Attachment 2- CCN Next Gen Dental Contractor Manual.docx

DEPARTMENT OF VETERAN AFFAIRS

VHA Office of Integrated Veteran Care Integrated External Networks

Community Care Network Next Generation Dental Network Contractor Manual

Version 5.0 September 17, 2025

TABLE OF CONTENTS

Version History

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.

PART 1: PERFORMANCE WORK STATEMENT SECTIONS

GENERAL INFORMATION

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

VA intends to deliver detailed information to the Contractor, through the Dental Manual, to properly configure its dental care administration systems to validate and process claims accurately and in a timely manner. It also provides the Contractor with details of VA’s distinct features including 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.

The Dental Manual contains the following:

1. Explains policies associated within the CCN program

2. Defines terminology, processes, and interfaces specific to VA

3. Provides information about Veterans

4. Defines VA claims processing logic

5. Provides a description of VA authorization related to various dental services and identification of VA unique features related to coverage and reimbursement Part 1 of the Dental Manual mirrors the structure of the PWS, with corresponding sections. For PWS sections that do not have associated content in the Dental Manual, the corresponding section is marked as “Reserved.” Part 2 of the Dental Manual aligns with the sections outlined in Section B.5, Price/Cost Schedule.

PROJECT MANAGEMENT - RESERVED

Post Award and Contract Kickoff Meetings – RESERVED Integrated Master Schedule – RESERVED Deployment and Implementation – RESERVED Risk Management – RESERVED Contract Performance Management – RESERVED Progress Reporting – RESERVED Service Organization Control Reporting – RESERVED Contractor Maintained Records – RESERVED Administrative Invoices The content in this section of the Dental Manual provides information on the file format and naming conventions for administrative invoices submitted by the Contractor to VA. Information on where to submit administrative invoices can be found in PWS Section 2.9.3.

Table one (1) shows the format used to create the file name. The file name will describe the category of administrative services.

Table 1. File Name Format

*Example of File Name: CCN-Dental-20280801-20280831.txt Table two (2) shows the format used to create the file header format for the administrative invoice.

Table 2. File Header Format

*Example of File Header (first line in file): REGD^20280801^20280831^12345 Table three (3) shows the format used to create the file footer format for the administrative invoice.

Table 3. File Footer Format

*Example of Footer Format (last line in file): Dental^259126.44^12345 Cooperation – RESERVED Transition Out - RESERVED

DENTAL NETWORK DEVELOPMENT AND MAINTENANCE

Dental Network Establishment and Maintenance - RESERVED Dental Provider Network - RESERVED Network Adequacy Management - RESERVED Dental Network Waiver Requests Table four (4) provides an overview of the steps taken to request, review, and communicate VA’s determination of Dental Network Waiver Requests.

Table 4. Dental Network Waiver Request Steps

The Contractor must ensure that the request form is fully and accurately completed. Incomplete or inaccurate submissions will be rejected and returned to the Contractor. In addition to the completed form, the Contractor is required to submit a corresponding comma-separated values (CSV) file containing the responses provided in the form. Both the completed form and the CSV file are mandatory components of a valid submission. The CSV file allows a singular submission for multiple counties and performance objectives (POs) to eliminate administrative burden on the Contractor.

Upon request from VA, the Contractor will provide additional data, clarification, or justification supporting the Dental Network Waiver Request. The Contractor will respond to VA within the timeframes specified in the contract. Dental Network Waiver Requests will be denied if not supported by a valid rationale and evidence or if VA determined that there are adequate providers/facilities to meet network adequacy standards.

Approved Dental Network Waiver Requests are effective as of the date of the approval by VA and will be valid for a maximum of 12 months, expiring on the last day of the preceding month of the following year.

VA will validate any statement or rationale made on a Network Waiver Request. VA may request additional information or evidence to support its Network Waiver Request(s). Network Waiver Requests submitted to VA are not guaranteed to be approved. Network Waiver Requests will be denied if not supported by a valid rationale and evidence or if VA determined that there are adequate providers/facilities to meet network adequacy standards.

Submission of Network Waiver Requests. Potential reasons the Contractor may request Network Waiver include:

1. Scarcity of available health care providers/facilities in the region precludes the Contractor from meeting the network adequacy access standards or the landscape of providers/facilities changed, and certain providers/facilities are not available resulting in the Contractor not meeting the standards.

2. The Contractor proposes to use a Single Case Agreement (SCA) in the cases of Assisted Reproductive Technology (ART)/In Vitro Fertilization (IVF), Transplants, and other services requested by VA.

VA requires conclusive evidence in its Network Waiver Request that the standards cannot be met because of scarcity or changes to the availability of providers/facilities, resulting in insufficient supply.

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

1. Number and geographical distribution of eligible network providers available within the county/parish and specialty referenced in the Network Waiver Request.

2. Prevailing market conditions within the geography and specialty referenced in the Network Waiver Request. The number and distribution of health care providers contracting with other health care plans (both commercial and Medicare) operating in the geography and specialty referenced in the Network Waiver Report Request.

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

4. How significant the Network Waiver Request is from the standards for Veteran access to health care providers including specialties.

Valid Rationales. VA will consider valid rationales for a Network Waiver Request such as, scarcity in specialties or in geographical area and recent changes in an area including, when a provider retires, is retiring soon, or relocates 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. VA will consider a Network Waiver Request when the current standards cannot be met based on provider/facility supply if the request indicates the Contractor is in the process of contracting with providers/facilities.

There are instances when VA will consider the Contractor’s reason for not contracting with a provider/facility that is available. For example, VA will require substantial and credible evidence to validate the potential of a network provider causing Veteran harm as rationale for not contracting with that network provider. The Contractor will select “Other” from the “Reason for Not Contracting” list on the Network Waiver Request Form and provide evidence in the “Additional Notes on Reason for Not Contracting” field.

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

1. Does not contract with any organizations

2. Contracts exclusively with another organization In these circumstances, VA will require substantial and credible evidence to validate the claim. In the “Reason for Not Contracting” list on the Network Waiver Request Form, the Contractor will select either “Provider Does Not Contract with Any Organization” or “Other,” if the provider/facility contracts exclusively with another organization. The Contractor will then provide evidence in the “Additional Notes on Reason for Not Contracting” field. VA will consider evidence including a letter or email from the provider or facility’s office stating the policy and refusal to contract when reviewing the Network Waiver Request.

VA will consider inappropriate credentialing rationale if the Contractor provides substantial and credible evidence. 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 Waiver Request is Being Requested as Appropriate” from the “Reason for Not Contracting” list on the Network Waiver Request Form. The Contractor will provide evidence in the “Additional Notes on Reason for Not Contracting” field. Evidence of inappropriate credentialing may include 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 or similar binding agreement with a provider/facility. VA does not consider “Inability to Contract” as a valid sole rationale for a Network Waiver Request to the network adequacy standards. VA will 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 Waiver 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 not accept claims of interim contracting efforts on a Network Waiver Request. For example, the Contractor selects “In the Process of Negotiating a Contract with Provider” as a “Reason for Not Contracting” on the Network Waiver 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. Upon VA’s decision on a Network Waiver 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 will now meet adequacy standards.

Single Case Agreement and Continuity of Care - RESERVED CCN Next Generation Dental Network Regions - RESERVED Accreditation Accreditation Waiver Process. Below are the business rules for the Contractor to follow related to accreditation waiver requests. Requests should be submitted as needs are identified versus collection (e.g., batching) and submitting in bulk.

Table five (5) outlines additional details for submitting and evaluating accreditation waivers.

Table 5. Accreditation Waiver Steps

· Stated impact to Network Accreditation (e.g., Utilization Review Accreditation Commission (URAC))

· Evidence of efforts to recruit providers that would meet VA accreditation requirements

· Assessment of impact and potential alternatives to waivers (e.g., Veteran will have to drive 100 miles to see a different provider)

· Duration of the waiver request

· How the Contractor proposes to ensure like standard of quality

· Assessing quality of care impacts

· Ensuring waiving of accreditation requirements does not affect other contractual standards, such as business requirements and contractual legal reviews

· Documenting steps and key decisions

· Maintaining decision documentation

Credentialing Table 6 outlines areas of specific interest for credentialing for VA.

Table 6. Areas of Specific Interest for Credentialing

Dental Network Provider Data for VA’s Provider Directory - RESERVED Operations Support - RESERVED

ELIGIBILITY DATA MANAGEMENT

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 (Electronic Data Interchange (EDI) Gateway/Data Access Service (DAS)) between the Contractor and VA, and how the Contractor will manage eligibility files with updated and accurate information. This guidance will enable the Contractor to better configure eligibility data management processes to support VA's processes and ensure Veterans receive timely care from network providers.

Member Information Member information will be configured using the data fields and descriptions, outlined in Dental Manual Section 4, “Eligibility Data Management” to ensure accurate and timely eligibility file updates. Additional guidance for non-standard VA concepts, as well as non-standard interfaces to and from VA for updating specific types of information can also be found in this section.

The DAS Interface Control Document (ICD) outlines eligibility file specification and field-by-field descriptions. VA’s method for transmitting member information will be EDI Gateway/DAS.

Eligibility File Transmission Frequency As Veteran’s VCE codes are updated, prior VCEs for Veterans are maintained to allow for the Contractor to accurately adjudicate claims retroactively.

Table seven (7) outlines high-level details related to the Contractor activities and the outcomes with the daily eligibility file update.

Table 7. Daily Eligibility File Updates

Member Query Queries for a specific member are sent to VA with a standardized format. The standard query format allows VA to exchange member information in a similar manner with multiple Contractors. The query and response will be through EDI Gateway/DAS, based on VA specifications.

Table eight (8) outlines the member file query specification.

Table 8. Member Query Specification

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 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, 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 on 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 Member Address Information VA will provide the member address as the address of record for transmitting information, Explanation of Benefits (EOB), or other information. Table 9. VA Address Types outlines the member address types provided by VA to the Contractor.

Table 9. VA Address Types

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. Use of the VCE code that indicates the broadest eligibility for services or that aligns best with the VA-approved referral should be used.

Table 10 outlines the complete listing of VCE codes that will be provided by VA to the Contractor.

Table 10. Description of Veteran Eligibility Codes

Note:

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

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

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

Geocoding processing times are CST zone.

This population includes Veterans and non-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 or 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.

For COMPACT Act 2020, eligible Individuals are ones who served in the active military service, regardless of length of service, and who were discharged, excluding anyone who received a dishonorable discharge or was discharged or dismissed by reason; are not enrolled in the VA health care system established by 38 USC 1705; and served in the Armed Forces for a period of more than 100 cumulative days; and was deployed in a theater of combat operations; or while serving in the Armed Forces, was the victim of a physical assault of a sexual nature, a battery of a sexual nature, or sexual harassment.

Note: Updates to the VCE code list are rare, but will be communicated prior to the update, through established communication with VA as well as in the Dental Manual.

CUSTOMER SERVICE - RESERVED

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 acts 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 a referral and authorization information system that allows the network provider to view a Veteran’s electronic health record. This system can also track referral workflows and exchange data and documentation between VA and network providers, which improves care coordination among VA, the Contractor, and the network provider.

It is essential that the network provider verifies and obtains the necessary authorization for dental services before providing care.

When medical services are necessary for your dental patient, an approved medical referral, which is a separate referral from the dental referral, is required before delivering the services.

Figure 2 below outlines the referral process and associated downstream actions.

Figure 2. Dental Referral Process 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 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, and 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 Referral 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:

1. https://www.va.gov/COMMUNITYCARE/docs/providers/HSRM-Quick-Reference-Guide.pdf

2. https://www.va.gov/COMMUNITYCARE/docs/providers/HSRM-User-Guide.pdf 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:

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

2. Validating and matching services billed against what is authorized on the VA-Approved Referral

3. Ensuring the correct Dental VA Fee Schedule (DVAFS) rate is applied when paying claims Table 11 provides an example of information within a Dental Treatment Plan.

Table 11. Example of Dental Treatment Plan

Extraction Code Set (D7140, D7210, D7250)

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 EDI 278 transaction, ensuring all the required information from the ADA Dental Claim Form is included, as well as all supporting documentation for the requested services. Additional detail related to the ADA Dental Claim form can be found in Dental Manual Section 9.2.2, “VA-Specific Instructions for Completing the 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 to Community Care and the network provider seeks to provide services not included in the applicable VA-Approved Referral.

Figure 4. Dental Request for Services Process Table 12 provides additional details regarding the process of transmitting an RFS.

Table 12. Process for Transmitting Requests for Services

Note: The Contractor will not process a Statement of Actual Services as an RFS. The Statement of Actual Services will be processed as a claim(s).

For additional information refer to Medical Manual Section 9.2.2, “VA-Specific Instructions for Completing the ADA Dental Claim Form” and Appendix C: Dental Code Sets.

For additional information refer to Medical Manual Section 9.2.2, “VA-Specific Instructions for Completing the ADA Dental Claim Form” and Appendix C: Dental Code Sets.

Request for Service Statuses. VA is making high level recommendations below to align terminology with the Contractor, as shown in Table 13.

Table 13. RFS Statuses

Canceled Contractor canceled the RFS at the provider’s request.

Once the accuracy and completeness of the RFS is accepted by the Contractor, the Contractor will send to VA or move to Contractor Utilization Review.

An Urgent RFS is a request submitted to address dental conditions requiring prompt attention to relieve severe pain, mitigate the risk of infection, and prevent the condition from worsening into a more serious or emergent state. This request aims to ensure timely intervention for immediate dental issues to alleviate discomfort and avoid potential complications.

A Standard RFS is a request submitted for dental services for treatment of non-urgent conditions aimed at maintaining overall dental health and preventing future issues.

PHARMACY - RESERVED

MEDICAL DOCUMENTATION - RESERVED

CLAIMS PROCESSING AND ADJUDICATION FOR DENTAL NETWORK SERVICES RENDERED

The Claims Processing and Adjudication section details claims management, from claims intake processing through pricing and payment, to ensure the Contractor 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).

Claims Submission and Processing Timeframes Timely Filing. Timely filing is 180 days from the date of service. 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 to the Contractor. The Contractor may continue to process and adjudicate claims that are not submitted within the 180 day deadline when the Contractor determines an allowed exception condition (listed below) is detected.

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

1. 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, and submits the remittance advice document to VA as justification.

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

3. When VA directs the Contractor to reprocess claims, even if reprocessing occurs beyond the timely filing deadline.

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.

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 and appropriate payments to the network provider, and sends an invoice for reimbursement to VA.

Figure 5 and Table 14 depict a scenario for when a network provider submits a claim to the Contractor that passes the Clearinghouse, Gateway or 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 it be, construed as a requirements or sequencing presentation.

Figure 5.Claim Edit Scenario (Clean Claim) Table 14. Claim Edit Scenario (Clean Claim)

EDI 837D

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)

EDI 837D

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

EDI 837D Coordination of Benefits (COB)

VA-Specific Instructions for Completing the ADA Dental Claim Form The Contractor will comply with ADA and VA-specific requirements related to claim submission. 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 Contractor will notify the claimant 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. For additional information, refer to Dental Manual Section 6.1, “Request for Services (RFS).”

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 must be 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:

1. Header information (fields 1 and 2)

2. Dental benefit plan information (field 3)

3. Policy holders/subscriber information (fields 12 through 15)

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

5. Ancillary claim/treatment information (field 38)

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

7. 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:

1. Other coverage (fields 4, 5, 8 through 11)

2. Patient ID/account number (field 23)

3. Record of service provided (fields 25 through 28, 29a, 34, 34a) Table 14. Claims Processing Information Fields with VA-Specific Instructions

Predetermination/Preauthorization Number

Policyholder/Subscriber Identification (ID)

Place of Treatment

Billing and Treating National Provider Identifiers (NPI)

Treatment Location

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.

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 others will require line-by-line as outlined in Table 15. Claims not meeting these validations standards will be rejected.

Table 15. Level of Review

Claim Edits and Validation The network provider submits the EDI 837D transaction using the format and values as described by the Contractor and industry standard guidelines. VA also requires specific situational attributes to be included in claims submitted by the network provider.