Cardiology 8 Skilled Home Health and Home Infusion Therapy 8 Office-Based Diagnostic and Therapeutic Tests 9 and Procedures Behavioral Health 9 Residential Treatment Facilities 9 Authorizations 10 General Process 10 VA Referral for Authorized Care 10 Covered Services 10 Additional Information for Specific Services 10 Non-Covered Services 11 Requesting Authorization for Additional Services 11 Pharmacy 12 Durable Medical Equipment and 13 Home Infusion Provider Notification Packets 14 Appointment Scheduling 15 Urgent Care Reporting 15 Inpatient Authorization Process and Discharge 15 Planning Medical Documentation 16 Medical Documentation Content 16 Return of Medical Documentation 16 Additional Requirements for Medical 17 Documentation Critical Findings 19 Claims 20 Provider Claims Process 20 Claims Submission 20 Remittance Advice and Claims Payment 20 Claims Questions and Status Updates 21 Primary Care Requirements 22 Primary Care Overview 22 Authorizations 22 Routine Diagnostic Testing 22 Appointments 22 Medical Records and Documentation 23 1

3 Table of Contents Fargo, North Dakota 24 Scheduling Initiative Medical Documentation Returned to Fargo, VAMC 24 Critical Findings 24 Claims 24 Requests for Additional Services 24 Complaint and Grievance Process 25 Health Care Management and 26 Administration Clinical Quality and Veteran Safety Measures 26 Definitions and Acronyms 27 2

4 Overview Participating providers in the Patient-Centered Community Care (PCCC) network agree to comply with all Health Net Federal Services, LLC, (HNFS) and U.S. Department of Veterans Affairs (VA) program rules, policies and procedures. As a provider in our PCCC network, you have access to approximately 5.2 million veterans eligible to receive care under the PCCC program, including thousands of veterans eligible for VA s Veterans Choice Program. All network providers must review and comply with requirements listed in the HNFS Preferred Provider Network Provider Manual and this document. Find the most recent version of this handbook at About PCCC Patient-Centered Community Care is the U.S. Department of Veterans Affairs (VA) program which provides 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. The program 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. Health Net Federal Services 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 Federal Services provides veterans access to 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 Federal Services uses systematic and integrated processes to coordinate care between VA and local community providers. Except where otherwise indicated (for example, Fargo, North Dakota Scheduling Initiative), Health Net Federal Services is responsible for scheduling appointments, and collecting and submitting required medical documentation from the rendering provider. Health Net Federal Services is responsible for claims processing. Veterans Choice Program The Veterans Access, Choice and Accountability Act (VACAA) of 2014, directs the establishment of the Veterans Choice Program (VCP) to better meet the health care needs of our nation s veterans. Under VCP, eligible veterans can obtain approved care in their community. Health Net Federal Services PCCC network providers who see veterans under VCP agree to comply with the terms specified in the Veterans Choice Program Participation Agreement. Network providers should also review the HNFS Veterans Choice Program Participating Provider Handbook, which defines Veterans Choice Program guidelines and provider responsibilities. Document Purpose The HNFS PCCC Network Provider Handbook 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 HNFS Preferred Provider Network Provider Manual, available upon request. Responsibility for Provision of Services Providers and HNFS 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 Federal Services 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. Providers must meet all credentialing/accreditation/ certification requirements to participate in the PCCC program and be activated by HNFS as a PCCC network provider to provide services under this program. Providers must be currently credentialed by HNFS in accordance with the requirements of the Preferred Provider Network Provider Manual (available upon request). 3

5 Except for those provider categories previously granted waivers by VA, providers must be Medicare-certified and meet all Medicare Conditions of Participation and Conditions for Coverage, where such conditions exist. Please refer to the HNFS Conditions of Participation for Network Providers. Certain provider types have additional accreditation/ certification/reporting requirements. See Additional Provider Participation Requirements in the Important Provider Tools section of this handbook. Provider must continuously maintain all licenses, accreditations, certifications, and professional liability insurance and must report any lapse immediately to HNFS. including no-show, canceled or rescheduled appointments. Medical documentation must be faxed to HNFS ( ) within the time frame indicated in the provider packet. All medical documentation must be submitted to HNFS before claims will be paid. Providers must report critical findings, adverse events, close calls, and unintentional unsafe acts to VA within 24 hours. Hospitals must report admissions within 24 hours. Providers of skilled home health and home infusion therapy must comply with the Service Contract Act. Providers must make routine appointments available for veterans within 30 days of a request by HNFS. In-office wait times for appointments must not exceed 20 minutes beyond their scheduled appointment time. Health Net Federal Services will issue all authorizations to the provider for PCCC services upon request from VA for a specific veteran. Health Net Federal Services will issue a provider notification packet to the scheduled provider with each authorization, after the appointment has been scheduled. The notification packet outlines the specific clinical and other requirements for the authorized care. Note: Health Net Federal Services will fax a reference copy of VA s referral documents under separate cover. Receipt of these reference documents does not represent an approved authorization. Providers will render only those services listed on an authorization provided by HNFS. Providers must contact HNFS for authorization to provide any services in addition to those listed on the authorization. When requesting services not covered by an existing authorization, providers should complete the HNFS Request for Additional Services form and then print and fax the form to The episode of care authorized by HNFS is not considered complete and payable until complete medical documentation is returned to HNFS. 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, 4

6 Provider Tools Please review this section for information on the following: Requirements for maintaining accurate information The HNFS website provides information about PCCC benefits, processes, requirements, and operations, as well as access to business tools and forms. For quick access to PCCC provider information, visit Requirements for Maintaining Accurate Information It is important for network for providers to keep their demographic information up to date to ensure HNFS provides accurate information to veterans and to speed accurate claims adjudication. Network providers should use the Provider Demographic Update form, available at forms to submit any changes electronically. Demographic information includes: practice address telephone number fax number tax Identification Number billing address location addition location deletion practitioner deletion To ensure continuity of care, any provider leaving a network group must notify HNFS 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 HNFS of a need to continue services with another provider. 5

7 Important Provider Information Please review this section for information on the following: General administrative requirements Privacy or security incidents Office and appointment access standards Identification cards not issued Cost-shares and deductibles No-show, canceled and rescheduled appointments 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 & Medicaid Services (CMS) exclusionary list will be prohibited from network participation. See for further detail. Network providers are required to immediately (within 24 hours) report to HNFS in writing, but not later than three (3) 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. the date otherwise noted on the authorization form. Urgent care appointments must be completed within 48 hours. Office wait time for appointments must not exceed 20 minutes. Identification Cards Not Issued Although veterans may be issued cards by VA for other programs, VA does not issue PCCC program identification cards to veterans. The authorization is proof the veteran is eligible for care approved under the PCCC program. Providers should verify the identity of the veteran through a government issued identification card, such as a driver s license, military card or passport. Cost-Shares and Deductibles Veterans have no cost-shares, deductibles or out-of-pocket expenses under the PCCC program. No-Show, Canceled and Rescheduled Appointments Providers must report all no-show, canceled and rescheduled appointments to HNFS at or by fax at Providers must not bill the veteran, VA or HNFS for no-show, canceled or rescheduled appointments. Health Net Federal Services 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. Privacy or Security Incidents Providers must report to HNFS any privacy or security breaches containing veteran information within 24 hours. Direct any privacy or security concerns to hngss_incidents@healthnet.com. Office and Appointment Access Standards Providers must comply with the office and appointment access standards specified in the Preferred Provider Network Provider Manual. However, providers must also comply with these specific PCCC access standards: Routine appointments must be completed within 30 calendar days of being scheduled, the clinical need date, or 6

8 Provider Network Please review this section for information on the following: Accreditation and certification Credentialing Privileging Licensing Additional provider participation requirements Accreditation and Certification Except for those provider categories previously granted waivers by VA, participating providers must meet all Medicare Conditions of Participation (CoP) and Conditions for Coverage (CfC), where such conditions exist, subject to Centers for Medicare & Medicaid Services (CMS) modification, as required by the U.S. Department of Health and Human Services (HHS). 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. Please refer to the HNFS Conditions of Participation for Network Providers. Credentialing Health Net Federal Services 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 (certain exceptions apply), 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 and USSC Sentencing Guidelines, 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 HNFS. 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 Provider Participation Requirements Providers who participate and receive payment through the PCCC program must be credentialed by HNFS or its subcontractor. In addition to meeting the HNFS credentialing requirements under PCCC, certain provider types must meet specific VA requirements. Prior to performing authorized services, providers must complete the HNFS Additional Provider Requirements form that applies to their practice, attach documentation (where requested) and certify the facility meets all applicable requirements. An executed copy of the applicable forms must be returned to HNFS. Additional Provider Requirements forms apply to: outpatient facilities performing computed tomography, magnetic resonance imaging (MRI), breast MRI, nuclear medicine, and positron emission tomography exams facilities performing cancer surgery, cardiac catheterizations and/or percutaneous coronary interventions, and implants cardioverter defibrillators radiation oncology centers laboratories 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 7

9 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 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 (ARRT). 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 HNFS 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 boardeligible 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. Please also note audiologist requirements detailed under Audiology in the Authorizations section. Unless otherwise authorized by HNFS, 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 Management of Pregnancy, found at 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 the referring VA facility and approved in writing by HNFS. Facilities performing cardiac surgery are required to report to the Society for Thoracic Surgery (STS) National Adult Cardiac Surgery Database, unless an exception is authorized by the referring VA facility and approved in writing by HNFS. 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 HNFS. 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 HNFS. Skilled Home Health and Home Infusion Therapy Unless otherwise authorized by the referring VA facility and approved in writing by HNFS, 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 Federal Services will monitor CMS reporting databases for compliance. Providers supplying skilled home health or home infusion therapy must comply with the requirements of the Service 8

10 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 Every 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. Behavioral Health 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. 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. Master s level counselors (LPMHC, LCPC,LMFT, LMT) providing mental health care must hold a full, current, and unrestricted license to independently practice mental health counseling, which includes diagnosis and treatment. For both inpatient and outpatient behavioral health care, participating providers are advised of VA/DoD Clinical Practice Guidelines for the diagnosed behavioral health diagnosis found at These are baseline criteria and do not replace clinical judgment. Residential Treatment Facilities Residential treatment facilities must be licensed by the state. If a state lacks an established licensing program the facility must hold an appropriate accreditation (The Joint Commission, The Council on Accreditation of Rehabilitation Facilities or similar accreditation). Professional providers working in such institutions are, by nature of employment by the facility, covered services. 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 9

11 Authorizations Please review this section for information on the following: General process VA referral for authorized care Covered services Additional information for specific services (included emergency care information) Requesting authorization for additional services Pharmacy Durable medical equipment and home Infusion General Process All initial care under PCCC requires prior authorization from and scheduling by HNFS. When the veteran s local VA health care facility indicates a veteran is eligible to receive care in the community, HNFS processes the authorization request from VA and coordinates with the veteran to assign a provider for care. Health Net Federal Services will issue a provider notification packet to the initial servicing provider. See the Provider Notification Packet section of this handbook for more information. VA Referral for Authorized Care All services under PCCC must be first authorized by VA. A request for care (authorized referral) is then submitted by VA to HNFS. Health Net Federal Services will authorize services based on the referral documents submitted by VA and 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 Federal Services will issue a provider notification packet containing specific requirements for the services covered in the authorization to the servicing provider. All services must be performed by PCCC participating providers and facilities. Note: Health Net Federal Services will fax a reference copy of VA s referral documents to the servicing provider under separate cover. Receipt of these reference documents does not represent an approved authorization. Covered Services Covered services under the PCCC program are limited to the health care services set forth on the authorization received from HNFS. Only services authorized by HNFS and VA will be paid for under the PCCC program. Unless otherwise indicated, 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). Providers may request approval for services not specifically indicated as covered in the initial authorization (the provider notification packet will indicate excluded services). See the Requesting Authorization for Additional Services section to learn more. Health Net Federal Services will only include specific codes in the provider s authorization packet if indicated on the 7078/7079 form. Please refer to the clinical notes included in your provider notification packet. Providers should use their clinical judgment when determining the scope of services to be performed based on what VA has ordered. Requests for additional services not contained in the authorization(s) must be submitted to HNFS. Refer to the provider notification packet for more information and instructions. Health Net Federal Services will work directly with VA to obtain new authorizations for the requested services. Note: Reference copies of VA s referral documents alone do not guarantee payment. The provision of health care services is to be limited to that set forth in the provider notification packet. All claims must correlate with authorizations and returned medical documentation. Only the authorized practitioner may render and bill for services. (See also Requesting Authorization for Additional Services. ) For questions regarding an authorization, contact the HNFS PCCC Call Center at Additional Information for Specific Services 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 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 on the provider notification packet or VA consult document provided by HNFS. As an alternative to contacting the VAMC directly, the 10

12 emergency facility may notify HNFS by calling or faxing to within 72 hours of the veteran s self-presenting. Health Net Federal Services will notify VA with the required information. All notifications must include: veteran s full name last four (4) digits of Social Security number condition for which the veteran is being seen 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 not life threatening, the network facility must contact HNFS for authorization before admitting or treating the veteran. Notify HNFS by one (1) of the following methods, within HIPAA guidelines: Call Fax admitting sheet to If the emergency facility does not notify either VA or HNFS 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 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 local emergency medical services. The facility will follow the above guidelines for notifying VA or HNFS. If the treating physician 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 HNFS (see above for contact information) prior to transport or admission. Audiology Initial testing results relating to potential hearing aids needs must be submitted directly to VA within two (2) business days. All hearing aids will be ordered by VA through its national hearing aid contract. When hearing aids are issued, medical documentation for follow up appointments such as fittings and adjustments must be returned. Authorizations may include the impression to create the hearing aid, but not the device itself. Civilian network providers must send hearing aid impressions to VA and can request reimbursement for shipping charges by using CPT on their itemized claim. The authorization packet will include instructions regarding where to send the impressions. Note: Audiology assistants are not eligible to treat or screen veterans. Provider offices should decline the authorizations if they do not have licensed audiologists available to render the required services. Infertility Services Effective March 31, 2017, VA will reimburse for authorized assisted reproductive technology (ART) services, including a maximum of three (3) complete in vitro fertilization (IVF) cycles, for eligible veterans and spouses under PCCC only (not VCP) who are determined to have a service-connected condition which results in their inability to procreate without the use of fertility treatment. Optometry Authorization for a routine eye exam includes: visual acuity test, color blindness test, retinoscopy, refraction (manual or with use of autorefractor or aberrometer), slit lamp examination, glaucoma test, pupil dilation, and visual field test. An authorization for a routine eye exam does not include digital retina imaging. A veteran s glasses or contacts are a covered benefit only when the prescription is filled at the VA Medical Center (VAMC). Providers should always refer veterans back to the local VAMC for these services. If the veteran requests to fill an eyeglass or contact lens prescription outside the local VAMC, the services are deemed as a non-covered benefit. Non-Covered Services Providers should not offer non-covered services to veterans. Prior to performing non-covered services, network providers must inform the veteran care is not covered, estimate the cost of the service, and get written approval from the veteran that he or she is assuming full financial responsibility for the services. Requesting Authorization for Additional Services Under PCCC, additional prior authorization from HNFS is required when the veteran: requires care beyond the approved dates, requires care beyond the number of visits/units authorized, 11

13 needs care for another medical condition or body part (including other joints), and/or must see a different non-ancillary provider for evaluation/ treatment. Also, the following services require an additional authorization from HNFS when not already specified as covered in the existing authorization: home health home infusion imaging only when requiring sedation inpatient admission physical, occupational or speech therapy skilled nursing surgery (outpatient or inpatient), if specifically excluded from the original authorization urgent consultations required as a result of a newly identified critical finding (such as cancer) To request additional authorization, submit a completed Request for Additional Services form, available and fax it to HNFS at Once HNFS receives a completed Request for Additional Services form, HNFS will coordinate with the veteran s authorizing VA health care facility, as appropriate, to determine whether additional care can be authorized in the community or if VA can provide care to the veteran. Pharmacy VA is primarily responsible for supplying the veteran with all prescribed non-urgent/non-emergent medications, medical/ surgical supplies and nutritional products. Participating providers must prescribe in accordance with the VA National Formulary (VANF), which includes provisions for requesting non-formulary drugs. Routine Prescriptions Routine prescriptions may also be needed to treat a variety of medical conditions. To help veterans obtain routine prescriptions, providers should follow the steps identified below: 1. Consult the VANF to see which medications are available for prescribing. Providers will be contacted by a VA pharmacist if the prescriptions they issue do not follow the VANF. In these situations, the provider can re-write the prescription for a VA National Formulary drug or they can complete a request for a medically necessary non-formulary drug. Note: It may take up to four (4) days after receiving a completed non-formulary request to render an approval/ disapproval decision. 3. The provider should fax or mail the veteran s prescription to the host VAMC. VAMC contact information is available on our website. Note: See Controlled Substances for exception. Alternately, the provider can issue a written prescription to the veteran who can mail or physically present it to their VAMC pharmacy for processing. The provider must also give the veteran a copy of the authorization letter/fax, which must accompany all prescriptions presented for filling in a VA pharmacy. Note regarding to New York state law requiring prescriptions for controlled and non-controlled medications be processed in electronic format for in-state pharmacies: Pharmacy guidelines under PCCC and VCP have not changed when submitting prescriptions to be processed at a VA pharmacy located within a federal facility. We ask you to adhere to the guidelines outlined in this Handbook when prescribing medications for your PCCC and VCP patients, as VA pharmacies are currently not set up to accept electronic prescriptions. Urgent Prescriptions Urgent prescriptions could be required for a variety of medical conditions such as acute pain management and infections. An urgently needed prescription is one which in the provider s clinical opinion cannot wait to be filled by a VA pharmacy and mailed to the veteran. Keep in mind it takes approximately four (4) days for a prescription to reach a veteran by mail after it is transmitted to a VA pharmacy by the provider. To help veterans obtain urgently needed prescriptions, providers should follow these steps: 1. Consult the VANF to see which medications are available for prescribing. Note: There are two (2) file options: sorted alphabetically by generic drug name and sorted by VA drug class. 2. Issue a prescription for up to a 14-day supply of VANF 2. Providers are encouraged to prescribe VANF drugs whenever clinically possible to avoid prescription fulfillment delays and inconvenience to veterans. 12

14 medication and instruct the veteran that he/she may take the prescription to any non-va pharmacy of their choice to be filled at their own expense, after which they may seek reimbursement from the purchased care office at their host VAMC. If a veteran chooses to take an urgently needed prescription to a VA pharmacy to avoid out of pocket expenses, it will be filled if it follows the VANF. In these cases, the provider is required to provide a patient with a copy of the authorization letter/fax required for prescriptions to be filled in a VA pharmacy. Prescription Requirements VA requires providers include the following information on all routine and urgent prescriptions: provider s name and address provider s personal DEA number provider s telephone and fax numbers provider s National Provider Identifier provider s Social Security number provider s date of birth and gender VA cannot fill incomplete prescriptions. Please help your PCCC patients by complying with this requirement. Consider faxing prescriptions to VA directly to better protect your personal information. Controlled Substances the ordering VA facility for approval in advance. Urgent and Emergent DME Effective April 7, 2017, urgent or emergent DME/prosthetics must be provided by the treating physician/facility and or a DME supplier at the time of treatment and prior to the veteran leaving the provider s facility for an authorized episode of care. Claims for urgent/emergent DME should be submitted to HNFS. These items may include, but are not limited to: splints, crutches, canes, slings, soft collars, etc. Failure to plan or coordinate in advance of a scheduled procedure shall not constitute as an urgent or emergent need. Home Infusion Referrals for home infusion services will be communicated directly by a VAMC referral nurse. Referrals will be made by telephone 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. VA generates the authorization and issues it to HNFS. Health Net Federal Services forwards the 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 forwards it to the VAMC referral nurse. Health Net Federal Services will send the , with sections 4(a), 4(b) and 4(c) in the Authorization Remarks field, to the provider. Remember the following protocol when prescribing scheduled medications. Prescriptions for Schedule II medications must be mailed or presented in person in their original form. Faxed Schedule II prescriptions are not accepted. Prescriptions for Schedule III-IV prescriptions may be faxed by the provider and must have a pen and ink provider s signature. Electronic signatures are not accepted. Durable Medical Equipment and Home Infusion Durable Medical Equipment Health Net Federal Services 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 13

15 Provider Notification Packets After an appointment is scheduled, HNFS will send the provider notification packet to the scheduled facility or provider. These provider notification packets provide casespecific clinical requirements, VA standards and guidelines of the PCCC authorized care. Packets may include, but are not limited to: VA s referral for authorized care and any clinical notes or medical documentation provided by VA Veteran s name and contact information type and amount of service requested (for example, number of visits/procedures/ treatments) initial appointment date scheduled for the veteran medical documentation return guidelines VA point of contact for emergencies (such as reporting critical findings) or additional information/ authorization needs Health Net Federal Services authorization number reminder the veteran should be seen within 20 minutes of the scheduled appointment time instructions for: - communicating no-show appointments - requesting ongoing treatment and/or extended services for VA approval - reporting critical findings to VA - notifying the veteran of test results Information on the VA National Formulary Note: Health Net Federal Services may fax a reference copy of VA s referral documents to the servicing provider under separate cover. Receipt of these reference documents does not represent an approved authorization. 14

16 Appointment Scheduling Please review this section for information on the following: Appointment scheduling overview Urgent care reporting Inpatient authorization process and discharge planning Health Net Federal Services 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 completed within 48 hours of scheduling. Office wait time for appointments must not exceed 20 minutes. Providers must report all no-show, canceled or rescheduled appointments to HNFS at or by fax at Note: Providers must not bill veterans, or request reimbursement from VA or HNFS for no-show, missed or canceled appointments. Authorizations containing the notation of urgent require the veteran be scheduled for and complete care within 48 hours of scheduling. 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. 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: urgent scheduling written report per contract performance standards (No oral report required.) Inpatient Authorization Process and Discharge Planning Providers are responsible for notifying HNFS of veteran inpatient admissions and discharges. Health Net Federal Services 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 HNFS. Provider notification packets will instruct inpatient facilities how to handle post-inpatient coordination. For discharges, HNFS 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 HNFS of an inpatient admission or discharge call or fax a notification to Participating providers are required to provide immediate (within 24 hours) notification to HNFS of discharges against medical advice; notification is to be by fax or telephone, using the fax/telephone numbers provided on the provider notification packet. Urgent Care Reporting Urgent with oral 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: urgent scheduling oral report plus written report per contract performance standards 15

17 Medical Documentation Providers must submit medical documentation to HNFS prior to claims submission to avoid claim denial. Claims will not be paid until medical documentation is returned to HNFS. If claims are denied for missing or incomplete medical documentation, please return complete medical documentation and then resubmit the claim. Please review this section for information on the following: Medical documentation content Return of medical documentation Additional requirements for medical documentatio Critical findings Medical Documentation Content At the completion of the authorized episode of care, participating providers must submit medical documentation to HNFS that includes: veteran identification; to include name, sex, last four (4) digits of Social Security number, and date of birth a summary of the encounter, including any procedures performed and recommendations for further testing or follow up (such as, discharge summary for inpatient) results of any ancillary studies/procedures which would impact recommended follow up (for example, positive biopsy results from a gastroenterology provider who recommends surgery) any recommended prescriptions and treatment plans Return of Medical Documentation Health Net Federal Services must deliver medical documentation to VA within 14 days after the initial appointment for outpatient care and 30 days after discharge for inpatient care. To fulfill our requirement for a thorough review and deliver in this time frame, providers are requested to deliver medical documentation to HNFS within the following time frames: Tips for returning medical documentation: Report no-shows, canceled or rescheduled appointments to HNFS at Reporting immediately will avoid repeated medical documentation reminders for veterans who did not keep their appointments. Health Net Federal Services will contact the veteran and attempt to reschedule the appointment. Return medical documentation within the time frame indicated on the provider packet to HNFS. Use the Required Medical Documentation Content checklist, located at to ensure all elements of the medical documentation are complete. Include date, time and person contacted at VA when a critical finding is reported. (See Critical Findings section.) Return medical documentation to HNFS, even if VA has also requested a copy. Utilize the veteran-specific cover sheet from your provider notification packet to expedite medical documentation processing. It includes a bar code specific to a single episode of care for an individual veteran. Using this cover sheet expedites processing of medical documentation and delivery to the veteran s medical file. If the bar-coded fax sheet is not available, HNFS offers a generic fax cover sheet at Do not combine documentation for multiple authorizations. Do not submit claims with medical documentation as HNFS cannot accept faxed claims for processing. Refrain from copying the cover sheet, as this may degrade the copy quality and delay processing of documents. Fax the complete documentation to Participating providers must not bill HNFS until they have submitted medical documentation for inpatient and outpatient care, as applicable, to HNFS. Health Net Federal Services will consider exceptions for highly unusual circumstances. This process will be audited on a regular basis. - Initial medical documentation within 10 calendar days from the first appointment date - Medical documentation for the last appointment within 10 calendar days from the last appointment - Inpatient discharge summary within 25 days from the discharge date 16

18 Additional Requirements for Medical Documentation Visit for the following medical documentation requirements forms: Audiology Blind/Low Vision Rehabilitation Gastroenterology Inpatient Admissions Mental Health Oncology Pathology Radiology Skilled Home Health Surgery Audiology Initial testing results and medical documentation for followup appointments must be faxed to VA and HNFS. Initial testing results related to potential hearing aids needs must be returned within two (2) business days. Medical documentation for follow-up appointments such as fittings and adjustments must be returned within 14 business days. 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 (2) to four (4) 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 within the VA Low Vision Visual Functioning Questionnaire. Gastroenterology Medical documentation submitted to HNFS for veterans referred for gastroenterology procedures (for example, colonoscopy, sigmoidoscopy, esophagogastroduodenoscopy, endoscopic retrograde cholangiopancreatography), and endoscopic ultrasonography must include information stated in the Gastroenterology Medical Documentation Requirements form. 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 HNFS. Mental 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 Mental 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 docs/va_safety_planning_manual.pdf. The plan must include the Veterans Crisis Line telephone number Oncology Medical documentation submitted to HNFS for veterans referred for medical/radiation oncology services must include information stated in the Oncology Medical Documentation Requirements form. Report the following to VA within 48 hours as critical findings: A new diagnosis of cancer any clinical suspicion of possible new malignant finding progression of previously diagnosed cancer 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 HNFS receipt of a VA request for the slides. Radiology Films and reports must each be identified by veteran name, 17

19 date of birth, last four (4) 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 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 (5) business days of HNFS s receipt of a VA request. Skilled Home Health The initial plan of care must be submitted to VA and HNFS within three (3) business days of authorization. Discharge summary must be submitted within five (5) days of completion of authorized episode of care. Surgery Upon the veteran s discharge after an authorized surgical procedure, participating providers are required to complete and return to HNFS the VA Purchased Surgical Care Patient Outcome form, along with the other required clinical feedback. 18

20 Critical Findings 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. Critical findings must be reported to VA. Please refer to the chart below for critical findings reporting deadlines. Any initial findings must be followed up by submission of complete medical documentation to HNFS within the time frame indicated in the provider notification packet issued by HNFS. Contact with VA (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. To report a critical finding to VA, refer to the VA contact information on page two of the provider notification packet issued by HNFS. Critical Finding Return Date Veteran requires one (1) of the following: urgent follow-up care after completion of the authorized episode of care urgent additional care during the authorized episode of care urgent specialty care beyond the expertise of the community provider, when a separate authorization is required urgent treatment from the referring VA provider Critical findings on outpatient imaging or laboratory testing, or during evaluation and treatment Newly-identified suicide risk in a Veteran not referred for inpatient mental health treatment A new diagnosis of cancer, any clinical suspicion of possible new malignant finding or progression of previously diagnosed cancer. 24 hours 24 hours by phone, upon completion of the test, evaluation or treatment 48 hours of diagnosis 19

21 Claims Please review this section for information on the following: Provider claims process Claims submission Remittance advice and claims payment Claims questions and status updates Provider Claims Process The HNFS 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. In most cases, clean claims will be processed within 30 days. Patient-Centered Community Care claims must be submitted to HNFS within 90 days of the date of service, or upon the conclusion of a series of authorized visits. (Veterans Choice Program claims must be submitted to HNFS within 120 days of the date of service, or upon the conclusion of a series of authorized visits.) Before preparing a claim, remember participating providers must not bill veterans, VA or HNFS for: No-show, canceled or rescheduled appointments. Rendered care not included on the authorization. Note: Authorizations alone do not guarantee payment. The provision of health care services is to be limited to that set forth in the authorization. All claims must correlate with the care specified on the authorization. Only the authorized practitioner may render and bill for services. Submit medical documentation prior to claims submission to avoid claim denial. Claims will not be paid without medical documentation. If claims are denied for missing or incomplete medical documentation, please return complete medical documentation and then resubmit the claim. Claims Submission Participating providers are encouraged to submit health care claims via HIPAA-compliant electronic data interchange (EDI) transaction sets through HNFS designated clearinghouse, Change Healthcare. Visit 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: If you are unable to submit via EDI, please complete a CMS1450 (UB04) or 1500 paper claim form, and mail to the address below. Only original (non-copied) claim forms will be accepted. Additionally, HNFS cannot accept faxed claims. Health Net Federal Services, LLC Patient-Centered Community Care PO Box 9110 Virginia Beach, VA Remember to include the authorization number when submitting via EDI. For detailed instructions on how to complete a paper claim form, please view the Medicare Claims Processing Manual located on Medicare s website. 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 (CPT ) and Health Care Procedure Coding System (HCPCS) 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. Electronic Funds Transfer To request, make changes to or cancel payments via electronic funds transfer (EFT), go to to download the EFT Authorization Agreement form. Fax the completed form with a voided check or bank letter to (916)

22 For new enrollments, please allow four (4) weeks for the registration process to be completed, which includes pre-note verification. If after four (4) weeks you do not start receiving EFT, please the HNFS Finance Team at Note: Do not fax medical documentation or claims containing patient information to the HNFS Finance Team. Electronic Remittance Advice Health Net Federal Services offers a choice of clearinghouses from which to receive electronic remittance advice (ERA)/835 statements for VCP and PCCC claims. We encourage you to research each to determine which one meets the needs of your practice. You may only be enrolled with one clearinghouse with HNFS from the list below for VCP and PCCC claims. If you switch from one clearinghouse to another, your previous enrollment will be canceled. Please allow 30 days to begin receiving your ERAs from the clearinghouse with which you registered. When registered for one of the clearinghouses, you will only be able to review your remittance with that particular clearinghouse. Availity Register with Availity at Once logged in, click on the ERA Enrollment box. Payer name: ERAHEALTHNET Payer ID: Change Healthcare (formerly Emdeon) Register with Change Healthcare at Payer name: Health Net Federal Services VA PC3 & VCP Payer ID: Corrected Claims Electronic claims can be corrected and resubmitted. To resubmit a corrected paper claim, make the correction on an original red/white CMS claim form and mail to HNFS/PCCC, PO Box 9110, Virginia Beach, VA for processing. Reconsideration Requests/Allowable Charge Reviews Claims reconsideration or allowable charge review requests must be made in writing. Adjustment determinations are made on a claim-by-claim basis. Note: Claims rejected by our optical character recognition (OCR) system must be re-submitted via EDI or U.S. mail (on an original red/white CMS 1500/1450 claim form). As these claims were not accepted and therefore, never entered our system for processing, they are considered new claims and cannot by submitted via fax for reconsideration. Please refer to p. 21 for claims submittal time frames. An allowable charge review is a written notice from the provider to HNFS 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 Federal Services 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 provider s contact information including telephone number original claim number 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. Appeals VA program benefits are determined by VA and cannot be appealed through HNFS. Claims Questions and Status Updates Providers can check the status of PCCC claims at Registration is required. Once logged in, select Claim Status Inquiry under Claims Management in the left-hand menu. Choose Patient-Centered Community Care in the payer field when submitting your claim status inquiry. Search for claims by patient identification number or claim number. Search by the veteran s information or claim number to obtain the status. For additional claims questions, contact HNFS at

23 Primary Care Requirements Please review this section for information on the following: Primary care overview Authorizations Routine diagnostic testing Routine diagnostic radiology Routine diagnostic services Appointments Medical records and documentation Primary Care Overview 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. Primary care providers must have 24-hour on-call coverage. If it is determined that these or other additional services are required, complete the Request for Additional Services form and fax it to HNFS at The form is available at Authorizations Covered services under the PCCC program are limited to those services listed in the authorization. Providers must contact HNFS for authorization to provide any services in addition to those listed on the authorization. Primary care services may be authorized for one (1) fiscal year up to 24 visits. If additional visits are necessary, beyond what is indicated in the authorization, providers must complete the Request for Additional Services form at Primary care authorizations are inclusive of initial visits, follow-up visits and acute primary care services. These include, but are not limited to: routine diagnostic tests routine diagnostic radiology preventive services Routine Diagnostic Testing Routine diagnostic testing is defined as: 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 (5) 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 (5) business days of the initial appointment. Routine Diagnostic Services If diagnostic testing and/or radiology and preventive services cannot be performed within the primary care practice, please notify HNFS immediately. Appointments Health Net Federal Services 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. Providers must report 22

24 all veteran no-show, canceled or rescheduled appointments to HNFS by telephone using the contact number listed on the individual provider packet or by fax at Note: Providers must not bill veterans or request reimbursement from VA or HNFS for no-show, canceled or rescheduled appointments. Medical Records and Documentation Providers must return medical documentation from the initial visit within the time frame indicated on the provider packet. Medical documentation for all subsequent visits must be maintained within the office, and made available upon request. Medical records should always be maintained up-todate and comply with the medical community standards. The record must include required veteran demographics and clinical information as needed to support the care provided and services performed. Note: A single comprehensive medical primary care record must be accessible to VA. Use the cover sheet provided in the provider notification packet when returning medical documentation to HNFS, as it includes a bar code specific to a single episode of care for an individual veteran. Using this cover sheet ensures medical primary care records are accessible to VA. Complete medical records must be submitted to HNFS at the end of the authorization, or after visit 24. Claims will not be paid until medical documentation is returned to HNFS. 23

25 Fargo, North Dakota Scheduling Initiative As of October 3, 2016, the Fargo, North Dakota VA Medical Center (VAMC) directly schedules care with providers for Veterans authorized under PCCC who are in the Fargo, North Dakota area. The Fargo VAMC is responsible for all elements of care coordination and continuity of care, to included access to care, transition of care, coordination of inpatient services, and referral follow up. Once an appointment is scheduled, the Fargo VAMC will send the authorization request and appointment information to HNFS for processing and a notification letter to the provider. This notification letter will also include any necessary clinical information needed for the appointment. Health Net Federal Services will issue a provider notification packet to the provider. (See Provider Notification Packet section in this handbook for additional information.) Critical Findings Critical findings must be submitted to the referring provider. See Critical Findings section in this handbook for reporting timelines. Claims Claims are submitted to HNFS for processing. Requests for Additional Services If additional services are required, including inpatient care, providers must submit the Fargo Secondary Authorization Request Form, available at to the VAMC for review. (Note: This form is specific to the Fargo VAMC.) Routine orders for care shall be submitted to the provider within two (2) business days after HNFS receives the authorization from HNFS. Urgent orders for care shall be submitted to the provider prior to care being delivered but no later than one (1) business day after the contractor has received the order from VA. Providers shall notify the Fargo VAMC within 72 hours of veterans self-presenting to an emergency department for care. Medical Documentation Returned to Fargo, VAMC Medical documentation must be submitted to the Fargo VAMC. Refer to the provider notification packet received from HNFS for return time frames and contact information. 24

26 Complaint and Grievance Process The HNFS PCCC Call Center performs customer service functions with knowledgeable, courteous and responsive staff, with support available from 6:00 a.m. 10:00 p.m., Monday through Friday, Eastern time. Telephone support is available through the toll-free number, All veteran complaints about any aspect of care are required to be submitted to HNFS within one (1) business day of notification. Health Net Federal Services and VA reserve the right to audit oral and written complaints and handling of complaints. Health Net Federal Services is required to temporarily refrain from referring veterans to participating providers where VA has notified HNFS of concerns or issues with a provider until such time when the concern has been resolved. Written grievances may also be submitted to HNFS. Complete and print an HNFS Grievance Form or send a letter with the following: name, address and telephone number of the person submitting the grievance the veteran s name, address and telephone number if different from the submitter the veteran s Social Security number a description of the issue(s), including the day, time and details the name of the involved provider(s) or HNFS associates or departments the provider s address if the complaint is about a provider appropriate supporting documents Fax to: (916) Mail to: Health Net Federal Services, LLC Attn: Grievances 2025 Aerojet Road Rancho Cordova, CA Do not use the grievance form for questions or disputes regarding claims. For assistance with claims inquiries not answered by information available at contact HNFS. Note: Anyone can file a grievance; however, if the grievance is from someone other than the involved veteran, HNFS may not be able to give a full response without authorization to disclose medical information on file. 25

27 Health Care Management and Administration Participating providers are required to report to HNFS 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 HNFS using FDA Form 3500, and a copy of the completed form submitted to FDA online must also be submitted to HNFS. The FDA reporting form can be found at htm. All reported veteran safety events will be investigated, confirmed and resolved by HNFS. facilities performing cardiac surgery, cardiac catheterizations/ percutaneous coronary interventions (PCI), and /or implantation of cardioverter defibrillators: STS 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 VA and HNFS 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 HNFS policies, including, but not limited to HNFS 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 HNFS with all CMS-reported data not later than time of publication of the data on the CMS website. In addition, The Joint Commission s (TJC) ORYX National Hospital Quality Measures results will be provided to HNFS no later than the date of publication by the TJC. The CMS and ORYX metrics must be reported to HNFS regardless of whether the data is published on existing TJC 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 26

28 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 VA 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 HNFS or the applicable payer, or payer s designee, for the rendition of covered services that may be required under a benefit program or an HNFS 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 VA has provided an authorization to pay. CPG: clinical practice guidelines. Critical finding (or critical value, critical test result): The U.S. Department of Veterans Affairs (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. 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 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 the HNFS 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) 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, education, training, and licensure. 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. 27

29 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 cumulativedose >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 HNFS. 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. VANF: VA National Formulary 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 regional oversight for the VA Medical Centers. 28