Attachment Q- Network Adequacy Rate Waiver Form- Dental Network.pdf

IVC Network Adequacy Waiver of Payment Rates Request

Contractor PO/PE:

CDT Codes Impacted:

Use this area to enter narrative text for your Waiver of Payment Rates Request, such as known community shortfalls. Please include the following details to ensure a comprehensive submission:

• NPI/Tax ID associated with this request

• Provider Information: Include specific location addresses and any other relevant details

• Number of Providers in Practice: If this is a group practice request, provide the total number of providers

• Number of Veterans Seen in the Last Six Months: Include this data if applicable

• Specific Codes Being Requested: If the request applies to all services, explicitly state this

• Justification of Needs: Explain how Veterans would be impacted if the provider were to leave the network

• Scarce or Rural Resource: Indicate whether the provider is considered a scarce or rural resource

• Justification of Existing Providers: Provide details on how many providers are already contracted within the same catchment area and delivering the same service(s).

Request Date:

Revised July 2025

Parts I-IV to be completed by Contractor

Region:

VAMC:

Contract Status:

Proposed Rate:

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Part I: Request Details

Part III: Justification and Additional Information

Part IV: Table of Non-Contracted Providers

List all providers/facilities you have identified in or near the VAMC’s catchment, with whom you have not contracted, but have outreached for inclusion into network. Each additional provider/facility should be listed separately. In the “Reason for Not Contracting” field, select one of the following options: Provider is no longer practicing (e.g., deceased, retired); Provider does not provide services at the office/facility address listed in database; Provider does not provide services in the specialty type listed in the database and for which this Deviation is being requested; Provider does not contract with any organization; Sanctioned provider on List of Excluded Individuals and Entities (LEIE); In the process of negotiating a contract with provider; Provider is at capacity and is not accepting new patients; Inability to contract with provider (Note: Inability to contract with provider is not a valid sole rationale for submitting request); or Other. If you select “Inability to Contract with Provider" or "Other” from the “Reason for Not Contracting” list, please elaborate in the “Additional Notes” field.

Provider/Facility Name:

Provider NPI:

Provider Street Address:

Provider City:

Provider State:

Provider ZIP Code:

Provider Phone Number:

Reason for Not Contracting:

Notes:

Waiver of Payment Rates Request Form

No other Providers Available to Outreach Separate file of Providers Attached

Part V: Internal VA Review

Parts V-VI to be completed by VA

VA Notes:

Note: CORs acknowledged and have coordinated this document through Office of Integrated Veteran Care (IVC) , Rate Waiver Review Board and the Contracting Officer. This document will be saved for record keeping.

Rate Waiver Committee:

NA Recommendation:

Contracting Officer (CO): Decision:

CO Decision Date:

Expiration Date (if applicable):

Revised July 2025

N/A

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