CCN Next Gen_Draft_Dental_Manual_v3.1.pdf

Do Not Disclose – Source Selection Sensitive Information See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

DEPARTMENT OF VETERAN AFFAIRS

VHA Office of Integrated Veteran Care

Integrated External Networks

Community Care Network Next Generation

Dental Network

Contractor Manual

Version 3.1

January 24, 2025

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

TABLE OF CONTENTS

PART 1: PERFORMANCE WORK STATEMENT SECTIONS

1 GENERAL INFORMATION - RESERVED

1.1 Introduction

1.2 Scope of Services – RESERVED

1.3 Applicable Documents - RESERVED

2 PROJECT MANAGEMENT - RESERVED

2.1 Post Award and Contract Kickoff Meetings - RESERVED

2.2 Integrated Master Schedule (IMS) - RESERVED

2.3 Deployment and Implementation - RESERVED

2.4 Risk Management - RESERVED

2.5 Contract Performance Management - RESERVED

2.5.1 Quality Assurance Surveillance Plan - RESERVED

2.5.2 Quality Assurance Program and Plan - RESERVED

2.5.3 Quality Improvement Plan - RESERVED

2.6 Progress Reporting - RESERVED

2.7 Service Organization Control (SOC) Reporting - RESERVED

2.7.1 SOC 1 and SOC 2 Reporting Specifications and Deliverables - RESERVED

2.8 Contractor Maintained Records - RESERVED

2.9 Cooperation - RESERVED

2.10 Transition Out - RESERVED

3 DENTAL NETWORK DEVELOPMENT AND MAINTENANCE - RESERVED

3.1 Dental Network Establishment and Maintenance - RESERVED

3.1.1 Dental Network Adequacy Plan - RESERVED

3.2 Dental Provider Network - RESERVED

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

3.3 Network Adequacy Management - RESERVED

3.3.1 Dental Network Deviation Requests

3.4 Credentialing - RESERVED

3.4.1 Credentialing Requirements - RESERVED .......................................Error! Bookmark not defined.

3.5 Dental Network Provider Data for VA’s Provider Directory - RESERVED

3.6 Operations Support - RESERVED

4 ELIGIBILITY DATA MANAGEMENT

4.1 Member Information

4.2 Eligibility File Transmission Frequency

4.3 Member Query

4.4 Member Address Information

4.5 Veteran Community Care Eligibility Codes

5 CUSTOMER SERVICE - RESERVED

5.1 Contractor Contact Center - RESERVED

5.1.1 Contractor Contact Center Support to VA Staff - RESERVED

5.1.2 Contractor Contact Center Supporting Network Providers - RESERVED

5.1.3 After-Call Surveys - RESERVED

5.1.4 Contractor Contact Center Training Materials and Response Scripts - RESERVED

5.1.5 Contractor Contact Center Testing and Full Operating Capability - RESERVED

5.2 Contractor Self-Service Capabilities - RESERVED

5.2.1 Contractor IVR with Self-Service Capabilities - RESERVED

5.2.2 Contractor Self-Service Portal - RESERVED

5.2.3 Dental Network Provider Attestation - RESERVED

5.2.3.1 Dental Network Provider Profile Attestation - RESERVED

5.2.3.2 Dental Network Provider Profile Quarterly Attestation - RESERVED

5.2.4 Contractor Self-Service Portal and VA-Provided Referral and Authorization System - RESERVED . 22

5.2.5 Contractor Self Service Portal Testing and Full Operational Capability - RESERVED

5.3 Contractor Use of VA-Provided Ticketing Tool - RESERVED

5.4 Information Technology Support - RESERVED

5.5 Dental Network Provider Satisfaction Surveys - RESERVED

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

5.6 Contractor Customer Service Quality Assurance - RESERVED

5.7 Customer Service Performance Requirements and Reporting - RESERVED

5.7.1 Contractor Contact Center Performance Requirements - RESERVED

5.7.2 Contractor Self-Service Portal Performance Requirements - RESERVED

5.7.3 Dental Network Customer Service Performance Report - RESERVED

6 REFERRALS

6.1 Request for Services (RFS)

6.2 Supporting Documentation for RFS

7 PHARMACY - RESERVED

8 MEDICAL DOCUMENTATION - RESERVED

8.1 Medical Documentation Data Elements for Inclusion - RESERVED

8.2 Medical Documentation Submission Timeframes - RESERVED

8.3 Medical Documentation Compliance - RESERVED

8.4 Critical Findings - RESERVED

8.5 Medical Documentation Central Submission System - RESERVED

8.6 Medical Documentation and Audit - RESERVED

9 CLAIMS PROCESSING AND ADJUDICATION FOR DENTAL NETWORK SERVICES

RENDERED

9.1 Claims Submission and Processing Timeframes

9.2 Claims Processing and Adjudication

9.2.1 Clean Claim Edit Scenario

9.2.2 VA-Specific Instructions for Completing the ADA Dental Claim Form

9.2.3 Claims Validation

9.2.4 Claim Edits and Validation

9.2.5 Line Level Validation

9.2.6 Urgent Dental Care Claims Processing

9.2.7 Encounter Data Submission

9.2.8 Reject or Deny: Claim Edit Scenario

9.2.9 Duplicate Claim Check

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

9.2.10 Referral Matching

9.2.11 Provider Validation

9.2.12 Taxonomy Validation

9.3 Claims Reprocessing and Adjustment - RESERVED

9.4 Test Claim Tracers

9.5 Claims Reporting - RESERVED

10 REIMBURSEMENT SUBMISSION TO VA

10.1 Resubmission of Rejected and Denied 837D COB to VA

10.2 Dental Network Provider Claims Appeals - RESERVED

10.3 Invoicing Accuracy - RESERVED

10.4 Accounting and Access to Records – RESERVED

11 COORDINATION OF BENEFITS (COB) – RESERVED

11.1 Debt Collection - RESERVED

11.2 Issuance of Explanation of Benefits (EOB) - RESERVED

12 PROGRAM INTEGRITY

12.1 Program Integrity (PI) Responsibilities

12.2 Predictive Analysis - RESERVED

12.3 Anti-Fraud and Abuse Support

12.4 Fraud and Abuse Training and Education - RESERVED

12.5 Cost Avoidance and Recovery/Recoupment Reports - RESERVED

12.6 Termination of Network Agreement - RESERVED

12.7 Veteran and Network Provider Flags - RESERVED

12.8 Case Lifecycle

12.9 Dental Overutilization Review - RESERVED

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

12.10 Payment Integrity

12.11 Pre-Payment Review - RESERVED

12.12 Post-Payment Review

12.13 Recoupment Action - RESERVED

12.14 Annual Independent Payment Audit - RESERVED

12.15 Error Determination Rebuttals - RESERVED

12.16 Audit Review Action - RESERVED

12.17 Reduction of Improper Payment Performance Goals - RESERVED

12.18 Program and Payment Integrity Site Visits

13 CLINICAL QUALITY AND PATIENT SAFETY MONITORING - RESERVED

13.1 Clinical Quality Monitoring Plan (CQMP) - RESERVED

13.2 Clinical Quality and Patient Safety Improvement Program (CQPSIP) Component of the CQMP -

RESERVED

13.3 Clinical Quality and Patient Safety Issues Identification - RESERVED

13.4 Peer Review of Identified Quality and Patient Safety Issues - RESERVED

13.5 VA Participation in Peer Review Committees - RESERVED

14 TECHNOLOGY - RESERVED

14.1 Communication and Access to Contractor Systems - RESERVED

14.2 Configuration Management and Testing - RESERVED

14.2.1 Software Development (Optional Task) - RESERVED

14.3 Continuity of Operations Plan - RESERVED

14.3.1 Data Integrity - RESERVED

14.4 Information and Data Exchange Requirements - RESERVED

14.4.1 VA System Integration Requirements - RESERVED

14.4.2 Exchange of EDI Transactions - RESERVED

14.5 Technology Compliance Requirements - RESERVED

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

14.5.1 Social Security Number (SSN) Reduction - RESERVED

14.5.2 Equivalent Facilitation for 508 Compliance - RESERVED

14.5.3 Compatibility with Assistive Technology – RESERVED

15 TRAINING - RESERVED

15.1 Training Plan - RESERVED

15.1.1 Provider and Contractor Personnel Outreach and Education Program - RESERVED

15.1.2 Provider Only Training - RESERVED

15.1.3 Contractor-Provided VA Training Program for Contractor Network Providers, Contractor Personnel, and VA Staff - RESERVED

15.1.4 Contractor Dental Network Staff Training Sessions – RESERVED

15.1.5 Contractor Training Materials - RESERVED

15.2 VA Provided Training - RESERVED

15.2.1 Training Requirements Under the MISSION Act, Section 133 - RESERVED

15.3 Opioid Training Requirements - RESERVED

16 OPTIONAL TASK: DENTAL APPOINTMENT SCHEDULING - RESERVED

16.1 Administrative Management - RESERVED ........................................ Error! Bookmark not defined.

16.2 Dental Appointment Scheduling Process - RESERVED

16.3 Daily Dental Appointment Scheduling Reporting - RESERVED

PART 2: B.5 PRICE/COST SCHEDULE SECTIONS

APPENDIX A: RFS DOCUMENTATION REQUIREMENTS

APPENDIX B: LIMITATIONS AND EXCLUSIONS

APPENDIX C: DENTAL CODE SETS

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Version History

Version Date Description

2.0 Revised structure to match

PWS for ease of use;

moved requirements to PWS; moved content to Price/Cost Schedule and EDI Companion Guide.

3.1 1/24/2025 Revisions to align with

PWS.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

PART 1: PERFORMANCE WORK STATEMENT SECTIONS

1 GENERAL INFORMATION - RESERVED

1.1 Introduction

The Community Care Network (CCN) Next Generation Dental Network Contractor Manual, hereinafter referred to as the Manual, provides detailed information on the Department of Veterans Affairs’ (VA’s) distinct features related to coverage, payment, and reimbursement for the CCN Next Generation Dental Network Contractor, hereinafter referred to as the Contractor. The CCN Next Generation Dental Network Performance Work Statement (PWS) provides the requirements for the Contractor and is the primary authority for operational requirements.

The Manual is intended to deliver detailed information to the Contractor to properly configure its dental care administration systems to validate and process claims accurately and in a timely manner. It is also meant to provide the Contractor with a deeper understanding of the VA dental benefits, network requirements, and claims processing to enable better administration of services to Veterans and network providers and build a strong partnership with VA. To comply with VA’s legislative and regulatory policies, the Contractor’s existing dental administration systems, which may align to other industry standards, will likely need to be reconfigured to effectively administer VA’s CCN Next Generation Dental Network. The Manual’s content is intended to assist with that reconfiguration.

The Manual contains the following:

• Explanation of policies associated within the CCN Next Generation program:

o Defines terminology, processes, and interfaces specific to VA o Provides information about Veterans

• Definition of VA claims processing logic

• Description of VA authorization related to various dental services and identification of VA unique features related to coverage and reimbursement

Part 1 sections of the Manual are identical to the sections in the PWS. For PWS sections with no Manual content, the section is marked as “Reserved” in the Manual.

Part 2 sections of the Manual align with sections of Request for Proposal (RFP) Section B.5 Price/Cost Schedule.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

VA expects there may be Manual changes outside the established semi-annual update cycle. These changes may include, but are not limited to, updates due to regulatory and/or statutory changes. For changes requiring immediate implementation, the VA Contracting Officer (CO) will administer guidelines or instructions in the form of a VA CO technical direction letter.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

1.2 Scope of Services – RESERVED

1.3 Applicable Documents - RESERVED

2 PROJECT MANAGEMENT - RESERVED

2.1 Post Award and Contract Kickoff Meetings - RESERVED

2.2 Integrated Master Schedule (IMS) - RESERVED

2.3 Deployment and Implementation - RESERVED

2.4 Risk Management - RESERVED

2.5 Contract Performance Management - RESERVED

2.5.1 Quality Assurance Surveillance Plan - RESERVED

2.5.2 Quality Assurance Program and Plan - RESERVED

2.5.3 Quality Improvement Plan - RESERVED

2.6 Progress Reporting - RESERVED

2.7 Service Organization Control (SOC) Reporting - RESERVED

2.7.1 SOC 1 and SOC 2 Reporting Specifications and Deliverables - RESERVED

2.8 Contractor Maintained Records - RESERVED

2.9 Cooperation - RESERVED

2.10 Transition Out - RESERVED

3 DENTAL NETWORK DEVELOPMENT AND MAINTENANCE - RESERVED

3.1 Dental Network Establishment and Maintenance - RESERVED

3.1.1 Dental Network Adequacy Plan - RESERVED

3.2 Dental Provider Network - RESERVED

3.3 Network Adequacy Management - RESERVED

3.3.1 Dental Network Deviation Requests

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Below outlines the process for a Contractor’s Network Deviation Request:

• Contractor submits request using Network Deviation Request Form (Attachment TBD, “Network Adequacy Deviation Request”) to VA

• VA will receive and evaluate the Network Deviation Request Form

• VA will inform the Contractor of the final determination

VA will validate any statement or rationale made on a Network Deviation Request. VA may request additional information or evidence to support its Network Deviation Request(s). Network Deviation Requests submitted to VA are not guaranteed to be approved. As such, if the Contractor’s Network Deviation Request does not provide a valid rationale and is not sufficiently supported with evidence, or enough providers/facilities, as determined by VA, are available to meet Network Adequacy Standards, then the Network Deviation Request will be denied, and the contract standards must be met.

Submission of Network Deviation Requests. Potential reasons the Contractor may request Network Deviation from the current Drive Time standards include:

• Scarcity of available network providers/facilities precludes the Contractor from meeting the Drive Time standards or the landscape of providers/facilities changed and certain providers/facilities are not available resulting in the Contractor not meeting the Drive Time standards

• Contractor contracted with other network providers/facilities that may be located beyond the limits in the distance criteria, but who are the currently available providers/facilities most accessible to the regions Veterans to address the changed provider/facility landscape

VA requires conclusive evidence in its Network Deviation Request that the Drive Time standards cannot be met because of scarcity or changes to the availability of providers/facilities, resulting in insufficient supply. Approved Network Deviation Requests are effective from the date of approval by VA and will run for no longer than 12 months, ending on the last day of the preceding month of the following year.

VA Review of Deviation Requests. When evaluating a Network Deviation Request, VA will consider:

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

• Number and geographical distribution of eligible network providers available within the county/parish and specialty referenced in the Network Deviation Request

• Prevailing market conditions within the geography and specialty referenced in the Network Deviation Request: number and distribution of network providers contracting with other dental commercial plans operating in the geography and specialty referenced in the Network Deviation Report Request

• Whether the service area is comprised of Highly Rural, Rural, or Urban areas, or some combination of the three

• How significant the Network Deviation Request is from Drive Time standards for Veteran access to network providers including specialties

Valid Rationales. VA will consider valid rationales for a Network Deviation Request such as scarcity in specialties or in region and recent changes in an area including, but not limited to: a provider retires, is retiring soon, or moves to a different office location.

VA will use Contractor provided evidence such as letters or emails documenting a retirement, documented calls with the provider/facility office, news articles, or descriptions of sources used to validate provider/facility locations. If a Contractor uses a phone call to the provider/facility office as evidence, then the Contractor will include the date of the call, the name of the provider/facility staff contacted, and the corresponding office number.

There are instances when VA will consider an organization’s reason for not contracting with a provider/facility that is available (e.g., if the Contractor asserts an available network provider may cause a Veteran harm). VA will consider substantial and credible evidence to consider Veteran harm rationale. In the “Reason for Not Contracting” list on the Network Deviation Request Form, the Contractor will select “Other” and provide evidence in the “Additional Notes on Reason for Not Contracting” field.

VA will also consider the Contractor’s rationale for a deviation if a provider/facility:

• Does not contract with any organizations; or

• Contracts exclusively with another organization.

In these circumstances, VA will consider substantial and credible evidence to validate the claim. In the “Reason for Not Contracting” list on the Network Deviation Request Form, the Contractor will select either “Provider Does Not Contract with Any Organization” or “Other,” if the provider/facility contracts exclusively with another

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only organization. The Contractor will then provide evidence in the “Additional Notes on Reason for Not Contracting” field. VA will consider evidence including but not limited to, a letter or email from the provider or facility’s office stating the policy and refusal to contract when reviewing the Network Deviation Request.

VA will consider inappropriate credentialing rationale if the Contractor provides substantial and credible evidence. In the “Reason for Not Contracting” list on the Network Deviation Request Form, the Contractor will select either “Other” or “Provider Does Not Provide Service in the Specialty Type Listed in the Database and for which the Network Deviation Request is Being Requested as Appropriate.” The Contractor will provide evidence in the “Additional Notes on Reason for Not Contracting” field.

Evidence of inappropriate credentialing could be an official document stating and demonstrating that the provider’s current credentialing status in the relevant provider database conflicts with the Credentialing Requirements.

Invalid Rationales. VA defines “Inability to Contract” as the Contractor’s inability to successfully negotiate and establish a contract with a provider/facility. VA does not consider “Inability to Contract” as a valid sole rationale for a Network Deviation Request to the Network Adequacy Standards. VA will generally not accept the Contractor’s assertion that it cannot meet current Network Adequacy Standards solely because providers/facilities are not willing to contract with the Contractor.

For example, the Contractor selects “Inability to Contract with Provider” as a “Reason for Not Contracting” on the Network Deviation Request. The Contractor then states that the network provider is not willing to accept the Contractor’s proposed payment rates, and therefore, refused to contract with the Contractor. VA would consider the Contractor’s inability to contract rationale to be invalid.

VA will only accept Network Deviation Request when the current Drive Time Standards cannot be met based on provider/facility supply. VA will only accept a Network Deviation Request that indicates the Contractor is in the process of contracting with providers/facilities. VA will only consider credentialed and contracted providers/facilities will not accept claims of interim contracting efforts on a Network Deviation Request. For example, the Contractor selects “In the Process of Negotiating a Contract with Provider” as a “Reason for Not Contracting” on the Network Deviation Request. The Contractor then states that contracting negotiations are still underway with a provider, and the provider will be in-network as soon as the contract is signed and executed. VA will consider the rationale to be invalid because the Contractor does not currently have an established, effective contract with that provider.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Upon VA’s decision on a Network Deviation Request, the Contractor will receive the decision (approval or denial) via electronic notification, noting the effective date and termination date of the waiver, as well as the type of care to which the Drive Time requirements will now meet adequacy standards. VA will retain all approved deviations in a central repository to apply waivers to Network Adequacy Reports.

3.4 Credentialing - RESERVED

3.5 Dental Network Provider Data for VA’s Provider Directory - RESERVED

3.6 Operations Support - RESERVED

4 ELIGIBILITY DATA MANAGEMENT

VA will determine eligibility prior to transmitting a VA Approved Dental Referral to the Contractor.

This section outlines VA’s eligibility data management processes and provides guidance to receive, update, and manage eligibility information for Veterans and the use of Veteran Community Care Eligibility (VCE) codes. This section defines non-standard interfaces that will be used between VA and the Contractor as well as potential requirements needed to configure the Contractor’s systems. The subsections outline the frequency, methodologies, and processes for data configuration and transmission (adopting industry standard Electronic Data Interchange (EDI) 271 and 834 transactions or a similar VA-generated file) between the Contractor and VA, and how the Contractor will manage eligibility files with updated and accurate information. Through this guidance, the Contractor can better configure eligibility data management processes to support VA's processes and ensure Veterans receive timely care from network providers.

For this section, the below defines key terminology and provides additional context related to non-standard terminology.

• Veteran: As defined in 38 United States Code (U.S.C.) Section 101(2), a Veteran is an individual who served in the active military, naval, or air service, and who was discharged or released under conditions other than dishonorable. (Note: Not all Veterans are eligible for VA health care benefits, and not all Veterans are enrolled in VA’s health care system)

• Member: A Veteran eligible for VA health care benefits and may be actively enrolled in VA health care system. (Note: Veterans may be eligible for VA health care benefits but not enrolled in VA’s health care system)

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

4.1 Member Information

Member information will be configured using the data fields and descriptions defined in this subsection to ensure accurate and timely eligibility file updates. Additional guidance is included for non-standard VA concepts, as well as non-standard interfaces to and from VA for updating specific types of information.

The Data Access Service (DAS) Interface Control Document (ICD) outlines eligibility file specification and field-by-field descriptions. VA’s method for transmitting member information deviates from industry standard method (e.g., EDI 834).

4.2 Eligibility File Transmission Frequency

VA will submit one-time record seeding and the transfer of daily updates to eligibility files to ensure VA and the Contractor's member information is synchronized to accurately process VA Approved Referrals and claims. VA will transmit eligibility files to the Contractor on the following frequencies:

• One-time Record Seeding: An initial load of enrollment and eligibility data will be performed for all Veterans who are currently enrolled in the VA health care system with active VCE codes.

• Daily Updates: Updates to daily file include Veterans demographic and contact information changes, identity changes, and administrative Community Care eligibility (e.g., VCE codes).

Table 1 outlines high-level details related to the Contractor activities and the outcomes with the daily eligibility file update.

Table 1. Daily Eligibility File Updates

Sequence Activity Outcome

1 Transmit Member Updates

VA transmits daily member updates to the Contractor’s system using an American Standard Code for Information Interchange (ASCII) formatted text file as defined by VA.

ASCII Text

2 Parse File and Perform Updates

The Contractor’s system reads through or parses the eligibility file sent by VA. The Contractor’s system will perform an update

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Sequence Activity Outcome when a matching member record is found or will add a new member record when a matching record is not found.

Determine Member’s VCE Code(s) Have Changed

When performing an update of member information, the Contractor’s system will also determine or detect if the member’s VCE codes have changed by comparing existing codes with codes included in the daily update file sent by VA.

4 Create Eligibility Period Record for Member

If a member’s VCE codes changes, the Contractor’s system will derive an eligibility or coverage end date, using the date the code changed, to create a historical eligibility/coverage span using the begin date supplied by VA and the end date derived by the Contractor’s system. Historical VCE records for Veterans will be maintained.

4.3 Member Query

If queries for a specific member are needed, queries will be sent to VA with a standardized format. The standard query format allows VA to exchange member information in a similar manner with multiple Contractors.

Table 2 outlines the member file query specification.

Table 2. Member Query Specification

Field Data Type Field Length Description

ICN Alphanumeric 29 Internal VA Patient Identifier; Integration Control Number. Required.

Member Query Transmission Frequency. Frequency of queries vary and are sent to VA based on business need. VA will respond to the Contractor’s member query in the

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only next daily member file transmission. There will not be a separate distinct member query response from VA to the Contractor. To reconcile the status of the previous day’s query, the Contractor will evaluate the next day’s member file transmission to determine if the member data requested is contained in the member file. This query process is done to improve the accuracy and completeness of member data in the Contractor's platform.

Figure 1 outlines the process flow for the member update query. The process model and the description below are not precise descriptions of required steps, but rather, describe expected results from VA-driven processes.

Figure 1. Member Update Query

4.4 Member Address Information

VA will provide the member address as the address of record for transmitting information, explanation of benefits (EOBs), or other information.

Table 3 outlines the member address types provided by VA to the Contractor.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Table 3. VA Address Types

Type Description Used as Mailing Address

Permanent Address

Member’s address of residence; will include effective date(s)

If no temporary mailing address and address is not identified as a bad address, then use mailing address.

Temporary Address

If the temporary address is active, it will be transmitted; and include effective date(s).

If the temporary address is active based on effective dates, then use mailing address.

4.5 Veteran Community Care Eligibility Codes

This section defines VA’s use of custom VCE codes to communicate eligibility related to the VA Medical Benefits Package. VCE codes will be used by the Contractor as part of claims adjudication for the processing of certain claims and are included in member files.

Note: A member may have more than one VCE code at one time.

Table 5 outlines the complete listing of VCE codes that will be provided by VA to the Contractor.

Table 4. Description of Veteran Eligibility Codes

VCE VCE

Code Description

Basic B

Enrolled Veterans in the VA health care system meets the primary criteria for VA’s Community Care program.

These Veterans do not qualify for other static eligibilities; for example: Grandfathered, Hardship (General Best Medical Interest), State No Full-Service VA, or urgent care. These Veterans, however, can be considered for Service Not Available, Access Standards, or Episodic Best Medical Interest.

Hardship H Enrolled Veterans in the VA health care system. This eligibility is considered General Best Medical Interest.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

VCE VCE

Code Description

Veterans who meet the John S. McCain III, Daniel K.

Akaka, Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 (MISSION Act) access standards (Wait Time and Drive Time) may still face unusual or excessive burdens in accessing care at VA based on environmental or geographic inaccessibility (including air, boat, ferry) or medical condition and Veteran has received a consult. This eligibility has an expiration (6 months or 12 months).

Ineligible X

Veterans who do not meet the criteria for enrollment in VA health care nor the criteria for not enrolled covered Veterans. This also includes Veterans who were eligible and subsequently became ineligible for VA health care.

Grandfathered G

Enrolled Veterans who are driving distance-eligible under Veterans Choice Program. Require the Veteran

(1) be distance-eligible on the day before the MISSION Act was signed (June 5, 2018), and (2) is distance-eligible under Veterans Choice Program rules as of the start of the MISSION Act on June 6, 2019, and lives in one of the five States with the lowest population density from the 2010 Census: North Dakota, South Dakota, Montana, Alaska, and Wyoming.

Note:

• Records with VCE status of “G” (Grandfathered) are sent with the monthly geocoding process.

• Geocoding processing times are Central Standard Time (CST) zone.

State No Full- N Enrolled Veterans who reside in a State with no full-

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

VCE VCE

Code Description

Service VA service VA medical facility.

Entitled Care (added in the

5.13 release)

E

Not enrolled covered Veterans who are 50 to 100% rated service-connected and otherwise entitled to hospital care, medical services, extended care services, and Community Care services.

Note: Not enrolled Covered Veterans ("Entitled Care") records are included in geocoding processes to obtain rurality information.

Geocoding processing times are CST zone.

Restricted Care (added in the

5.13 release)

R

Not enrolled covered Veterans who otherwise entitled to hospital care, medical services, extended care services, and Community Care services; however, they are only eligible for care related to their service-connected conditions (less than 50% service-connected, and 0% non-compensable).

This population includes Veterans if they meet the following eligibility: Discharged or released from active military service for a disability incurred or aggravated in the line of duty for that disability for the 12-month period following discharge or release; Military Sexual Trauma (MST); or Mental Health Other Than Honorable (OTH); as otherwise documented in their record.

Note: Not enrolled Covered Veterans (Restricted Care) records are included in geocoding processes to obtain rurality information.

Geocoding processing times are CST zone.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

5 CUSTOMER SERVICE - RESERVED

5.1 Contractor Contact Center - RESERVED

5.1.1 Contractor Contact Center Support to VA Staff - RESERVED

5.1.2 Contractor Contact Center Supporting Network Providers - RESERVED

5.1.3 After-Call Surveys - RESERVED

5.1.4 Contractor Contact Center Training Materials and Response Scripts -

RESERVED

5.1.5 Contractor Contact Center Testing and Full Operating Capability -

RESERVED

5.2 Contractor Self-Service Capabilities - RESERVED

5.2.1 Contractor IVR with Self-Service Capabilities - RESERVED

5.2.2 Contractor Self-Service Portal - RESERVED

5.2.3 Dental Network Provider Attestation - RESERVED

5.2.3.1 Dental Network Provider Profile Attestation - RESERVED

5.2.3.2 Dental Network Provider Profile Quarterly Attestation - RESERVED

5.2.4 Contractor Self-Service Portal and VA-Provided Referral and Authorization System - RESERVED

5.2.5 Contractor Self Service Portal Testing and Full Operational Capability -

RESERVED

5.3 Contractor Use of VA-Provided Ticketing Tool - RESERVED

5.4 Information Technology Support - RESERVED

5.5 Dental Network Provider Satisfaction Surveys - RESERVED

5.6 Contractor Customer Service Quality Assurance - RESERVED

5.7 Customer Service Performance Requirements and Reporting - RESERVED

5.7.1 Contractor Contact Center Performance Requirements - RESERVED

5.7.2 Contractor Self-Service Portal Performance Requirements - RESERVED

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

5.7.3 Dental Network Customer Service Report - RESERVED

6 REFERRALS

VA refers care to the dental network and sends a VA Approved Referral to both the network provider and the Contractor. The VA Approved Referral serves as VA’s authorization for the network provider to deliver the referred services and for the Contractor to process claims and pay the network provider for care delivered. VA has an established referral and authorization information system that will allow the network provider to view a Veteran’s electronic health record. This system also has the capacity to track referral workflow and exchange data/documentation between VA and network providers, which increases care coordination among VA, the Contractor, and the network provider. Figure 2 outlines the referral process and associated downstream actions. The table is not intended to be, nor should it be, construed as a requirement.

Figure 2. Dental Referral Process

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

A VA Approved Referral is the mechanism VA uses to refer and authorize care by a network provider. A VA Approved Referral number must be included on claims submitted by the network provider to the Contractor for services provided by network providers. VA Approved Referrals include a consult order outlining duration, visits, and services related to a specialty, subspecialty, or category of care.

VA Approved Referrals and any other data, including accompanying medical documentation will be used to properly adjudicate claims that network providers submit related to a VA Approved Referral.

VA Referral Process. This section provides process descriptions and models for VA Approved Referrals that address various scenarios including referred Veteran care where the network provider requests no deviations from the VA Approved Referral, referred Veteran care where the network provider seeks to provide services in addition to those referred, referred Veteran care where the network provider seeks to provide services not included in the VA Approved Referral.

VA will approve the referral using its referral management system and send the VA Approved Referral to the network provider via an EDI 278 transaction (preferred), secure fax, or email to validate and adjudicate claims submitted by the network provider to the Contractor. The Contractor stores or records the VA Approved Referral (e.g., dental codes, effective date, termination date, date generated) to support authorization of care and to validate and adjudicate claims submitted by the network provider.

Figure 3. Approved Dental Process

The electronic referral and authorization processing system used by VA to accelerate Veteran’s access to Community Care allows VA, the Contractor, and network providers to better manage VA Approved Referrals. VA primarily uses a referral and authorization system to prepare a VA Approved Referral and referral package. The referral and authorization system also provides additional functions that can be used by the network provider.

The functions and instructions for using the referral and authorization system are described in detail in the Quick Reference Guide for Network Providers.

Referral Episode of Care Validation. VA will issue a VA Approved Referral including the dental treatment plan with specific American Dental Association (ADA) Current Dental Terminology (CDT) code sets and provide the Contractor with authorization and referral to allow them to properly adjudicate claims. The Contractor’s capabilities should include, but are not limited to:

• Validating the VA Approved Referral and any other data/attachments needed to properly adjudicate claims

• Validating and matching the VA Approved Referral to account the Dental Treatment Plan and potential multiple referrals and authorization

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

• Ensuring the correct fee schedules are used to pay claims

6.1 Request for Services (RFS)

If a network provider wishes to modify or add additional services, additional CDT codes, or modify the area of oral cavity, and/or tooth anatomy, if applicable, they must submit an RFS to the Contractor. The Contractor will submit validated RFSs to VA for approval using an RFS ADA Dental Claim Form. The RFS may result in an update to an already existing referral number.

Figure 4 outlines, for illustrative purposes only, the scenario where VA refers a Veteran care to Community Care and the network provider seeks to provide services not included in the appropriate referral and authorization.

Figure 4. Approved Dental Process

Table 5 provides additional details regarding the process for transmitting RFS.

Table 5. Process for Transmitting Requests for Services

Step Number Action

Referring network provider creates and signs (electronic or wet signature) ADA Claim form providing the information requested and any supporting dental documentation.

2 Referring network provider sends a signed (electronic or wet signature) ADA claim form to the Contractor for validation. The

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Step Number Action

Contractor ensures all required documentation is included, and that the RFS is complete and error-free.

The Contractor sends the RFS to VA via EDI 278 (preferred method), direct secure messaging, secure email, secure fax, eHealth Exchange, or VA’s identified referral and authorization information system.

VA receives the RFS EDI 278 transaction, direct secure message, eHealth Exchange, secure online file exchange, secure email, secure fax or through VA’s identified referral and authorization information system, including information requested and any supporting attachments (dental documentation and/or eligibility documentation).

VA sends the determination (with a referral number, if approved) via EDI 278, direct secure messaging, secure email, secure fax, eHealth Exchange, or VA’s identified referral and authorizations information system to the Contractor and the network provider. If the referral is for VA network dental provider care, the referral process ends at approval. If the referral is to another network dental provider, the Contractor will receive and adjudicate all claims associated with a VA Approved Dental Referral made to a network provider, regardless of the network provider status of other providers submitting claims.

6.2 Supporting Documentation for RFS

Certain services require a minimum set of documentation in the RFS to be approved by the VA Dental Service Chief (DSC) reviewer. All documentation material, including any duplicate radiographic images submitted for review, must be of diagnostic quality (e.g., dental images) and legible. The VA DSC reviewer will determine the quality and legibility of the documentation. Additionally, the DSC reviewer may request additional documentation for clarification before deciding to authorize treatment.

Requests for preauthorization plans are submitted with all supporting documentation.

Only complete requests will be considered. All dental policies for clinical procedures/preauthorization guidelines issued by VA are followed. For additional

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only information for documentation requirements, refer to Appendix A. For more information regarding exclusions and limitations, refer to Appendix B.

7 PHARMACY - RESERVED

8 MEDICAL DOCUMENTATION - RESERVED

8.1 Medical Documentation Central Submission System - RESERVED

8.2 Medical Documentation Data Elements for Inclusion - RESERVED

8.3 Medical Documentation Submission Timeframes - RESERVED

8.4 Medical Documentation Compliance - RESERVED

8.5 Critical Findings - RESERVED

8.6 Medical Documentation and Audit - RESERVED

9 CLAIMS PROCESSING AND ADJUDICATION FOR DENTAL NETWORK

SERVICES RENDERED

The Claims Adjudication, Processing, Pricing, and Payment section details claims management from claims intake processing through pricing and payment to ensure Contractors can accurately receive, process, and manage claims for care provided to Veterans. The intake process and methodology are outlined in the Claims Processing section and detail the types of EDI transactions and ADA Dental claims form related to claims submission. Claims adjudication and validation processes are described in detail (e.g., clean, denied, rejected) with Contractor responsibilities designated at each level.

The life cycle of claims validation outlines the process at each step prior to pricing and payment (e.g., member validation, provider validation, duplicate claims, point of service (POS) validation, and referral and authorization validation). The pricing and payment sections describe Dental VA Fee Schedule (DVAS) and pricing methodologies at the claim and line level.

9.1 Claims Submission and Processing Timeframes

Timely Filing. When calculating timely filing, compute the number of days between the Date of Service (DOS) on the claim and the receipt date of the claim. The Contractor may continue to process and adjudicate claims that are not submitted within the VA defined timely filing deadline when the Contractor determines an allowed exception condition (listed below) is detected.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Only under the following exception conditions is the Contractor allowed to process claims that are submitted outside of the calculated timely filing period:

• Claim is submitted to VA or another VA Contractor acting on behalf of VA within the timely filing deadline, as indicated on a copy of remittance advice from the prior submission. The Contractor uses the remittance date to compute timely filing instead of the DOS.

• The Contractor uses the referral receipt date to compute timely filing in cases where VA sends the referral to the Contractor past the DOS.

• The Contractor processes claims, upon notification, when VA identifies claims to be reprocessed even if reprocessing occurs beyond the timely filing deadline.

9.2 Claims Processing and Adjudication

Clean Claim: This section provides instructions and models for processing and adjudicating claims and includes various scenarios such as “clean claims” submitted by the network provider, as well as rejected and denied claim scenarios and rules. A clean claim is a claim that contains all the required data elements necessary for adjudication without requesting supplemental information from the submitter.

9.2.1 Clean Claim Edit Scenario

Upon receipt of a network provider claim and during processing when a claim is received and processed by the Contractor, additional industry standard validation edits and VA specified edits which are defined below will be applied to the claim prior to adjudication. When all edits and validations are passed and no additional information is needed or required for processing, the Contractor adjudicates the claim, generates accurate, appropriate payments to the network provider, and sends an invoice for reimbursement to VA.

Figure 5 and Table 6 depict a scenario for when a network provider submits a claim to the Contractor that passes the Clearinghouse, Gateway, system level edits, and is intended to provide the Contractor with a business context in which claims are submitted that do not require additional data or information to be processed. This figure and table are not intended to be, nor should they be, construed as a requirements or sequencing presentation.

Figure 5.Claim Edit Scenario (Clean Claim)

Table 6. Claim Edit Scenario (Clean Claim)

Ref. Activity Outcome

1 Edits Applied at Clearinghouse

Upon receipt of a claim from the network provider, Health Insurance Portability and Accountability Act (HIPAA) and Strategic National Implementation Process (SNIP) edits at various levels are applied to the claim. When all edits are passed, an acknowledgment response is sent to the network provider and processing of the claim continues.

EDI 837D

See FAR 2.101 and FAR 3.104

An exact copy of the original claim received from the network provider is sent to VA prior to SNIP level edits.

EDI 837D (e.g., Raw, Encounter Data)

2 Gateway or System Edits are Applied

Additional and situational edits, defined by VA, and standard edits are applied to claims submitted by network providers at the Gateway or system level.

When edits are passed, processing of the claim continues.

Receipt and Validation of Claim from Provider and Response from Contractor

Upon receipt, the Contractor confirms the validity of the claim by matching the referral, member, network provider information, and duplicate checking. When all validation edits are passed and no additional information or documentation is needed or required, processing and adjudication of the claim continues.

EDI 837D

4 Adjudication, Pricing, and Payment of Clean Claim

Coding edits, grouping, and pricing are applied to the claim and claim line items and payment disbursement information is generated by the Contractor’s system.

Remittance Advice and Payment Sent to Network Provider

Remittance advice and payment is generated by the Contractor and sent to the network provider.

EDI 835 RA, Automated Clearing House (ACH)/Electronic Financial Transaction (EFT), Check

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Ref. Activity Outcome

6 Invoice Sent to VA for Reimbursement

Claim invoice is generated by the Contractor and sent to VA for reimbursement.

EDI 837D Coordination of Benefits (COB)

9.2.2 VA-Specific Instructions for Completing the ADA Dental Claim Form

The Contractor will comply with ADA and VA-specific requirements. In addition to the information below, refer to the instructions provided on the ADA website.

Claims submitted on unapproved claim forms will be rejected. When an unapproved claim form is submitted, the claimant will be notified in writing that to be considered for payment, the claim must always be submitted on approved claim forms and any additional information, if required, will be submitted and received by the Contractor within the timely filing deadline. The Contractor will reject any ADA Dental Claim Form with “Request for Predetermination/Preauthorization” selected.

This section provides an overview for network providers on how to complete the layout of ADA Dental Claim Form in compliance with VA requirements. The required fields are completed in accordance with ADA and VA-specific guidelines and claims with incomplete or erroneous information will be rejected. VA requires network providers to complete the following fields:

• Header information (fields 1 and 2)

• Dental benefit plan information (field 3)

• Policy holders/subscriber information (fields 12 through 15)

• Record of service provided (fields 24, 29, and fields 30 through 32)

• Ancillary claim/treatment information (field 38)

• Billing dentist or dental entity (fields 48, 49, and 51)

• Treating dentist and treatment location information (fields 53 through 56)

In addition, the following may be required or may become required as the result of input into another field:

• Other coverage (fields 4, 5, 8 through 11)

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

• Patient ID/account number (field 23)

• Record of service provided (fields 25 through 28, 29a, 34, 34a)

Table 7. Claims Processing Information Fields with VA-Specific Instructions

Claims Processing Information Fields VA-Specific Instructions

Type of Transaction Fields 1 All claims submitted to the Contractor must be for “Statement of Actual Services.”

Predetermination/Preauthorization Number

Field 2

Must contain the referral/authorization number provided on the VA-supplied authorization form. Claims submitted without a referral/authorization number will be denied. Acceptable format: “VAXXXXXXXXXX”.

Policyholder/Subscriber Identification (ID)

Field 15

Network provider must include the Veterans VA-assigned integrated control number (ICN), 17 alpha-numeric characters (10 digits + "V" + 6 digits) which can be found on the VA Approved Dental Referral. Will also accept Veteran's full 9-digit social security number (SSN) - no dashes, no spaces.

Relationship to Policyholder/ Subscriber Field 18 This field must always be “Self.”

Place of Treatment

Field 38

Network provider must enter the two-digit Place of Service code; a HIPAA standard. All current codes are available online from the Centers for Medicare and Medicaid Services

(CMS).

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Claims Processing Information Fields VA-Specific Instructions

Billing and Treating National Provider Identifiers (NPI)

Fields 49, The Billing and Treating NPI is required on all claim submissions.

The NPI is an identifier assigned to HIPAA-covered providers by the Federal Government.

Treatment Location

Field 56

Network provider must include a street address for the physical location where the treatment was rendered. Network providers may not use a Post Office Box.

Additional instructions on completing the ADA Dental Claim Form can be found in the 2024 ADA Dental Claim Form Completion Instructions, including the Area of the Oral Cavity and Tooth Anatomy code sets.

9.2.3 Claims Validation

The claims adjudication system will validate all claims received by the network provider to confirm dates of service are consistent with period of validity and in the VA Approved Dental Referral. Certain fields will require validation at the claim level while other will require line-by-line as outlined in Table 8. Claims not meeting these validations standards will be rejected.

Table 8. Level of Review

Field Level of Review

VA Approved Dental Referral Number Claim

Period of Authorization Claim

Name of Veteran Claim

Dental Treatment Plan/CDT Code Line

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Field Level of Review

Dental Treatment Plan/ Area of Oral Cavity or Tooth Anatomy

Line

ICN Claim

Date of Birth Claim

Pro…