Attachment 2 CCN Next Generation West Medical Contractor Manual.pdf

DEPARTMENT OF VETERANS AFFAIRS

VHA Office of Integrated Veteran Care

Integrated External Networks

Community Care Network Next Generation Medical Network

Contractor Manual

Version 5.0 September 10, 2025 ii

TABLE OF CONTENTS

PART 1: PERFORMANCE WORK STATEMENT SECTIONS

1 GENERAL INFORMATION

1.1 Introduction - RESERVED

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 – RESERVED

2.3 Deployment and Implementation – RESERVED

2.4 Risk Management – RESERVED

2.5 Contract Performance Management – RESERVED

2.6 Progress Reporting – RESERVED

2.7 Service Organization Control Reporting – RESERVED

2.8 Contractor Maintained Records – RESERVED

2.9 Administrative Invoices

2.10 Cooperation – RESERVED

2.11 Transition Out - RESERVED

3 MEDICAL NETWORK DEVELOPMENT AND MAINTENANCE - RESERVED

3.1 Medical Network Establishment and Maintenance - RESERVED

3.2 Medical Provider Network - RESERVED

3.3 Network Adequacy Management - RESERVED

3.3.1 Medical Network Waiver Requests

3.3.2 Single Case Agreement and Continuity of Care - RESERVED iii

3.4 CCN Next Generation Medical Network Regions - RESERVED

3.5 Accreditation

3.6 Credentialing

3.7 Medical Network Provider Data for VA’s Provider Directory – RESERVED

4 CCN HEALTH BENEFIT PACKAGE - RESERVED

4.1 CCN Medical Network Healthcare Services - RESERVED

4.2 CCN Complimentary and Integrated Healthcare Services – RESERVED

4.3 Urgent Care - RESERVED

4.4 Community Nursing Home Care - RESERVED

4.4.1 Nursing Home Quality Standards

4.4.2 Care Coordination - RESERVED

4.4.3 Death of a Veteran – RESERVED

4.5 Home Health Care - RESERVED

4.6 Dialysis - RESERVED

4.7 Organ Donation and Transplants - RESERVED

4.8 Durable Medical Equipment - RESERVED

4.9 Emergency Care - RESERVED

5 ELIGIBILITY DATA MANAGEMENT

5.1 Member Information

5.2 Eligibility File Transmission Frequency

5.3 Member Query to VA

5.4 Member Address Information

5.5 Eligible Individual

5.6 Veteran Community Care Eligibility Codes

iv

6 CUSTOMER SERVICE - RESERVED

7 REFERRALS

7.1 Request for Services (RFS)

7.2 Emergency Care

7.2.1 Notification Procedure Upon Veteran Self-Presentation to In-Network Emergency Care Facility .. 28

7.2.2 Inpatient Admissions - RESERVED

7.3 Urgent Care

8 UTILIZATION MANAGEMENT

8.1 UM Accreditation - RESERVED

8.2 Clinical Criteria for UM Decisions, Utilization Review, and Referrals - RESERVED

8.2.1 Medical Necessity Criteria - RESERVED

8.2.2 Interrater Reliability (IRR) - RESERVED

8.2.3 Utilization Management Review

8.2.4 Inpatient Utilization Management Review

8.2.5 Outpatient Utilization Management Review - RESERVED

8.3 Communication Services - RESERVED

8.4 Appropriate Professionals - RESERVED

8.5 Timeliness of UM Recommendations - RESERVED

8.6 Clinical Information (Relevant Information for Decisions) - RESERVED

8.7 Appeals Process (Restrictions) - RESERVED

8.8 Pharmaceutical Management - RESERVED

8.9 VA Audits - RESERVED

9 PHARMACY - RESERVED

9.1 Retail Immediate Need Pharmacy - RESERVED

9.1.1 VA Formulary Management - VA Urgent/Emergent Formulary

9.1.2 Pharmacy Eligibility Data Management

9.1.3 Urgent/Emergent Prescriptions

9.1.4 Urgent/Emergent Prescription Performance Metrics – RESERVED v

9.1.5 Prior Authorization

9.1.6 IVF and Infertility Prescriptions – RESERVED

9.1.7 Contingency Plan for Disaster Response

9.1.8 Vaccinations

9.1.9 Refunds and Reimbursements - RESERVED

9.2 Real-Time Pharmacy – RESERVED

9.3 Routine/Maintenance Prescriptions

9.4 Medical Benefit - RESERVED

9.4.1 Specialty Pharmacy

10 MEDICAL DOCUMENTATION - RESERVED

11 CLAIMS PROCESSING AND ADJUDICATION FOR MEDICAL NETWORKS SERVICES

RENDERED

11.1 Claims Submission and Processing Timeframes

11.2 Claims Processing and Adjudication

11.2.1 Claims Processing

11.2.2 Claims Adjudication

11.2.3 NCPDP Transactions and Claims Processing, Management, and Payment

11.3 Electronic Visit Verification (EVV)

11.4 Claims Reprocessing and Adjustment - RESERVED

11.5 Medical Network Provider Claim Appeals - RESERVED

11.6 Test Claim Tracers

11.7 Claims Reporting - RESERVED

11.8 Claims for Services Rendered to Veterans Assigned to Other CCN Region - RESERVED

12 REIMBURSEMENT SUBMISSION TO VA

12.1 Resubmission of Claim Invoices Processed by VA

12.2 Invoicing Accuracy - RESERVED

12.3 Accounting and Access to Records - RESERVED

vi

13 COORDINATION OF BENEFITS (COB) - RESERVED

14 PROGRAM INTEGRITY

14.1 Timelines for Fraud, Waste, and Abuse Cases

14.2 Prohibited Actions – RESERVED

14.3 Compliance with the False Claims Act - RESERVED

14.4 Fraud, Waste, and Abuse Flags - RESERVED

14.5 Predictive Analytics and Machine Learning to Identify and Combat Fraud, Waste, and Abuse -

RESERVED

14.6 Post Payment Review to Combat Fraud, Waste, and Abuse - RESERVED

14.7 Support for Investigative Agencies on Fraud, Waste, and Abuse Cases - RESERVED

14.8 Fraud, Waste, and Abuse Training and Education Program for Network Providers - RESERVED

14.9 Recovery and Recoupment Actions Related to Fraud, Waste, and Abuse Cases - RESERVED

14.10 Payment Suspension and Termination of Network Agreements Due to Fraud, Waste, and Abuse 1

14.11 Payment Integrity

14.12 Cost Avoidance, Recovery, and Recoupment Reports - RESERVED

14.13 Program and Payment Integrity Site Visits - RESERVED

15 CLINICAL QUALITY AND PATIENT SAFETY MONITORING

16 TECHNOLOGY - RESERVED

17 TRAINING - RESERVED

18 OPTIONAL TASKS - RESERVED

PART 2: B.5 SUPPLIES OR SERVICES AND PRICE/COST

B.5.2 VA Payment Hierarchy B.5.3.1 Waivers of Payment Rates – RESERVED vii

B.5.3.2 Computation of “Lesser of” Payment Rates – RESERVED B.5.3.3 Medicare Rates B.5.3.4 VA Fee Schedule B.5.3.5 Alaska Payment Hierarchy B.5.3.6 Pricing and Coverage Deviations Clinical Determinations and Indications List

1. ART/IVF and Other Infertility Services

2. Chimeric Antigen Receptor T-cell Biologic Infusion Therapy

3. Complementary and Integrative Health Services

4. Laser Hair Removal and Electrolysis

5. Dialysis

6. Durable Medical Equipment

7. Emergency Care

8. Home Health Care

9. Home Infusion Therapy

10. Intensity-Modulated Radiotherapy

11. Residential Rehabilitation Treatment Programs

12. Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP)

13. Skilled Nursing Facility – Community Nursing Home

14. Telehealth Payment

15. Live Donor Transplant

16. Vision/Eye Care viii

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

For VA Internal Planning Purposes Only

PART 1: PERFORMANCE WORK STATEMENT SECTIONS

1 GENERAL INFORMATION

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 Contractor(s) (Contractor). The CCN Next Generation Medical Network – East and CCN Next Generation Medical Network – West Performance Work Statements (PWSs) provide the requirements for the Contractor and is the primary authority for operational requirements.

VA intends to deliver detailed information to the Contractor, through the Medical Manual, 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 details of 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:

1. Explains policies associated within the CCN program

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

3. Provides information about Veterans and eligible individuals

4. Defines VA claims processing logic

5. 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 Manual mirrors the structure of the PWS, with corresponding sections. For PWS sections that do not have associated content in the Medical 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.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

1.1 Introduction - RESERVED

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 – RESERVED

2.3 Deployment and Implementation – RESERVED

2.4 Risk Management – RESERVED

2.5 Contract Performance Management – RESERVED

2.6 Progress Reporting – RESERVED

2.7 Service Organization Control Reporting – RESERVED

2.8 Contractor Maintained Records – RESERVED

2.9 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

Field Name Field Format Sample Data

CCN Text CCN

Region Designation Text Dental

Invoice Start Date Date 20280801

Invoice End Date Date 20280831

File Extension Text .TXT *Example of File Name: CCN-Dental-20280801-20280831.txt

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Table two (2) shows the format used to create the file header format for the administrative invoice.

Table 2. File Header Format

Field Name Field Format Field Contents Sample Data

Region Designation Text Alpha Numeric Dental

Invoice Start Date Date CCYYMMDD 20280801

Invoice End Date Date CCYYMMDD 20280831

Number of Enrolled Veterans Billed this Month

Numeric Count of enrolled and eligible members for this month

12345

*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

Field Name Field Format Field Contents Sample Data

Region Designation Text Alpha Numeric Dental

Total Invoice Amount Billed Accounting Numeric with 2-digit decimal 259126.44

Total Number of Enrolled Veterans Numeric Should match enrolled

Veteran count in Header 12345

*Example of Footer Format (last line in file): Dental^259126.44^12345

2.10 Cooperation – RESERVED

2.11 Transition Out - RESERVED

3 MEDICAL NETWORK DEVELOPMENT AND MAINTENANCE - RESERVED

3.1 Medical Network Establishment and Maintenance - RESERVED

3.2 Medical Provider Network - RESERVED

3.3 Network Adequacy Management - RESERVED

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

3.3.1 Medical Network Waiver Requests

Table 1 provides an overview of the steps taken to request, review, and communicate VA’s determination of Medical Network Waiver Requests.

Table 4 - Medical Network Waiver Request Steps

Sequence Step Step Description

Submission of Medical Network Waiver Request

The Contractor initiates the process by submitting a Network Waiver (Attachment G, “Medical Network Waiver Request form”) to VA through the platform specified by the VA. Example platforms include Microsoft Dynamic or secure messaging platforms.

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.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Sequence Step Step Description

VA review of Medical Network Waiver Request Form

VA will review and ensure that the Network Waiver Request submitted by the Contractor is complete, accurate, and meets the necessary criteria for review and consideration. Medical Network Waiver Requests submitted to VA are not guaranteed to be approved.

Upon request from VA, the Contractor will provide additional data, clarification, or justification supporting the medical network waiver request. The Contractor will respond to VA within the timeframes specified in the contract. Medical 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.

VA Will Inform the Contractor of the Final Determination

Upon the VA’s decision on a Medical Network Waiver Request, the Contractor will receive an electronic notification from the VA indicating approval or denial of the request. The notification will include the effective date and termination date of the waiver, as well as the type of care to which will now meet adequacy standards. The Contractor is responsible for tracking and reporting types of care meeting alternate network adequacy standards due to an approved Medical Network Waiver.

Approved Medical 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

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

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 healthcare 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

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only 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 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 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 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.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

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.

3.3.2 Single Case Agreement and Continuity of Care - RESERVED

3.4 CCN Next Generation Medical Network Regions - RESERVED

3.5 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 2 outlines additional details for submitting and evaluating accreditation waivers.

Table 5 - Accreditation Waiver Steps

Sequence Step Waiver Process Description

1 Individual Waiver Request

Proposal including alternative qualification standards.

• Stated impact to Network Accreditation (e.g., See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Sequence Step Waiver Process Description

Preparation 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

2 Waiver Submission

The Contractor submits the waiver request to VA Contracting Officer (CO) via secure email.

VA Assessment of Waiver Request

VA conducts a multi-part assessment, including:

• 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

VA Notification of Waiver Assessment Decision

The VA COR notifies the Contractor through a formal memorandum of approval or denial of the waiver request.

3.6 Credentialing

Table 3 outlines areas of specific interest for credentialing for VA.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Table 6 - Areas of Specific Interest for Credentialing

Credentialing Interest Area Description

Hospital Accreditation Joint Commission (JC) and Accreditation Association for Hospitals/Health Systems (AAHHS) or equivalent accrediting entity.

Rehabilitation Facilities Accreditation

Commission on Accreditation of Rehabilitation Facilities (CARF). Waivers required when Medicare Nursing Home Compare scores fall below threshold.

Potential Prohibition from Network Participation

Verify provider is not on the Health and Human Services (HHS) Office of the Inspector General (OIG) exclusionary list, System for Award Management (SAM) exclusionary list, and unsuitable providers exclusionary list.

Services Outside Provider’s Scope of Practice Including Certified Medical Examiners for the Federal Motor Carrier Safety Administration

Requires validation through the credentialing process.

Compliance Programs

Confirm that all health care providers, practitioners, and facilities follow all elements of the HHS OIG compliance program guidance for hospitals. For additional information, refer to https://oig.hhs.gov/compliance/general-compliance-program-guidance/.

Continuous Query (CQ) Monitoring

Ensure network providers undergoing initial credential verification by the National Practitioner Data Bank (NPDB), established under the Health Care Quality Improvement Act of 1986 and the Joseph Maxwell Cleland and Robert Joseph Dole Memorial Veterans Benefits and Health Care Improvement Act of 2022 (Cleland-Dole Act) will be enrolled

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Credentialing Interest Area Description in CQ monitoring.

Providers with No National Accreditation Standards

Conduct comprehensive background and evaluation.

Tribal Health Care Providers (THP), Federally Qualified Healthcare Centers (FQHCs), and Academic Teaching Facilities

THPs, FQHCs, and Academic Teaching Facilities are encouraged to be added to the network.

3.7 Medical Network Provider Data for VA’s Provider Directory – RESERVED

4 CCN HEALTH BENEFIT PACKAGE - RESERVED

4.1 CCN Medical Network Healthcare Services - RESERVED

4.2 CCN Complimentary and Integrated Healthcare Services – RESERVED

4.3 Urgent Care - RESERVED

4.4 Community Nursing Home Care - RESERVED

4.4.1 Nursing Home Quality Standards

When VA receives the quarterly report detailing all community nursing homes in its network along with their Medicare Nursing Home Compare star ratings (Deliverable: X), any nursing homes identified with star ratings below VA standards will necessitate 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 (1)- or two (2)-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 aforementioned thresholds, VA will initiate a

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only 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 (1)-or two (2)-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.

4.4.2 Care Coordination - RESERVED

4.4.3 Death of a Veteran – RESERVED

4.5 Home Health Care - RESERVED

4.6 Dialysis - RESERVED

4.7 Organ Donation and Transplants - RESERVED

4.8 Durable Medical Equipment - RESERVED

4.9 Emergency Care - RESERVED

5 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 eligible individual 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 and eligible individual receive timely care from network providers.

5.1 Member Information

Member information will be configured using the data fields and descriptions, outlined in Medical Manual Section 5, “Eligibility Data Management” to ensure accurate and timely eligibility file updates. Additional guidance for non-standard VA concepts such as eligible individual, as well as non-standard interfaces to and from VA for updating specific types of information can also be found in this section.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

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.

5.2 Eligibility File Transmission Frequency

As Veteran’s and eligible individual’s VCE codes are updated, prior VCEs for Veterans and eligible individuals 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 7 - 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 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

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Sequence Activity Outcome 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 and eligible individual will be maintained.

5.3 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. The query and response will be through EDI Gateway/DAS, based on VA specifications.

Table 5 outlines the member file query specification.

Table 8 - Member Query Specification

Field Data Type Field Length Description

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

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Figure 1 Member Update Query

5.4 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 outlines the member address types provided by VA to the Contractor.

Table 9 - 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.

5.5 Eligible Individual

VA defines an eligible Veteran in VA’s member enrollment system, established and operated under 38 USC § 1705, and may provide the eligible individual (in conjunction

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only with the Veteran’s treatment), with services through the CCN. The eligible individual is defined according to the services provided and will be linked to the Veteran through a relationship to the Veteran. The eligible individual identification process will be followed, even if the eligible individual receiving care is a Veteran.

Table 7 outlines a list of eligible individual types and the valid relationship types between the eligible individual and the Veteran and the valid VCE code.

Table 10 - Description of Eligible Individual

Eligible Individual Type

VCE

Code

Relationship to Veteran

Definition

ART/IVF A Spouse or Partner

The eligible individual is a legally married or unmarried, opposite-sex or same-sex partner of the eligible Veteran.

Marriage/Family Counseling C

Mother, Father, Child, Stepdaughter/Stepson, Legal Guardian, Spouse, Life Partner, Caregiver, or any member of the Veteran’s household

The eligible individual is a member of the Veteran’s immediate family, the legal guardian of a Veteran, a family caregiver of An eligible Veteran, or an individual who certified an intention to live in the Veteran’s household. The eligible individual is seen by a professional for reasons relating to the Veteran’s clinical care.

Newborn I Child

The eligible individual is a child whose birth mother is the eligible female Veteran, and who has not exceeded the date of birth plus seven consecutive calendar days.

Transplant T Live Organ Donor or potential organ donor

For solid organ or non-registry bone marrow transplant, the eligible individual is a clinically approved, individual donor who

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Eligible Individual Type

VCE

Code

Relationship to Veteran

Definition volunteered to donate a solid organ, part of a solid organ, or bone marrow to an identified Veteran transplant recipient and provided informed consent to undergo elective removal of a solid organ, part of a solid organ, or bone marrow.

5.6 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 8 outlines the complete listing of VCE codes that will be provided by VA to the Contractor.

Table 11 - 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 eligibility;

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.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

VCE VCE

Code Description

Hardship H

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

Veterans who meet 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 (six months or twelve 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.

Urgent Care U Enrolled Veterans who received care through VA from either a VA or network provider within the past 24 months.

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. These Veterans are eligible for episodic care and flu shots.

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.

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 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

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

VCE VCE

Code Description 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/IVF A

Eligible individual who is a legally married or unmarried, opposite-sex or same-sex partner of the eligible Veteran.

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

Marriage/Family C Eligible individual who is a family member or other responsible person (e.g., Parent, Child, See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

VCE VCE

Code Description

Counseling Stepdaughter/Stepson, Legal Guardian, Spouse, Life Partner) for the interpretation or explanation of the results of psychiatric or other medical examinations and procedures and/or advice on how to assist the enrolled Veteran.

Newborn I

Eligible individual who is the newborn of an enrolled female Veteran receiving care from VA.

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.

VHA Transplant Program T

Eligible individual who is a person related to or associated with an enrolled Veteran participating in the VHA Transplant Program.

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.

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 Manual.

6 CUSTOMER SERVICE - RESERVED

7 REFERRALS

VA refers care to the Community Care Network and sends a VA Approved Referral to both the network provider and the Contractor. This 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 the care provided.

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Under VA Community Care authorities, health care services require authorization. It is essential that the network provider verifies and obtains the necessary authorization for these procedures before providing care (noted exception for Urgent Care and Emergency Care).

When additional medical services are necessary, a VA Approved Referral is required before delivering the services. For more information, please refer to Medical Manual Section 7.1, "Request for Services."

VA Approved Referral. 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 scenarios when the network provider does not request deviations from the VA Approved Referral.

VA will approve the referral using its referral management system and send the VA Approved Referral to the network provider and Contractor via an EDI 278/DAS 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.

The referral and authorization system, used by VA to accelerate Veteran’s access to Community Care, allows VA, 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.

Referral Episode of Care and 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:

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

2. Validating and matching the VA Approved Referral to account for RFS processes and potential multiple referrals and authorization

3. Ensuring the correct fee schedules are used to pay claims

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

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.

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/DAS 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.

Figure 2. Referral Scenario (No Deviation)

Table 12 - Referral Scenario Activity and Outcomes

Ref. Activity Outcome

1 VA Approves Referral

A VA Approved Referral and referral package are sent to the network provider to include specific authorized diagnosis code(s), procedural overview, duration, and quantities related to the episode.

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

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

EDI 278/DAS.

Veteran Visit Completed with No Deviation from Initial Referral

The network provider completes the visit, prepares, and sends a claim to the Contractor’s system for adjudication and payment. The submitted claim must include the VA Approved

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only

Ref. Activity Outcome Referral number.

EDI 837.

Claim Adjudicated and Payment to Provider is Generated

The Contractor validates the claim submitted by the network provider and uses the VA Approved Referral to properly adjudicate the claim and accurately generate payment to the network provider.

EDI 835 RA, ACH.

4 Claim Invoice Sent to VA for Reimbursement

The Contractor generates a claim invoice for reimbursement and sends to VA.

EDI 837COB.

7.1 Request for Services (RFS)

If additional services are required, that were not previously approved by VA, the Network Provider will submit an RFS to the Contractor for VA approval prior to additional services being rendered. Upon VA approval, a VA Approved Referral and referral package is sent to the network provider and copied to the Contractor.

Care coordination and case management efforts will be managed by the VA. When care coordination needs are identified or communicated by the provider, they are referred to the VA without delay.

Table 10 outlines the outcomes when VA refers Veteran care to Community Care and the network provider seeks to provide services not included in the original VA Approved Referral and VA approves the additional services.

Table 13 -VA Approved RFS Scenario Ref. Activity Outcome

1 Network Provider Requests Services

The network provider submits RFS to the Contractor to request additional, modified, or extended services from VA.

Contractor Self Service Portal.

Contractor receives and acknowledges receipt of RFS.

Contractor acknowledges and transmits receipt of RFS to network provider, and generates unique

RFS ID.

EDI 278/DAS

3 Contractor evaluates RFS submission for

Upon receipt, the Contractor reviews the RFS and other documentation submitted by the network

Referral Review and Matching. As part of ensuring that an RFS is complete and error-free, RFSs will be reviewed in relation to VA Approved Referrals. If the RFS does not include a valid VA Approved Referral number or services being requested are unrelated to a VA Approved Referral, the RFS will be rejected. The provider may resubmit the RFS

Ref. Activity Outcome package completeness.

provider for submission to VA. If more information/documentation is required or missing, the Contractor rejects the RFS and requests additional information.

EDI 278/DAS.

4 Contractor performs UR on RFS.

The Contractor reviews the services requested, the documentation and justification provided, and the scope of the original VA Approved Referral, then makes a recommendation for VA’s consideration.

Contractor’s UM Platform

5 Transmit RFS Package

Provides an RFS package to VA.

EDI 278/DAS

VA Reviews RFS and makes final determination.

Decision in the form of an Approved Referral is transmitted back to Contractor, Veteran, and Network Provider.

EDI 278/DAS, secure fax, secure email, mail, or message.

7 Veteran Visit Completed

The network provider completes the visit, prepares, and sends a claim to the Contractor’s system for adjudication and payment. The submitted claim must include the referral number.

EDI 837.

Claim Adjudicated and Payment to Provider is Generated

The Contractor validates the claim submitted by the network provider and uses the VA Approved Referral to properly adjudicate the claim and accurately generate payment to the network provider.

EDI 835 Electronic Remittance Advice (RA), Automated Clearing House (ACH).

9 Claim Invoice Sent to VA for Reimbursement

The Contractor generates a claim invoice for reimbursement and sends to VA.

EDI 837 Coordination of Benefits (COB).

See FAR 2.101 and FAR 3.104

For VA Internal Planning Purposes Only with the required information. The VA Approved Referral match is not always applicable for emergency care, as VA issues emergency care referrals retrospectively.

Duplicate RFS. If an RFS is submitted for services already approved by VA and a valid VA Approved Referral exists, a response must be sent to the provider with the VA Approved Referral number.

Request for Service Statuses. VA is making recommendations below to align terminology with the Contractor, as shown in Table 11.

Table 14 - RFS Statuses

Status Definition

Approved VA reviewed and approved some or all of the care requested in the RFS.

Canceled

Contractor canceled the RFS at the provider’s request.

Pending Contractor Physician review

Contractor needs additional clinical review by a physician rather than an admin.

Pending Contractor review Contractor has for initial review.

Accepted Contractor received the request from the community provider (Date stamp and time).

Once the accuracy and…