Veterans Choice Program and Patient-Centered Community Care Fargo Scheduling Initiative Provider Orientation Webinar

Transcription

1 Veterans Choice Program and Patient-Centered Community Care Fargo Scheduling Initiative Provider Orientation Webinar October 2016

2 The Fargo Scheduling Initiative is effective October 3, 2016 for the Region 4/Fargo, North Dakota area only. Please visit for detailed information. 2

3 Introduction The U.S Department of Veterans Affairs (VA) Veterans Choice Program (VCP) and Patient- Centered Community Care (PCCC) program provide eligible Veterans access to care through a comprehensive network of community-based providers. These programs augment VA s ability to provide specialty inpatient and outpatient health care services to Veterans. Health Net Federal Services, LLC (HNFS) was awarded its PCCC contract in In 2014, HNFS expanded its services with VA in support of the Veterans Access, Choice and Accountability Act, which funded VCP. 3

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

5 Veterans Choice Program For Veterans who have faced unacceptable waiting times for needed medical care, or for whom a regular VA medical center (VAMC) is inaccessible, the Veteran Choice Program (VCP) makes it possible for Veterans to receive the needed care from a non-va health care provider in their community. VCP is Veteran-driven: All Veterans who were enrolled with VA as of August 1, 2014 received a Choice Card. Veterans can choose to contact the customer service number on the Choice Card to initiate care; however, they must meet one of the VCP eligibility requirements: live more than 40 miles from a VA health care facility are unable to get a VA appointment within 30 days of their preferred date/the date determined medically necessary by their physician Veterans must seek care from providers who are part of the HNFS network or who have accepted the VCP terms of participation. All initial care requires prior authorization. 5

6 Patient-Centered Community Care Patient-Centered Community Care (PCCC) supplements VA s ability to provide specialty inpatient and outpatient health care services, as well as behavioral health care, limited emergency care and newborn care services to enrolled Veterans. PCCC is VA-driven. VA initiates the request for care outside of its facility. Care must be provided by an HNFS PCCC network provider. All initial care requires prior authorization. 6

7 Options for Providers In order to treat Veterans under PCCC or VCP, providers must join the HNFS PCCC provider network or register as a VCP participating provider. Here s a chart to help illustrate some of the differences between the two options. PCCC Network Provider signs an HNFS network contract and completes the credentialing process. Provider is listed in our Preferred Provider Network for all current and future VA programs. Providers are considered the first option for referrals and authorizations. Provider can render services to VCP-or PCCC-eligible Veterans. VCP Participation Provider agrees to Veterans Choice Program Terms of Participation (online). Certification is complete when VCPeligible Veterans select the provider for authorized care. Provider can only render services to VCPeligible Veterans upon receipt of an authorization. 7

8 Provider Participation Participating providers agree to comply with all HNFS and VA program rules, policies and procedures. These documents are available on the HNFS website, Rendering providers must: be Medicare participating (certain exceptions apply), have an active unrestricted state license, be DEA licensed (as applicable), have no sanctions, and provide a Type 1 and/or Type 2 NPI (as applicable).. 8

9 Program Requirements The following slides provide a brief overview and highlight the following important elements: eligibility appointments authorizations and covered services requesting additional services referring to other providers critical findings medical documentation claims procedures As a reminder, PCCC contracted providers are eligible to receive both PCCC and VCP authorizations. Participating VCP providers are limited to receive only VCP authorizations. 9

10 Eligibility VA is responsible for determining eligibility and authorizing care. Eligibility for VA health care is based on Veteran status, service-connected disabilities, or exposures, income and other factors. 10

11 Fargo Scheduling Initiative: Differences in Process New Scheduling Procedure Veterans call the Veterans Choice Call Center. Calls are routed to Fargo VAMC. Fargo VAMC staff schedules the appointments. Fargo VAMC faxes the provider information concerning the appointment, including medical records. Health Net Federal services provides the authorization letter to the Veteran and the provider. Provider sends required medical documentation to the Fargo VAMC. Provider sends secondary authorization request (SAR) to the Fargo VAMC. Provider contacts the Fargo VAMC for scheduling questions. Questions unrelated to scheduling will be directed to HNFS. Fargo VAMC provides care coordination for Veterans under Veterans Choice Program. Old Scheduling Procedure Veterans called the Veterans Choice Call Center. Calls were routed to Health Net Federal Services, LLC (HNFS). Health Net Federal Services scheduled the appointments. Health Net Federal Services faxed the provider information concerning the appointment, including medical records. Health Net Federal Services provided the authorization letter to the Veteran and the provider. Provider sent required medical documentation to HNFS. Provider sent SAR to HNFS. Provider contacted HNFS for scheduling, program and claims questions. Health Net Federal Services provided care coordination for Veterans under Veterans Choice Program. 11

12 Fargo Process Overview Veteran calls Veterans Choice Call Center to confirm eligibility (for VCP)/Local VA clinic refers Veteran for care with a non-va community provider (for PCCC). Fargo VAMC locates HNFS network or VCP provider who can accept the Veteran as a patient. Fargo VAMC schedules appointment on behalf of Veteran. Fargo VAMC forwards appointment information to HNFS. Fargo VAMC faxes the provider information about the appointment, including medical records. Health Net Federal Services faxes authorization letter to the provider and Veteran. Health Net Federal Services receives and processes claim. 12

13 Authorizations and Covered Services All initial care under PCCC and VCP requires prior authorization. In general, PCCC and VCP 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). 13

14 Appointments The Fargo VAMC is responsible for coordinating initial appointments with a provider s office or facility. Providers are strongly encouraged to contact Veterans with a courtesy appointment reminder. Providers must notify the Fargo VAMC of missed, canceled, or rescheduled appointments. Providers may not bill the Veteran, VA or HNFS for missed or canceled appointments. Appointments must be scheduled within 30 days of the clinically indicated date. Veterans must be seen within 20 minutes of their scheduled appointment time. 14

15 Appointment and Authorization Information After the Fargo VAMC schedules an appointment, they will fax the provider information with the appointment details and other important information. The information from the Fargo VAMC will include appointment details, Veteran contact information, applicable clinical information, and a Fargo-specific Secondary Authorization Request (SAR) form. Fargo VAMC will notify HNFS that an appointment has been scheduled and HNFS will issue an authorization letter to the Veteran and the provider. In addition to the authorization details, the letter from HNFS to the provider will include instructions for returning medical documentation to the Fargo VAMC, claims information and other program details. It is important the appointment information from the Fargo VAMC and the authorization letter from HNFS be distributed to the appropriate departments within the practice/facility. Note: Please allow two business days for routine care and one business day for urgent care from when VA makes the appointment to when HNFS faxes the authorization. 15

16 Emergency Care Emergency care should be provided to any eligible Veteran who self-presents to an emergency room (ER). The ER must contact the Fargo VAMC within 72 hours (either by phone or by fax). Note: Fargo VAMC can only authorize emergency care for PCCCeligible Veterans. Emergency room visits are only a covered benefit under VCP when provided as part of the authorized episode of care. 16

17 Inpatient Care Providers must: Coordinate all inpatient admissions and discharges with the Fargo VAMC. Submit the Fargo-specific Secondary Authorization Request (SAR) form to the Fargo VAMC for all inpatient admissions. Notify the Fargo VAMC within 72 hours of an emergency admission (this also applies to weekend notifications). Coordinate discharges with the Fargo VAMC: For Veterans who are to be transferred back to a VA clinic or a different facility. For Veterans who require discharge planning to their home, and may require supplies, home health or equipment. 17

18 Transition of Care Fargo VAMC will coordinate all transitions of care, including those necessitated by a provider leaving the network and when a primary provider refers a Veteran for specialty care. Fargo VAMC will review all requests for additional care (see Secondary Authorization Requests slides). The new servicing provider must receive a new, unique authorization from HNFS before initiating treatment. 18

19 Request for Additional Services Additional prior authorization from the Fargo VAMC is required when the Veteran: requires care beyond the approved dates; requires care beyond the number of visits/units authorized; needs care for another medical condition or body part (including other joints); must see a different non-ancillary provider for evaluation/treatment; and/or requires an inpatient admission. 19

20 Secondary Authorization Request Form To request an additional authorization, fax a completed Fargo Secondary Authorization Request (SAR) form (provided by the Fargo VAMC and available at to the Fargo VAMC at (701) Fargo VAMC will review the request. To expedite the review, please include: The completed SAR form. All applicable medical documentation. Justification for the request. If approved by the Fargo VAMC, HNFS will fax an updated authorization to the requesting provider. 20

21 Critical Findings Providers must report critical findings to referring provider. VA defines critical findings as a test result value or interpretation that, if left untreated, could be life threatening or place the Veteran at serious health risk. Critical values/results are those results from laboratory, cardiology, radiology departments, and other diagnostic areas that are determined to be critical, regardless of the ordering priority. 21

22 Urgent Care Urgent care is coordinated through the Fargo VAMC. Providers must notify the Fargo VAMC within 24 hours when Veterans require: Urgent additional care during the episode of care Urgent follow-up after completion of the episode of care 22

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

24 Medical Documentation Medical documentation may include, but is not limited to: discharge summary relevant medical history and physical examination initial and final diagnoses or diagnostic impressions specific care or services provided, including medication use and medication allergies or sensitivities Veteran s response to care or services list of all medications recommended or ordered durable medical equipment (DME) or prosthetics recommended follow up 24

25 Medical Documentation continued Medical documentation must be faxed to the Fargo VAMC at (701) within the time frame specified in the provider packet. Tips: Do not combine documentation for multiple authorizations. Do not submit claims with medical documentation. An electronic or written signature is required to be considered complete. 25

26 Prescriptions Prescription medications must be prescribed in accordance with the VA National Formulary (VANF). Routine prescriptions VA requires Veterans fill all routine (non-urgent/non-emergent) prescriptions at VA pharmacies. Veterans who fill routine prescriptions elsewhere may not be reimbursed. Please advise your Veteran patients accordingly to help them avoid unexpected expenses. Fax the prescription to the local VA pharmacy or Give Veteran a copy of the HNFS authorization to physically take or mail along with the prescription to a local VA pharmacy for fulfillment. Urgent prescriptions Providers may issue Veterans with up to a 14-day supply of VANF prescriptions when needed urgently. Veterans may take urgent prescriptions to any non-va pharmacy to be filled at his/her own expense and seek reimbursement from the Purchased Care office at their local VA health care facility. 26

27 Prescriptions continued VA pharmacies must have the prescribing provider s information on file in order to fill prescriptions. As such, VA requires the following prescribing provider information on all routine and urgent prescriptions: name address personal DEA number (not a generic facility number) telephone number date of birth Social Security number fax number National Provider Identifier (NPI) gender Incomplete prescriptions cannot be filled and will be returned to the prescribing provider. 27

28 Prescriptions continued If a non-va provider would like to administer a prescribed medication to a Veteran in his/her office (such as an injectable), that provider must purchase the medication and submit a claim to HNFS for reimbursement. VA pharmacies cannot dispense medications directly to non- VA providers. Medications must be on the VA National Formulary and be part of the treatment authorized per the terms of the provider packet. 28

29 Other Health Insurance For VCP-eligible Veterans with commercial other health insurance (OHI), the primary and secondary payers are determined based on whether the Veteran s care is related to a service-connected injury. The Fargo VAMC will determine if the Veteran s care is related to a serviceconnected injury. Non-service-connected claims must be filed with the OHI carrier before submitting claims to HNFS with the explanation of benefits from the primary payer for payment determination. It is appropriate to collect a copayment from the Veteran for the OHI, if applicable. Service-connected claims must be sent to HNFS and should not be submitted to the OHI. Note: Veterans Choice Program does not coordinate benefits with other government programs such as Medicare, Medicaid and TRICARE. 29

30 Reimbursement Only authorized services are eligible for reimbursement. For more information, refer to the Fargo Claims Quick Reference Chart, located at 30

31 Clean Claims All claims must be submitted to HNFS, and not to VA or Medicare. A clean claim is a claim that complies with billing guidelines and requirements, has no defects or improprieties, and does not require special processing that would prevent timely payment. Clean claims will be processed within 30 days, and providers will receive their payments from HNFS. Claims for authorized services must be submitted within 120 days (VCP or 90 days (PCCC), regardless of other health insurance (OHI) claim processing times. Providers cannot bill the Veteran, VA or HNFS for missed or canceled appointments. 31

32 Electronic Claims Submission HNFS accepts electronic data interchange (EDI) claims for PCCC and VCP through Change Healthcare (formerly Emdeon). Visit to register. Payer Name: Health Net VA Patient-Centered Community Care Program Payer ID: Note: This payer name and ID applies to PCCC and VCP electronic claims. 32

33 Paper Claim Submission Paper claims can be mailed to: Health Net Federal Services, LLC Patient-Centered Community Care PO Box 9110 Virginia Beach, VA Health Net Federal Services, LLC Veterans Choice Program VACAA PO Box 2748 Virginia Beach, VA

34 Claim Status Providers can check the status of their claims at Once registered, you can search by the Veteran s information or claim number to obtain the status. Once logged in, select the Claim Status Inquiry under Claims Management in the left-hand menu. Choose Patient-Centered Community Care (for VCP and PCCC claims) in the payer field when submitting your claim status inquiry. Search for claims by patient identification number or claim number. If you have additional questions about a claim, contact us at for VCP claims or for PCCC claims. 34

35 EFT/ERA Health Net Federal Services offers and encourages electronic options for provider remits and claims payment. Electronic Remittance Advice (ERA): Complete the ERA registration process (through Availity or ChangeHealthcare) to stop receiving paper remittance advices. Electronic Funds Transfer (EFT): Complete and submit the HNFS Electronic Funds Transfer form, available at ww.hnfs.com/go/forms. Learn more at > Claims. 35

36 Important Contact Numbers Scheduling and Clinical Inquiries (Fargo VAMC) All Other Inquiries (Health Net Federal Services) Veterans Choice Call Center: Monday Friday, 9:00 a.m. 5:00 p.m. Eastern time, excluding certain holidays Monday Friday, 8:00 a.m. 4:30 p.m. Central time, excluding certain holidays Patient-Centered Community Care Call Center: Monday Friday, 6:00 a.m. 10:00 p.m. Eastern time, excluding certain holidays 36

37 Provider Resources Be sure to view the following online resources: Fargo Quick Reference Chart Fargo Claims Quick Reference Chart Visit 37

38 Thank you for serving our nation's Veterans!