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. 2 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. 3 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. 4 General Administrative Requirements • • • • 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. 5 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. 6 Primary Care Requirements The following slides will provide a brief overview of the PCCC program and highlight the following IMPORTANT elements: • • • • • • 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. 7 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. 8 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. 9 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. 10 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 11 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. 12 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. 13 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. 14 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. 15 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 16 Process Flow for Return and Transmission of Medical Documentation 17 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. 18 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. 19 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: • • • • • • requested VA pharmacy (location and station numbers) provider name tile Individual DEA# NPI# Social Security Number • • • • • • • 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. 20 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. 21 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. 22 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. 23 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 24 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. 25 Thank You For Your Time!