Veterans Choice Program and Patient-Centered Community Care Claims and Billing Tips Webinar

Transcription

1 Veterans Choice Program and Patient-Centered Community Care Claims and Billing Tips Webinar August 2018

2 Introduction The U.S. Department of Veterans Affairs (VA) Veterans Choice Program (VCP) and Patient-Centered Community Care (PCCC) programs provide eligible veterans access to care through a comprehensive network of community-based providers. These programs augment VA s ability to provide specialty inpatient and outpatient health care services to veterans. Health Net Federal Services, LLC (HNFS) was awarded its Patient-Centered Community Care (PCCC) contract in In 2014, HNFS expanded its services with VA in support of the Veterans Access, Choice and Accountability Act, which funded Veterans Choice Program (VCP), a subset of PCCC. HNFS contract with VA to manage PCCC and VCP will expire Sept. 30,

3 Proud to Support VA in Regions 1, 2 and 4 HNFS manages three regions which cover 13 VISNs, and encompass all or portions of 37 states. Plus the District of Columbia, Puerto Rico and the U.S. Virgin Islands. 3

4 HNFS Contract with VA to End HNFS contract with VA to manage PCCC and VCP will expire Sept. 30, Our priority remains to work closely with VA and our community providers to ensure a smooth transition as we close out our contract. We ask you continue to treat existing veterans under your care as appropriate through the end of the contract, and submit your claims and supporting documentation to HNFS (for care authorized by HNFS). The end of HNFS' contract with VA does not affect VA s contract with TriWest Healthcare Alliance, which administers the western region of the VCP and PCCC networks. Visit 4

5 Process Overview Process for referrals/authorizations received prior to Aug. 1, 2018 (or July 3 for mileage-eligible veterans), for care rendered prior to Oct. 1, This presentation covers this process. VCP: Local VA medical center (VAMC) refers veteran for care with a non-va community provider or veteran calls Veterans Choice Call Center to initiate care. PCCC: Local VAMC refers veteran for care with a non-va community provider. HNFS* locates a network or VCP provider who can accept the veteran as a patient. HNFS* schedules appointment on behalf of veteran. HNFS is not permitted to schedule appointments beyond Sept. 30, HNFS faxes the provider information about the appointment, including the authorization number, veteran contact details and additional details given to HNFS by VA. PCCC or VCP provider treats veteran and submits claim (electronically or mailed) to HNFS. Separately, provider faxes medical documentation to HNFS.* Claims for services on or after Oct. 1, 2018 will be coordinated directly through VA (see slide 10). HNFS receives and processes claim. (For PCCC only, medical documentation is required before claim can process.) *For VAMCs participating in a scheduling initiative, tasks marked with an * are the responsibility of the local VAMC, not HNFS. Visit 5

6 Process Overview continued Process for referrals/authorizations received on or after Aug. 1, 2018 (or July 3 for mileage-eligible veterans) VCP: Local VA medical center (VAMC) refers veteran for care with a non- VA community provider/veteran calls Veterans Choice Call Center to initiate care. Note: Calls to Veterans Choice Call Center will route to VA staff as of Oct. 1, Local VAMC locates a network or VCP provider who can accept the veteran as a patient. Local VAMC schedules appointment on behalf of veteran. Local VAMC gives the provider information about the appointment, including the authorization number, veteran contact details and additional details. Provider treats veteran and submits claim and medical documentation to local VAMC. Local VAMC receives and processes claim. PCCC: Local VAMC refers veteran for care with a non- VA community provider. Visit to locate the appropriate phone number to the veteran s local or assigned VAMC. 6

7 Authorizations and Covered Services All initial care under VCP and PCCC requires prior authorization. Eligibility for VCP and PCCC is determined by VA. Unless otherwise indicated, authorizations cover services related to evaluation and treatment for the episode of care, including routine clinical procedures and other necessary diagnostic services (for example, anesthesiology, radiology and pathology/laboratory services). When a provider in your practice is selected to render services, he or she will receive an authorization (also called a provider packet) from HNFS. In order to expedite claims processing, please include the authorization number specified on the provider packet you received from HNFS when submitting your claim. 7

8 Authorizations and HNFS Contract Close Out Existing authorizations: Authorizations already approved by HNFS remain valid; however, we have adjusted existing authorizations that extend beyond the contract expiration date to reflect an end date of Sept. 30, Please review updated authorizations carefully to avoid unexpected claims denials. Authorization period: HNFS will only authorize services under PCCC and VCP, as appropriate, through Sept. 30, Care on or after Oct. 1, 2018, will transition to the veteran s local VAMC, Office of Community Care. Requesting additional services: Effective July 3, 2018, HNFS no longer can accept requests for additional services for VCP and PCCC authorizations. Providers must submit these requests to the veteran's local or assigned VAMC. Visit to locate the appropriate VAMC's phone number. 8

9 Copayments and Billing Veterans VA will invoice the veteran for any applicable copayments. You may not bill the veteran, VA or HNFS for missed, rescheduled or canceled appointments, or services rendered for which no authorization was obtained. Providers may not seek reimbursement from or have any recourse against veterans for covered services authorized by HNFS. 9

10 Submitting Claims: VA or HNFS? Claims for VCP/PCCC care authorized by HNFS must be submitted to HNFS. However, not all veteran care is billed through these two programs. In some circumstances, claims must be submitted directly to VA for processing. Submit to HNFS Submit to VA All HNFS-authorized VCP/PCCC care (dates of service prior to Oct. 1, 2018). Exception: HNFS will accept and process claims for authorized inpatient admission stays that begin prior to Oct. 1, 2018, but extend beyond the contract end date. Corrections to claims originally processed by HNFS. Patient not eligible/va direct care. Eligibility for VCP/PCCC is determined by VA, not HNFS. Review the authorization from VA, as veterans not eligible for VCP/PCCC may be eligible for VA direct care. Services outside of VCP/PCCC authorization grace period. If care was provided more than 7 days in advance of the authorization effective date or more than 60 days after the authorization end date, the claim must be submitted to VA, even if HNFS authorized the services. Dates of service on or after Oct. 1, 2018 (even if within the 60-day grace period). Exception: HNFS will accept and process claims for authorized inpatient admission stays that begin prior to Oct. 1, 2018, but extend beyond the contract end date. 10

11 Reimbursement All VCP and PCCC claims for HNFS-authorized care must be submitted to HNFS, and not to VA or Medicare. Only authorized services are eligible for reimbursement. HNFS requires the submittal of a Request for Taxpayer Identification Number and Certification (W-9) form in order to issue claims payment for VCP and PCCC claims. Provider reimbursement will closely follow Medicare guidelines respective to the type of service authorized and performed. Provider fees can be viewed online at the Centers for Medicare and Medicaid Services. Reimbursement methodologies for HNFS network providers are found in the applicable Preferred Provider Agreement rate exhibits. 11

12 Claims Submission: Timely Filing Claims Submittal Time Frame Due to VA guidance and HNFS Sept. 30, 2018 PCCC/VCP contract expiration, HNFS is waiving previous claims timely filing requirements. Providers must submit claims for HNFS-authorized care with dates of service Sept. 30, 2018 and earlier to HNFS by March 26, 2019 (120 business days after HNFS contract expiration date). HNFS continues to recommend submitting claims within 30 days after rendering services. HNFS will automatically reprocess claims that originally denied for timely filing by Sept. 30, Exception: Claims that originally denied for timely filing and have since been reprocessed by HNFS and denied for a different reason will not be reprocessed through this effort. 12

13 Medicare Submission Requirements All electronic and paper VCP and PCCC claims submitted to HNFS must follow Medicare requirements. Medicare s Claims Processing Manual at is an excellent reference, which walks you through how to properly fill out each line of the CMS 1500 claim form. Find additional information at > Claims. 13

14 Submit Clean Claims A clean claim is a claim that complies with billing guidelines and requirements, has no defects or improprieties, and does not require special processing that would prevent timely payment. Clean claims will be processed within 30 days, and providers will receive their payments from HNFS. HNFS can accept electronic and paper claims. 14

15 Electronic Claims Submission Why choose an electronic data interchange (EDI) claims submission process over paper? EDI provides you with an electronic acknowledgement of claim receipt. EDI claims enter into the claims processing system faster. EDI allows for faster claims payments. 15

16 Electronic Claims Submission continued HNFS accepts EDI claims for PCCC and VCP through Change Healthcare. Visit the Change Healthcare website to register: Payer Name: Health Net VA Patient-Centered Community Care Program Payer ID: Note: This payer name and ID applies to PCCC and VCP electronic claims. 16

17 Paper Claim Submission HNFS recommends electronic claims submission. However, if you choose to submit paper claims, they must be mailed (via regular U.S. mail) to: Health Net Federal Services, LLC Veterans Choice Program VACAA PO Box 2748 Virginia Beach, VA Health Net Federal Services, LLC Patient-Centered Community Care PO Box 9110 Virginia Beach, VA ***HNFS cannot accept claims sent via fax or certified mail for processing.*** 17

18 Paper Claims Submission continued Paper claims received by HNFS are scanned for processing by an optical character recognition (OCR) system. Claims rejected by the OCR must be resubmitted as a new claim, as they never entered our system for processing. If submitting a paper claim, please keep the following tips in mind: Do not photocopy the CMS 1500 (version 02/12). Only original current red and white copies are acceptable. Accurately complete each field in the claim form and type clearly within the field space provided. If required text does not appear within a field, or crosses over an adjacent field, the claim will reject upon submission. We strongly recommend typing content using Times New Roman font (either 10 or 12 point) without highlights, italics or bold texts. Other types of fonts and handwritten claims are accepted, but could result in the claim being rejected by our OCR system. The claim form must be clean and free from stains, handwritten notations, circles or scribbles, strike-overs, crossed-out information, or correction fluid, such as Wite-Out. 18

19 Other Health Insurance (OHI) PCCC All care delivered to a veteran under PCCC must be authorized by HNFS even when another health insurance is present. Care authorized under PCCC is not influenced by the veteran s OHI information. Providers will always bill HNFS for authorized and rendered services, even if OHI is present. 19

20 Other Health Insurance VCP All care delivered to a veteran under VCP must be authorized by HNFS even when another health insurance is present. Please follow these guidelines for services rendered on or after April 20, 2017: VA is the primary payer for care provided through VCP and will coordinate benefits should a veteran have other health insurance (OHI). As such, providers should not bill OHI carriers or collect OHI copayments from veterans receiving care through VCP. VA will bill veterans directly for any applicable VCP copayments. Submit all VCP claims to HNFS as the primary payer. Do not bill a veteran s OHI carrier (as primary or secondary) or include that carrier s Explanation of Benefits with your claim to HNFS. 20

21 Chiropractic and Acupuncture Claims Chiropractors and acupuncturists treating veterans under VCP and PCCC must follow Medicare guidelines when submitting claims to HNFS. While many chiropractic and acupuncture procedures are not covered by Medicare, certain rules must be followed in order to obtain payment. In general, HNFS reimburses VCP and PCCC claims based on the most current Medicare Fee Schedule. However, many chiropractic and acupuncture procedures are not covered by Medicare. For services where a Medicare rate isn t available, the VA Fee Schedule will be applied. In limited circumstances where the VA rate also does not exist, reasonable billed charges will be allowed. 21

22 Chiropractic and Acupuncture Claims continued We offer a Chiropractic and Acupuncture Claims guide at > Resources. If you are new to submitting claims per Medicare guidelines, we encourage you to use this guide as a checklist when preparing your claims. 22

23 Home Health Claims Home health agencies must follow Medicare guidelines when submitting claims to HNFS. Claim Requirements Providers must submit an initial claim, also called a Request for Anticipated Payment (RAP) and a final claim. In order to complete the RAP and a final claim, an Outcome and Assessment Information Set (OASIS) must be completed. However, the OASIS does not need to be submitted to HNFS with either the RAP or final claim. We offer home health billing information at > I m a Provider > Claims > Home Health Billing. Prospective Payment System HNFS pays Medicare-certified home health agencies using a prospective payment system modeled on Medicare s plan. Medicare-certified billing is handled in 60-day-care episodes, allowing home health agencies to receive two payments of 60 percent and 40 percent, respectively, per 60-day cycle. This two-part payment process is repeated with every new cycle, following the patient s initial 60 days of home health care. 23

24 Medical Documentation Medical documentation must be faxed to HNFS at within the following time frames to allow HNFS sufficient time to review and deliver it to VA, per contract requirement. (Visit for exceptions.) VCP Outpatient: 60 calendar days of the first appointment and 60 calendar days from the last date of service Inpatient: 25 days after discharge PCCC Outpatient: 10 calendar days of the initial appointment and 10 calendar days from the last date of service Inpatient: 25 days after discharge Note: For PCCC only, HNFS cannot pay claims until medical documentation is received. Fax cover sheet options (either is acceptable): HNFS includes a bar-coded fax cover sheet with each provider notification packet issued to the initial servicing provider (recommended). Use this veteran-specific cover sheet when returning medical documentation to help expedite processing. For providers who do not have access to the bar-coded fax cover sheet, HNFS offers a downloadable generic fax cover sheet at 24

25 Medical Documentation continued Tips: Use one fax cover sheet per authorization. Processing may be delayed if the cover sheet (bar-coded or generic) is combined with documentation for multiple authorizations. Do not mail medical documentation. Deliver medical documentation via fax to HNFS within the time frames listed in the previous slide. These time frames are also specified in the HNFS provider notification packet. Refer to the Required Medical Documentation Content checklist, available at to ensure you are submitting complete documentation. Providers must fax medical documentation to HNFS, even if VA has also requested a copy (per the terms of our contract with VA). Do not submit claims with medical documentation, as we cannot accept faxed or black and white claims for processing. Note: VA may request medical documentation that cannot be scanned or faxed, such as CDs or X-rays. In these cases, the non-scannable medical documentation must be mailed to the requesting VAMC. 25

26 Online Claim Status Providers can check the status of their claims at Once registered, you can search by the veteran s information or claim number to obtain the status. Once logged in, select Claim Status Inquiry under Claims Management in the left-hand menu. Choose Patient-Centered Community Care (for VCP and PCCC claims) in the payer field. 26

27 EFT/ERA HNFS offers and encourages electronic options for provider remits and claims payment. Electronic Remittance Advice (ERA): Complete the ERA registration process (through Availity or Change Healthcare) to stop receiving paper remittance advices. You may only be enrolled with one clearinghouse with HNFS for VCP and PCCC claims. Electronic Funds Transfer (EFT): Complete and submit the HNFS Electronic Funds Transfer form, available at Learn more at > Claims. 27

28 Appeals VA program benefits are determined by VA and cannot be appealed through HNFS. 28

29 Corrected Claims To resubmit an electronic claim with a correction, make the correction and submit. To resubmit a paper claim with a correction, make the correction on an original claim form and submit for processing. 29

30 Returning Incorrect Payments If you receive an incorrect payment for a claim, return it to HNFS. Please specify the error (example, Attn: Finance Dept.: Incorrect provider paid ) or clearly detail what portion of the payment was incorrect. Return Payment Address: Health Net Federal Services, LLC PO Box 2890 Rancho Cordova, CA

31 Claims Submission Summary (for HNFS-authorized care) Before During After 31

32 Before You Submit Fax a legible copy of your W-9 to HNFS using the HNFS W-9 Cover Sheet. Register with Change Healthcare to begin submitting claims electronically. Sign up for electronic funds transfer and electronic remittance advice statements to begin receiving payments and remittance advices electronically. 32

33 When You Submit Submit claims for HNFS-authorized care to HNFS by March 26, We recommend submitting claims within 30 days after rendering services. If submitting a paper claim, use the most current version of the original red CMS 1500/UB04 form and follow the Medicare Claims Processing Manual when completing the form. In order to expedite claims processing, please include the authorization number specified on the HNFS provider packet you received. Be sure to list the authorization number exactly as it appears on the provider packet, as omitting or adding additional characters may cause a delay in the claim review process. Find more When You Submit tips at > Claims. 33

34 After You Submit Use the bar-coded, veteran-specific cover sheet from your provider packet or a generic fax cover sheet available at to return complete, legible and signed medical documentation within the time frame indicated in the packet. Check status at Review our Rejected Claims at Submission and Tips for Resubmitting Denied Claims pages at > Claims, should your claim reject or deny. Claims rejected by our optical character recognition (OCR) system must be resubmitted via EDI or U.S. mail (on an original red/white CMS 1500/1450). As these claims never entered our system for processing, they are considered new claims and cannot by submitted via fax. Return incorrect payments to Health Net Federal Services, LLC, PO Box 2890, Rancho Cordova, CA

35 Reminder Many of the top provider inquiries can be answered online! Many of the questions providers ask over the telephone can be answered on our website. We encourage providers to check our website before calling. Our Frequently Asked Questions page is a good resource for additional information. Please visit our website for the latest news and updates on VA programs at 35

36 Provider Resources Program resources from HNFS: VCP and PCCC Quick Reference Charts Claims Quick Reference Chart Provider forms VA prescription fulfillment information and more > Resources 36

37 Important Contact Numbers Note: Our PCCC and VCP customer service lines will remain open during normal business hours through Sept. 30, HNFS will open a new provider services line on Oct. 1, 2018, to assist with claims inquiries after the contract end date. Patient-Centered Community Care Call Center: Monday through Friday, 6:00 a.m. 10:00 p.m. Eastern time, excluding certain holidays Veterans Choice Call Center: Monday through Friday, 9:00 a.m. 5:00 p.m. Eastern time, excluding certain holidays Medical documentation, both programs: Fax:

38 Contract Close Out Reminders Claims: Providers must continue to submit claims for HNFS-authorized services to HNFS for payment (dates of service through Sept ). HNFS will accept and process these claims through March 26, You can continue to check claim status and history at Claims for services on or after Oct. 1, 2018/authorized by VA, will be coordinated directly through VA. Exception: HNFS will accept and process claims for authorized inpatient admission stays that begin prior to Oct. 1, 2018, and extend beyond the contract end date. Medical documentation: Providers must continue to fax medical documentation to HNFS per program guidelines. (Visit for exceptions.) Visit

39 Thank you for serving our nation's veterans!