Disclaimer
Please read.
I am a private citizen that is also a disabled veteran. I am providing this information to the public in that context. I will not in any way receive compensation for providing this information. I am making a full disclosure that I do receive a VA compensation from injuries I sustained while serving on active duty. I also receive compensation from the Department of Defense (DOD) from injuries that I sustained while employed by the DOD.
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Below I highlighted some of the questions and answers from the Patient-Centered Community Care Program (PCCC also known as PC3). At the bottom of this document, you will find a link to the full PCCC Q&A website.
I will also provide information about why the VA is now covering acupuncture. This is my opinion based on reading though many military documents and studies on acupuncture/auriculotherapy.
It is my opinion that VA is reimbursing for acupuncture treatments after seeing the results from studies conducted directly from the military tri services (Army, Navy, Air Force) for the use in pain reduction, reducing patients’ opiates dependencies and cost savings to the government. It is not because of the free acupuncture treatments VA patients received. I know some will bitch and complain about my conclusion.
At the bottom of this “Q&A” will be a link that connects you to the online application to be credentialed to participate in the program. NOTE: You can confirm if where you practice is covered by the program by clicking on the specified link at the end. This link provides a map with participating regions.
What is the Patient-Centered Community Care Program?
The Patient-Centered Community Care (PCCC) program provides eligible Veteran’s access to care through a comprehensive network of community-based providers when the Department of Veterans Affairs (VA) cannot provide the care in its own facilities. Such access is especially critical in instances when the local VA medical center (VAMC) lacks the needed specialists, has extended wait times, or is located an extraordinary distance from the Veteran’s home.
The program will augment the VA’s ability to provide specialty inpatient and outpatient health care services to its enrolled Veterans. Health Net Federal Services, LLC (Health Net), supports VA in providing care to Veterans in three PCCC regions.
These three regions – Regions 1, 2 and 4 – encompass all or portions of 37 states, plus the District of Columbia, Puerto Rico and the U.S. Virgin Islands.
When will my Health Net Preferred Provider Network contract be accessed by a VA participant?
The goal of the PCCC program is to complement VA’s health care system. Health Net will contact network providers to schedule appointments for Veterans when VAMCs issue authorizations.
Do Veterans have cost-shares, deductibles, or out-of-pocket expenses under the PCCC program?
No. Veterans will have no cost-shares, deductibles or out-of-pocket expenses under the PCCC program. Providers will receive their payments under the PCCC program from Health Net. Providers are prohibited from billing Veterans, VA, or Health Net for no-show, missed or canceled appointments, or services rendered by the provider for which no authorization was obtained.
As a PCCC provider, how do I contact Health Net?
Providers may call Health Net at 1-800-979-9620 for help with the following issues:
o questions regarding authorizations
o extensions on authorizations
o claims questions or inquiries
o grievances
What are the credentialing requirements?
Credentialing requirements and procedures vary according to benefit program. Please refer to our Provider Credentialing page for more information. Key credentialing requirements include, but are not limited to:
o agrees to conditions of participation per the participation agreement
o has a signed Medicare agreement or participate with Medicare on a claim-by-claim basis for eligible Medicare beneficiaries
o has a current, valid, unrestricted professional license(s) to provide a medical service within Health Net’s service area
o not excluded from federally funded health care programs, as determined by the U.S. Department of Health and Human Services, Office of Inspector General, and demonstrated by absence from the List of Excluded Individuals and Entities (LEIE)
o maintains professional liability coverage with limits of at least $1 million per occurrence and $3 million in aggregate, or as specified in your PPA
o has completed education and training appropriate to application specialty
o has no felony convictions
o has no current Medicare or Medicaid sanctions
o has no current disciplinary actions (including, but not limited to, licensure and hospital privileges)
o signs an unmodified Credentials Attestation, Authorization and Release
Who do I contact with critical findings for a Veteran?
To report a critical finding, notify Health Net by phone at 1-800-979-9620.
Critical findings on outpatient imaging or laboratory testing, or during evaluation and treatment, must be transmitted to VA and Health Net by phone within 24 hours upon completion of the test/evaluation/treatment.
A new diagnosis of cancer must be reported to VA and Health Net within 48 hours of diagnosis.
Immediate notification (within 24 hours) to the authorizing VA facility and Health Net is necessary if the provider determines the Veteran requires:
o Urgent follow up after completion of authorized episode of care.
o Urgent additional care during the authorized episode of care.
Find more information on critical findings on the Timeline for Reporting PCCC Critical Findings page.
Claims/Reimbursement
How do I get reimbursed under the PCCC program?
Claims adjudication will be handled by Health Net. Covered services under the PCCC program are limited to the health care services set forth on the authorization received from Health Net. All medical documentation must be returned before claims will be paid.
How do I view provider rates?
Provider fees can be viewed online at the Centers for Medicare and Medicaid. For assistance, download step-by-step instructions.
Reimbursement methodologies for your Health Net PPN Participating Provider Agreement (PPA) are found in the applicable PPA rate exhibits.
How do I sign up for electronic funds transfer?
Providers must complete the Electronic Funds Transfer form.
Who do I contact if I have claims issues?
Questions about a claim or to inquire about a status update, contact Health Net at 1-800-979-9620.
How do I request a claims adjustment?
Claims adjustment procedures are program-specific, and requests must be made in writing. Adjustment determinations are made on a claim-by-claim basis.
Before submitting a request for claim adjustment, first review your Health Net PPN Provider Participation Agreement and the applicable rate exhibits.
What is a clean claim?
A clean claim is a claim that complies with billing guidelines and requirements, has no defects or improprieties, includes substantiated medical documentation as defined by the provider notification packet and does not require special processing that would prevent timely payment. Remember to include the VA authorization number in the appropriate segment, exactly as it appears on the authorization. Omitting or adding additional characters to the authorization field may cause rejections of the submission or denials.
Does Health Net pay interest on claims over thirty days? If so, at what rate?
Yes, Health Net will pay interest on clean claims with a process date greater than 30 calendar days from the date of receipt. The interest rate is one percent calculated on an annual basis.
Where do I mail my claims?
Providers are to submit Patient-Centered Community Care paper claims to: Health Net Patient-Centered Community Care PO Box 9110 Virginia Beach, VA 23452 Faxed claims will not be accepted for processing.
For more information, view our Claims page.
How soon will my claims be paid?
Clean claims for which we have received all required medical documentation (faxed separately) will be processed within 30 calendar days of receipt.
What is required for my claims to be paid?
Claims must comply with billing guidelines and requirements, have no defects or improprieties, include substantiating medical documentation as defined by the provider notification packet (to be faxed in separately) and not require special processing that would prevent timely payment.
How do I sign up for electronic data interchange?
The PCCC program accepts electronic data interchange (EDI) claim submissions through Change Healthcare (formerly Emdeon). To register, visit Change Healthcare’s website.
Authorizations
Is prior authorization required?
Yes. Health Net will issue authorizations to providers for PCCC covered services, upon request from VA. A provider notification packet will be sent to the provider which outlines the specific clinical and other requirements for the care provided under the authorization.
How to become a Veterans Choice Program and/or Patient-Centered Community Care Provider Non-VA Medical Care Program Fact Sheet for Interested Providers The Veterans Choice Program, or Choice Program, is a temporary program that provides Veterans the ability to receive medical care in the community if VA cannot schedule an appointment within 30 days of the Veteran’s preferred date, or the date determined medically necessary by their provider, or if the Veteran resides more than 40 miles from their closest VA medical facility. It was authorized under the Veterans Access, Choice and Accountability Act of 2014 and provides $10 billion for non-VA medical care to eligible Veterans. The temporary program will end when the allocated funds are used or no later than August 7, 2017. The Choice Program does not impact existing VA health care or any other Veteran benefits. VA has expanded its Patient-Centered Community Care (PC3) contracts with Health Net Federal Services and TriWest Healthcare Alliance to include implementing the Choice Program. PC3 is a VA nationwide program to provide eligible Veterans access to certain medical care when the local VA medical facility cannot readily provide the care due to lack of an available specialist, long wait times, geographic inaccessibility, or other factors. PC3 has been the VA method of purchasing care in the community. The Choice Program supplements PC3 and allows coverage for more services for eligible Veteran’s and provides Veterans more flexibility in their choice to receive care in the community or through VA.
