1. Access Management & Care Coordination (AM & CC) Jason Chaddock, Chief Louis Stokes Cleveland VA Medical Center East Blvd. Cleveland, OH Northeast Ohio HFMA/AAHAM Conference February 16, 2017

2. AM & CC
Section within Patient Care Administration Services (PCAS) designed to manage, coordinate and oversee Care in the Community (CITC) with clinical and administrative oversight.
Responsible for CITC programs.
CITC Consults
Veterans Choice
Choice-First Consults, Choice-Wait List Consults, Geoburden
CITC Authorizations
Provider Agreements

3. Pre-authorized Care – 38 USC 1703
CITC Process
Provider enters request for Non-VA Care
Request must be approved  Chief of Staff or designee
AM & CC Staff coordinate care by working with Veteran and Vendor
Authorization entered
Medical information and authorization is faxed to vendor
Appointment scheduled
Medical records of appointment/care requested
Episode of Non-VA Care is completed
Vendor submits bill to Community Care Office for payment

4. Veterans Access, Choice, and Accountability Act of 2014 (VACAA).
On August 7, 2014, the President and Congress enacted the Veterans Access, Choice, and Accountability Act of 2014 ("Choice Act"). This act included a variety of ways to improve Veteran access to healthcare. The biggest change was the establishment of the Veterans Choice Program (per Section 101 of the new law).
The Veterans Choice Program (VCP) created a new process for some Veterans to receive health care in their communities rather than waiting for a VA appointment or traveling to a far-away VA facility.
Third Party Administrator – Northeast Ohio
Health Net Federal Services

5. Veterans Choice - Eligibility
Veteran must be enrolled in VA health care and meet at least one of the following criteria:
You are told by your local VA medical facility that they will not be able to schedule an appointment for care either:
Within 30 days of the date your provider determines you need to be seen; or
Within 30 days of the date you wish to be seen if there is no specific date from your provider.
Your current residence is more than 40 miles driving distance from the closest VA medical facility (including Community-Based Outpatient Clinics) that has a full-time primary care physician.”
You need to travel by plane or boat to the VA medical facility closest to your home.
You face an unusual or excessive burden in traveling to the closest VA medical facility based on geographic challenges, environmental factors, or a medical condition. Staff at your local VA medical facility will work with you to determine you are eligible for any of these reasons.
Your specific health care needs, including the nature and frequency of the care needed, warrants participation in the program. Staff at your local VA medical facility will work with you to determine if you’re eligible for any of these reasons.
You reside in a State or a United States Territory without a full-service VA medical facility that provides hospital care, emergency services, and surgical care having a surgical complexity of standard, and reside more than 20 miles from such a VA medical facility. NOTE: This criterion applies to Veterans residing in Alaska, Hawaii, New Hampshire, Guam, American Samoa, Commonwealth of the Northern Mariana Islands, and the U.S. Virgin Islands. Also note that some Veterans in New Hampshire reside within 20 miles of White River Junction VAMC.

6. Veterans Choice Veterans Choice Process
Provider determines services/care is needed
Service not provided, cannot schedule with appropriate timeframe, etc.
AM & CC Staff contact Veteran to explain Veterans Choice Program
Veteran must opt-in to participate in Veteran Choice Program
Medical documentation and eligibility uploaded to Health Net
Health Net coordinates with Veteran and Vendors within network
Health Net provides authorization and medical documentation to vendor and works with vendor to schedule appointment
Health Net responsible for retrieving medical records and providing to VA
Vendor submits bill to Health Net for payment

7. What We Do The VA Care Team: The VA Care Team:
CITC Consult is entered requesting service (once approved it can take one of 2 paths)
What We Do
Non VA Care
Our team manages the entire consult from beginning to end
Veterans Choice Program
Our team manages the front and back end
What does this mean?
The VA Care Team:
Ensures that all approval/eligibility/auths. are obtained
Contact the Veteran/Vendors and coordinate/schedule the apt.
Documents appropriately the scheduled appointment
Continues to communicate with the Veteran with any ?s
Assures all pertinent records are given to the provider/Veteran
Follows up with the Vendors and obtains medical records
Processes/documents pertinent information into CPRS
Communicates with health care team regarding Veterans care
Manages follow up appointments/records and continued care r/t the consult request – continued documentation.
The VA Care Team:
Ensures that all approval/eligibility/auths are obtained
Calls the Veteran and explains the Choice program
Uploads all necessary documents into the Choice Portal
Continues to monitor portal for updates
Requests updates as needed from portal
Obtains medical records from portal
Processes/documents pertinent information in CPRS
Manages complaints, opt-outs, questions, escalation line

8. Provider Agreements
Veterans Choice Program (VCP) Provider Agreements are one tool VA was authorized to use as part of the Veterans Access, Choice and Accountability Act of 2014 (VACAA).
Approved Provider Agreements allow VA to partner directly with community providers when the VCP contractors are unable to provide services. The agreements utilize VACAA funds and require community providers to meet the same eligibility requirements as providers who furnish care through agreements with the contractors, however the VCP Provider Agreements are NOT contracts, they are just that – Provider Agreements.

9. Patient Transfer Center
The Patient Transfer Center is responsible for managing Veterans in the community.
Pre-Authorized Care and Emergency Care (38 USC 1703)
Unauthorized Emergency Care (38 USC 1728 and 38 USC 1725)
Vendors must contact the Patient Transfer Center to provide notification a Veteran is in your facility.
Notification must be made within 72 hours of admission/treatment
Veterans may be transferred to the VA, process starts with Patient Transfer Center
Hours of operation
Monday – Friday, 7:00am to midnight
Saturday and Sunday, 7:00am to 4:00pm
Telephone Number to call (216) ext. 5596

10. Questions… Jason Chaddock Snjezana (Mary) Coyner, RN
Chief, AM & CC Nurse Manager, AM & CC
Patient Care Administrative Service Patient Care Administrative Service
Louis Stokes Cleveland VA Medical Center Louis Stokes Cleveland VA Medical Center
10701 East Blvd East Blvd.
Cleveland, OH Cleveland, OH 44106
(216) ext (216) ext. 4103
Health Net Federal Services
1 (866)
Billing Address: Veterans Choice Program
PO Box 2748, Virginia Beach, VA 23450

11. VISN10 Office of Community Care (OCC)
Scott Walker, VISN 10 Manager
Northeast Ohio HFMA/AAHAM Conference
February 16, 2017
Note name change

12. VISN10 Office of Community Care
What is Community Care?
Community care (aka Fee, Fee Basis, Non-VA Care, or Purchased care) is a program that arranges or pays for medical services for Veterans outside a VA medical facility. Community Care is not an entitlement program, but a method of healthcare delivery for eligible Veterans when VA care is not available. Veterans should always seek care at a VA whenever possible.
Does Community Care need to be approved in advance?
Yes; to ensure that VA pays for such care, services should always be pre-authorized. There are, however, 2 instances when care may be paid for even if it is not pre-authorized; i.e. emergent care.
Bullet 1 – emphasize that it is not an entitlement.
Bullet 2 – it is really yes and no depending upon the type of care

13. VISN10 Office of Community Care
Emergent Non-VA Care
38 U.S.C Un-authorized care is when a Veteran obtains care without pre-authorization for a service connected condition in an emergency.
38 U.S.C (Millenium Bill) - Mill Bill care is when a Veteran obtains care without pre-authorization for a non-service connected condition in an emergency.
_______________________________________________________
Under both instances, VA may pay for this type of care if it is clinically determined that VA facilities were not feasibly available and if Veterans meet a series of administrative & clinical eligibility criteria.

14. VISN10 Office of Community Care
Un-authorized Care (38 U.S.C. 1728)
To meet the administrative eligibility requirements, care or services must have been rendered to a Veteran for at least one of the following:
An adjudicated service connected disability
A non-service connected disability associated with and held to be aggravating a service connected disability
For any disability of a Veteran rated permanently and totally disabled (P&T) due to a service connected disability
For any illness, injury, or dental condition of a Veteran participating in the Chapter 31, Vocational Rehabilitation Program, for the reasons enumerated under 38 CFR 17.47(i)
Firs focus on admin eligibility
Bullet 1 and 2 - Link back in some way to the service connection

15. VISN10 Office of Community Care
Un-authorized Care (38 U.S.C. 1728) (cont.)
To meet the clinical eligibility requirements, the following criteria must also be met:
When such care or services are rendered in a medical emergency of such a nature that a prudent layperson reasonably expects that delay in seeking immediate medical attention would be hazardous to life or health
VA or other Federal facilities were not feasibly available to provide the needed care
________________________________________________________
Claims must be filed within 2 years after the date of service or discharge
Clinical focus
Will define prudent layperson in a couple of slides

16. VISN10 Office of Community Care
Millennium Bill Emergent Care (38 U.S.C. 1725)
To meet the administrative eligibility requirements, ALL of the following criteria must be met:
Veteran is enrolled in the VA Health Care System
Veteran has received health care services from the VA within a 24-month period preceding the emergency treatment (system auto-enrolls)
Veteran has no other form of health insurance coverage
Treatment was provided in a hospital, emergency room department, urgent care clinic, or a similar facility providing emergency care to public
Veteran is financially liable for payment
Veteran has no other contractual or legal recourse against a third party
Administrative focus first. More stringent that 1728 unauthorized. Must meet all rather than just one.

17. VISN10 Office of Community Care
Millennium Bill Emergent Care (38 U.S.C. 1725) (cont).
To meet the clinical eligibility requirements, the following criteria must be also met:
Care was rendered in a medical emergency of such a nature that a prudent layperson would have reasonably expected that delay in medical treatment would have been hazardous to life or health
VA / Federal Facilities were not feasibly available at the time of the emergency event
__________________________________________________________
Claims must be filed within 90 days after the date of discharge or date of death of Veteran

18. VISN10 Office of Community Care
The prudent layperson definition of an emergency medical condition commonly in practice is any medical or behavioral condition of recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patient’s health in serious jeopardy, cause serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy. This prudent layperson definition of emergency medical condition focuses on the patient’s presenting symptoms rather than the final diagnosis when determining whether to pay emergency medical claims.
Determined by the nurse reviewer

19. VISN10 Office of Community Care
Claims Adjudication Process
There are 2 methods to submit claims; electronically OR via snail mail.
EDI Routing #12115
A processed claim is one that the Program Office has either,
Approved for VA payment;
Denied VA reimbursement; OR
Rejected back to the non-VA provider
Approved means the claim is the routed to the FSC in Austin, Texas for final payment.
Denied – under 1725 or 1728
Reject – coding error, modifier error, revenue code issue, DOS outside auth date range

20. VISN10 Office of Community Care
Customer Service (M-F, 10am to 2pm)
Cleveland: x2003
Cincinnati:
Dayton: x7677
Columbus:
Chillicothe: x5550

21. VISN10 Office of Community Care
Questions/Comments?
Thank you.