Attachment G- Required Dental Provider Information- Dental Network.docx
DOCX document 204 KB Posted
- Attached to
- Q503--CCN Next Gen - Dental Network
- Solicitation number
- 36C10G26R0004
About this file
This document is an attachment detailing required dental provider information for the Department of Veterans Affairs (VA) Community Care Network (CCN) Next Generation Dental program. The comprehensive template mandates specific data collection for dental providers, including critical elements such as provider contact details, care site information, demographic data, professional credentials, and service capabilities. Key requirements include capturing provider names, physical addresses, telehealth indicators, specialty services, licensure details, National Provider Identification (NPI), Tax Identification Number (TIN), and specific VA-specific identifiers like Clinical Quality Steerage metrics and patient acceptance status. The document emphasizes precise provider information collection, with special attention to Veterans' healthcare needs, including options for emergency department care, provider availability, and specific service offerings like commercial driver's license health checks.
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Text version
Required Dental Provider Information
1. Name (Group or Individual)
2. Photograph (Optional)
3. Educational background (Optional)
4. Physical address of all provider care sites: note – no P.O. Boxes or Commercial Mail Receiving Agencies (CRMAs) shall be allowed in the Provider Directory
a. For home health services: covered counties and states
5. Telehealth indicator
a. State(s) in which the provider is eligible to deliver services
b. If provider is 100% telehealth/virtual or performs at-home services
6. POC for scheduling or further guidance
a. Name
b. Direct Telephone
7. Care site contact information
a. Telephone
b. Fax
c. Email
d. Website
e. Hours of operation
f. Mailing or Billing Address
8. Basic demographics
a. Gender
b. Race
c. Date of Birth, if applicable
d. Languages available for service delivery
9. Specialty/specialties of the provider
10. Services available with the provider
a. Include Federal Motor Carrier Safety Administration (FMCSA)'s National Registry of Certified Medical Examiners to provide Health Checks of Veterans seeking or renewing Commercial Driver's License
b. For home health services, include agency hours of operation and coverage areas
11. Affiliated facilities
12. National Provider Identification (NPI)
13. Tax Identification Number (TIN)
14. Licensure, license number, license state, expiration date
15. High Performing Provider (HPP) or other relevant designations (see Section 13.0 Clinical Quality and Patient Safety Monitoring)
16. Training courses completed (List of trainings to be provided by the VA at implementation)
17. Special identifier for:
a. Emergency dept care
b. Radial button to indicate whether the provider is currently accepting Veterans as new patients
c. Care Type
d. Clinical Quality Steerage metrics (i.e., Med Doc Compliance, Compliance / VA Training Compliance, Scheduling Grid availability, Conformance to RFS)
18. Status: Accepting new patients or not accepting new patients
19. Contract Dates
a. Effective
b. Termination Authorized Use Only Attachment G – Required Dental Provider Information image1.png
File details come from the government source that posted it. Updated .