With the introduction of the Maintaining Internal System and Strengthening Integrated Outside Networks (“MISSION”) Act, the VA restructured and streamlined their Authorization process. At the same time, when the VA stood up the Community Care Network (“CCN”), the VA also strengthened the Notification system for Emergency Care. While these processes are known throughout the community, the VA utilizes them in different manners. Let’s look at how they work and how it will impact your Veteran population.
Definition of Authorization:
Authorization is the more straight-forward concept of the two. Essentially, even though a Veteran now has the option to seek care from a hospital or clinic that is not a VA facility, the VA still must approve that care via an authorization. It’s not a guarantee as the Veteran must meet one of these five criteria set forth by the VA to determine eligibility:
- The Veteran needs a service not available at a VA medical facility,
- The Veteran lives in a U.S. state or territory without a full-service VA medical facility.
- The Veteran qualifies under the “Grandfather” provision related to distance eligibility under the Veteran Access, Choice, and Accountability Act (“VACA Act”).
- The Veteran contacts an authorized VA official to request the care required, but the VA has determined that they cannot furnish it,
- Authorization is in the Veteran’s best medical interest, of the Veteran to access care or services when looking at a host of factors; Distance, Nature, Frequency, Timeliness, Improved Continuity of Care, Quality of Care, or the Veteran faces an unusual burden.
Authorizations can be found in the Health Share Referral Management Portal (“HRSM”) as the VA coordinates that care with the CCN. Also, if your organization is planning a specific test, the VA publishes the Standardized Episodes of Care Billing Code listing. This list possesses the codes that require pre-authorization versus those that do not.
We’ve seen how the VA has modernized what happens with planned services, let’s look at the VA treats care that is emergent in nature.
Definition of Notification:
Emergency care is unexpected and unplanned, which means that a Veteran cannot get a prior authorization for hospital care. Veterans can seek emergency care when there is an injury, illness, or symptom so severe that without immediate treatment, an individual believes their life or health is in danger. When a Veteran arrives for emergency treatment, a hospital has 72 hours to notify the VA of the Veteran arriving for treatment. The hospital can utilize one of three methods to notify the VA:
- Online at https://emergencycarereporting.communitycare.va.gov/#/request,
- By phone at (844) 724-7842, or
- In person with the appropriate VA official at the nearest VA medical facility.
This notification period allows the VA an opportunity to see if one of their facilities can receive the patient as a bed or a bay is available. If there is an opportunity to transfer the Veteran, the VA will coordinate that care and move the patient from the hospital. However, if the VA finds that there is no bed or bay available, the VA will look to authorize the care or a certain number of days until discharge is appropriate, or a transfer can occur without incident. By utilizing one of the three methods listed above, the VA will establish a connection with the hospital and request updates to the Veteran’s care. If a request from the VA is not completed, the VA can review the case for an adverse determination. Therefore, it is important to follow up with the VA at a regular interval as this notification will transform into an authorization.
The information needed to successfully initiate a notification is listed below.
It is imperative that a hospital notify the VA within the 72 hours of when treatment begins. The window is set up to see if the Veteran can be transferred in real time. The window does not start at discharge, but admission. If the Veteran presents unconscious, mentally altered, or fails to present their VA coverage information, the hospital can still initiate the Notification period. However, a hospital must present those facts to the VA while they consider the case.
As we continue to see elevated levels of Veterans seeking treatment outside the VA network, knowing and understanding the intricacies of the VA is vital to getting your claims authorized. This step is just the first part in getting your claim processed and paid by the VA. Most hospitals find that navigating the VA claims process is best accomplished by a dedicated VA specialist, either internal or outsourced, who can focus exclusively on mastering the VA’s regulations and processes.
EnableComp continues to stay on top of current developments. Our team is committed to ensuring we are up to date with the latest VA changes, definitions, and any new challenges regarding VA claims. Our VA expertise and knowledge allows us to locate gaps, refine processes, and establish best practices to succeed with Military claims. If you’re interested in learning more, let us know.