Attachment Q- Network Adequacy Rate Waiver Form- Dental Network_02_24_26 v3.pdf

IVC Network Adequacy Dental Waiver of Payment Rates Request

Contractor PO:

CDT Codes Impacted:

Request Date:

Revised January 2026

Parts I-III to be completed by Contractor

VISN:

VAMC:

CCN Contract Status:

Proposed Rate:

CCuurrrreenntt RRaattee::

Part I: Request Details

Part II: Justification and Additional Information

Scarcity/Rurality:

Use this area to enter narrative text for your Waiver of Payment Rates Request, such as known community shortfalls. Please include the following details to ensure a comprehensive submission:

NPI(s)/Tax ID(s) associated with this request.

Provider Information: Include specific location addresses and any other relevant provider details.

Number of Providers in Practice: If this is a group practice request, list the total number of providers.

Number of Veterans seen in last 6 months.

Specific Code(s) Requested for waiver: If the request applies to all services, explicitly state this.

Justification of need: Provide details on number of providers currently contracted within the same catchment area and delivering same service(s). Explain how Veterans would be impacted if provider were to leave the network.

Part III: Table of Non-Contracted Providers

List all providers/facilities you have identified in or near the VAMC’s catchment, with whom you have not contracted, but have outreached for inclusion into network. Each additional provider/facility should be listed separately. In the “Reason for Not Contracting” field, select one of the following options: Provider is no longer practicing (e.g., deceased, retired); Provider does not provide services at the office/facility address listed in database; Provider does not provide services in the specialty type listed in the database and for which this Deviation is being requested; Provider does not contract with any organization; Sanctioned provider on List of Excluded Individuals and Entities (LEIE); In the process of negotiating a contract with provider; Provider is at capacity and is not accepting new patients; Inability to contract with provider (Note: Inability to contract with provider is not a valid sole rationale for submitting request); or Other. If you select “Inability to Contract with Provider" or "Other” from the “Reason for Not Contracting” list, please elaborate in the “Additional Notes” field.

Provider/Facility Name:

Provider NPI:

Provider Street Address:

Provider City:

Provider State:

Provider ZIP Code:

Provider Phone Number:

Reason for Not Contracting:

Notes:

Waiver of Payment Rates Request Form

No other Providers Available to Outreach Separate file of Providers Attached

Part IV: Internal VA Review

Part IV to be completed by VA

VA Decision Details:

Note: CORs acknowledged and have coordinated this document through Office of Integrated Veteran Care (IVC) , Rate Waiver Review Board and the Contracting Officer. This document will be saved for record keeping.

Rate Waiver Review Board Recommendation:

NA Recommendation:

Contracting Officer (CO) Decision:

CO Decision Date:

Expiration Date (if applicable):

Revised January 2026

N/A

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