VA Patient-Centered Community Care
Provider Orientation Webinar
Introduction
The Patient Centered Community Care (PCCC)
program provides eligible Veterans access to
care through a comprehensive network of
community-based providers when the
Department of Veterans Affairs (VA) cannot
provide the care in their own facilities.
The program will augment VA’s ability to
provide specialty inpatient and outpatient
health care services to their enrolled Veterans.
VA awarded Health Net Federal Services, LLC
(Health Net) PCCC contracts in September,
2013.
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Health Net: Proud to support VA in PCCC 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.
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Provider Participation
• You recently entered into a Provider Participating Agreement
with Health Net, MHN, or MulitPlan to render care under this
new contract.
• Participating providers in the Patient-Centered Community
Care (PCCC) network agree to comply with all Health Net and
Department of Veteran Affairs (VA) program rules, policies
and procedures, including the PPN Provider Manual and the
PCCC Benefit Program Requirements, which is available on
the Health Net website, www.hnfs.com, by selecting “I’m
a Provider” under the Department of Veteran Affairs
Programs.
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General Administrative Requirements
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All services, facilities, and providers must be in compliance with all applicable
federal and state regulatory requirements.
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 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.
You are required to immediately (within 24 hours) report to Health Net in writing,
but not later than three days, the loss of or other adverse impact to a provider’s
certification, credentialing, privileging, or licensing.
The PCCC Program does not issue an identification card to Veterans for this
program. The authorization is proof the Veteran is eligible for care under the PCCC
program.
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General Administrative Requirements
• Covered services under the PCCC program are limited to the
health care services set forth on the authorization received from
Health Net.
• Under PCCC, any services that have not been authorized will not
be paid.
• You are required to see Veterans within 20 minutes of scheduled
appointment.
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PCCC Program Requirements
The following slides will provide a brief overview of the PCCC
program and highlight the following IMPORTANT elements:
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Eligibility and Authorizations
Appointments
Medical Documentation
Provider Information Packet
Claims Procedures
Additional information can be found in the PCCC Benefits Program
Requirements, which is available on the Health Net website,
www.hnfs.com, by selecting “I’m a Provider” under the Department
of Veteran Affairs Programs.
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Eligibility and Authorization
• VA is responsible for determining eligibility and authorizing care.
Eligibility for VA health care is based on Veteran statuses,
service-connected disabilities or exposures, income and other
factors.
• 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.
• 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
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What You Need to Know About the Appointment
• You will receive a call from Health Net to schedule initial
Veteran appointments.
• Veterans will not have an ID card.
• Notify Health Net of no-show, missed, cancelled or
rescheduled appointments. Contact Health Net at 1-800979-9620..
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Provider Notification Packet
Health Net will send you a notification packet after an
appointment is scheduled. The packet will include VA and
Veteran documentation, instructions for returning medical
documentation, and other key information regarding authorized
services.
• Please see the “Provider Notification Packets” section of the
Benefit Program Requirements for additional information.
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Medical Documentation to be Transmitted to Health Net
At the completion of the authorized episode of care, you must
submit medical documentation, as outlined in the Provider
Notification Packet, within 10 days of the appointment. Fax
medical documentation to 855-300-1705.
Note:
• Use the cover sheet provided.
• Do not combine documentation for multiple authorizations.
• Do not submit claims with medical documentation.
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Medical Documentation
Medical documentation may include, but is not limited to:
• Relevant medical history and physical examination
• Initial and final diagnoses / diagnostic impressions
• Specific care / services provided, including medication use
and medication allergies or sensitivities
• Veteran’s response to care / services
• List of all medications and recommended/ ordered durable
medical equipment /prosthetics
• Instructions given to Veteran
• Recommended follow-up
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Process Flow for Return and Transmission of Medical Documentation
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Pharmacy and Durable Medical Equipment (DME)
• You must prescribe all medications in accordance with the VA
National Formulary, which includes provisions for requesting
non-formulary drugs.
• (http://www.pbm.va.gov/PBM/nationalformulary.asp),
• Prescriptions must be transmitted by fax to VA for processing.
• IMPORTANT: 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, without refills.
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Pharmacy and Durable Medical Equipment (DME)
If the medication is needed on an ongoing basis, the prescribing
provider must register with VA pharmacy or Consolidated Mail
Outpatient Pharmacy. The follow information is required for
registration:
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requested VA pharmacy (location and
station numbers)
provider name
tile
Individual DEA#
NPI#
Social Security Number
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date of birth
gender
address
telephone #
fax #
point of contact (POC)
E-mail address
Instructions will be provided with the authorization.
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Pharmacy and Durable Medical Equipment (DME)
• Most DME products and medical supplies will be provided by
VA.
• VA will order/procure all DME that is not bundled under other
health care services.
• Exceptions to this requirement, such as DME for surgeries,
require provider coordination with the ordering VA facility for
approval in advance.
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Audiology
• Initial testing results relating to potential hearing aids needs
must be submitted directly to VA within two business days.
• VA will order all hearing aids through the VA’s national hearing
aid contract.
• When hearing aids are issued, medical documentation for
follow up appointments such a fittings and adjustments must
be returned within 10 days.
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Home Infusion
• Referral for home infusion services will be communicated
directly by a Veteran Affairs Medical Center Community
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 the 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.
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Home Infusion
• Home Infusion Therapy Provider completes the PCCC Home
Infusion Form and faxes form to the Veteran Affairs Medical
Center Community Referral RN.
• Referral RN sends form to non-VA Care Coordinator/Fee Basis
Coordinator.
• Non-VA Care Coordinator/Fee Basis Coordinator adds Sections
4(a), 4(b) and 4(c) in the Authorization Remarks section of
Form 10-7079.
• Non-VA Care Coordinator or Fee Basis Coordinator sends the
completed Form 10-7079 to Health Net .
• Health Net sends Form 10-7079 to Provider.
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Process Flow for Home Infusion
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PCCC Home Infusion Form
VA PCCC Home Infusion Order
Instructions
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VA Case Manager selects a Home infusion Therapy (HIT) Provider calls in/faxes orders to HIT Provider.
HIT Provider completes form and returns to VA Case Manager.
Upon receipt of completed form from HIT Provider, VA Case Manager sends form to non-VA Care Coordinator/Fee Basis Coordinator.
Non-VA Care Coordinator/Fee Basis Coordinator adds Sections 4(a), 4(b) and 4(c) in the Authorization Remarks section of Form 10-7079.
Non-VA Care Coordinator or Fee Basis Coordinator sends the completed Form 10-7079 to Health Net.
Section 1: Dates
Date of
Referral
Desired
Start Date/Time
Section 2: Patient Information
Last
Name
Date of
Birth
Street
Address
First
Name
Middle
Initial
SSN
Gender
City
Primary
Phone
State
Secondary
Phone
ZIP
M F
Section 3: VA Information
VA Facility
Name
VA Case
Manager
Fax Number
(required)
Phone Number
(required)
Section 4: Order Information
Provider Use Only
Section 4(b):
Section 4(c):
HIT Provider Enter
HIT Provider Enter
Codes
Units
Section 4(a):
VA Case Manager Confirms Orders
Primary
ICD-9:
HCPCS
Drug:
HCPCS
Per Diem:
Diagnosis
Drug/ Dose/
Frequency
Drug
Duration
Nursing frequency
Labs ordered
through Quest
Contact
information for
Other Providers in
home
(Example: Vancomycin 1gm every 12 hours)
(Example: 7 days / 14 doses)
Days:
CPT
Nursing: 99601/99602
(Example: 2x per week)
HCPCS
Units:
HCPCS
Units:
Units
Units:
(example: Peak/Trough Q week)
Phone:
(Example: PT/OT/HHA/Wound Care arranged through VAMC)
Fax:
Other
Codes:
Other
Section 5: Provider Information (Required)
Provider
Name
Fax
Number
City/State
Phone Number
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Clean Claims
• A “clean claim” is a claim that complies with billing guidelines
and requirements, has no defects or improprieties, including:
• Substantiating medical documentation as defined by the provider
notification packet and does not require special processing that would
prevent timely payment.
For additional information, see the “Claims Procedures” section of the
Benefit Program Requirements for additional information.
• Clean claims will be processed within 30 days.
• All medical documentation must be returned before claims will
be paid.
• Veterans have no cost-shares, deductibles, or out-of-pocket
expenses under the PCCC program.
• Providers will receive their payments under the PCCC program
from Health Net.
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Electronic Claims Submission
Health Net accepts Electronic Date Interchange (EDI) claims
submissions through Emdeon.
Visit http://www.emdeon.com/physicians/ to register.
Payer Name:
Health Net – VA Patient Centered Community Care Program
Pay ID: 68021
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Paper Claim Submission
Paper claims can be mailed to:
Health Net Patient Centered Community Care
PO Box 9110
Virginia Beach, VA 23452
For questions about a claim or to inquire about a status update,
contact Health Net at 1-800-979-9620.
Note: Electronic funds transfer will be established soon.
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Behavioral Health Providers
Please visit http://www.healthquality.va.gov/ and review
VA/DOD Clinical Practice Guidelines (CPGs). Here you will find
important topics such as:
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Assessment and Manage of Patients at Risk for Suicide
Bipolar Disorder in Adults (BD)
Major Depressive Disorder (MDD)
Post Traumatic Stress Disorder (PTSD)
Substance Use Disorder (SUD)
These guidelines provide a baseline criteria to follow but do
not replace clinical judgment.
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Labor, Delivery, and OB/GYN Prenatal Care
• Please visit http://www.healthquality.va.gov/up/ and review
VA/DOD Clinical Practice Guidelines (CPGs). Here you will find
specific guidelines for Pregnancy Management.
• These guidelines provide a baseline criteria to follow but do
not replace clinical judgment.
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In conclusion
Many of your questions can be answered in the Benefits
Program Requirements on the Health Net web page, and we
encourage you to read all requirements prior to providing
patient care. If you need additional assistance, and wish to speak
with someone, please contact at us at 1-800-979-9620.
Health Net thanks you for providing quality care for America’s
Veterans.
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Provider Resources
Please visit the Provider Portal on our website for the latest news
and updates on the program. Visit www.hnfs.com > Department
of Veteran Affairs Programs > I’m a Provider
Be sure to view the following resources:
• PCCC Benefit Program Requirements and Errata Sheet
• Provider Quick Reference Chart
• Provider Newsletter
• Program News
• Program FAQs
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Thank You For Your Time!