Patient-Centered Community Care (PCCC) Benefit Program Requirements

Transcription

1 Health Net Federal Services Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014 HH1013x106 (09/14)

2 Contents Overview...4 Provider Tools...6 Requirements for Maintaining Accurate Information... 6 Online at 6 Important Provider Information...7 General Requirements... 7 Fraud, Waste and Abuse... 7 Privacy or Security Incidents... 7 Office and Appointment Access Standards... 7 Veteran ID Cards... 7 Covered Services... 7 Accreditation and Certification... 7 Credentialing... 8 Privileging... 8 Licensing... 8 Additional Requirements for Specific PCCC Services... 8 Audiology... 8 Laboratory Services... 8 Radiology Services... 9 Radiation Oncology... 9 Rehabilitation Medicine... 9 Labor, Delivery and OB/GYN Prenatal Care... 9 Surgery Cardiology Skilled Home Health Office-Based Diagnostic and Therapeutic Tests and Procedures Additional Requirements for Behavioral Health Providers Primary Care Requirements...11 Eligibility and Authorization Routine Diagnostic Services Appointments Medical Records and Documentation Prior Authorizations...13 General Process Authorizations Provider Notification Packets Appointment Scheduling Inpatient Authorization Process and Discharge Planning Emergency Health Care Services Page 2 of 24 Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014

3 Pharmacy and Durable Medical Equipment Home Infusion Claims Procedures...16 Provider Claims Process Claims for Labor an Delivery Services Claims for Pharmacy Costs Remittance Advice and Claims Payment Rejected Claims Denied Claims and Resubmissions Claims Questions and Status Updates Office Procedures...18 Return of Medical Documentation Content of Medical Documentation to be Transmitted to Health Net Additional Requirements for Medical Documentation Critical Findings Pathology Radiology Surgery Oncology Gastoenterology Skilled Home Health Inpatient Rehabilitation Blind/Low Vision Rehabilitation Mental Health Inpatient Mental Health Complaint and Grievance Process...21 Health Care Management and Administration Clinical Quality and Veteran Safety Measures Questions or Comments...22 Definitions...22 Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014 Page 3 of 24

4 Overview Participating providers in the Patient-Centered Community Care (PCCC) network agree to comply with all Health Net Federal Services, LLC, (Health Net) and Department of Veteran Affair s (VA) program rules, policies and procedures including, the Health Net Preferred Provider Network Provider Manual and this PCCC Benefit Program Requirements document. The current versions of both the PPN Provider Manual and the PCCC Benefit Program Requirements can be found on About PCCC: Patient-Centered Community Care (PCCC) is a new Department of Veterans Affairs (VA) program to provide eligible Veterans access to health care through a comprehensive network of community-based, non-va medical professionals who meet VA quality standards when VA must supplement care outside its own facilities. Such access is especially critical in instances when the local VA medical center lacks the needed specialists, has extended wait times or is located an extraordinary distance from the Veteran s home. The program will augment VA s ability to provide specialty inpatient and outpatient health care services to their enrolled Veterans. Health Net supports VA in providing care to Veterans in three PCCC regions. These three regions Regions 1, 2 and 4 encompass all or portions of 37 states, plus the District of Columbia, Puerto Rico and the U.S. Virgin Islands. Under the PCCC program, VA is responsible for determining eligibility and for authorizing care. Eligibility for VA health care is based on Veteran status, service-connected disabilities or exposures, income and other factors. Health Net provides VA a network of providers accredited in accordance with URAC Health Network Accreditation standards that meet all of the requirements of the PCCC program. Health Net uses systematic and integrated processes to coordinate care between VA and local community providers. Health Net is responsible for scheduling appointments, collecting and submitting required medical documentation from the rendering providers, and paying claims. Page 4 of 24 Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014

5 The Purpose of this Document: Health Net PCCC Benefit Program Requirements define provider roles and responsibilities including appointment access standards; patient safety and safety events; health care services and prescriptions; authorization and care coordination requirements; clinical training components; medical documentation and report coordination with VA; and claims processing, patient billing and reimbursement information. This document is a supplement to the Preferred Provider Network Provider Manual, available at Responsibility for Provision of Services: Providers and Health Net do not have an employer-employee, principal-agent, partnership, joint venture, or similar arrangement. Providers make all independent health care treatment decisions and are responsible for the costs, damages, claims, and liabilities that result from their own actions. Health Net does not endorse or control the clinical judgment or treatment recommendations made by providers and not all services are contracted or covered services. Key Requirements: The following items are key aspects specific to the PCCC program. Please review this document in its entirety for complete program details and requirements. Providers must meet all credentialing / accreditation / certification to participate in the PCCC program and be activated by Health Net as a PCCC network provider to provide services under this program. Providers must be currently credentialed by Health Net in accordance with the requirements of the Preferred Provider Network Provider Manual. Providers must be Medicare-certified and meet all Medicare Conditions of Participation and Conditions for Coverage without exception, where such conditions exist. Certain services have additional accreditation / certification / reporting requirements as provided in the section entitled Additional Requirements for Specific PCCC Services. Provider must continuously maintain all licenses, accreditations, certifications, and professional liability insurance and must report any lapse immediately to Health Net. Providers must make appointments available for Veterans within 14 days of a request by Health Net. Office wait times for appointments must not exceed 20 minutes beyond their scheduled appointment time. Health Net will issue all authorizations to the provider for PCCC services upon request from VA for a specific Veteran. A provider notification packet will be sent with each authorization after the appointment has been scheduled with the provider which outlines the specific clinical and other requirements for the authorized care. Providers will render only those services listed on an authorization provided by Health Net. Providers must contact Health Net for authorization to provide any services in addition to those listed on the authorization. The episode of care authorized by Health Net is not considered complete and payable until complete medical documentation is returned to Health Net. Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014 Page 5 of 24

6 Providers will be paid for all authorized services according to their PCCC Compensation Exhibit of their Participating Provider Agreement. Providers collect no copayments/cost-shares/ deductibles from Veterans. Providers must not bill the Veteran for any services, including no-show, missed or cancelled appointments. Medical documentation must be faxed to Health Net ( ) within 10 days of the appointment. All medical documentation must be returned before claims will be paid. Providers must report critical findings, adverse events, close calls, and unintentional unsafe acts to VA and Health Net. Hospitals must report admissions within 24 hours. During this time the provider is placed on a no referral status to ensure no additional cases are referred. This window is intended to allow sufficient time for the provider to complete authorized care or, if the care needs to be transitioned, to notify Health Net of a need to continue services with another provider. Note: Participating providers are responsible for updating their contact information with Health Net. Go to for the Provider Demographic Update Form. Health Net s website provides information about the PCCC benefits, processes, requirements, and operations, as well as access to business tools and forms. Visit > Department of Veterans Affairs Programs > I m a Provider for more program details and important updates. Providers of skilled home health and home infusion therapy must comply with the Service Contract Act. Provider Tools Requirements for Maintaining Accurate Information It is important network providers keep their demographic information up-to-date to ensure Health Net provides accurate information to Veterans and to speed accurate claims adjudication. Providers should use the Provider Demographic Update Form to submit any changes electronically. To ensure continuity of care, any provider leaving a network group must notify Health Net 90 days prior to his or her departure. Page 6 of 24 Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014

7 Important Provider Information General Administrative Requirements All services, facilities, and providers must be in compliance with all applicable federal and state regulatory requirements. Any provider on the Centers for Medicare and Medicaid Services (CMS) exclusionary list will be prohibited from network participation. See for further detail. Participating providers are required to immediately (within 24 hours) report in writing, but not later than three days, the loss of or other adverse impact to a provider s certification, credentialing, privileging, or licensing. Loss of facility accreditation status is required to be reported as soon as the facility is notified. The report is to contain information detailing the reasons for and circumstances related to the loss or adverse impact. Health Net will immediately cease to refer Veterans to the impacted provider until such time as the circumstances contributing to the event or loss have been resolved. Fraud, Waste and Abuse Refer to Health Net s Preferred Provider Network Provider Manual for definitions, details and reporting processes. The document is available online at > Department of Veterans Affairs Programs > I m a Provider. Privacy or Security Incidents Providers must report to Health Net any privacy or security breaches containing Veteran information within 24 hours. Contact Health Net at hngss_incidents@healthnet.com. Office and Appointment Access Standards Providers must comply with the Office and Appointment Access Standards of the Preferred Provider Network Provider Manual. However, providers must also comply with these specific PCCC Benefit Program Requirements: Specialty care appointments must be made within 14 calendar days. Preventive care appointments must be made within 14 calendar days. Office wait time for appointments must not exceed 20 minutes. Beneficiary Identification (ID) Card The PCCC program will not issue identification (ID) cards to Veterans for this program. It is suggested the provider verify the identity of the Veteran through a government-issued identification card (for example,driver s license, military card, or passport). The authorization received from Health Net is the provider s authorization to provide the specific services to a particular Veteran. Only eligible Veterans who have been authorized by VA will be referred for care by Health Net. Covered Services Covered services under the PCCC program are limited to the health care services set forth on the authorization received from Health Net. Any services that have not been authorized by Health Net and VA will not be paid for under the PCCC program. Accreditation and Certification Participating providers must meet all Medicare Conditions of Participation (CoP) and Conditions for Coverage (CfC), where such conditions exist subject to The Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014 Page 7 of 24

8 Centers for Medicare & Medicaid Services (CMS) modification, as required by the U.S. Department of Health and Human Services. These conditions may be met through CMS certification or accreditation by organizations deemed by CMS to meet or exceed the CMS Medicare standards set forth in the CoP/CfC. Credentialing Health Net and its subcontractors ensure that providers comply with the credentialing requirements of the Preferred Provider Network Provider Manual. The PCCC program has additional benefit program requirements that include Medicare credentialing, accreditations, certifications, and provider privileging. All participating providers must be credentialed in accordance with the requirements of CoP and CfC, where such conditions exist subject to CMS modification. In accordance with requirements outlined in the Office of the Inspector General s Compliance Program Guidance for Hospitals ( compliance-guidance/index.asp and USSC Sentencing Guidelines ( Guidelines/2011_Guidelines/index.cfm), all services, facilities and providers must have a compliance program in place that includes the seven elements of an effective compliance program. Privileging Every procedure, test or other aspect of clinical care must be performed by providers with demonstrated current competence, either though current unrestricted privileges to provide the care as required by Medicare CoP and CfC, or other measures of demonstrated competency. Participating providers are required to make available all evidence of current credentialing and competency upon written request by Health Net. Licensing All participating providers and clinicians are required to have a full, current and unrestricted license in the state where the service(s) are delivered. Additional Requirements for Specific PCCC Services Audiology Initial testing results relating to potential hearing aids needs must be submitted directly to VA within two business days. All hearing aids will be ordered by the VA through the its national hearing aid contract When hearing aids are issued, medical documentation for follow up appointments such a fittings and adjustments must be returned Laboratory Services Clinical laboratories must meet requirements of the Clinical Laboratory Improvement Amendments (CLIA 88) of the Public Health Services Act (Title 42 United States Code (U.S.C.) 263a), per HHS implementing regulations under Title 42, Code of Federal Regulations Part 493. Radiology Services Outpatient facilities providing advanced diagnostic imaging procedures are required to be accredited in accordance with Medicare Improvements for Patients and Providers Act (MIPPA 2008), currently applicable to all providers of computed tomography, magnetic resonance imaging (MRI), breast MRI, nuclear medicine, and positron emission tomography exams. American College of Radiology and the Intersocietal Accreditation Commission have been deemed by CMS to provide this accreditation. Facilities providing mammography are required to meet Food and Drug Administration requirements per the Mammography Quality Standards Reauthorization Act of 1998, as amended Page 8 of 24 Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014

9 by H.R Clinicians performing interventional radiology procedures are required to have both General Diagnostic American College of Radiology certification as well as specific current Boards in interventional radiology. All radiologic technologists are required to be certified by the American Registry of Radiologic Technologists (AART). Mammography technologists must have advanced ARRT certification in mammography. Radiation Oncology Radiation oncology practices are required to be accredited by the American College of Radiology or the American College of Radiation Oncology. Exceptions may be submitted to Health Net for written approval for National Cancer Institute-participating programs. Medical directors for radiation oncology practices are required to be board-certified in radiation oncology or therapeutic radiology by the American Board of Radiology, the American Osteopathic Board of Radiology, or the Royal College of Physicians and Surgeons of Canada. A full-time medical physicist is required to be part of each radiation oncology practice. These medical physicists are required to be certified by the American Board of Radiology in therapeutic radiological physics or radiological physics. Rehabilitation Medicine All speech language pathologists are required to have a full, current and unrestricted license in the state in which services are provided. In states without licensure requirements for speech pathologist (Colorado and South Dakota), American Speech-Language-Hearing Association certification may be substituted for licensure. Unless otherwise authorized by Health Net, providers of blind or low vision rehabilitation are required to be certified by the Academy for Certification of Vision Rehabilitation & Education Professionals. All rehabilitation services are required to conform to Medicare benefits policy rules for certification and re-certification of treatment plans and content of treatment plans. Labor, Delivery and OB/GYN Prenatal Care Participating providers must review the VA / DoD Clinical Practice Guidelines for Pregnancy Management found at 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 nonaccredited facility is authorized by referring the VA facility and approved in writing by Health Net. 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. Facilities performing cardiac surgery are required to report to the Society for Thoracic Surgery National Adult Cardiac Surgery Database, unless an exception is authorized by the referring VA facility and approved in writing by Health Net. Cardiology Facilities performing cardiac catheterizations and / or percutaneous coronary interventions Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014 Page 9 of 24

10 are required to participate in the National Cardiovascular Data Registry (NCDR) CathPCI Registry, unless otherwise authorized by the referring VA facility and approved in writing by Health Net. Facilities implanting cardioverter defibrillators (ICDs) are required to participate in the NCDR ICD Registry, unless otherwise authorized by the referring VA facility and approved in writing by Health Net. Skilled Home Health and Home Infusion Therapy Unless otherwise authorized by the referring VA facility and approved in writing by Health Net, skilled home health providers are required to perform better than the state average on at least 50 percent of CMS quality measures for home care. Health Net will monitor CMS reporting databases for compliance. Providers supplying skilled home health or home infusion therapy must comply with the requirements of the Service Contract Act, including wage and benefit requirements for applicable workers. The Department of Labor determines the levels of wages and benefits based on location of services. These can be found at Annually in September, participating providers must review the current and applicable wage determination to assure they remain compliant with it and the Service Contract Act. Office-Based Diagnostic and Therapeutic Tests and Procedures Diagnostic and therapeutic procedures performed in a setting other than an inpatient facility, hospital clinic or ambulatory surgery center are required to be performed in a safe manner by qualified physicians within their licensed scope of practice. Physicians are required to be appropriately trained and proficient in performing any such procedures. The same credentialing requirements are required for office-based procedures. Processes for using sedation during a procedure are required to conform to the requirements in Medicare CoP for medical centers or ambulatory surgical centers. Additional Requirements for Behavioral Health Providers Providers of evidence-based psychotherapies (EBPs) are required to have specialized training and experience in EBPs. This includes foundational instruction on the theoretical and applied components of the therapy and ongoing supervision or expert consultation on the implementation of the therapy. For example, a Veteran being referred for cognitive processing therapy is required to be seen by a provider who has specialized training and experience in that treatment modality. The following is a list of EBPs VA currently uses: cognitive processing therapy for post-traumatic stress disorder (PTSD) prolonged exposure therapy for PTSD cognitive behavioral therapy (CBT) for depression acceptance and commitment therapy for depression interpersonal psychotherapy for depression behavioral family therapy for serious mental illness multiple family group therapy for serious mental illness social skills training for serious mental illness integrated behavioral couples therapy for relationship distress Page 10 of 24 Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014

11 CBT for insomnia CBT for chronic pain motivational interviewing for motivation, engagement, and adherence motivational enhancement therapy for substance use disorders contingency management for substance use disorders behavioral couples therapy for substance use disorders CBT for substance use disorders Veterans with a history of military sexual trauma (MST), and being treated for a behavioral health problem related to MST, may receive care from a provider of the gender of their choice. For both inpatient and outpatient behavioral health care, participating providers are advised of Veterans Affairs / Department of Defense (VA / DoD) Clinical Practice Guidelines (CPGs) for the diagnosed behavioral health diagnosis found at These are baseline criteria and do not replace clinical judgment. Primary Care Requirements The following sections identify the key requirements that differ from the PCCC specialty providers, and are specific to primary care providers within the PCCC program. Primary care is defined as any care in scope of licensure, which can be performed in the provider s office, without conscious sedation. Primary care is directed toward health promotion and disease prevention and includes the management of acute and chronic medical conditions. Ancillary services such as labs, radiology and pathology that cannot be performed within the primary care provider s office setting must be referred to a network provider or VA facility (no new VA pre-authorization is required). Diagnostic and treatment such as MRI, CT, or any procedure that requires conscious sedation or to be performed outside the provider s office must be preauthorized by VA. If it is determined that these or other additional services are required, complete the Request for Additional Services and submit to Health Net. The form is available on Authorizations Covered services under the PCCC program are limited to those services listed in the authorization. Providers must contact Health Net for authorization to provide any services in addition to those listed on the authorization. Primary care services may be authorized for one fiscal year up to 24 visits. If additional visits are necessary, beyond what is indicated in the authorization, providers must complete the PCCC Request for Additional Services form found on Health Net website, Primary care authorizations are inclusive of initial visits; follow up visits; and acute primary care services. These include, but is not limited to: Routine diagnostic tests Routine diagnostic radiology Preventative services Primary care providers must have (24) hour on-call coverage. Routine Diagnostic Testing Routine diagnostic testing is defined as: Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014 Page 11 of 24

12 Complete Blood Count Prothrombin Time/ International Normalized Ration Standard 12-lead electrocardiogram Fecal Occult Blood Test Urinalysis Routine chemistry tests Partial Thromboplastic Time Routine diagnostic laboratory test must be completed within five business days of the initial appointment. Routine Diagnostic Radiology Routine diagnostic testing includes: Chest x-rays (Antero Posterior/Lateral) Extremity x-rays Abdomen Spine Bones and joints Routine diagnostic testing excludes MRI, CT or any procedure that requires conscious sedation. Routine diagnostic radiology test must be complete within five business days of the initial appointment. Routine Diagnostic Services If diagnostic testing and / or radiology and preventative services can not be preformed within the primary care practice, please notify Health Net immediately. Appointments Health Net is responsible for coordinating the Veteran s initial appointment with a primary care provider s office. Providers are strongly encouraged to contact Veterans with a courtesy appointment reminder. Notify Health Net of any no show, missed, cancelled or rescheduled appointments. Contact Health Net at or fax Medical Records and Documentation Providers must return medical documentation of the initial visit within 10 days. Medical documentation for all subsequent visits must be maintained within the office. Medical records shall should always be maintained up-to-date and comply with the medical community standards. The record must include required veteran demographics and clinical information as needed to support the care provided provide care, treatment, and services performed. Note: A single comprehensive medical primary care record must be immediately accessible to VA. Complete medical records must be submitted to Health Net at the end of the authorization, or after visit 24. Claims will not be paid until medical documentation is returned. Prior Authorization General Process Health Net provides coordination and oversight to support orders of authorized care by VA. Providers will receive the VA Authorization Form, which includes all health care services authorized and contains the following information: VA authorization Veteran s name and contact information purpose of authorization and relevant diagnoses and other medical documentation type and amount of service requested (for example, number of visits / procedures / treatments) Page 12 of 24 Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014

13 preferred appointment date, if specified by the Veteran date by which return of information is needed preferred gender of provider VA point of contact for emergency situations or additional information / authorization needs where to submit required medical documentation station and authorization number Authorizations All services will be authorized by VA and the care request will be submitted to Health Net. Health Net will coordinate with the provider and Veteran to obtain an acceptable appointment date and time while considering appointment wait time and Veteran commute times to ensure compliance with VA requirements. Health Net will prepare a provider notification packet containing specific requirements for the services covered in the authorization. All services must be performed by PCCC participating providers and facilities. Requests for additional services not contained in the authorization(s) must be submitted to Health Net. Refer to the provider notification packet for more information and instructions. Health Net will work directly with the VA to obtain new authorizations for the requested services. Note: Authorizations alone do not guarantee payment. The provision of health care services is to be limited to that set forth in the authorization form. All claims must correlate with authorizations and returned medical documentation. Only the authorized practitioner may render and bill for services. For questions regarding an authorization, contact Health Net s PCCC Call Center at After an appointment is scheduled, Health Net will send the provider notification packets to each scheduled facility or provider. These provider notification packets provide casespecific clinical requirements, VA standards and guidelines of the PCCC authorized care. Packets may include, but are not limited to: VA s authorization, and any clinical notes or medical documentation provided with the authorization. The Veteran s name and demographics, diagnosis, specific services authorized, date and time of appointment already arranged, and authorization begin and end dates. Comprehensive information about provider options for completing and returning medical documentation. Instructions for communicating kept and no-show appointments. Reminder instructions that the Veteran should be seen within 20 minutes of the scheduled appointment time. Instructions and due dates for returning the required medical documentation as a pre-condition of payment and a reminder that claims for services rendered will not be considered until the return of accurate medical documentation is complete. Service-specific checklist(s). For example, customized to correspond to the services authorized by VA. Instructions for ongoing treatment and/or extended service requests for VA approval. Instructions for reporting critical findings. Instructions for notifying the Veteran of test results. Instructions for submitting claims. Provider Notification Packets Information on how to handle emergent situations. Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014 Page 13 of 24

14 Information on the VA National Formulary. Instructions for reporting suicide risk. Information about the Suicide Prevention Safety Plan found at, VA_Safety_planning_manual.pdf, including the Veterans Crisis Line telephone number. Appointment Scheduling Health Net is responsible for coordinating all appointments with a provider s office or facility, however, providers are strongly encouraged to contact Veterans with a courtesy appointment reminder. Providers must comply with the following access care standards for care: Urgent care appointments must be within 48 hours. Office wait time for appointments must not exceed 20 minutes. Providers must report all no-show, missed or cancelled appointments to Health Net at or by fax at Note: Providers must not bill Veterans, or request reimbursement from VA or Health Net for no-show, missed or cancelled appointments. Be aware, Veterans will not provide an ID card for the PCCC program. All information needed by the provider or the facility will be included on the authorization form and provider notification packet. Authorizations containing the notation of urgent require the Veteran be scheduled for care within 48 hours. Return of medical documentation is the same as for routine care, unless the authorization also specifies urgent with oral report or urgent with written report. Urgent care is defined as care considered essential to evaluate and stabilize conditions. Urgent care is care that if not provided will likely result in unacceptable morbidity/pain when there is a significant delay in evaluation or treatment. Urgent care is not the same as a medical emergency. Urgent medical care does not threaten life, limb or vision, but needs attention to prevent it from becoming a serious risk to health. Furthermore: Urgent with oral report must be provided to point of contact as designated on the authorization within 48 hours of finding. The following will be written on the authorization: o Urgent scheduling. o 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: o Urgent scheduling. o Written report per contract performance standards. No oral report required. Inpatient Authorization Process and Discharge Planning Providers are responsible for notifying Health Net of Veteran inpatient admissions and discharges. Health Net will coordinate and communicate admissions and discharges from an inpatient facility whenever inpatient health care is ordered. Inpatient facilities are responsible for providing status updates directly to the authorizing VA and Health Net. Provider notification packets will instruct inpatient facilities how to handle postinpatient coordination. For discharges, Health Net coordinates with the authorizing VA facility, as necessary, to facilitate the transfer of the Veteran back to a VA facility and / or for other services, such as home health services. To notify Health Net of an inpatient admission or discharge call or fax a notification to Note: Participating providers are required to provide immediate (within 24 hours) notification to Health Net of discharges against medical advice; Page 14 of 24 Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014

15 notification is to be by fax or telephone, using the fax / telephone numbers provided on the authorization. Emergency Health Care Services Veterans seeking emergency care may self-present to an emergency facility for serious conditions. If the Veteran s condition is life threatening, the facility must contact VA at VETS (8387) within 24 hours. If 24 hour notification is not made, the facility should contact the Veteran s assigned Veterans Affairs Medical Center (VAMC) within 72 hours. The VAMC can be identified by the Veteran or a family member. If unknown, search the VA Directory (www. va.gov/directory) and notify the VAMC in closest proximity to the facility. As an alternative to contacting the VA or VAMC directly, the emergency facility may notify Health Net by calling or faxing at within 72 hours of the Veteran s self-presenting. Health Net will notify VA with the required information. All notifications must include: Veteran s full name last four digits of Social Security number the condition for which the Veteran is being seen the mode of transportation by which the Veteran arrived, and if by ambulance, a copy of the trip report, if possible If a Veteran s condition is non life threatening, the network facility must contact Health Net for authorization before admitting or treating the Veteran. Notify Health Net by one of the following methods, within HIPPA guidelines: call Note: If the emergency facility does not notify either VA or Health Net within 72 hours, the facility must submit the claim directly to VA within 90 days of the emergency encounter for the claim to be considered. Contact VA at VETS (8387) for more information. Emergency Health Care Services During an Authorized Appointment When a provider determines the Veteran requires emergency health care services during an authorized appointment, he or she will seek immediate treatment at a facility or via local emergency medical services. The facility will follow the above guidelines for notifying VA or Health Net. If the treating provider or facility is able to stabilize the Veteran and still requires additional medical services in a facility, the treating provider or facility will notify VA or Health Net (see above for contact information) prior to transport or admission. Pharmacy and Durable Medical Equipment VA is primarily responsible for supplying the Veteran with all prescribed nonurgent/emergent medications, medical / surgical supplies and nutritional products. Participating providers must prescribe in accordance with the VA National Formulary ( nationalformulary.asp), which includes provisions for requesting non-formulary drugs. Prescriptions must be transmitted by fax to VA for processing. Incomplete prescriptions will not be processed and will be returned to the prescribing provider. If there is an urgent need for a Veteran to start a medication and it is not possible for the Veteran to obtain the medication from a VA pharmacy, a provider may prescribe a prescription for up to a 14-day supply, fax admitting sheet to (804) Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014 Page 15 of 24

16 without refills. The Veteran should be informed the prescription can be dispensed by a network pharmacy, without charge to the Veteran, or from a non-contracted source and the VA will reimburse the Veteran directly. If the medication is needed on an ongoing basis, the prescribing provider must send the VA pharmacy or Consolidated Mail Outpatient Pharmacy the following information: provider s name address personal DEA number (not a generic facility number) telephone number fax number National Provider Identifier Health Net will coordinate requests for durable medical equipment (DME) with the ordering VA facility. Most DME products and medical supplies will be provided by VA. Requests for exceptions to this requirement may be considered under special circumstances. Exceptions to this requirement, such as DME for surgeries, require provider coordination with the ordering VA facility for approval in advance. Home Infusion Referral for home infusion services will be communicated directly by a Veteran Affairs Medical Center Community (VAMC) referral nurse. Referral will be by phone or fax to the home infusion provider. This process constitutes the referral for care and allows the provider to deliver care and ensure accuracy and timing of orders. The authorization is generated by VA and issued to Health Net. Health Net forwards an authorization by fax to the home infusion provider for submittal with their claim. Medical documentation for home infusion includes the nursing notes and treatment plan. The Home Infusion Therapy provider completes the PCCC Home Infusion Form and it to the VAMC referral nurse. Health Net will send the , with sections 4(a), 4(b) and 4(c) in the Authorization Remarks, to the provider. Claims Procedures Provider Claims Process Health Net s process for receiving and paying providers is designed to ensure the medical claims received by VA are complete and accurate. A clean claim is a claim that complies with billing guidelines and requirements, has no defects or improprieties, includes substantiating medical documentation as defined by the provider notification packet and does not require special processing that would prevent timely payment. Clean claims will be processed within 30 days. Claims aged more than 30 days will be paid interest in addition to the payable amount. Before preparing a claim, remember participating providers must not bill Veterans, VA or Health Net for: no-show, missed or cancelled appointments rendered care not included on the authorization form Note: Authorizations alone do not guarantee payment. The provision of health care services is to be limited to that set forth in the authorization form. All claims must correlate with the care specified on the authorization. Only the authorized practitioner may render and bill for services. Participating providers are encouraged to submit health care claims via HIPAAcompliant electronic data interchange Page 16 of 24 Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014

17 transaction sets through Health Net s designated clearinghouse, Emdeon. Visit to register. If already registered, providers may submit claims using the following information. Payer Name: Health Net VA Patient Centered Community Care Program Payer ID: Note: The provider notification packet will contain detailed information on how to submit a claim. Claims for Labor and Delivery Services For labor and delivery services, the provider must submit separate inpatient claims for the mother and newborn. Claims for Pharmacy Costs The provider must include the following with their claim: an 11-digit National Drug Code (NDC) number the corresponding Current Procedural Terminology and Health Care Procedure Coding System codes the quantity (package or unit) for each NDC number Remittance Advice and Claims Payment The remittance advice includes notification to the provider that there is no Veteran liability and the provider must not bill the Veteran for any amount not allowed for payment. The remittance advice also includes instructions for the provider on filing an allowable charge review or dispute of payment, should the provider not agree with the provider claims payment. Allowable Charge Reviews An allowable charge review is a written notice from the provider to Health Net that: Challenges, appeals or requests reconsideration of a claim (including a bundled group of similar claims) which has been denied or adjusted. Challenges a request for reimbursement for an overpayment of a claim. Seeks resolution of a billing determination or other contractual dispute. Health Net accepts allowable charge reviews from providers if they are submitted within 90 days of receipt of the decision, for example, health remittance advice indicating a claim was denied or adjusted. The allowable charge review must include: provider s name provider s ID number providers contact information including telephone number, and number assigned to the original claim Additionally, the allowable charge review request must include a clear identification of the item, date of service and a clear explanation as to why the provider believes the payment amount, request for additional information, request for reimbursement of an overpayment, or other action is incorrect. Claims Questions and Status Updates For questions about a claim or to inquire about a status update, contact Health Net at Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014 Page 17 of 24

18 Office Procedures Return of Medical Documentation Health Net must deliver medical documentation to VA within 14 days. To fulfill our requirement for a thorough review and deliver in this timeframe, providers are requested to deliver medical documentation to Health Net within 10 days of the appointment. If additional appointments are conducted, medical documentation must be submitted to Health Net within 14 calendar days upon completion of the episode of care. Medical documentation recording an authorized episode of inpatient care must be submitted to Health Net within 30 days after discharge. Using the cover sheet provided by Health Net, fax the complete documentation to Tips for returning medical documentation: Deliver medical documentation or a no show notification immediately following the first appointment. Use the provided checklist to ensure all elements of the medical documentation are complete. Return medical documentation to Health Net, even if VA has also requested a copy. The cover sheet provided includes a bar code which is specific to a single episode of care for an individual Veteran. Using the cover sheet expedites processing of medical documentation and delivery to the Veteran s file. Note: Do not combine documentation for multiple authorizations when using the provided cover sheet, as this will delay processing of the documents. Do not submit claims with medical documentation. Please refrain from copying the cover sheet, as this may degrade the copy quality and delay processing of documents. The Veteran must be notified of test results within 14 calendar days of the authorized episode of care. Participating providers must not bill Health Net until they have submitted medical documentation for both inpatient and outpatient care to Health Net. Health Net will consider exceptions for highly unusual circumstances. This process will be audited on a regular basis. Content of Medical Documentation to be Transmitted to Health Net At the completion of the authorized episode of care, participating providers must submit medical documentation to Health Net that includes: Veteran identification; to include name, sex, last four digits of Social Security number, and date of birth initial assessment and reassessments appropriate for clinical condition, including, but not limited to: o relevant medical history and physical examination, including inventory of body systems o vital signs o pain assessment (using 0 10 scale) initial and final diagnoses / diagnostic impressions therapeutic goals care plans and rationale, including rationale for diagnostic and therapeutic procedures diagnostic and therapeutic procedures, treatments, and tests and their results specific care / services provided, including medication use and medication allergies or sensitivities Page 18 of 24 Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014

19 Veteran s response to care / services safety measures required to protect the Veteran from injury Veteran s functional limitations and activity restrictions related to the care or services provided list of all medications and recommended / ordered durable medical equipment / prosthetics instructions given to Veteran recommended follow-up Additional Requirements for Medical Documentation Critical Findings Critical findings on outpatient imaging or laboratory testing, or during evaluation and treatment, must be transmitted to VA and Health Net by phone within 24 hours upon completion of the test / evaluation / treatment. Contact with VA and Health Net (for example, name of person contacted, date and time of contact) must be documented in the impression section of the diagnostic imaging report, or elsewhere in the medical documentation for non-imaging-related critical findings. Any initial findings must be followed up by submission of complete medical documentation within 10 days. To report a critical finding to Health Net, contact Health Net at Newly identified suicide risk in a Veteran not referred for inpatient behavioral health treatment is considered a critical finding. A new diagnosis of cancer must be reported to VA and Health Net within 48 hours of diagnosis. Immediate notification (within 24 hours) to the authorizing VA facility and Health Net is necessary if the provider determines the Veteran requires: urgent follow up after completion of authorized episode of care urgent additional care during the authorized episode of care Note: Refer to the provider notification packet for contact information to the authorizing VA Medical Center. Pathology Participating providers are not normally required to return pathology slides to the authorizing VA facility. However, providers must ensure pathology slides for biopsies performed under the PCCC program are made available to VA within five (5) business days of Health Net s receipt of a VA request for the slides. Radiology Films and reports must each be identified by Veteran name, date of birth, last four digits of the Social Security number and date of procedure. The name of the procedure, description and interpretation results of the exam must also be listed on each report. Interpreted radiology results must be communicated as oral reports submitted to VA and Health Net within 48 hours of the Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014 Page 19 of 24

20 examination, and the written report returned within 14 calendar days. Participating providers are required to make films available upon request from the authorizing VA facility within five business days of Health Net s receipt of a VA request. Surgery Upon the Veteran s discharge after an authorized surgical procedure, participating providers are required to complete and return to Health Net the VA Purchased Surgical Care Patient Outcome form, along with the other required clinical feedback. Oncology Medical documentation submitted to Health Net for Veterans referred for medical / radiation oncology services must include information stated in the Additional Medical Documentation for Medical / Radiation Oncology Form. All newly diagnosed cancer / carcinomas identified during test or treatment must be reported to VA and Health Net within 48 hours, as critical findings. Gastroenterology Medical documentation submitted to Health Net for Veterans referred for gastroenterology procedures (for example, colonoscopy, sigmoidoscopy, esophagogastroduodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography must include information stated in the Additional Medical Documentation for Gastroenterology Procedures Form. Skilled Home Health The initial plan of care must be submitted to VA and Health Net within three business days of authorization. Discharge summary must be submitted within five days of completion of authorized episode of care. Inpatient Rehabilitation Functional status and functional status change from onset of treatment through discharge documented using CMS Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) must be documented and reported to VA and Health Net. The IRF-PAI example can be found at: Forms/Downloads/CMS10036.pdf. Blind / Low Vision Rehabilitation The VA Low Vision Visual Functioning (VA LV VFQ 20) Survey is to be administered at baseline, and again within two to four weeks post-discharge or end of treatment. Since many respondents would be visually impaired or blind, a mail-out version of this survey should be used only when it is certain the respondent has appropriate assistance, as described in the instructions contained within the Instructions for the VA Low Vision Visual Functioning (VA LV VFQ 20) Survey. Behavioral Health The following information should be provided in the medical documentation and does not require Veteran authorization for disclosure: medication prescription and monitoring (as appropriate) counseling session start and stop times modalities and frequencies of treatment results of clinical tests and any summary of diagnosis functional status treatment plans symptoms prognosis or progress Page 20 of 24 Patient-Centered Community Care (PCCC) Benefit Program Requirements October 2014