Veterans Choice Program SDMGMA Third Party Payer Day Sioux Falls, SD September 20, 2016

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1 Veterans Choice Program SDMGMA Third Party Payer Day Sioux Falls, SD September 20, 2016

2 Veterans Choice Program (VCP) In August 2014, President Obama signed into law the Veterans Access, Choice and Accountability Act (VACAA) of 2014, which directed the establishment of a new program to better meet the health care needs of our nation's Veterans. The law directs the establishment of a Veterans Choice Card benefit, known as the Veterans Choice Program (VCP). 9/21/2016 Privileged and Business sensitive pursuant to FOIA Exemption 4 2

3 Proud to Support VA Health Net Federal Services, LLC (HNFS) supports VA in Regions 1, 2 and 4. These three regions 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 Health Net Federal Services 4

5 Authorizations Since VCP was implemented, HNFS has secured more than 611,000 medical appointments for Veterans in their communities. 5

6 South Dakota 6

7 Black Hills - Authorizations 7

8 VCP Process VA sends authorization to HNFS. VA determines the Veteran s eligibility for the program. HNFS verifies eligibility. HNFS sets an appointment with an approved community provider and notifies the Veteran. HNFS faxes a provider packet and copy of the VA authorization/consult to the provider. (Note: These documents are faxed separately.) HNFS pays the provider after a submitted claim is verified for eligibility and authorized services. 8

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10 Request for Additional Services Program Improvement All initial care under VCP requires prior authorization and, unless otherwise indicated, covers services related to the evaluation and treatment for the episode of care. As part of our continuing efforts to improve the quality and effectiveness of our services to Veterans and to improve the administrative process for providers, HNFS recently revised its guidelines for requesting additional services for VCP patients. Providers no longer need to submit a Request for Additional Services (RFAS) form to HNFS if the services are considered part of the Veteran s initial episode of care. 10

11 Request for Additional Services An RFAS should only be submitted to HNFS if the Veteran: requires care beyond the extended approved dates; requires care beyond the extended number of visits/units authorized; needs care for another medical condition or body part (including other joints); and/or requires an inpatient admission Providers also must request additional authorization for the following: services specifically excluded from the authorization urgent consultations required as a result of a newly identified critical finding (such as cancer) Referring Provider should share the HNFS Provider Packet details with all treating Providers. Note: Do not use the bar-coded fax cover page when submitting an RFAS form. The bar-coded fax cover page is for the submission of medical records only. 11

12 Recent Program Modifications January 19, 2016 Authorizations under the VCP are no longer be limited to a 60-day period. An episode of care may be valid for up to one year from the date of the first appointment. Providers should continue to refer to the approved authorization dates in the provider packet for specific details. March 1, 2016 In an effort to streamline the claims review and reimbursement process, VA revised its medical documentation requirement for VCP, which allows HNFS to expedite provider payment. Effective March 1, 2016, HNFS can issue reimbursement for authorized VCP services prior to receiving medical documentation. Providers must submit medical documentation within the following time frames to avoid recoupment efforts: Inpatient care: Submit medical documentation within 25 days of discharge (include a discharge summary). Outpatient care: Submit initial medical documentation within 60 days of the first appointment. Submit final medical documentation, which summarizes the results of medical care provided, within 60 days after completion of the episode of care. 12

13 Availity Claim Status Tool Program Improvement March 14, 2016 Providers can check VCP and PCCC claim status using the Availity Claim Status Tool a fast, easy-to-use online claim status tool that provides real-time claim status and payment information. To access Availity s online Claim Status Tool, providers must first register. Visit and click on Get Started to begin the registration process. (Providers can also access a link to Availity on our Claims page.) Providers who are already registered with Availity do not need to reregister. Simply use your existing user name and password. 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 when submitting your claim status inquiry. Search for claims by patient identification number or claim number. 13

14 Availity (continued) Availity Claim Status Tool offers claim status, billed amount, ineligible amount, paid amount, check/electronic funds transfer (EFT)/voucher, check date, payee name, and line item breakdowns. Save a telephone call and begin checking claims status online for your VCP and PCCC patients today. For more information, Availity offers downloadable quick reference guides, and live and recorded webinars at Look for additional enhancements to Availity information coming soon. 14

15 Provider Claims and Reimbursement All services require a prior authorization from HNFS to prevent claims denials. No payment will be made to a provider for services rendered to Veterans that are not authorized by VA and HNFS. Claims must be submitted within 120 days after services have been rendered. Medical documentation must be submitted to HNFS to avoid recoupment efforts. Inpatient care: Submit medical documentation within 25 days of discharge (include a discharge summary). Outpatient care: Submit initial medical documentation within 60 days of the first appointment. Submit final medical documentation, which summarizes the results of medical care provided, within 60 days after completion of the episode of care. 15

16 Claims and Reimbursement Provider reimbursement will follow Medicare guidelines respective to the type of service authorized and performed When seeing a Veteran for non-service connected care authorized under VCP, it may be appropriate to collect a copayment or cost-share according to other health insurance (OHI)* guidelines, when applicable. Providers must not bill Veterans or request reimbursement from VA or HNFS for no-show, missed or canceled appointments. Claims must be submitted to HNFS, and not VA or Medicare. 16

17 Claims Update Our Claims department has been working diligently to bring all claims associated with VCP within a processing time frame of 30 days or less. In support of this effort, HNFS has recently incorporated automation tools that have enabled an increasing percentage of claims to be auto-adjudicated based on immediate information validation. Program-wide denials have shifted to the following top categories: authorization reasons Primary Payor EOB number of VA authorized visits or no authorization on file duplicate submissions eligibility reasons 17

18 South Dakota VA Region Paid Claims 18

19 Claims Submission HNFS recommends using electronic data interchange (EDI) for claims submittal. Submit EDI claims through Change Healthcare (formerly Emdeon). Visit to register. EDI Payer Name: Health Net VA Patient-Centered Community Care EDI Payer ID: Paper claims can be mailed to: Veterans Choice Program PO Box 2748 Virginia Beach, VA Note: Do not attach medical documentation when submitting claims. 19

20 Other Health Insurance The authorization will indicate if the Veteran s care is related to a service-connected injury. However, the notification packet may or may not indicate a Veteran s other health insurance (OHI)* information. It is the provider s responsibility to inquire and confirm if OHI is present. Non-service-connected claims must be filed with the OHI carrier before submitting claims to HNFS with the explanation of benefits from the primary payer for payment determination. It is appropriate to collect a copayment from the Veteran for the OHI, if applicable. Service-connected claims must be sent to HNFS and should not be submitted to the OHI. *VCP does not coordinate benefits with other government programs such as Medicare, Medicaid and TRICARE. 20

21 Payment Disputes/Grievances HNFS conducts a thorough investigation of the concerns and takes actions as necessary to improve services. The person who submitted the grievance will receive a written response, usually within 60 days. Grievances must be submitted in writing Complete and print an HNFS Grievance Form (found on the website) or send a letter with the following: name, address and telephone number of the person submitting the grievance the Veteran s name, address and telephone number the Veteran s Social Security number a description of the issue(s), including the day, time and details the name of the involved provider(s) or HNFS associates or departments any appropriate supporting documents Fax to: (916) Mail to: Health Net Federal Services, LLC Attn: Grievances 2025 Aerojet Road Rancho Cordova, CA

22 Return of Incorrect Checks Providers receiving claims payments (with remittance advice statement) for services rendered by other provider(s) should return the payment to HNFS. Do not forward check(s) to correct providers or cash the check, even if a portion of the claims/check payment is for the provider who received the check. Return check(s), and remittance advice(s) to: Health Net Federal Services, LLC PO Box 2890 Rancho Cordova, CA Attach a note (example, "Attn. Finance Dept: incorrect provider paid ) or clearly detail what portion of the payment is correct/incorrect. 22

23 ERA/EFT HNFS recommends provider sign up for electronic funds transfer (EFT) to receive claims payment electronically. Providers can also receive remittance advices electronically by signing up for electronic remittance advice (ERA). Visit for information on how to initiate or make changes to the EFTs or ERAs. 23

24 Please visit our website for the latest news and updates on VA programs at 24

25 Resources Veterans Choice Call Center: Press 2 for providers /Press 2 to bypass the introduction/enter your ZIP code Press 1 = claims /Press 2 = contract questions / Press 3 = authorization questions Hours of operation for providers: Monday through Friday, 8:00 a.m. 6:00 p.m. Eastern time, excluding certain holidays ProviderRelations@HNFS.com Contacts Michelle Foley Provider Network Manager michelle.x.foley@healthnet.com Phone: (612) Betsy Zande Director, Provider Network Director Elizabeth.A.Zande@healthnet.com Phone: (518)

26 Thank you for serving our nation's Veterans!