Attachment G Medical Network Waiver Request Form.pdf

Authorized Use Only Medical Network Waiver (v9, July 2025)

Pre-Decisional Draft

Medical Network Waiver Request

Parts I-VII are to be completed by Contractor. If this form is not completed and accurate, it will be considered an initial rejection and will be sent back to the Contractor. Additionally, the Contractor must submit an accompanying CSV file containing the responses provided in the form. Both the completed form and the CSV file are mandatory for submission.

County(ies): Please submit a separate CSV file containing each county PO: Please submit a separate CSV file for different PO in alignment with the QASP Code/Cost Sets: Please submit a separate CSV file for each applicable code/code sets Request Date:

Contractor: PO

Associated Code/Code Set:

Specialty:

Counties:

Region:

VAMC:

QASP Category:

Taxonomy Code:

By submitting this Deviation request, the Contractor is attesting that they have:

• Checked all publicly available databases and sources to verify the accessibility of providers and facilities related to the requested deviation, and ensured that all information provided is accurate.

• Reviewed providers and facilities within or near the VAMC catchment area that offer the specialty mentioned in this request but are not under contract with the Contractor.

• Identified other contracted providers and facilities outside the catchment area that offer the specialty mentioned in this request and could provide the service if NA standards were adjusted.

Use this area to enter narrative text. Part of the justification must include submissions of provider recruitment efforts completed within the preceding 6-month time frame, including any provider relocations that impacted the network prior to the deviation request. Submissions for market over-saturation will not be approved. It must be clear what efforts were made by the TPA and why those efforts resulted in the need for a deviation request submission.

Part II: Rationale for Deviation

Part III: Justification and Additional Information

Part I: Request Details

Rurality:

Authorized Use Only Medical Network Waiver (v9, July 2025)

Pre-Decisional Draft

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Please indicate how you intend to provide Veterans access to services referenced in Part I. Include anticipated timeline for remediation and preferred changes to the Network Adequacy QASP Standards for this catchment area and specialty during the specified timeframe. The format for changes must be consistent with existing contractual standards.

Note: Deviations will not be approved beyond one year and will be reevaluated at that time.

VA Comments:

NA Decision:

NA Decision Date:

Approval Expiration Date:

Part IV: Resolution Plan

Part V: Internal VA Review (to be completed by VA)

Approval Date:

Start Date for PMR:

Remediation Date:

Expiration Date:

Next Review Date:

Revoke Date:

Part VI: Approval Details

Authorized Use Only Medical Network Waiver (v9, July 2025)

Pre-Decisional Draft