Submitting a CCN, PC3 Claim? Know How to Avoid Denied Claims
As a reminder, providers must include the Department of Veterans Affairs’ (VA) referral/authorization number with all VA Community Care Network (CCN) and Patient-Centered Community Care (PC3) claims submissions.
If you don’t include the VA referral/authorization number, your claim will be denied. The only exception is urgent care.
Remember:
- Providers are required to share the VA referral/authorization number with the ancillary providers included in a Veteran’s episode of care.
- Ancillary providers are required to use this same VA referral/authorization number when submitting their claim for the specific episode of care.
Review tips to ensure proper claims submission.
Avoid Denied Claims & Get Claims Paid Quicker
If you’re looking for tips to help, you’ve come to the right place. We’ve identified some common errors we see in claims processing. Be sure to take a look at what you and your billing team can do to get through the claims process easier and quicker.
To find the status of your claims, visit Availity.com. We’ve added more ways for providers to search for claims. In Availity, select Claims & Payments and then the Claim Status option.
CCN Drive Time and Access Requirements
Effective Dec. 1, 2021, the following CCN requirements apply for appointing and drive-time for Veterans. Please note the following:
| Category | Current | Future |
|---|---|---|
| Maximum Appointment Times for Urban, Rural, and Highly Rural locations | 30 days | 30 calendar days |
| Emergency Care in All Areas | 24 hours | One calendar day |
| Urgent Care in All Areas | 48 hours | Two calendar days |
| The Maximum Drive Times for Primary Care in Highly Rural Areas | 60 minutes | 45 minutes |
| Specialty Care Drive Times as Well as CIHS in Highly Rural Areas | 180 minutes | 100 minutes |
The following services are excluded from the drive-time standards: telehealth, non-urgent neurosurgery and cardiothoracic surgery, rheumatology, and dermatology.
See the charts below for details regarding the newly implemented drive-time and access standards.
Maximum Appointment Availability Times
| Category | Primary Care | Specialty Care | Dental Care | Emergent Care | Urgent Care |
|---|---|---|---|---|---|
| Urban | 30 calendar days | 30 calendar days | 30 calendar days | One calendar day | Two calendar days |
| Rural | 30 calendar days | 30 calendar days | 30 calendar days | One calendar day | Two calendar days |
| Highly Rural Location | 30 calendar days | 30 calendar days | 30 calendar days | One calendar day | Two calendar days |
Drive-Time Standards Based on Location
| Category | Drive-Time |
|---|---|
| Primary Care – Highly Rural | 45 minutes |
| Specialty Care – Highly Rural | 100 minutes |
| Complementary and Integrated Healthcare Services – Highly Rural | 100 minutes |
| General Dentistry – Highly Rural | 45 minutes |
| Specialized Dentistry – Highly Rural | 100 minutes |
For more information, please refer to the CCN Provider Handbook.
SEOC Guidance on CCN Referrals Under Complementary and Integrative Health Services
When VA refers a Veteran to a specialty provider under Complementary and Integrative Health Services (CIHS), the specialty provider is expected to function within the scope and licensure required by state regulation. The provider who is performing the service should bill under their own National Provider Identifier (NPI) and be credentialed by TriWest or its delegate for that specific specialty.
In the course of the Veteran’s treatment, if another specialty is recommended for the Veteran, a Request for Services (RFS) should be completed by the community provider and sent to VA with supporting medical documentation.
The VA facility community care clinical staff (or whoever has been given the authority by the Chief of Staff to review the request) will review the request from the community provider, along with the supporting medical documentation, to make a clinical decision on whether the request is appropriate. One exception is if that same provider is credentialed under CCN for a second specialty and that provider recommends treatment using that second specialty as an additional modality. The other exception is if the specialty is provided by a credentialed provider within the providers office. In these situations, the second specialty treatment can be provided under the initial authorization.
For more information regarding CIHS, refer to this VA web page.
VA Requires Medical Records for All CCN Services
A reminder that medical records and documentation are required for all provided services under CCN. Providers are required to submit medical documentation directly to the authorizing VA Medical Center (VAMC), preferably via upload to VA’s HealthShare Referral Manager (HSRM).
Standard, Urgent and High-Priority timeframes may apply based on the type of care provided. However, providers should submit urgent and emergent care documentation as soon as it is complete. Referrals to screen for cancer or to treat a suicidal Veteran are other examples of higher priority medical documentation to return quickly.
All medical documentation must be signed (written or electronic), and/or initiated by the submitting provider or practitioner. In addition, no release of information (ROI) is required.
VA requires providers submit medical documentation to the authorizing VAMC within the following timeframes:
- Initial medical documentation for outpatient care – 30 days of the initial appointment
- Final outpatient medical documentation – 30 days of the completion of the Standardized Episode of Care (SEOC) authorization letter
- Medical documentation for inpatient care – 30 days, and will consist of a discharge summary
- Any medical documentation requested by VA for urgent follow up – upon request
Medical Documentation should be returned to the authorizing VAMC or Veteran’s assigned VAMC location.
For more detailed information, refer to the Medical Records and Documentation Requirements Quick Reference Guide.
Provider Handbook Updates
The following information was inserted on Page 24 of the CCN Provider Handbook and on Page 14 of the PC3 Provider Handbook regarding ancillary providers submitting claims with the VA referral/authorization number:
Referring providers are required to share the VA referral/authorization number with the ancillary providers included in a Veteran’s episode of care. The ancillary provider must use this same VA referral/authorization number when submitting their claim for the specific episode of care. If the VA referral/authorization number is not included, the claim will be denied.
The following information was inserted on Page 10 of the CCN Provider Handbook regarding changes to the Drive-Time and Appointing Standards made by VA:
Drive-Time Standards Based on Location
| Category | Drive-Time |
|---|---|
| Specialty Care – Highly Rural | 100 minutes |
| Specialized Dentistry – Highly Rural | 100 minutes |
Maximum Appointment Availability Times
| Category | Primary Care | Specialty Care | Dental Care | Emergent Care | Urgent Care |
|---|---|---|---|---|---|
| Urban | 30 calendar days | 30 calendar days | 30 calendar days | One calendar day | Two calendar days |
| Rural | 30 calendar days | 30 calendar days | 30 calendar days | One calendar day | Two calendar days |
| Highly Rural Location | 30 calendar days | 30 calendar days | 30 calendar days | One calendar day | Two calendar days |