Attachment L Explanation of Benefits EOB Template.docx
DOCX document 33 KB Posted
- Attached to
- Q201--CCN-Next Gen Medical
- Solicitation number
- 36C10G26R0003
About this file
This document is an Explanation of Benefits (EOB) template for the Department of Veterans Affairs (VA) Community Care Network (CCN) Next Generation program. The template outlines the process for veterans to understand claims processing, benefits eligibility, and customer service procedures. Key details include: veterans must have a VA-issued identification card, be enrolled in the patient enrollment system, and have an approved referral to receive CCN benefits. The template provides guidance on claim submissions, with providers required to obtain authorization prior to performing healthcare services, except in urgent or emergency care scenarios.
The document includes instructions for veterans on how to dispute claims, file appeals, and report potential fraud or service quality issues, with all inquiries directed to the VA Customer Service Number (877-881-7618). The EOB template is associated with Solicitation Number 36C10G26R0003 for the CCN Next Generation Medical program, administered by the Department of Veterans Affairs. The template serves as a standardized communication tool to explain healthcare claim processing, payments, and veteran benefits within the Community Care Network program.
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Text version
CCN NG Contractor Correspondence Address, Logo…
**DUPLICATE COPY**
Veteran name Veteran Address City, State Zip
Explanation of Payment/Benefit ****This is NOT a Bill**** Enclosed is your Department of Veterans Affairs (VA) Community Care Network (CCN) Explanation of Payment/Benefit for services received.
Respectfully, Your VA CCN Support Team
Understanding Your VA CCN Explanation of Benefits/Payments (EOB/P) This VA CCN EOB/P serves as a record of claims paid or denied. Be sure to retain a copy for your records. If other services are not shown, they will be included on an EOB for the period in which the claim processed to completion.
Please review the services and supplies stated on this EOB/P. If you find any service or supplies that you did not receive or were charged by a health care professional you did not see, please call the VA Customer Service Number: (877)881-7618.
| VA CCN Eligibility: To receive VA CCN benefits your must have a VA issued identification card, enrolled in the VA’s patient enrollment system, and have an Approved Referral for services provided in the Community Care Network. If your claim was denied for lack of eligibility or referral, please call the number on the back of your VA issued identification card. |
| Authorizations/Referrals: In order to be reimbursed by the VA CCN program, providers are required to obtain authorization prior to performing health care services, except in the case of Urgent or Emergency Care obtained with a network CCN provider. The provider must submit a request for authorization within 72 hours of Emergency Care. For additional information contact VA Customer Service Number: (877)881-7618. |
| Timely Filing: VA CCN guidelines require timely filing by the Providers. Claims are denied if received after the timely filing deadline. |
| Disputes and Appeals: Contact the CCN NG Contractor to request review. |
Grievances: If a provider fails to give you the quality of care and service for which you believe you are entitled. Please contact VA Customer Service Number: (877)881-7618
Additional Contact Information:
VA Customer Service Number: (877)881-7618
To report suspected Fraud or Abuse:
Payment Integrity/Fraud Waste and Abuse Hotline (877)881-7618
Dear {Patient Name}, Action has been taken on the below referenced claim for services provided under the Community Care Network adjudicated by CCN NG Contractor. If you do not agree with the action taken on the referenced claim, you have 90 days from the date of this letter to request a review. Please contact the VA Customer Service Number: (877)881-7618 for additional information.
THIS IS NOT A BILL
Claim ID: XXXXXXXXXXX Date Received: <01/01/2001> Date Adjudicated by CCN NG Contractor: <01/01/2001> Rendering Provider: <Community Provider Name> Associated Referral ID: <XXXXXXXXX> Date of Service: <01/01/2001-01/01/2001>
| Date of Service |
| Service Code |
| Service Description |
| Billed Charges |
| Paid Amount |
| <MM/DD/YYY> |
| <Proc/ Rev Code> |
| <Procedure or Rev Code Description> |
| <Line Billed Amt> |
| <Line Paid Amt> |
Repeat for additional lines
| Claim Total |
| <Total Billed Amt> |
| <Total Paid Amt> |
If the CCN NG Contractor denies a claim for non-covered services and the issue is not resolved with the Community Provider and CCN NG Contractor, you have the right to file a claim with VA in the event the Community Provider bills you for services.
If you have additional questions, please contact the VA Customer Service Number: (877)881-7618.
Respectfully, Your VA CCN Support Team
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