Transcript Payer Name: Health Net – VA Patient Centered Community Care

VA Patient-Centered Community Care
Primary 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 primary care and 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 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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Primary Care 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
Requirements for Primary Care
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
primary 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 appointments with a
provider’s office. 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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Requirements for Primary Care
• Primary care services may be authorized for one fiscal year up
to 24 visits.
• If additional visits are necessary, providers must complete the PCCC
Request for Additional Services found on Health Net website,
www.hnfs.com, by selecting “I’m a provider” under the Department of
Veteran Affairs Programs.
• Primary care authorizations are inclusive of initial visits; follow
up visits; and acute primary care services. This includes, but is
not limited to:
• Routine diagnostic tests
• Routine diagnostic radiology
• Preventative services
• Primary care providers must have (24) hour on-call coverage.
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Primary Care (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 in five
business days of the initial appointment.
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Primary Care (Routine Diagnostic Radiology)
Routine Diagnostic Testing
Includes:
• Chest x-rays (Antero
Posterior/Lateral)
• Extremity
• Abdomen
• Spine
• Bones and joints
Routine Diagnostic Testing
Excludes:
• MRI
• CT
• Procedure that requires
conscious sedation
Routine diagnostic radiology test must be complete in five
business days of the initial appointment
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Routine Diagnostic Services
Health Net expects diagnostic testing and / or radiology and
preventative services to be performed within the primary care
practice. If these services are not available within the practice
please notify Health Net immediately.
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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 or fax 804-622-3559.
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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
At the completion of the initial visit, you must submit medical
documentation within 10 days after the visit.
Notes for all subsequent visits must be faxed to Health Net.
Return medical documentation and notes with the fax cover
sheet included in the Provider Notification Packet. Fax medical
documentation to 855-300-1705.
Important: Claims will not be paid until medical documentation
is returned.
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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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Medical Records
Medical records shall be maintained up-to-date and comply with
the medical community standards. The record must include
required demographic and clinical information as needed to
provide care, treatment, and services performed.
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 the 24th visit.
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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.
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.
Note: Incomplete prescriptions will not be processed and will be returned to
the prescribing provider.
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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 the 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
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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 in
the Provider Notification Packet.
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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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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.
Note: Medical Documentation must be returned within 10 days.
Clean claims will be processed within 30 days and providers will receive their
payments under the PCCC program from Health Net. Veterans have no costshares, deductibles, or out-of-pocket expenses under the PCCC program.
For additional information, see the “Claims Procedures” section of the Benefit
Program Requirements for additional information.
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Claims Submission
• Electronic claims submission is available through Emdeon. If you are
already registered, you may submit claims using the following information
• Payer Name: Health Net – VA Patient Centered Community Care
Program
• Payer ID: 68021
• Electronic Funds Transfer (EDI) will be available soon.
• 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.
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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
• Primary Care Quick Reference Chart
• Provider Newsletter
• Program News
• Program FAQs
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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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Thank You For Your Time!