TriWest Healthcare Alliance

TriWest Healthcare Alliance

Department of Veterans Affairs (VA) Patient-Centered Community Care (PC3) Program Provider Handbook

Your Guide to VA's PC3 Program Policies and Procedures

PC3 Introduction

We want to thank you for continuing to serve our Veterans as the Community Care programs continue to evolve and transition into the Community Care Network (CCN) in Regions 4 and 5. TriWest remains focused on providing the highest levels of customer service to Veterans and the community providers who serve them. Our commitment to minimizing administrative burden for provider offices and assuring timely and accurate claims payment will remain unchanged.

The existing Patient-Centered Community Care (PC3) network will transition over time to allow for CCN implementation to occur region-by-region in a phased approach. As of Sept. 30, 2021, servicing of the Department of Veterans Affairs (VA) Patient-Centered Community Care (PC3) contract ended and the service line of 855-PCCCVET (855-722-2838) has been closed for callers except for those providers from Alaska and the U.S. territories in the Pacific, including Guam, America Samoa, and Northern Mariana Islands.

Please submit all Claims Reconsideration Requests to the Claims Written Correspondence address: TriWest Claims PO Box 42270 Phoenix. AZ 85080-2270

For referral questions, contact the VA Medical Center.

For information on the CCN, please review the CCN Provider Handbook or contact a TriWest provider services representative.

Using This Provider Handbook

This Provider Handbook gives you and your staff basic, important information about the PC3 program while emphasizing key operational aspects of the programs and its requirements. You may use this handbook to assist in coordinating care for Veterans.

This Provider Handbook is also available electronically on the TriWest Payer Space on Availity at . We recommend registering for an account on Availity if you haven't already.

TriWest TriWest

Copyright ? 2021 TriWest Healthcare Alliance - All Rights Reserved.

Table of Contents

A. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

B. Patient-Centered Community Care (PC3) . . . . . . . . . . . . . . . . . . . . . . . . 4

C. Veterans Choice Program (VCP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

i.Policy Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 ii.PC3 Regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 iii.Your Contractor for PC3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

D. Resources: Availity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

E. TriWest's Interactive Voice Response (IVR) System . . . . . . . . . . . . . . . . . . 6

F. Program Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

G. PC3 Network Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

i.PC3 Local Network Representatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

H. Certified Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

I. Provider Credentialing Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

J. Provider Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

K. Updating Provider Demographic Information . . . . . . . . . . . . . . . . . . . . . 8

L. Appointing and Authorization Process . . . . . . . . . . . . . . . . . . . . . . . . . 9

M. Access to Care Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

i.Authorization Letters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 ii.Request for Services (RFS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 iii.Routine, Urgent, Emergent ? Determining Your RFS Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 iv.Inpatient Care Coordination and Transfer Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 v.Emergency Health Care Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 vi.Urgent Care Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 vii.Covered and Excluded Urgent Care Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 viii.Telehealth Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

N. Critical Findings Notification Process . . . . . . . . . . . . . . . . . . . . . . . . . 12

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Table of Contents (cont.)

O. Medication and Durable Medical Equipment (DME) Process . . . . . . . . . . . . 13

i.DME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

P. Mental Health Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Q. Labor, Delivery, and OB/GYN Prenatal Care . . . . . . . . . . . . . . . . . . . . . . 14

R. Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

S. Submitting Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

T. Checking Claims Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

U. Medical Documentation Requirements . . . . . . . . . . . . . . . . . . . . . . . . 15

i.Specialty Provider Guidelines and Additional Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

V. Health Insurance Portability and Accountability Act (HIPAA) of 1996 . . . . . . . 15

W. Complaint Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

X. Additional Provider Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Y. Provider Contract Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

i.Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 ii.Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 iii.Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 iv.Provider Directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 v.Electronic Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 pliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 vii.VA-Specific Requirements for Certain Services and Professionals ? Applicable to the PC3 Program 17 viii.Insurance Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 ix.Pharmacy/Prescribing Guidelines ? Applicable to the PC3 Program . . . . . . . . . . . . . . . . . . . . . . . . 19 x.Medical Documentation Guidelines ? Applicable to the PC3 Program . . . . . . . . . . . . . . . . . . . . . . . . . 19 xi.Medical Documentation Content Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 xii.Specific Medical Documentation Submission Timelines and Deadlines . . . . . . . . . . . . . . . . . . . . . . 20 xiii.Claims Submission Rules and Procedures ? Applicable to the PC3 Program . . . . . . . . . . . . . . . . . . . 22

Z. Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

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Overview

The Veterans Choice Program (VCP) ended on June 6, 2019, but there will be some program requirements that will continue for the foreseeable future. VCP providers are now known as Certified providers. Certified providers who want to continue treating Veterans through PC3 referrals and authorizations can continue to do so, but will need to ultimately become a credentialed PC3 or CCN provider.

Patient-Centered Community Care (PC3)

PC3 is a program that started in 2013 to provide Veterans coordinated, timely access to high-quality care from a comprehensive network of civilian community providers. The PC3 program was designed to ensure Veterans receive coordinated, evidence-based care through civilian community providers when VA facilities are not able to provide primary care or specialty service. Services NOT included are nursing home care, hospice, long-term acute care, homemaker and home health aide services, chronic dialysis treatments, dental care, and compensation and pension examinations.

Veterans Choice Program (VCP)

In August 2014, the Veterans Access, Choice and Accountability Act (VACAA) of 2014 became law and directed the establishment of the Veterans Choice Program (VCP). It was developed to better meet the health care needs of our nation's Veterans in light of long VA wait times or when VA medical facilities were too far from a Veteran's home. The MISSION Act was passed in June of 2018 and required the end of VCP as of June 6, 2019. The MISSION Act provides guidance and some modifications to the PC3 program as it serves as a bridge to full implementation of the Community Care Network (CCN).

Policy Resources

The statutes governing PC3 can be found in the United States Code, Title 38. VA directs TriWest on how to administer these programs. This direction comes through modifications to the Code of Federal Regulations (CFR), Title 38. TriWest's contract with VA is subsequently modified to be in compliance with these statutes and regulations.

PC3 Regions

In the United States, the VA PC3 program is divided into six separate regions. These regions will be replaced with a new regional structure as the CCN is implemented.

? PC3 Region One ? Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, and West Virginia.

? PC3 Region Two ? Alabama, Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, and Virginia.

? PC3 Region Three ? Alabama (southern portion) Arkansas, Florida (western panhandle portion), Illinois (southern portion), Indiana (southern portion), Kansas, Kentucky, Louisiana, Missouri, Mississippi, Oklahoma, Tennessee, Texas, Virginia (western portion), and West Virginia (western portion).

? PC3 Region Four ? Colorado, Indiana, Illinois, Iowa, Michigan, Minnesota, Montana, Nebraska, North Dakota, Ohio, South Dakota, Utah, Wisconsin, and Wyoming.

? PC3 Region Five ? Arizona, California, Colorado (southern portion), Hawaii, Idaho, Nevada, New Mexico, Oregon, Texas, Washington and the U.S. territories in the Pacific, including Guam, American Samoa, and the Northern Mariana Islands.

? PC3 Region Six ? Alaska.

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Your Contractor for PC3

TriWest is responsible for administering VA PC3 until the transition to CCN is complete in all regions. Beginning in late January 2022, the U.S. territories in the Pacific, including Guam, American Samoa, and the Northern Mariana Islands will transition to the CCN Region 4 territory of responsibility. PC3 Region 6 (Alaska) will be fully transitioned to CCN Region 5 in March 2022.

VA PC3 Regions

Region 6

AK

WA

OR ID

NV

CA

UT

Region 5

HI

AZ

NORTHERN MARIANA ISLANDS

AMERICAN SAMOA

ND MT

Region 4

SD WY

NE

CO KS

MN WI

IA IL

MO

OK

AR

NM

Region 3

MS

TX

LA

MI

OH IN

KY

ME

VT

Region 1

NY

NH

MA CT

RI

PA

NJ

DE MD

WV

VA

TN

NC

SC

Region 2

AL GA

PUERTO RICO

FL

US VIRGIN ISLANDS

GUAM

VA CCN Regions

Region 5

AK

WA

OR ID

Region 4

NV UT

CA

MT WY CO

HI

Region 4

NORTHERN

MARIANA

ISLANDS

AMERICAN SAMOA

NM AZ

GUAM

ND

MN

SD Region 2 WI MI

ME

VT

Region 1 NH

NY

MA

CT RI

NE KS OK

TX

IA MO AR LA

PA

IL

OH

IN

KY TN

MD WV

VA

NC

Region 3

SC

GA

MS

AL

NJ DE

FL PUERTO RICO

US VIRGIN ISLANDS

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