Transcription

VA Community Care NetworkCONTENTSVA CCNProvider Manual

VA CommunityCare NetworkContents . 1Overview . 4Important Note about This Manual . 4What Is VA CCN? . 5Network Resources . 5UnitedHealthcare . 5United Behavioral Health . 6OptumHealth Care Solutions, LLC . 6Logistics Health, Inc. . 7CVS Caremark Pharmacy . 7UnitedHealthcare Vision . 7Provider Resources. 7Online . 7VA Community Care Provider Portal and Website . 7Optum VA Community Care Network Provider Portal. 7Support by Phone . 8Covered Services . 8Health Care Services. 8Request for Services . 9Durable Medical Equipment, Medical Devices, Orthotic and Prosthetic Items . 10Assisted Reproductive Technologies (ART) In Vitro Fertilization (IVF) . 11Transplants . 12Urgent Care . 13Pharmacy . 14VA CCN Complementary and Integrative Healthcare Services (CIHS) . 17VA CCN Health Care Service Exceptions . 17Excluded VA CCN Health Care Services . 17Credentialing . 17Professional Credentialing, Licensing and Accreditation . 18Provider Responsibilities . 19Updating Demographic Information. 19Non-Discrimination . 21Veteran Appointments . 21Provider Satisfaction Surveys . 21Dental Provider Requirements . 21Out-of-Network Providers . 21PCA-1-21-02306-Optum-QRG 062320212 of 55Users are responsible for ensuring they work from the latest approved version. This document was last modified 07/01/2021 2021 United HealthCare Services, Inc. All Rights Reserved.v1.9

VA CommunityCare NetworkFraud, Waste and Abuse Reporting . 22Eligibility and Enrollment . 22Confirming Eligibility . 22Primary Care Provider (PCP) Designation . 22Referrals . 23Referral for Emergent Medical Services. 24Health Care Management . 25Critical Findings . 25Clinical Quality Management . 25High-Performing Providers and Centers of Excellence . 26Medical Documentation. 33Access to Records. 33Submitting Medical Documentation . 33Reimbursement and Claims Process . 34Reimbursement . 34Claims Processing and Filing . 35Timely Filing . 36Claims Submission . 36Claims Processing Timelines . 37Claim Denials . 37Claim Reconsiderations. 38Provider Training and Resources . 40Training . 40Community Provider Toolkits . 40HSRM Training and Resources . 40VA Recommended Training . 41VA Required Training . 41Acronyms . 41Glossary . 43Appendix A – Sample VA Referral Packet . 47PCA-1-21-02306-Optum-QRG 062320213 of 55Users are responsible for ensuring they work from the latest approved version. This document was last modified 07/01/2021 2021 United HealthCare Services, Inc. All Rights Reserved.v1.9

VA CommunityCare NetworkOVERVIEWWelcome to the Department of Veterans Affairs (VA) Community Care Network (CCN) Provider Manual.We’ve collected important information about the VA CCN that will help you deliver care to Veterans inyour community.This VA CCN Provider Manual (this “Manual”) applies to Covered Services you provide to Veterans as partof the VA CCN. Veteran eligibility and coverage are determined by VA.This Manual is for any facility, ancillary provider, physician, physician organization, other health careprofessional, supplier or other entity engaged in the delivery of health care services under VA CCN(collectively “provider”) participating in one of the Optum VA CCN partner networks or in a leased networkmanaged by a vendor that has subcontracted with Optum or one of its affiliates for VA CCN (see the“Network Resources” section below for more information on Optum VA CCN partner networks).As used in this Manual, “you,” “your” or “provider” refers to any provider as defined above. Except whereexpressly indicated, the information included in this Manual is applicable to all types of providers subject tothe Manual.As used in this Manual, “us,” “we” or “our” refers to Optum or UnitedHealthcare (collectively “Optum”) or oneof the other VA CCN-affiliated Network Partners (collectively “Network Partner(s)”) with which you havecontracted for VA CCN.This Manual is a binding part of your contract with Optum or Network Partner (the “Participation Agreement”)and includes requirements that you must comply with for the VA CCN, including the following categories ofinformation, which will help you better understand VA CCN requirements, as well as how to collaborate withVA and deliver and coordinate care for the Veterans you will be serving: Provider resourcesCovered servicesCredentialingProvider responsibilitiesEligibility and enrollmentReferralsPharmacy and durable medical equipment (DME)Health care managementMedical documentationReimbursement and claims processProvider training and resourcesThe table of contents contains hyperlinks to specific sections. This enables providers and staff to accessneeded information quickly and efficiently.Terms and acronyms in this Manual are defined the first time they appear. They are also spelled out in theGlossary and Acronyms sections at the end of this Manual.Important Note about This ManualThe Manual will be updated in January, April, July and October. In addition, off-cycle updates may becompleted as determined by Optum. Notice of VA CCN Provider Manual updates will be posted on theOptum VA Community Care Network Provider Portal. The latest version will be posted to the Optum VACommunity Care Network provider portal, provider.vacommunitycare.com Training & Guides. Pleasecheck back for updated versions. This guide was updated July 1, 2021, for physicians, health careprofessionals, facilities and ancillary providers currently participating in the VA CCN.PCA-1-21-02306-Optum-QRG 062320214 of 55Users are responsible for ensuring they work from the latest approved version. This document was last modified 07/01/2021 2021 United HealthCare Services, Inc. All Rights Reserved.v1.9

VA CommunityCare NetworkWhat Is VA CCN?VA recognizes that while the health care landscape is constantly changing, VA’s unique population andbroad geographic demands will continue to require community-based care for Veterans. VA is committed toproviding eligible Veterans with the care they need when and where they need it. A significant component ofhaving one method for Veterans to receive care from community providers is the ability for VA to purchasecommunity services through the CCN contracts awarded to third-party administrators (TPAs). Optum wasawarded Region 1, Region 2 and Region 3.Region 1ConnecticutDelawareDistrict ofColumbiaMaineMarylandMassachusettsNew HampshireNew JerseyNew YorkNorth CarolinaPennsylvaniaRhode IslandVermontVirginiaWest VirginiaRegion aMissouriNebraskaNorth DakotaOhioSouth DakotaWisconsinRegion OklahomaPuerto RicoSouth CarolinaTennesseeU.S. Virgin IslandsRegions are based on provider locations. The provider may receive referrals for Veterans residing in adifferent state than the provider’s location.CCN is fully deployed in Regions 1, 2 and 3. VA CCN gives Veterans the opportunity to receive care from anetwork of community health care professionals, facilities, pharmacies and suppliers.Veterans have sacrificed to serve our country, and this is an opportunity to provide them with the timely,accessible and high-quality care they deserve. Providers can help Veterans access a network of communityhealth care through their contract with Optum or another Network Partner. VA CCN only covers Veterans,not families or dependents. VA determines a Veteran’s eligibility to get care from community providers.NETWORK RESOURCESOptum’s complete and comprehensive health care provider network includes:UnitedHealthcareUnitedHealthcare provides the network for traditional medical services for VA CCN.PCA-1-21-02306-Optum-QRG 062320215 of 55Users are responsible for ensuring they work from the latest approved version. This document was last modified 07/01/2021 2021 United HealthCare Services, Inc. All Rights Reserved.v1.9

VA CommunityCare NetworkThe UnitedHealthcare network includes: Primary care providers Specialty and sub-specialty providers Acute care hospitals Laboratories Specialty pharmacies Ambulatory surgery centers Long-term acute care facilities Federally Qualified Health Centers (FQHCs) Rural Health Clinics (RHCs) Urgent care facilities Ancillary services, including home health, DME, hospice care, dialysis and diagnostic radiologyUnited Behavioral HealthUnited Behavioral Health (UBH) provides a network of behavioral health and substance use disorderfacilities and providers who perform Complementary and Integrative Healthcare Services (CIHS) forVA CCN. The UBH network includes: Psychiatric hospitalsInpatient and outpatient mental health and substance use disorder programsPsychiatristsPsychologistsSocial workersMarriage and family therapistsCounselorsVA CCN CIHS includes biofeedback, hypnotherapy, relaxation techniques and Native American healing.UBH serves all areas, except Puerto Rico and the U.S. Virgin Islands. Those areas are covered by aleased network.OptumHealth Care Solutions, LLCOptumHealth Care Solutions, LLC, (OHCS) provides a network of freestanding physical health providersand services for VA CCN, which includes: Physical therapyOccupational therapySpeech therapyChiropractic servicesAcupunctureThe OHCS network also includes providers who provide some CIHS, including: Massage therapyTai chiOHCS provides tai chi in all areas. All other specialties listed above are provided by OHCS in all areas,except Puerto Rico and the U.S. Virgin Islands. Those areas are covered by a leased network.PCA-1-21-02306-Optum-QRG 062320216 of 55Users are responsible for ensuring they work from the latest approved version. This document was last modified 07/01/2021 2021 United HealthCare Services, Inc. All Rights Reserved.v1.9

VA CommunityCare NetworkLogistics Health, Inc.Logistics Health, Inc. (LHI) provides a network of general and specialized dental providers covering allgeographic areas. This network provides outpatient dental care to all eligible Veterans.CVS Caremark PharmacyCVS Caremark Pharmacy serves as a pharmacy benefits manager (PBM) and a retail pharmacy networkcovering all geographic areas for the VA CCN. The retail pharmacies provide prescription fulfillment servicesfor urgent or emergent prescriptions from VA CCN and VA providers with an approved referral or UrgentCare Eligibility Record Number (UCERN).UnitedHealthcare VisionUnitedHealthcare Vision provides a network of eye care professionals covering all geographic areas.This network provides routine eye examinations.PROVIDER RESOURCESOnlineVA Community Care Provider Portal and WebsiteVA has VA CCN provider resources available at va.gov/COMMUNITYCARE/providers.HealthShare Referral Manager (HSRM) is VA’s online portal for managing referrals and authorizations.HSRM enables electronic file sharing between VA and providers by allowing VA CCN providers to sign in toview approved referrals, submit medical documentation and Request for Service (RFS) forms.More information on HSRM can be found in the HSRM Training and Resources section of this manual.Optum VA Community Care Network Provider PortalOptum VA Community Care Network provider portal is available at provider.vacommunitycare.com.The provider portal contains Training & Guides, News & Announcements and Documents & Links. A newCOVID-19 section has been added where providers can view the latest VA Community Care Networkinformation related to COVID-19. Additional self-service functionality is available from the Medical/BehavioralProvider icon after you sign in.Optum’s portal provides: Claim status and submission Provider resources and education Real-time pharmacy dispensing information to help prevent medication errors Referral status Veteran eligibilityOnline assistance is available through online chat from 8 a.m. – 6 p.m. provider’s local time, Monday –Friday, excluding federal holidays, at provider.vacommunitycare.