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VAPatient-Centered Community Care
Network Provider Handbook April 2017
A Wholly-Owned Subsidiary of Centene Corporation
1
Overview 3 About PCCC 3
Veterans Choice Program 3
Document Purpose 3
Responsibility for Provision of Services 3
Key Requirements 3
Provider Tools 5 www.hnfs.com 5
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
Table of Contents
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
2
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
3
OverviewParticipating 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
www.hnfs.com/go/VA.
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).
4
• 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.
• 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 1-855-300-1705.
• 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,
including no-show, canceled or rescheduled appointments.
• Medical documentation must be faxed to HNFS
(1-855-300-1705) 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.
5
Provider ToolsPlease review this section for information on the following:
• www.hnfs.com
• Requirements for maintaining accurate information
www.hnfs.com
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 www.hnfs.com/go/VA.
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 www.hnfs.com/go/
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.
6
Important Provider InformationPlease 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 www.oig.hhs.gov/exclusions/index.asp
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.
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
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
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 1-866-606-8198 or by fax at
1-855-300-1705. Providers must not bill the veteran, VA or
HNFS for no-show, canceled or rescheduled appointments.
7
Provider NetworkPlease 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
8
MRI, nuclear medicine, and positron emission tomography
exams. American College of Radiology and the Intersocietal
Accreditation Commission have been deemed by CMS to
provide this accreditation.
Facilities providing mammography are required to meet Food
and Drug Administration requirements per the Mammography
Quality Standards Reauthorization Act of 1998, as amended
by H.R.4382. Clinicians performing interventional radiology
procedures are required to have both General Diagnostic
American College of Radiology certification as well as specific
current Boards in interventional radiology.
All radiologic technologists are required to be certified by
the American Registry of Radiologic Technologists (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 board-
eligible physical medicine and rehabilitation physician, and
otherwise appropriately provides rehabilitation physician
services under Medicare policies.
All speech language pathologists are required to have a full,
current and unrestricted license in the state in which services
are provided. In states without licensure requirements for speech
pathologist (Colorado and South Dakota), American Speech-
Language-Hearing Association certification may be substituted
for licensure. 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
www.healthquality.va.gov. These are baseline criteria and
do not replace clinical judgment.
Surgery
Facilities performing cancer surgery are required to be
accredited by the Commission on Cancer of the American
College of Surgeons, unless authorization to a non-accredited
facility is authorized by 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
9
Contract Act, including wage and benefit requirements for
applicable workers. The Department of Labor determines the
levels of wages and benefits based on location of services.
These can be found at www.wdol.gov. 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.
The following is a list of EBPs VA currently uses:
• cognitive processing therapy for post-traumatic stress
disorder (PTSD)
• prolonged exposure therapy for PTSD
• cognitive behavioral therapy (CBT) for depression
• acceptance and commitment therapy for depression
• interpersonal psychotherapy for depression
• behavioral family therapy for serious mental illness
• multiple family group therapy for serious mental illness
• social skills training for serious mental illness
• integrated behavioral couples therapy for relationship
distress
• CBT for insomnia
• CBT for chronic pain
• motivational interviewing for motivation, engagement, and
adherence
• motivational enhancement therapy for substance use
disorders
• contingency management for substance use disorders
• behavioral couples therapy for substance use disorders
• CBT for substance use disorders
Veterans with a history of military sexual trauma (MST), and
being treated for a behavioral health problem related to MST,
may receive care from a provider of the gender of their choice.
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 www.healthquality.va.gov. 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.
10
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 1-800-979-9620.
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
1-877-222-VETS (8387) within 24 hours. If 24 hour notification
is not made, the facility should contact the veteran’s assigned
Veterans Affairs Medical Center (VAMC) within 72 hours. The
VAMC can be identified on the provider notification packet or
VA consult document provided by HNFS.
As an alternative to contacting the VAMC directly, the
11
emergency facility may notify HNFS by calling 1-800-979-9620
or faxing to 1-855-300-1705 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 1-800-979-9620.
• Fax admitting sheet to 1-855-300-1705.
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 1-877-222-VETS (8387) for
more information.
Emergency Health Care Services during an Authorized
Appointment
When a provider determines the veteran requires emergency
health care services during an authorized appointment, he
or she will seek immediate treatment at a facility or 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® 99002 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,
12
• 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 www.hnfs.com/go/forms,
and fax it to HNFS at 1-855-300-1705.
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.
2. Providers are encouraged to prescribe VANF drugs
whenever clinically possible to avoid prescription
fulfillment delays and inconvenience to veterans.
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
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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
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
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 10-7079, with sections 4(a), 4(b) and 4(c) in the
Authorization Remarks field, to the provider.
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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 case-
specific 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.
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Appointment SchedulingPlease 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 1-800-979-9620 or by fax at
1-855-300-1705.
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 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
• 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
1-800-979-9620 or fax a notification to 1-855-300-1705.
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.
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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:
- 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
Tips for returning medical documentation:
• Report no-shows, canceled or rescheduled appointments
to HNFS at 1-800-979-9620. 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 www.hnfs.com/go/forms, 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 www.hnfs.com/go/forms.
• 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 1-855-300-1705.
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.
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Additional Requirements for Medical Documentation
Visit www.hnfs.com/go/forms 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 follow-
up 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 http://www.mentalhealth.va.gov/
docs/VA_Safety_planning_manual.pdf.
The plan must include the Veterans Crisis Line telephone
number 1-800-273-8255.
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,
18
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.
19
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
24 hours
Critical findings on outpatient imaging or laboratory testing, or during evaluation and treatment 24 hours by phone, upon completion of the test, evaluation or
treatmentNewly-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.
48 hours of diagnosis
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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 www.changehealthcare.com to
register.
If already registered, providers may submit claims using the
following information.
• Payer Name: Health Net – VA Patient-Centered
Community Care Program
• Payer ID: 68021
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 23452
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 www.hnfs.com/go/forms to
download the EFT Authorization Agreement form. Fax the
completed form with a voided check or bank letter to
(916) 353-6829.
21
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 email 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 www.availity.com. Once logged
in, click on the ERA Enrollment box.
• Payer name: ERAHEALTHNET
• Payer ID: 68021
Change Healthcare (formerly Emdeon)
• Register with Change Healthcare at
www.changehealthcare.com.
• Payer name: Health Net Federal Services VA PC3 & VCP
• Payer ID: 68021
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 23452 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
www.availity.com. 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 1-800-979-9620.
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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 1-855-300-1705. The form is available
at www.hnfs.com/go/forms.
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
www.hnfs.com/go/forms.
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
23
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 1-855-300-1705.
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-to-
date and comply with the medical community standards. The
record must include required veteran demographics and clinical
information as needed to support the care provided 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.
24
Fargo, North Dakota Scheduling InitiativeAs 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.)
• 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.
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 www.hnfs.com/go/Fargo, to the
VAMC for review. (Note: This form is specific to the Fargo
VAMC.)
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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, 1-800-979-9620.
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) 353-6826
Mail to: Health Net Federal Services, LLC
Attn: Grievances
2025 Aerojet Road
Rancho Cordova, CA 95742
Do not use the grievance form for questions or disputes
regarding claims. For assistance with claims inquiries not
answered by information available at www.Availity.com,
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.
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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
www.fda.gov/Safety/MedWatch/HowToReport/default.
htm. All reported veteran safety events will be investigated,
confirmed and resolved by HNFS.
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
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
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Definitions and AcronymsHere 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.
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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.
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VAPatient-Centered Community Care
Network Provider Handbook
A Wholly-Owned Subsidiary of Centene Corporation
VH0317x039 (03/17)
