Attachment H Required Medical Provider Information.docx
DOCX document 203 KB Posted
- Attached to
- Q201--CCN-Next Gen Medical
- Solicitation number
- 36C10G26R0003
About this file
The document is an Attachment H detailing required medical provider information for the Department of Veterans Affairs (VA) Community Care Network (CCN) Next Generation Medical contract. The comprehensive template mandates extensive provider documentation including name, contact information, demographic details, professional credentials, services offered, and administrative metadata such as National Provider Identification (NPI), Tax Identification Number (TIN), and licensure information.
Key requirements include capturing provider specialties, telehealth capabilities, service areas, affiliated facilities, languages spoken, and specific VA-related identifiers like emergency department care indicators, DEA information, and clinical quality steerage metrics. The document also requires providers to specify whether they are currently accepting new veterans as patients, their contract dates, and training course completions, with the goal of creating a detailed, standardized directory of medical providers eligible to serve veterans through the VA's Community Care Network.
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Text version
Required Medical 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
g. Place of Service (POS) Code
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. HPP or other relevant designations (see Section 14.0 Quality and Patient Safety)
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. Drug Enforcement Administration (DEA)
d. Care Type
e. Clinical Quality Steerage metrics (i.e., Med Doc Compliance, Value Based Clinical Quality Metrics, Compliance / VA Training Compliance, Scheduling Grid availability, VA System Use, Conformance to RFS)
18. Status: Accepting new patients or not accepting new patients
19. Contract Dates
a. Effective
b. Termination Authorized Use Only Attachment H – Required Dental Provider Information image1.png
File details come from the government source that posted it. Updated .