Attachment 2 CCN Next Gen West Medical Network Contractor Manual.docx

DEPARTMENT OF VETERANS AFFAIRS

VHA Office of Integrated Veteran Care Integrated External Networks

Community Care Network Next Generation Medical Network West Contractor Manual

Version 4.0 May 29, 2025

TABLE OF CONTENTS

PRE-DECISIONAL DRAFT

Do Not Disclose – Source Selection Sensitive Information See FAR 2.101 and FAR 3.104 PRE-DECISIONAL - For VA Internal Planning Purposes Only

PART 1: PERFORMANCE WORK STATEMENT SECTIONS

General Information - RESERVED Introduction The Community Care Network (CCN) Next Generation Contractor Medical Manual, hereinafter referred to as the Medical 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 Medical Network Contractors (Contractor). The CCN Medical Network Performance Work Statement (PWS) provides the requirements for the Contractor and is the primary authority for operational requirements.

The Medical Manual is intended to deliver detailed information to the Contractor to properly configure its health care administration systems to validate and process claims accurately and in a timely manner. It also provides the Contractor with a details of the VA’s distinct features including health 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 Medical Manual contains the following:

· Explanation of policies associated within the CCN program

· Defines terminology, processes, and interfaces specific to VA

· Provides information about Veterans and Collateral of Veterans

· Defines VA claims processing logic

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

VA expects there may be Medical 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 CO will administer guidelines or instructions in the form of a VA CO technical direction letter.

Scope of Services - RESERVED Applicable Documents - RESERVED

PROJECT MANAGEMENT - RESERVED

Post Award and Contract Kickoff Meetings - RESERVED Integrated Master Schedule (IMS) - RESERVED Deployment and Implementation - RESERVED Risk Management - RESERVED Contract Performance Management - RESERVED Quality Assurance Surveillance Plan (QASP) - RESERVED Quality Assurance Program and Plan - RESERVED Quality Improvement Plan - RESERVED Progress Reporting - RESERVED Service Organization Control (SOC) Reporting - RESERVED SOC 1 and SOC 2 Reporting Specifications and Deliverables - RESERVED Contractor Maintained Records - RESERVED Cooperation - RESERVED Transition Out - RESERVED Medical network development and maintenance - RESERVED Medical Network Establishment and Maintenance - RESERVED Medical Network Adequacy Plan - RESERVED

Medical Provider Network - RESERVED Mobile Healthcare Services - RESERVED Network Adequacy Management - RESERVED Medical Network Deviation Requests Below outlines the process for a Contractor’s Network Deviation Request:

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

2. VA will receive and evaluate the Network Deviation Request Form

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

Scarcity of available health care providers/facilities in the region 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.

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

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 the 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:

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. The number and distribution of healthcare providers contracting with other healthcare plans (both commercial and Medicare) 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 healthcare providers including specialties.

Valid Rationales. VA will consider valid rationales for a Network Deviation Request such as, scarcity in specialties or in geographical area and recent changes in an area including, but not limited to, 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 Network Deviation Request when the current Drive Time 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 provider., The Contractor will select “Other” from the “Reason for Not Contracting” list on the Network Deviation 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 Deviation if a provider/facility:

Does not contract with any organizations 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 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 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. 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” from the “Reason for Not Contracting” list on the Network Deviation Request Form. 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 or similar binding agreement 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 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 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. 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 will now meet adequacy standards..

Single Case Agreement (SCA) and Continuity of Care In accordance with the requirement established the PWS, the Contractor will need to establish an SCA with a community provider when that provider is not part of the Contractor’s network. An SCA is a one-time contractual agreement between the Contractor and an out-of-network provider that allows a Veteran to receive care from a provider not in the Contractors’ network and the out-of-network provider to receive claims payment from the Contractor consistent with terms set in the PWS. An SCA is applicable to a single Veteran for a single episode of care and terminates immediately following completion of the Veteran’s episode of care.

The following business rules will be applied in instances where the use of an SCA is required:

VA will provide the Contractor with the preferred health care provider information (full name and demographics) using the Contractor Developed and VA Approved Template and transmit it to the Contractor through VA’s referral management system.

If a provider is identified as in-network, the Contractor will notify VA, and the VA established referral process will be followed.

If VA does not provide a preferred health care provider, the Contractor will provide VA with a list of applicable providers authorized to provide the required services.

Once VA and the Contractor have agreed to use a specific provider, the Contractor will provide VA a copy of the signed SCA notification.

If an agreement cannot be reached between the Contractor and the targeted SCA provider, the Contractor will engage VA with additional providers for consideration.

The Contractor’s SCA template contains provisions including, but not limited to, the following:

Acceptance of payment as set forth in the PWS Requirement for a VA Approved Referral to provide care Provision of Medical Documentation for clinical care rendered to the Veteran or Collateral of a Veteran Agreement to not bill or attempt to collect payment from the Veteran or Collateral of a Veteran Table 1 summarizes the process for identifying when a SCA is required, the use of the SCA, and referencing of the SCA as part of the claims adjudication process. The steps below are not intended to be exhaustive but rather provide the Contractor with a general sequence of steps to guide use and management of SCAs.

Table 1. SCA Steps

VA transmits a VA Approved Referral to the Contractor with no provider identified.

The Contractor contacts VA referring facility and identifies the required provider.

Or Provider elects to leave the Contractor’s provider network during an active VA Approved Referral and episode of care.

VA requests the Contractor add a specific provider using SCA.

CCN Next Generation Regions - RESERVED Accreditation Accreditation Waver 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 2 outlines additional details for submitting and evaluating accreditation waivers.

Table 2. 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 This section provides additional guidance regarding credentialing of providers, including required data, identifying high performing providers, managing required updates from network providers, and exchanging information with VA.

Table 3 outlines areas of specific interest credentialing for VA.

Table 3. Areas of Specific Interest for Credentialing

Medical Network Provider Data for VA’s Provider Directory - RESERVED Operations Support - RESERVED CCN Health Benefit Package - RESERVED CCN Medical Network Healthcare Services - RESERVED CCN Complimentary and Integrated Healthcare Services - RESERVED Community Nursing Home Care - RESERVED Nursing Home Quality Standards After go-live, VA will review Medicare Nursing Home Compare scores every 180 calendar days. During these reviews, nursing homes identified with star ratings below VA standards will require new waiver determinations. VA will initiate the waiver process and notify the Contractor of the waiver determination.

VA may initiate a waiver exception request to include one- or two-star facilities for inclusion in the network based on VA’s needs.

If VA determines that network adequacy cannot be met for nursing homes due to the exclusion of nursing homes below the above thresholds, VA will initiate a waiver exception using the VHA CCN Community Nursing Home (CNH) Star Rating Waiver Request Form.

The Contractor will be notified if a community nursing home with a one-or two-star rating is approved for network recruiting efforts. Nursing homes approved through a waiver require accreditation through CARF and/or appropriate accrediting entities. Waivers are valid for 12 months from the date of approval.

Care Coordination - RESERVED Death of a Veteran – RESERVED Dialysis - RESERVED Transplants - RESERVED VA Approved Referral and Authorization - RESERVED Transplant Network Compliance - RESERVED CTC Evaluation and Monitoring Program - RESERVED CTC Quality Monitoring Program - REERVED Transplant Center Quarterly Status Monitoring Report Submission - RESERVED Timeliness Standards – RESERVED Durable Medical Equipment - RESERVED Urgent/Emergent Prescriptions for DME and Medical Devices - RESERVED DME for Discharge - RESERVED Routine Prescriptions for DME and Medical Devices - RESERVED Oral Appliance Therapy (OAT) for Obstructive Sleep Apnea (OSA) - RESERVED Home Infusion Therapy - RESERVED Custom Hand Splints - RESERVED Eyeglasses and Specialty Lenses - 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 Collateral of Veteran 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. This guidance will enable the Contractor to better configure eligibility data management processes to support VA's processes and ensure Veterans and Collateral of 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 USC 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).

Collateral of Veteran: An eligible family member or other individual (e.g., organ donor) who is seen by VA either within a VA facility or non-VA facility for reasons relating to Veteran’s clinical care or military service (e.g., infertility services).

Member: A Veteran or Collateral of Veteran is 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).

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 such as Collateral of Veteran, 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., Electronic Data Interchange (EDI) 834).

Eligibility File Transmission Frequency 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. The initial load will also include Collateral of Veterans with active VCE codes.

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

As Veteran’s and Collateral of Veteran’s VCE codes are updated, prior VCEs for Veterans and Collateral of Veterans are maintained to allow for the Contractor to accurately adjudicate claims retroactively.

Table 4 outlines high-level details related to the Contractor activities and the outcomes with the daily eligibility file update.

Table 4 - Daily Eligibility File Updates

Member Query to VA 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.

Table 5. Member Query Specification outlines the member file query specification.

Table 5. 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, 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 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 6. VA Address Types outlines the member address types provided by VA to the Contractor.

Table 6. VA Address Types

Collateral of Veteran VA defines an eligible Veteran in VA’s member enrollment system, established and operated under 38 USC § 1705, and may provide the Collateral of Veteran (in conjunction with the Veteran’s treatment), with services through the CCN. The Collateral of Veteran is defined according to the services provided and will be linked to the Veteran through a relationship to the Veteran. The Collateral of Veteran identification process will be followed, even if the Collateral of Veteran receiving care is a Veteran.

Table 7. Description of Collateral of Veterans outlines a list of collateral types and the valid relationship types between the Collateral of Veteran and the Veteran and the valid VCE code.

Table 7. Description of Collateral of Veterans

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 8. Description of Veteran Eligibility Codes outlines the complete listing of VCE codes that will be provided by VA to the Contractor.

Table 8. 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 Central Standard Time (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 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.

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.

ART includes all treatments or procedures that include the In vitro handling of both human oocytes and sperm, or of embryos, for the purpose of establishing a pregnancy. This includes, but is not limited to:

IVF

Embryo transfer Gamete intrafallopian transfer Zygote intrafallopian transfer Tubal embryo transfer Gamete and embryo cryopreservation, oocyte and embryo donation, and gestational surrogacy

Newborn care and post-delivery care for a newborn child for the date of birth plus seven calendar days after the birth of the newborn when the birth mother is a female Veteran enrolled in VA health care and receiving maternity care furnished by VA or under authorization from VA and the child is delivered either in a VA facility, or in another facility pursuant to a VA authorization for maternity care at VA expense.

The VHA Transplant Program consists of solid organ (e.g., kidney, liver, heart, lung, kidney, and/or pancreas) and bone marrow/stem cell life-saving procedures.

Customer Service - RESERVED Contractor Contact Center - RESERVED Contractor Contact Center Support to VA Staff - RESERVED Urgent Care (UC) Inquiries - RESERVED Contractor Contact Center Supporting Network Providers - RESERVED After-Call Surveys - RESERVED Contractor Contact Center Training Materials and Response Scripts - RESERVED Contractor Contact Center Testing and Full Operating Capability - RESERVED Contractor Self-Service Capabilities - RESERVED Contractor IVR with Self-Service Capabilities - RESERVED Contractor Self-Service Portal - RESERVED Medical Network Provider Attestation – RESERVED Medical Network Provider Profile Attestation – RESERVED Medical Network Provider Profile Quarterly Attestation – RESERVED Contractor Self-Service Portal and VA-Provided Referral and Authorization System - RESERVED Contractor Self Service Portal Testing and Full Operational Capability - RESERVED Contractor Use of VA-Provided Ticketing Tool - RESERVED Information Technology Support - RESERVED Medical Network Provider Satisfaction Surveys - RESERVED Contractor Customer Service Quality Assurance - RESERVED Customer Service Performance Requirements and Reporting - RESERVED Contractor Contact Center Performance Requirements - RESERVED Contractor Self-Service Portal Performance Requirements - RESERVED Medical Network Customer Service Performance Report - RESERVED Referrals - RESERVED VA Referral Process. This section provides process descriptions and models for VA Approved Referrals that address scenarios when the network provider does not request deviations from the VA Approved Referral.

VA will send the VA Approved Referral to the network provider and Contractor via an EDI 278 transaction (preferred), secure fax, or email. The Contractor stores or records the VA Approved Referral (e.g., code sets, effective date, termination date, date generated) to support authorization of care and to validate and adjudicate claims.

Referral Validation. VA will issue a VA Approved Referral and provide the Contractor with authorization and referral to allow them to properly adjudicate claims. The Contractor’s process should include, but is 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 for RFS Utilization Management processes and potential multiple referrals and authorization Ensuring the correct fee schedules are used to pay claims Authorized Care with No Deviation. In this scenario, VA makes a referral to a network provider and sends a copy to the Contractor, care is rendered consistent with the VA Approved Referral, and a claim is submitted with the referral number. The following figure and table are not requirements.

Upon receipt of a consult order or referral request from the Veteran’s provider, VA will review the order and approve the services, assist the Veteran in selecting or identifying a network provider, select the appropriate referral and authorization, and prepare the necessary documentation detailing the procedures and services being referred that will accompany the VA Approved Referral. In most cases, VA will also assist the Veteran with scheduling the appointment. When these activities are completed, 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.

Figure 2 outlines the referral process and associated downstream actions and Table 9 captures each activity and associated downstream outcomes. The table is not a requirement.

Figure 2. Referral Scenario (No Deviation) Table 9. Referral Scenario Activity and Outcomes

EDI 278, secure fax, secure email, or message.

The VA Approved Referral is also sent to the Contractor to be utilized for referral validation and claims adjudication.

EDI 278.

EDI 837.

EDI 835 RA, ACH.

EDI 837COB.

Request…