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. 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, 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. 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 PCCC Program Requirements The following slides will provide a brief overview of the PCCC program and highlight the following IMPORTANT elements: • • • • • 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. 7 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 8 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.. 9 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. 10 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. 11 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 12 Process Flow for Return and Transmission of Medical Documentation 13 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. 14 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: • • • • • • 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. 15 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. 16 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. 17 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. 18 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. 19 Process Flow for Home Infusion 20 PCCC Home Infusion Form VA PCCC Home Infusion Order Instructions 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 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. 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. 22 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 23 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. 24 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: • • • • • 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. 25 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. 26 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. 27 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 28 Thank You For Your Time!