Logistics Health Incorporated - VA Community Care …...health care through their contract with Optum or another Network Partner. VA CCN only covers Veterans, not families or dependents

CONTENTS

VA Community Care Network

VA CCN Provider Manual

PCA-1-20-01383-UHN-WEB_05122020 2 of 73 Users are responsible for ensuring they work from the latest approved version. This document was last modified on: 06/01/2020

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Contents ............................................................................................................................................................. 1

Overview ............................................................................................................................................................ 4

Important Note About This Manual ................................................................................................................. 4

What Is VA CCN? ........................................................................................................................................... 5

Network Resources ............................................................................................................................................ 6

UnitedHealthcare ............................................................................................................................................ 6

United Behavioral Health ................................................................................................................................ 6

OptumHealth Care Solutions, LLC ................................................................................................................. 6

Logistics Health, Inc. ...................................................................................................................................... 7

CVS Caremark Pharmacy .............................................................................................................................. 7

UnitedHealthcare Vision ................................................................................................................................. 7

Provider Resources ............................................................................................................................................ 7

Online ............................................................................................................................................................. 7

VA Community Care Provider Portal and Website ......................................................................................... 7

Optum VA Community Care Network Provider Portal .................................................................................... 7

Support by Phone ........................................................................................................................................... 8

Covered Services ............................................................................................................................................... 8

Health Care Services ...................................................................................................................................... 8

Request for Services ...................................................................................................................................... 9

Durable Medical Equipment, Medical Devices, Orthotic and Prosthetic Items ............................................ 10

Urgent Care .................................................................................................................................................. 11

Pharmacy ..................................................................................................................................................... 13

VA CCN Complementary and Integrative Health Services (CIHS) .............................................................. 15

VA CCN Health Care Service Exceptions ................................................................................................... 15

Excluded VA CCN Health Care Services ..................................................................................................... 16

Credentialing .................................................................................................................................................... 16

Professional Credentialing, Licensing and Accreditation ............................................................................. 16

Provider Responsibilities .................................................................................................................................. 18

Updating Demographic Information .............................................................................................................. 18

Non-Discrimination ....................................................................................................................................... 19

Veteran Appointments .................................................................................................................................. 19

Provider Satisfaction Surveys ...................................................................................................................... 20

Dental Provider Requirements ..................................................................................................................... 20

Out-of-Network Providers ............................................................................................................................. 20


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Fraud, Waste and Abuse Reporting ............................................................................................................. 20

Eligibility and Enrollment .................................................................................................................................. 21

Confirming Eligibility ..................................................................................................................................... 21

Primary Care Provider (PCP) Designation ................................................................................................... 21

Referrals ........................................................................................................................................................... 21

Referral for Emergent Medical Services ....................................................................................................... 22

Health Care Management ................................................................................................................................ 23

Critical Findings ............................................................................................................................................ 23

Clinical Quality Management ........................................................................................................................ 24

High-Performing Providers and Centers of Excellence ................................................................................ 24

Medical Documentation .................................................................................................................................... 28

Access to Records ........................................................................................................................................ 28

Documentation Guidelines ........................................................................................................................... 28

Submitting Medical Documentation .............................................................................................................. 29

Reimbursement and Claims Process ............................................................................................................... 30

Reimbursement ............................................................................................................................................ 30

Claims Processing and Filing ....................................................................................................................... 31

Timely Filing ................................................................................................................................................. 32

Claims Submission ....................................................................................................................................... 32

Claims Processing Timelines ....................................................................................................................... 32

Claim Denials ............................................................................................................................................... 33

Remittance Advice ........................................................................................................................................ 34

Claim Reconsiderations ................................................................................................................................ 34

Provider Training and Resources .................................................................................................................... 35

Training ......................................................................................................................................................... 35

Appendix A – VA Example of Documentation Inclusions ................................................................................ 41

Appendix B – Sample VA Referral Packet ....................................................................................................... 45

Appendix C – Dental Fee Schedule ................................................................................................................. 51


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OVERVIEW Welcome to the Department of Veterans Affairs (VA) Community Care Network (CCN) Provider Manual. Here, we have collected important information about the VA CCN that will help you deliver care to Veterans in your community.

This VA CCN Provider Manual (this “Manual”) applies to Covered Services you provide to Veterans as part of the VA CCN. Veteran eligibility and coverage are determined by VA.

This Manual is for any facility, ancillary provider, physician, physician organization, other health care professional, supplier, or other entity engaged in the delivery of health care services under VA CCN (collectively “provider”) participating in one of the Optum VA CCN partner networks or in a leased network that is being managed by a vendor that has subcontracted with Optum or one of its affiliates for VA CCN (see the “Network Resources” section below for more information on Optum VA CCN partner networks).

As used in this Manual, “you,” “your” or “provider” refers to any provider as is defined above. Except where expressly indicated, the information included in this Manual is applicable to all types of providers subject to the Manual.

As used in this Manual, “us,” “we” or “our” refers to Optum or UnitedHealthcare (collectively “Optum”) or one of the other VA CCN-affiliated Network Partners (collectively “Network Partner(s)”) with which you have contracted for VA CCN.

This Manual is a binding part of your contract with Optum or Network Partner (the “Participation Agreement”) and includes requirements that you must comply with for VA CCN, including the following categories of information, which will help you better understand VA CCN requirements, as well as how to collaborate with VA and deliver and coordinate care for the Veterans you will be serving:

• Provider resources • Covered services • Credentialing • Provider responsibilities • Eligibility and enrollment • Referrals • Pharmacy and durable medical equipment (DME) • Health care management • Medical documentation • Reimbursement and claims process • Provider training and resources

The table of contents contains hyperlinks to specific sections. This enables providers and staff to access needed information quickly and efficiently.

Terms and acronyms in this Manual are defined the first time they appear. They are also spelled out in the Glossary and Acronyms sections at the end of this Manual.

Important Note about This Manual

The Manual will be updated, as needed, and we’ll post the latest version to Optum VA Community Care Network provider portal, provider.vacommunitycare.com > Training & Guides. Please check back for updated versions. This guide was updated June 1, 2020, for physicians, health care professionals, facilities and ancillary providers currently participating in the VA CCN.

https://provider.vacommunitycare.com/tpa-ap-web/?navDeepDive=VACCN%20publicProviderHomeDefaultContent


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What Is VA CCN?

VA recognizes that while the health care landscape is constantly changing, VA’s unique population and broad geographic demands will continue to require community-based care for Veterans. VA is committed to providing eligible Veterans with the care they need when and where they need it. A significant component of having one method for Veterans to receive care from community providers is the ability for VA to purchase community services through the CCN contracts awarded to Third-Party Administrators (TPAs). Optum was awarded Region 1, Region 2 and Region 3.

Regions are based on provider locations. The provider may receive referrals for Veterans residing in a different state than the provider’s location. Each Region’s VA CCN Health Care Delivery Schedule is located on provider.vacommunitycare.com > Training & Guides. The schedules show when VA Medical Centers, identified by their name and station number, will be referring Veterans into the community. As used in the Delivery Schedules, VA facility state is where the facility is located, and the Veteran states are where Veterans who may access the VA facility reside.

CCN is fully deployed in Regions 1 and 2 and deployment will be finalized in Region 3 by June 19, 2020. VA CCN gives Veterans the opportunity to receive care from a network of community health care professionals, facilities, pharmacies and suppliers.

Veterans have sacrificed to serve our country, and this is an opportunity to provide them with the timely, accessible and high-quality care they deserve. Providers can help Veterans access a network of community health care through their contract with Optum or another Network Partner. VA CCN only covers Veterans, not families or dependents. VA determines a Veteran’s eligibility to get care from community providers.

Region 1 Region 2 Region 3

Connecticut

Delaware

District of Columbia

Maine

Maryland

Massachusetts

New Hampshire

New Jersey

New York

North Carolina

Pennsylvania

Rhode Island

Vermont

Virginia

West Virginia

Illinois

Indiana

Iowa

Kansas

Kentucky

Michigan

Minnesota

Missouri

Nebraska

North Dakota

Ohio

South Dakota

Wisconsin

Alabama

Arkansas

Florida

Georgia

Louisiana

Mississippi

Oklahoma

Puerto Rico

South Carolina

Tennessee

U.S. Virgin Islands

https://provider.vacommunitycare.com/


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NETWORK RESOURCES Optum’s complete and comprehensive health care provider network includes:

UnitedHealthcare

UnitedHealthcare provides the network for traditional medical services for the VA CCN. The UnitedHealthcare network includes:

• Primary care providers • Specialty and sub-specialty providers • Acute care hospitals • Laboratories • Specialty pharmacies • Ambulatory surgery centers • Long-term acute care facilities • Federally Qualified Health Centers (FQHCs) • Rural Health Clinics (RHCs) • Urgent care facilities • Ancillary services including home health, DME, hospice care, dialysis and diagnostic radiology

United Behavioral Health

United Behavioral Health (UBH) provides a network of behavioral health and substance use disorder facilities and providers who perform Complementary and Integrative Healthcare Services (CIHS) for VA CCN. The UBH network includes:

• Psychiatric hospitals • Inpatient and outpatient mental health and substance use disorder programs • Psychiatrists • Psychologists • Social workers • Marriage and family therapists • Counselors

VA CCN CIHS includes biofeedback, hypnotherapy, relaxation techniques and Native American healing.

UBH serves all areas, except Puerto Rico and the U.S. Virgin Islands. Those areas are covered by a leased network.

OptumHealth Care Solutions, LLC

OptumHealth Care Solutions, LLC, (OHCS) provides a network of freestanding physical health providers and services for VA CCN, which includes:

• Physical therapy • Occupational therapy • Speech therapy • Chiropractic services • Acupuncture


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The OHCS network also includes providers providing some CIHS, including:

• Massage therapy • Tai chi

OHCS provides tai chi in all areas. All other specialties listed above are provided by OHCS in all areas except Puerto Rico and the U.S. Virgin Islands. Those areas are covered by a leased network.

Logistics Health, Inc.

Logistics Health, Inc. (LHI) provides a network of both general and specialized dental providers covering all geographic areas. This network provides outpatient dental care to all eligible Veterans.

CVS Caremark Pharmacy

CVS Caremark Pharmacy serves as a pharmacy benefits manager (PBM) and a retail pharmacy network covering all geographic areas for the VA CCN. The retail pharmacies provide prescription fulfillment services for urgent or emergent prescriptions from VA CCN and VA providers.

UnitedHealthcare Vision

UnitedHealthcare Vision provides a network of eye care professionals covering all geographic areas. This network provides routine eye examinations.

PROVIDER RESOURCES

Online

VA Community Care Provider Portal and Website

VA has VA CCN provider resources available at va.gov/COMMUNITYCARE/providers.

When available in your area, VA Community Care Provider portal, also known as HealthShare Referral Manager (HSRM), will enhance efficiency with electronic file sharing between VA and providers by allowing VA CCN providers to sign in to view approved referrals and submit medical documentation.

Optum VA Community Care Network Provider Portal

Optum VA Community Care Network provider portal is available at provider.vacommunitycare.com. The provider portal contains Training & Guides, News & Announcements and Documents & Links. A new COVID-19 section has been added where providers can view the latest VA Community Care Network information related to COVID-19. Additional functionality is available from the Medical/Behavioral Provider icon after you sign in.

Optum’s portal provides:

• Claim status and submission • Provider resources and education • Real-time pharmacy dispensing information to help prevent medication errors • Referral status

http://www.va.gov/COMMUNITYCARE/providers



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• VA CCN provider directory • Veteran eligibility

Online assistance is available through online chat from 8 a.m. – 6 p.m. provider’s local time, Monday – Friday, excluding federal holidays, at provider.vacommunitycare.com > Medical/Behavioral Provider.

Support by Phone

A dedicated Provider Services support team is available to answer inquiries from 8 a.m. – 6 p.m. provider’s local time, Monday – Friday, excluding federal holidays.

• CCN Provider Services Region 1: 888-901-7407 • CCN Provider Services Region 2: 844-839-6108 • CCN Provider Services Region 3: 888-901-6613

To determine the appropriate phone number for the provider’s region, click here.

CCN Provider Services assists with:

• Benefits issue resolution • Claims status and issue resolution • Pharmacy issue resolution • Provider enrollment • Referrals status • Veteran eligibility

Tip: Providers can obtain much of this information and submit transactions on Optum VA Community Care Network provider portal. To learn more, please go to provider.vacommunitycare.com.

COVERED SERVICES

Health Care Services

Eligibility for community care is determined by VA before a Veteran can be referred to a community provider. VA will issue an approved referral to authorize a specific standardized episode of care (SEOC). SEOCs will indicate a set of services and procedures that relate to a specific category of care or sub-specialty and will include a specified number of visits, services and duration, not to exceed one year.

The VA health benefits may include, but are not limited to:

• Acupuncture • Ancillary services • Behavioral health (to include professional counseling and substance abuse) • Chronic dialysis treatment • Comprehensive rehabilitative services • Dental care • Emergent care • Geriatrics (Non-institutional extended care services, including, but not limited to: non-institutional

geriatric evaluation, non-institutional adult day health care and non-institutional respite care) • Home health care (skilled and unskilled) • Hospice, palliative and respite care • Hospital services

https://www.provider.vacommunitycare.com/



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• Immunizations • Implants – when provided as part of an authorized surgical or medical procedure • Inpatient diagnostic and treatment services • Long-term acute care • Maternity* and women’s health • Outpatient diagnostic and treatment services (including laboratory services) • Pharmacy • Preventive care • Reconstructive surgery • Rehabilitative services and therapies • Residential care • Skilled nursing facility care – limitation of rehabilitation services is no more than 100 days per

calendar year • Urgent care**

* Newborns are covered under the Veteran’s maternity and newborn approved referral for the first seven days. Claims for newborns must be submitted with the Veteran’s Social Security number (SSN) or ICN and include the Veteran’s approved referral number. If newborn services are performed by an out-of-network provider, the claims will be denied and the out-of-network provider will need to submit claims directly to VA.

** As of March 18, 2020, Optum is administering the urgent care benefit for Region 1. The administration of the urgent care benefit for Regions 2 and 3 by Optum will be announced at a later date.

Request for Services

Providers must submit a Request for Services (RFS) Form 10-10172 to VA, when a need is identified for additional care that falls outside of the original referral and SEOC or if there is a need to extend the duration of the referral. VA will process all requests within three business days and the provider will be notified of the decision or outcome through their preferred method of communication. The notification will also indicate if the care will be provided within VA or in the community. This form is also used for DME, medical devices, orthotics, prosthetics, eyeglasses and oxygen requests.

The provider is required to send the completed form to VA the same day the provider determines care is needed.

This form can be uploaded into HSRM or sent to VA through secure email or secure fax and must include the provider signature. The signature is necessary since the RFS serves as physician orders. This form is available at provider.vacommunitycare.com > Documents & Links. A separate form is required for each service requested.

All requests must contain the following information: • Date of request • Veteran’s full name • Veteran’s date of birth • Veteran’s last four digits of SSN • Prescribing provider’s full name • Prescribing provider’s address • Prescribing provider’s phone number • Prescribing provider’s fax number • Prescribing provider’s specialty type



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• Prescribing provider’s signature • Diagnosis and International Classification of Diseases ICD-10 code(s) • Description and Healthcare Common Procedure Coding System (HCPCS) code for each item • Detailed information (brand, make, model, part number, etc.) and medical justification for each

prescribed item (if a specific brand/model/product is prescribed) • Item delivery location/address and expected delivery date • Check the applicable box indicating if education and/or fitting has been completed

VA will decide if the additional services are approved. If services are approved, VA will either issue an approved referral or VA will provide the services. If the services requested are not authorized by VA, the provider may request referral reconsideration from VA. Requests for referral reconsideration must be submitted to VA within 90 days from the date of denial.

Durable Medical Equipment, Medical Devices, Orthotic and Prosthetic Items Providers may only provide DME, medical devices, orthotics and prosthetics to eligible Veterans for an urgent or emergent condition. VA provides all non-urgent or non-emergent DME items. To locate more information on VA’s expansive list of DME, medical devices, orthotics and prosthetics, access prosthetics.va.gov/psas.

Urgent or Emergent DME, Medical Devices, Orthotics and Prosthetics

If a provider determines that DME, medical devices, orthotics and prosthetics are needed emergently or urgently to stabilize or decrease the risk of further injury, it is covered under the visit and can be provided by the community provider. Urgent or emergent DME, medical devices, orthotics and prosthetics may include, but are not limited to:

• Canes • Crutches • Manual wheelchairs • Slings • Soft collars • Splints • Walkers

Scheduled Procedures or Discharge

Providers must coordinate with VA in advance of a scheduled procedure or patient discharge to help ensure the DME, medical device, orthotics and prosthetics are approved and available to the Veteran when needed.

Purchase or Rental

Providers must help ensure the most cost-effective option for urgent or emergent DME or medical devices when considering renting or purchasing. The rental period may not be more than 30 days. Providers should submit requests for long-term DME needs to VA for fulfillment, using the RFS form. The RFS form must include the following:

Detailed information (brand, make, model, part number, etc.) and medical justification for each prescribed item (if a specific brand/model/product is prescribed)

Item delivery location/address and expected delivery date

https://www.prosthetics.va.gov/psas/index.asp


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Patient education was completed or mailed to provider to finalize education

Medical provider’s signature

Routine DME, Medical Devices, Orthotics and Prosthetics

Providers must submit all requests for routine DME, medical devices, orthotics and prosthetics to VA using an RFS form. VA will provide the DME, medical devices, orthotics and prosthetics to the Veteran. VA reserves the right to issue comparable, functionally equivalent DME, medical devices, orthotics and prosthetics.

Hearing Aids

The provider treating the Veteran must be an audiologist licensed in the state where services are being provided. Hearing aids cannot be purchased or provided by providers. Providers must provide the initial testing results related to the potential hearing aid needs to VA for review by completing the appropriate hearing aid order form based on the recommended make and model. The specific audiogram requirements are outlined in the Veterans Health Administration (VHA) Audiology Toolkit provided by VA with the approved referral. If the hearing aid request is approved, VA will place an order for the Veteran’s hearing aid. VA will send the hearing aid to the requesting provider who will be responsible for the Veteran’s follow-up care and hearing aid fitting.

Home Oxygen

Providers must submit all requests for home oxygen to VA for review and fulfillment using a RFS form including the definitive testing results and a detailed home oxygen prescription. Home oxygen equipment or supplies cannot be purchased or provided by providers. The need for home oxygen must always be planned sufficiently in advance of the procedure or patient discharge to avoid delay in fulfilling the prescription.

Sleep Apnea

Oral Appliance Therapy (OAT) is classified as medical treatment for a medical disorder, obstructive sleep apnea, which is provided by a licensed dentist. OAT for obstructive sleep apnea will be provided through Optum’s VA CCN dental network.

Follow-Up Care

Providers are responsible for all necessary follow-up care, including Veteran’s education, training, fitting and adjustment. VA will procure and send the requested item to the provider’s location, unless the provider indicates on the RFS form that training and education has already been completed, in which case the item may be sent to the Veteran directly.

Transplant Candidates/Chronic Dialysis

Providers must refer Veterans identified as transplant candidates back to the referring VA facility. The medical documentation must contain the recommendation and identification of the Veteran as a transplant candidate.

Urgent Care

As of March 18, 2020, Optum is administering the urgent care benefit for Region 1 of the VA CCN. The administration of the urgent care benefit for Regions 2 and 3 by Optum will be announced at a later


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date. Refer to provider.vacommunitycare.com for additional information and implementation. To determine the states included in each region, click here.

• Urgent care providers must be participating in the VA CCN and post Optum-provided signage that clearly identifies them as a VA urgent care benefit participating location.

• Eligible Veterans may receive urgent care without an approved referral.

Providers Required to Verify Veteran Eligibility

VA CCN urgent care providers are required to call the Urgent Care Eligibility Call Center to verify eligibility at 888-901-6609 prior to providing care to a Veteran. The automated Interactive Voice Response (IVR) is available 24 hours a day, seven days a week. If eligibility is not verified, it will cause a delay in the Veteran filling a prescription and may lead to your claim being denied if the Veteran is not eligible.

To verify eligibility, have the following information available:

Veteran information: • Last four digits of the Veteran’s SSN • Date of birth (MMDDYYYY)

Urgent care provider information: • National Provider Identifier (NPI) number • ZIP code of the urgent care location

If the Veteran is not eligible for the urgent care benefit, the Veteran will be required to pay out-of-pocket if they choose to be seen. The Veteran may contact VA to discuss urgent care eligibility status and possible reimbursement of out-of-pocket expenses.

Veterans may also verify eligibility for urgent care by calling 844-698-2311 or by checking the Veteran portal at vacommunitycare.com > I am a Veteran.

Covered Services

The urgent care benefit is considered open access. Eligible Veterans may go to an in-network urgent care facility, walk-in retail health clinic or on-campus outpatient hospital for care without a referral from VA. The urgent care benefit covers injuries and illnesses that require immediate attention, but are not life-threatening, such as:

• Cold and flu • Ear infection • Minor injury • Pink eye • Skin infection • Strep throat • Flu shot

If you have urgent care benefit questions, please call the Urgent Care Eligibility Call Center at 888-901-6609, 7 a.m. to midnight, provider’s local time, seven days a week.

Preventive and dental services are excluded.

http://provider.vacommunitycare.com/

https://vacommunitycare.com/


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Medical Documentation Requirements for Urgent Care

VA CCN urgent care providers must fax or securely email all medical documentation to the Veteran’s assigned VAMC, if known or the closest VAMC to the Veteran’s residential ZIP code within 30 days of the date of service. To locate the appropriate VA facility to submit your medical documentation, use the Find VA Locations locator tool at va.gov/find-locations.

For more information on the urgent care benefit, visit va.gov/communitycare > Urgent Care or provider.vacommunitycare.com > Training & Guides > Benefits > Urgent Care Benefits.

Pharmacy

Prescriber Requirements:

• Providers are prohibited from giving pharmaceutical samples to Veterans. • VA may use VA-approved alternate prescribing practices when issuing medication. • Incomplete prescriptions will be returned to the prescribing provider and will have to be resubmitted

to the authorizing VA facility’s pharmacy. • VA does not consider topical compounds urgent or emergent.

Prescribing Controlled Substances

Before prescribing controlled substances for a Veteran, VA requires providers to check their state’s prescription-monitoring program to see if the Veteran has been prescribed other controlled substances. This can help providers and Veterans help ensure appropriate use of controlled substances.

Urgent and Emergent Prescriptions

Providers can write an urgent or emergent prescription to be filled at a VA CCN retail pharmacy for up to a 14-day supply without refills. Opioids may be filled up to a seven-day supply or to state limits, whichever is less. When it is determined to be medically appropriate, a second prescription for opioids may be filled at a VA CCN retail pharmacy for up to a seven-day supply or state limits, whichever is less (up to a 14 days’ total supply). Buprenorphine may be filled for up to a 14-day supply within 30 days (up to a 28-day total supply). With the exception of Urgent Care, the prescription must be associated with an approved referral.

When urgent or emergent prescriptions are clinically needed for continued or maintenance treatment beyond the initial urgent/emergent 14-day supply, providers must generate a second prescription for the additional days’ supply. Providers should submit the second prescription to the referring VA facility’s pharmacy by electronic prescribing or fax.

Urgent or emergent prescriptions for the same drug and strength within 30 days of the original 14-day prescription will not be eligible at a VA CCN retail pharmacy with the exception of one-time continuation of pain or antibiotic therapy. Following the dispensing of the second 14-day supply by VA CCN retail pharmacy subsequent prescriptions for the same therapy will be required to be filled at the local VA pharmacy.

When a medication requires prior authorization, providers must submit supporting medical documentation for the urgent or emergent prescription to the VA CCN retail pharmacy. The retail pharmacy, through the PBM, will review and determine if the prior authorization drug request (PADR) is approved. If it is approved, the retail pharmacy will dispense the medication as appropriate. Providers can submit a PADR using electronic prescribing or fax to CVS Caremark at 888-836-0730. Providers can call CVS Caremark at 855-297-2026 with questions on the PADR submission process or status.

http://www.va.gov/find-locations/

https://va.gov/communitycare


https://vaccnprovidertemplate.logisticshealth.com/trainingdocs/VACCN-R1-D41-PrvTrng-VACCN-UrgentCare-AAG.pdf


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Using VA CCN Retail Pharmacies

VA CCN retail pharmacies support electronic prescribing and follow established clinical protocol for registration of new patients to determine a Veteran’s allergy and previous drug history. The pharmacy must dispense prescriptions in accordance with the VA pharmacy mandatory generic substitution policy.

Retail pharmacy network prescriptions that are not dispensed must always be reversed seven days after the date they were created.

Prescribing Without a Referral

If there is not an approved referral for emergency care, the Veteran will be required to pay out-of-pocket for the prescription. The prescribing provider must inform the Veteran of their option to contact the nearest VA to request reimbursement for any out-of-pocket expenses.

Routine and Maintenance Prescriptions

Providers with an approved referral must submit a prescription for routine and maintenance medication to the authorizing VA facility’s pharmacy to fulfill via fax or electronic prescribing. Prescribing providers need to include the following information when forwarding the Veteran’s prescription to the VA facility’s pharmacy:

• Veteran’s full name • Veteran’s date of birth • Veteran’s Integration Control number (ICN) or SSN • Prescribing provider’s full name • Prescribing provider’s National Provider Identifier (NPI) number • Prescribing provider’s tax identification number (TIN) • Prescribing provider’s own Drug Enforcement Agency (DEA) number and expiration date

(not a generic facility number) • Prescribing provider’s office address • Prescribing provider’s office phone number • Prescribing provider’s fax number (if applicable) • Prescribing provider’s discipline (e.g., physician, physician assistant, nurse practitioner, etc.)

When a prior authorization is required, a provider must submit the medical documentation along with the prescription to VA pharmacy for review. The referring VA pharmacy will determine if the PADR is approved and dispense the medication as appropriate. Providers can submit a PADR using electronic prescribing or by faxing to VA pharmacy.

Formularies: Finding VA’s Preferred Medications

• VA has an Urgent/Emergent Formulary and a National Formulary located at pbm.va.gov > VA National Formulary > Formulary Documents.

• The Urgent/Emergent Formulary is also available at provider.vacommunitycare.com > Formulary and Pharmacy Search.

• When prescribing for an urgent or emergent need, providers must use the Urgent/Emergent Formulary.

• For all routine maintenance prescriptions, please reference the VA National Formulary and submit the prescription directly to the VA pharmacy for fulfillment. The National Formulary is available at pbm.va.gov > VA National Formulary > Formulary Documents.

• The VA Formulary Search tool provides formulary alternatives to non-formulary drugs in the same VA drug class. The tool is available at pbm.va.gov/apps/VANationalFormulary.

https://www.pbm.va.gov/


https://www.pbm.va.gov/

https://www.pbm.va.gov/apps/VANationalFormulary


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• Additional information about VA’s formularies and requesting non-formulary medications, including VA National Formulary Frequently Asked Questions, is available at pbm.va.gov > VA National Formulary > Formulary Documents.

Seasonal Influenza (Flu) Vaccine

Flu vaccinations do not require a referral or copayment at a VA CCN retail pharmacy that offers flu vaccinations, in accordance with VA vaccination recommendations, at publichealth.va.gov > Health and Wellness > Vaccines and Immunizations and the Centers for Disease Control and Prevention (CDC) immunization protocols at cdc.gov/vaccines.

• A VA CCN retail pharmacy administering the flu vaccine must verify the Veteran’s eligibility before delivering a flu vaccination. Veterans are required to present a valid identification with full name and a photograph to verify eligibility and identity. The identification may be in the form of a Veteran Health Identification Card (VHIC), federal-issued identification (e.g., passport) or state-issued identification (e.g., driver’s license). Veterans who have a scheduled office visit with a provider may request a flu vaccination at no charge during the referred visit. Providers will follow the Claim Submission guidelines when requesting reimbursement for the flu vaccination.

Other Vaccinations

All other vaccinations require an approved referral from VA.

VA CCN Complementary and Integrative Health Services (CIHS)

VA’s medical benefits package includes CIHS based on VA’s determination that they promote, preserve and restore health, and are in accordance with generally accepted standards of medical practice. Where applicable, VA will issue an approved referral with a SEOC to include CIHS. More information on SEOCs can be found in the Referral Section of this manual.

CIHS providers should submit claims using the appropriate Current Procedural Terminology (CPT®) or

Healthcare Common Procedure Coding System (HCPCS) code for the CIHS services listed below:

• Biofeedback • Hypnotherapy • Massage therapy • Native American healing • Relaxation techniques (for example, meditation or guided imagery) • Tai chi

VA CCN Health Care Service Exceptions

The following services may be provided to Veterans directly by VA, but are not payable under your VA CCN Participation Agreement:

• Ambulance services (ambulance services must be referred directly to VA for payment consideration) • Home deliveries and non-approved maternity care services to include deliveries by direct entry

midwives (also known as lay midwives or certified professional midwives) and medical procedures not consistent with the standard of care for maternity care services

• Medical and rehabilitative evaluation for artificial limbs and specialized devices, such as adaptive sports and recreational equipment

• Nursing home care, including state Veterans’ home per diem

https://pbm.va.gov/

http://www.publichealth.va.gov/

https://cdc.gov/vaccines


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• Veteran travel • Yoga • CIH services: acupressure, Alexander technique, animal-assisted therapy (falls under recreation

therapy), aroma therapy, biofield therapies (healing touch, reiki and therapeutic touch), emotional freedom technique, rolfing, reflexology, somatic experiencing and zero balancing

Excluded VA CCN Health Care Services

The following services are excluded from the VA CCN health benefit package:

• Abortion or abortion counseling • Drugs, biologicals and medical devices not approved by the Food and Drug Administration (FDA)

unless they are used under approved clinical research trials • Gender alterations, however, medically indicated diagnostic testing or treatments related to gender

alterations are covered benefits • Hospital and outpatient care for a Veteran who is either a patient or inmate in an institution of

another government agency, if that agency has a duty to give the care or services • Membership in spas or health clubs • Out-of-network services

CREDENTIALING Optum, UnitedHealthcare or its designee must credential providers and facilities according to requirements from nationally recognized accrediting organizations. Credentialing is generally not required for health care professionals who are permitted to furnish services only under the direct supervision of another licensed independent practitioner or for hospital- or facility-based health care professionals who provide services to covered persons incidental to hospital or facility services. Providers who are currently credentialed and participating with Optum or UnitedHealthcare, as applicable, aren’t required to complete a separate credentialing application for the VA CCN.

Professional Credentialing, Licensing and Accreditation

All providers and practitioners in the VA CCN must be credentialed by the appropriate accrediting organization.

The credentialing process involves obtaining primary-source verification of the provider’s education, board certification, license, professional background, malpractice history and other pertinent data.

New providers who are not currently credentialed and participating with one of our Network Partners will have to complete a standardized, applicable, nationally accredited credentialing process to participate in the VA CCN. If a provider specialty is not credentialed under an accredited credentialing process, the provider must operate within the scope of the provider’s professional license and maintain and provide, upon request, the following documentation:

• Proof of identity with a government-issued photo and I-9 documentation • An active, unrestricted license from the state where the service is provided, if applicable

(unskilled home health excluded) • Criminal background disclosure • Current National Provider Identifier (NPI) number, if applicable (unskilled home health excluded)


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• Drug Enforcement Agency (DEA) number if controlled substances are prescribed • Education and training, if applicable (unskilled home health excluded)

• Professional references • Proof of professional liability insurance in an amount in accordance with the laws of the state in

which the care is provided • Tax ID number (TIN) • Work history

If you’re a provider licensed, registered or certified in more than one state, you must certify that:

• None of the licenses, registrations or certifications in those states has been terminated for cause • You haven’t involuntarily relinquished such license, registration or certification in any of those

states after being notified in writing by that state of a potential termination for cause

The provider must notify the appropriate Network Partner within five days of the occurrence of action, lapse or limit impacting the provider license, registration or certification as applicable. If any state in which a provider is licensed, registered or certified terminates such license, registration or certification, the provider will be removed from the VA CCN.

All services, facilities and providers must adhere to all applicable federal and state regulatory requirements. Optum will monitor the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) exclusionary list. If you’re on the exclusionary list, you won’t be eligible to participate in the network. See oig.hhs.gov/exclusions for more information about the exclusionary list. If you don’t maintain your credentialing status, your Provider Agreement could also be terminated.

In accordance with requirements outlined in the OIG’s Compliance Guidance, all services, facilities and providers, as applicable, must have a compliance program in place that includes:

• Conducting internal monitoring and auditing • Implementing compliance and practice standards • Designating a Compliance Officer or contact • Conducting appropriate training and education • Responding appropriately to detected offenses and developing corrective action • Developing open lines of communication • Enforcing disciplinary standards through well-publicized guidelines

Professional Liability Insurance Requirement

Providers must maintain, during the term of their Provider Agreement, professional liability insurance issued by a responsible insurance carrier of not less than (per specialty per occurrence):

• $1,000,000 per occurrence • $3,000,000 aggregate

In lieu of purchasing the required insurance coverage, provider may self-insure its medical malpractice and/or professional liability, as well as its commercial general liability coverage.

Unskilled or non-clinical providers (e.g., tai chi instructors, massage therapists, etc.) are only required to maintain insurance coverage consistent with the types and limits commonly necessary for their scope of practice, as determined by Optum and VA.

Providers must notify Optum of any change in professional liability insurance carrier. New professional liability policies must meet the coverage limits and other coverage requirements.

https://oig.hhs.gov/exclusions

https://oig.hhs.gov/compliance/compliance-guidance/index.asp


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Facility Accreditation

All inpatient facilities must maintain one of the following accreditations:

• Joint Commission accreditation • American Osteopathic Association – AOA • Commission on Accreditation of Rehabilitation Facilities – CARF

Rehabilitation facilities that maintain a Joint Commission accreditation are not required to maintain an additional CARF accreditation.

Facilities are required to immediately notify the appropriate Network Partner of any changes in facility accreditation.

CIHS Credentialing

When a CIHS provider’s practice area provides for certification or licensure, the provider must have and maintain that certification or licensure.

Like all providers, CIHS providers must comply with all applicable federal and state laws, statutes and regulatory requirements.

PROVIDER RESPONSIBILITIES

Updating Demographic Information

It is important for providers to report any outdated or incorrect demographic information as soon as possible. This allows us to provide accurate information to Veterans and referring providers through the VA CCN Provider Directory and will help ensure that claims are appropriately paid, and payments are made correctly. Providers are encouraged to view the online VA CCN Provider Directory and verify their information. Any corrections should be immediately reported to the Network Partner maintaining your record. Table 1: Provider Demographic Updates

Network Provider Type Submit Updates

UnitedHealthcare Medical professionals

Facilities

Ancillary providers

UHCprovider.com/mypracticeprofile

UnitedHealthcare Providers National laboratory

National ancillary providers

Email updates to [email protected]

http://www.uhcprovider.com/mypracticeprofile

mailto:[email protected]


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Network Provider Type Submit Updates

UnitedHealthcare Vision Vision providers spectera.com

Sign in with user ID and password.

Click on the Entity Management tab.

Complete changes and submit.

Provider can also submit changes through Attestation process.

United Behavioral Health Mental health

Substance abuse

providerexpress.com

Logistics Health Incorporated (LHI)

Dental providers All updates must be submitted via email to [email protected]

Optum Complex Care Management (Optum CCM)

Skilled nursing facilities For skilled nursing facilities (SNFs), follow the process defined by your Optum Regional Contract Team.

OptumHealth Care Solutions, LLC (OHCS)

Acupuncture

Chiropractic

Massage therapy

Occupational therapy

Physical therapy

Speech pathology

Tai chi

myoptumhealthphysicalhealth.com

Fax updates to 888-626-1701

Mail updates to:

Optum Provider Data Mgmt. MN103-0700 P.O. Box 1459 Minneapolis, MN 55440-1459

Non-Discrimination

Providers must provide all services for any person determined eligible by VA, regardless of the race, color, religion, sex or national origin of the person for whom such services are ordered.

Veteran Appointments

Providers must honor all appointments with Veterans for covered services with an approved referral.

If a provider cancels a Veteran’s appointment, the appointment must be rescheduled in a timely manner based on the medical necessity of the Veteran and the required VA CCN appointment availability standards, from the time of initial appointment request:

• Within 24 hours for emergent health care need • Within 48 hours for urgent health care need • Within 30 days for routine care need

Providers must not charge Veterans for missing a scheduled appointment.

https://www.spectera.com/PWP/Landing

https://www.providerexpress.com/



https://www.myoptumhealthphysicalhealth.com/


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Provider Satisfaction Surveys

Participating in the provider satisfaction survey is important because the results allow both VA and Optum to understand areas where the network experience can be enhanced for all stakeholders.

The survey was developed by VA and is required to be made available to providers with one or more claims submitted within a quarter.

Individual responses are confidential to VA.

To complete the survey, go to provider.vacommunitycare.com > News & Announcements. Select the Provider Satisfaction Survey hyperlink and follow the prompts to complete each question. Once finished, select Submit.

Questions related to the survey can be directed to CCN Provider Services for your region.

Dental Provider Requirements

VA CCN dental providers must comply with the most current version of the Code on Dental Procedures and Nomenclature published in the American Dental Association’s (ADA) Current Dental Terminology (CDT) manual. There is a separate provider manual for dental providers located at provider.vacommunitycare.com > Training & Guides > VA CCN Provider Manual for Dental Providers. Dental functionality is available from provider.vacommunitycare.com > Dental Provider.

Out-of-Network Providers

Out-of-network providers must submit health care claims directly to VA and follow the VA claim submission process. Supporting medical documentation must be submitted with the claim. You can find information on VA’s process at va.gov/communitycare.

Fraud, Waste and Abuse Reporting

Fraud is the intentional misrepresentation of information to gain undeserved payment for a claim. Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations or promises) any of the money or property owned by, or under the custody or control of, any health care benefit.

One example could be when a provider or staff member knowingly bills for services not provided or bills

more costly services than provided, including billing for brand name drugs when generics are dispensed.

Waste is the spending of federal health care dollars on services that are unnecessary. Abuse is a questionable practice that is inconsistent with accepted medical or business practices. Instances of waste or abuse may be unintentional, resulting from a variety of causes, including limited knowledge about best practices or delays in implementing new processes that would improve efficiencies.

As a provider, if you identify potential fraud, waste or abuse, report it to Optum immediately so we can investigate and respond.

To report suspected fraud or abuse, please contact Optum using one of the following methods:

Complete the Fraud, Waste and Abuse Reporting form available at provider.vacommunitycare.com > Document & Links.



https://www.provider.vacommunitycare.com/tpa-ap-web/?navDeepDive=VACCN%20publicHomeDefaultContent

https://va.gov/communitycare



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Phone: Optum Fraud, Waste, and Abuse Hotline:

• Region 1: 844-883-3461 • Region 2: 844-883-3669 • Region 3: 844-883-3684

To determine the provider’s region, click here. In cases of fraud, waste or abuse, Optum will make every reasonable attempt to recover improper payments for services delivered to Veterans or to anyone not eligible to receive a benefit as part of the VA CCN.

ELIGIBILITY AND ENROLLMENT

Confirming Eligibility

VA determines Veteran eligibility for community care. A Veteran must be eligible for community care in order to be referred to a provider participating in VA CCN. Veterans are required to present a valid identification with full name and a photograph to verify identity before receiving care. The identification may be in the form of a Veteran Health Identification Card (VHIC), U.S. government-issued passport or a state driver’s license. Veterans will not have a VA CCN health insurance identification card. An approved referral sent to the provider or the referral letter VA has sent the Veteran is proof of eligibility. Providers can confirm a Veteran’s enrollment status online at provider.vacommunitycare.com > Medical/Behavioral Provider or by calling CCN Provider Services for your region.

Primary Care Provider (PCP) Designation

Each Veteran will have a PCP. If the Veteran’s PCP is a VA CCN provider, VA will issue an approved referral to the PCP indicating the length of time it is valid, either six months or one year. VA may communicate a Veteran’s PCP assignment information on an approved referral. This helps ensure that providers can share pertinent medical documentation with the assigned PCP.

REFERRALS All services require an approved referral from VA before claims can be processed. Approved referrals from VA will authorize a specific SEOC that will include a specified number of visits and/or services related to a plan of care. The referral packet will include the referral with a SEOC, consult/order with chief complaint, patient history and clinical findings related to the chief complaint. The consult/order states what the VA provider is requesting from the community provider. Because VA does not want to delay treatment of a Veteran, in addition to the consult/order, the provider is approved for all medically necessary services for the quantities listed on the SEOC. Services the provider feels are medically necessary that are included within the SEOC may be completed without an additional approved referral. The VA SEOC billing code list of preapproved billing codes associated to the services within each SEOC are located at va.gov/COMMUNITYCARE/providers/PRCT_requirements.asp#list or provider.vacommunitycare.com > Documents & Links > Fee Schedules and VA SEOC Billing Codes > VA SEOC Billing Code List.

The approved referral will state the issue and expiration date. The expiration date may change based on the date of first appointment to allow for the complete time frame from first appointment to the expiration date. When recalculated, a new referral is not issued. However, the provider will be able to see the update in HSRM or provider.vacommunitycare.com > Medical/Behavioral Provider.


https://www.va.gov/COMMUNITYCARE/providers/PRCT_requirements.asp#list

http://provider.vacommunitycare.com/



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During the COVID-19 public health emergency, VA will allow providers to care for Community Care Network (CCN) patients through telehealth and telephonic consults, when clinically appropriate and with an approved referral from a VAMC. For additional details, please see the Treating Veterans during the COVID-10 Public Health Emergency reference document at provider.vacommunitycare.com

When approved referrals result in the need for urgent or emergent pharmacy prescriptions, or urgent or emergent prescriptions for DME, medical devices, orthotics and prosthetics, those supplies and services are also authorized as part of the SEOC.

VA will send approved referral information, including the referral number and any attachments, to the provider via HSRM, direct messaging, secure email or secure fax.

When VA is referring to a CCN laboratory with a lab and pathology SEOC, the standing lab order will be part of the referral packet.

Referrals for emergent services will follow a different process. See the section below on referrals for emergent medical services for more information about requesting an approved retroactive referral in those cases.

To verify the status of a referral, access HSRM or provider.vacommunitycare.com > Medical/Behavioral Provider or call CCN Provider Services for your region.

The approved referral and the referral number must be forwarded to any ancillary providers by the referring provider.

Any additional services not listed on the SEOC or extension of a treatment period will require making a referral request to VA using the RFS form, with the exception of laboratory or radiology services. Laboratory and radiology services are covered as long as there is an approved referral on file for the date of service(s) and condition.

It is the responsibility of providers to help ensure there is an approved referral before providing care or services to a Veteran, including when a Veteran self-schedules the appointment. This means that the provider may need to request a new referral from VA if the Veteran’s scheduled appointment falls outside of the approved referral’s dates of service. This applies to all visits, whether it is the Veteran’s initial visit or a follow-up appointment.

VA is required by law to bill a Veteran’s other health insurance (OHI) for care that is not related to a Veteran’s service-connected disability or Special Authority.

The precertification section of the approved referral will indicate if any of the procedures on the SEOC require precertification, as well as indicate if the Veteran has OHI. If the Veteran has OHI and the procedure requires precertification, the provider must notify VA through direct messaging, secure email, secure fax, telephone or EDI (when available), which will allow VA to pre-certify applicable services with the Veteran’s OHI. There is no requirement to wait for the approval or response prior to performing the test/procedure/admission included as part of the SEOC referral. The billing code list is located at va.gov/COMMUNITYCARE/providers/CPT_End_User_Agreement.asp.

For example referral packet, see Appendix B – Sample VA Referral Packet in this Manual.

Referral for Emergent Medical Services

Veterans are allowed to seek emergent medical care in a VA CCN emergency department without a referral. The provider must notify the appropriate VA official at the nearest VA facility within 72 hours.

https://vaccnprovidertemplate.logisticshealth.com/trainingdocs/VACCN-ProvTrng-COVID19.pdf

https://vaccnprovidertemplate.logisticshealth.com/trainingdocs/VACCN-ProvTrng-COVID19.pdf



https://www.va.gov/COMMUNITYCARE/providers/CPT_End_User_Agreement.asp


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Notification to the nearest VA can be by phone call, secure email, secure fax or EDI (when available). VA will determine if the Veteran is eligible to receive community care and, if eligible, issue a retroactive approved referral to the provider. Locate the local VA contact information at va.gov/COMMUNITYCARE/docs/providers/Facility_Contacts-CC_Providers.pdf#

After receiving an approved referral, the provider should follow the Claim Submission Process. The claim must be submitted to Optum within the VA CCN timely filing guidelines of 180 days from the date of service for outpatient care or date of discharge for inpatient care. Claims submitted outside of those timely filing requirements will be denied.

When a Veteran receives services for emergency care from an out-of-network provider, the claim needs to be submitted to VA as soon as possible. Non-service-connected care should be submitted within 90 days of the encounter and within two years for service-connected care. VA will evaluate eligibility for payment and process the claim accordingly.

Additional information on emergency care is on VA’s community care website at va.gov/COMMUNITYCARE/providers/info_EmergencyCare.asp.

Emergency claims submitted by a provider without an approved referral will be denied. The referral number is required on the claim. To determine the correct location for the referral number on the claim, access the Claims Submission section. Emergency claims denied without a referral or from an out-of-network provider would need to be submitted to VA for payment consideration.

If you are providing services to a Veteran under an approved referral and determine that the Veteran is experiencing an emergent symptom or condition, provide emergency treatment to the Veteran or assist the Veteran in seeking emergency treatment and notify the nearest VA immediately.

If a Veteran is receiving approved services and the treating facility determines the Veteran needs a higher level of care than the facility is capable of providing, the facility must notify VA through direct messaging, secure email, secure fax, telephone or EDI (when available). The request should include:

• Facility name and location • Admitting provider’s NPI • Admitting diagnosis • Date of admission • Any services already delivered (if available) • Appropriate attachments

Training on how to submit a referral is available at provider.vacommunitycare.com > Training & Guides.

HEALTH CARE MANAGEMENT

Critical Findings

Critical findings are findings or results that require immediate evaluation by a provider, such that failure to take immediate appropriate action might result in significant morbidity to, serious adverse consequences to or death of the Veteran.

When a provider makes a critical finding, the provider must communicate the finding, verbally or in writing, to the Veteran, referring provider and VA within either two business days of the discovery or the time frame required to provide any necessary follow-up treatment to the Veteran, whichever is quicker.

https://www.va.gov/COMMUNITYCARE/docs/providers/Facility_Contacts-CC_Providers.pdf

https://www.va.gov/COMMUNITYCARE/providers/info_EmergencyCare.asp



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Clinical Quality Management

Optum’s Clinical Quality Management (CQM) program helps ensure high-quality, safe health care services by using established quality monitoring and improvement principles.

We use our CQM program to:

• Identify the scope of care and services given • Monitor clinical performance against evidence-based clinical guidelines and service standards • Monitor and assess the quality and appropriateness of services given to Veterans • Review the medical qualifications of participating health care professionals • Achieve continued improvement of member health care and services • Enhance patient safety and confidentiality of Veteran medical information • Resolve identified quality issues

CQM also receives and reviews quality-of-service concerns received from VA, a Veteran or a provider about another provider.

High-Performing Providers and Centers of Excellence

Measures

Provider performance will be analyzed and monitored against specific quality and performance measures agreed upon by Optum and VA. Providers who meet the threshold for quality and performance measures are designated as High-Performing Providers, and institutions are designated as Centers of Excellence. Performance will be reviewed and monitored against the following quality and performance measures, which may change based on agreement with VA:

Individual Providers

• Healthcare Effectiveness Data and Information Set (HEDIS®) Measures

Table 2: HEDIS® Measures

HEDIS Measure Description

Breast Cancer Screening Percentage of women, ages 50-74, who had a mammogram to screen for breast cancer, per current HEDIS

® Technical Specifications.

Colorectal Cancer Screening Percentage of individuals, ages 50-75, who had an appropriate colorectal cancer screening, per current HEDIS


Screening intervals vary according to the method of screening. Eligible enrollees must have evidence one of the following:

Fecal occult blood test (last year)

FIT-DNA test (last three years)

Flexible sigmoidoscopy (last five years)

CT colonography (five years)

Colonoscopy (last 10 years)

Annual Flu Vaccine Percentage of individuals who received an influenza vaccination during the most recent flu season.


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HEDIS Measure Description

Adult BMI Assessment Percentage of individuals, ages 18-74, who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year, per current HEDIS

®

Technical Specifications.

Diabetes Care – Eye Exam Percentage of individuals, ages 18-75, with diabetes, who had an eye exam (retinal) performed, per current HEDIS


Diabetes Care – Kidney Disease Monitoring

Percentage of individuals, ages 18-75, with diabetes, who had medical attention for nephropathy, per current HEDIS


Diabetes – Blood Sugar Controlled

Percentage of individuals, ages 18-75, with diabetes, who had HbA1c control (<8.0%), per current HEDIS


Controlling Blood Pressure Percentage of individuals, ages 18-85, who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90), per current HEDIS


Reducing the Risk of Falling Percentage of individuals, ages 65 or older, who have been screened for fall risk by a primary provider.

Pharmacotherapy Management of COPD Exacerbation (PCE)

Percentage of COPD exacerbations with an inpatient discharge or ED visit, for individuals, ages 40 and older, who were dispensed appropriate medications (two measures): 1) A systemic corticosteroid within 14 days of the event 2) A bronchodilator within 30 days of the event

• Premium Designation

Other internal data included in High-Performing Provider designation is the Premium Designation data, which provides a designation for providers based on their ability to demonstrate consistent quality and cost-efficient outcomes. These designations help Veterans make informed decisions about their choices in health care providers. The Premium Designation program evaluates doctors in 16 premium specialty areas representing 47 credentialed specialties. All quality measures for the program are based on nationally recognized and established evidence-based performance measurements from organizations such as the National Quality Forum (NQF), the AQA Alliance, NCQA and specialty societies such as the American Medical Association (AMA) Physician Consortium for Performance Improvement (PCPI).

Group Practice Providers

Individual provider performance will be aggregated to determine group practice provider performance. A High-Performing Provider designation will be assigned at the group practice provider level.

Institutional Providers

Hospital Compare Measures

Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) Measures • Patients who reported that YES, they were given information about what to do during their recovery

at home • Patients who reported that NO, they were not given information about what to do during their

recovery at home • Patients who "Strongly Agree" they understood their care when they left the hospital • Patients who “Agree” they understood their care when they left the hospital


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• Patients who “Disagree” or “Strongly Disagree” they understood their care when they left the hospital • Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) • Patients who gave their hospital a rating of 7 or 8 on a scale from 0 (lowest) to 10 (highest) • Patients who gave their hospital a rating of 6 or lower on a scale from 0 (lowest) to 10 (highest) • Patients who reported YES, they would definitely recommend the hospital • Patients who reported YES, they would probably recommend the hospital • Patients who reported NO, they would not recommend the hospital

Acute Myocardial Infarction (AMI) Measures

• Average number of minutes before outpatients with chest pain or possible heart attack who needed

specialized care were transferred to another hospital • Average number of minutes before outpatients with chest pain or possible heart attack got an ECG • Median time to fibrinolysis • Outpatients with chest pain or possible heart attack who received drugs to break up blood clots

within 30 minutes of arrival • Outpatients with chest pain or possible heart attack who received aspirin within 24 hours of arrival or

before transferring from the emergency department, outpatients with chest pain or possible heart attack who received aspirin within 24 hours of arrival

Patient Safety Indicators (PSI) Measures include:

• Pressure sores • Deaths among patients with serious treatable complications after surgery • Collapsed lung due to medical treatment • Broken hip from a fall after surgery • Bleeding or bruising during surgery • Kidney and diabetic complications after surgery • Respiratory failure after surgery • Serious blood clots after surgery • Bloodstream infection after surgery • A wound that splits open after surgery on the abdomen or pelvis • Accidental cuts and tears from medical treatment

Hospital-Acquired Infection (HAI) Measures include:

• Central line-associated bloodstream infections (CLABSI) in ICUs and select wards • Catheter-associated urinary tract infections (CAUTI) in ICUs and select wards • Surgical site infections (SSI) from colon surgery • Surgical site infections (SSI) from abdominal hysterectomy • Methicillin-resistant Staphylococcus Aureus (MRSA) blood infections • Clostridium difficile (C.diff.) intestinal infections

An individual provider, group practice provider or institutional provider must meet or exceed the threshold to achieve the designation of a High-Performing Provider or Center of Excellence.

Potential Quality Issue Review

For VA CCN, Optum assesses medical records, claims, referrals and other relevant documentation during the potential quality issue (PQI) investigation process. All care provided under the VA CCN contract,


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including medical surgical, behavioral health, dental, pharmacy, and all complimentary integrated health services, are within the scope for PQI investigations. PQI includes quality of service and/or quality of care concerns, including CMS and National Quality Forum (NQF)-identified “Never Events,” in all or any of the following categories:

• Surgical events • Product or device events • Patient protection events • Care management events • Environmental events • Radiologic events • Criminal events • Documentation events • Dental events

Providers may be contacted regarding a potential quality issue by an Optum VA CCN representative.

If you become aware of a PQI while providing care to a Veteran, please complete and submit the PQI Referral Form, which is available at provider.vacommunitycare.com > Documents and Links.

Provider Participation

Providers are required to participate in the CQM process in accordance with their Provider Agreement and VA requirements.

Activities that are related to the CQM process may include:

• Participating in the investigation of grievances, PQIs, trends and quality studies • The request of medical records*, including what documents to send. Optum CQM activities that may

require medical records include investigation of a PQI, grievance or identification of possible care concern, trends seen in data, and clinical quality studies requiring medical record data. • The volume of requests depends directly on the number of grievances, PQIs and/or selection for

study sample. • Optum must request records upon receipt of PQIs, trends, grievances and/or quality studies. • The number of pages will vary based on the episode(s) of care and documentation of

care provided. • *Please note that Optum is not authorized to reimburse providers for the costs of medical

records requested in connection with the CQM process for CCN. • Complying with peer review, patient safety and clinical quality programs and procedures established

by Optum or VA, including: • Concurrent reviews • Retrospective reviews • Allowing Optum and its designees to have access to provider records within the requested time

frame and providing complete medical records upon request • Participating in audits regarding performance assessments of provider practices • Responding to peer review communications and directed corrective actions within specified time

frames • Documentation and submission of HEDIS

® and/or HEDIS

®-like data for Veterans referred to the

provider’s practice.

Failure to submit medical records and/or data may impact provider network status. Also, failure to submit timely information will impede the patient safety investigation process.



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On-Site Provider Reviews

As part of the Clinical Quality Management Plan (CQMP), Optum may conduct on-site evaluations of providers who have been identified for further evaluation based on performance indicators. Optum may help the provider in developing an action plan to help remedy an area of concern.

CQM Confidentiality

Providers are responsible for helping to ensure the privacy and security protection of information in accordance with applicable federal, state and local laws and provisions applicable to sensitive and personally identifiable health care information.

All Clinical Quality information shall be treated as confidential and in accordance with applicable federal, state and local laws and regulations.

• Individual Veterans will be referred to by number only, using names only when specific reference is necessary.

• Everything related to CQM activities are considered privileged and confidential information. • We limit PHI access to the minimum necessary.

MEDICAL DOCUMENTATION Providers are responsible for creating, maintaining and submitting a Veteran’s medical documentation to VA according to established requirements.

Access to Records

You are required to: • Send VA copies of the Veteran’s medical or administrative records related to care • Give access to records to VA or Optum for all dates of service that occurred when you were a

contracted provider

Monitoring the Quality of Medical Care Through Review of Medical Records

A well-documented medical record reflects the quality of care delivered to Veterans. VA and Optum will review medical records as part of oversight activities. Providers should maintain medical records in a manner that is current, detailed and organized. This allows for effective and confidential patient care and quality reviews.

Documentation Guidelines

VA requires the following guidelines to be met and items to be included within the medical documentation, when applicable:

• Encounter notes must include any procedures performed and recommendations for further testing or follow-up (e.g., discharge summary for inpatient)

• In lieu of encounter notes, a clinical summary may be provided for ancillary services when appropriate (e.g., physical therapy, occupational therapy, speech and language pathology and nutrition services)

• Results of testing or imaging such as magnetic resonance imaging (MRI) or computed tomography (CT) scan

• Images must be provided to VA upon request


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• Actual results of any ancillary studies/procedures that would impact recommended follow-up, such as biopsy results (e.g., biopsy results from the provider who recommends a follow-up, such as surgery)

• Any recommended prescriptions, medical devices, supplies or equipment and treatment plans • Other medical documentation based on clinical need

Medical documentation must also include: • Provider authentication (including a written signature, written initials or electronic signature and

provider phone number) • The Veteran’s unique identifier

• Integration Control Number (ICN) – primary beneficiary ID; or • Social Security number (SSN) – secondary beneficiary ID; or • Electronic Data Interchange Patient Identifier (EDIPI); or • Patient Control Number (PCN)

• Veteran’s full name (including suffix) • Veteran’s date of birth • Approved referral number

For example documentation, see Appendix A - VA Example of Documentation Inclusions in this Manual.

Submitting Medical Documentation

Providers must submit medical documentation directly to VA and the referring provider, using one of the following:

• HealthShare Referral Manager (HSRM) va.gov/communitycare > For Providers > Request and Coordinate Care

• VA Exchange for Community Care Partners at va.gov/VLER/vler-health-exchange-partners.asp > VA Exchange for Community Care Providers

• Direct Messaging – Secure, encrypted email – Direct Messaging, va.gov/VLER/vler-health-direct > Secure fax

Submission Time Frames

Medical documentation must be submitted to VA and the referring provider when applicable, according to the following time frames:

• Outpatient care • Within 30 days of the Veteran’s initial appointment • Within 30 days of completing care included on an approved referral

• Inpatient care • Within 30 days of discharge to include, at a minimum, the discharge summary

• When VA requests medical documentation, it will include the submission deadline • For urgent requests from VA, documentation is required within 24 hours of receiving the request

Failure to Comply

If a VA CCN provider does not comply with submission requirements, VA will notify Optum.

A representative from Optum will notify the provider of failure to comply. Providers have 30 days to respond to VA with corrected medical documentation.

https://www.va.gov/COMMUNITYCARE/providers/Care_Coordination.asp

https://www.va.gov/VLER/vler-health-exchange-partners.asp%20%3e%20VA%20Exchange%20for%20Community%20Care%20Providers

https://www.va.gov/VLER/vler-health-exchange-partners.asp%20%3e%20VA%20Exchange%20for%20Community%20Care%20Providers

https://www.va.gov/VLER/vler-health-direct.asp


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VA CCN Medical Documentation Training and Assistance

Optum offers training and assistance to providers for submission of timely medical documentation to VA. Training material is located on provider.vacommunitycare.com > Training & Guides.

Clinical Quality Medical Documentation Requirements

Providers will be required to:

• Submit medical records to Optum directly or through its designee, immediately upon receipt of request, no later than 21 days for expedited requests or 30 days for routine requests, for purposes of clinical quality review

• Maintain a release of medical records with the Veteran’s signature on file

REIMBURSEMENT AND CLAIMS PROCESS As VA CCN is implemented in your area, it is imperative that registration and billing staff are aware of the appropriate third-party administrator in order to bill and be paid quickly. Please share these details with your staff. On the VA CCN referral, look for the following Affiliations and Networks specific to the VA CCN region indicating Optum is the third-party administrator.

Affiliation: • CCN1 • CCN2 • CCN3

Network • CC Network 1 • CC Network 2 • CC Network 3

When you see the above Affiliations and Networks on an approved referral, the Veteran should be registered as VA CCN, and the claim should be submitted to Optum (or LHI for dental claims) using EDI, secure fax, mail or the provider portal. For an example, see Appendix B – Sample VA Referral Packet in this Manual.

Reimbursement

Providers will be reimbursed in accordance with the payment provisions and requirements in their respective Provider Agreements and any applicable payment appendices. For Covered Services rendered by providers to Eligible Veterans, the contract rates will be the lesser of:

(1) Provider’s Eligible Charges (as defined in the Provider Agreement and any applicable payment appendices), or

(2) The applicable contract rates determined in accordance with the Provider Agreement and any applicable payment appendices. All coding and billing guidelines issued by CMS will be followed by provider in submitting claims unless otherwise specified in the Provider Agreement and any applicable payment appendices.



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Services reimbursed under CMS MS-DRG payment methodology, episodic payments and payment appendices where reimbursement is based on a negotiated percentage of the facility-specific Medicare rate letter, such as Critical Access Hospitals and Rural Health Clinics, are not subject to lesser of logic. Services reimbursed under CMS APC methodology may be subject to lessor of logic as determined by CMS.

Where a CMS methodology does not utilize the lesser of the calculations (e.g., MSDRG, Episodic Payments, payment appendices where reimbursement is based on a negotiated percentage of the facility-specific Medicare Rate Letter, such as Critical Access Hospitals and Rural Health Clinics), the contract rates will not include the lesser of the calculations.

Long-Term Care Hospitals (LTCH) (also known as Long-Term Acute Care facilities) will not be subject to the LTCH Prospective Payment System (PPS) rules that, under Medicare, could result in reimbursement reductions. For all services that LTCHs provide, the payment will be 100% of Medicare rates.

Medical providers contracted for VA CCN as part of a UnitedHealthcare Participation Agreement who receive an approved medical referral identified by a medical SEOC to include dental services must file medical CPT or HCPC codes to Optum and dental CDT codes to LHI. Reimbursement for dental services as part of a medical referral will be in accordance with your UnitedHealthcare payment appendix.

The VA Fee Schedule is available at provider.vacommunitycare.com > Documents & Links.

Medical providers contracted for VA CCN, as part of a UnitedHealthcare Participation Agreement, who receive an approved dental referral signified by Category of Care: dental and a dental SEOC, must file medical CPT or HCPC codes to Optum and dental CDT codes to LHI. Payment for dental services as part of a dental referral will be in accordance with the fee schedule in Appendix C.

Claims Processing and Filing

Electronic submissions are preferred for sending claims to Optum using EDI from a vendor, clearinghouse or billing service.

Providers must submit claims on nationally recognized claims forms, including:

• CMS-1500 • Veteran’s SSN or ICN in box 1a • Referral number in box 23

• UB04 or CMS-1450

• Veteran’s SSN or ICN in box 60 • Referral number in field 63A

• American Dental Association (ADA) claim form (dental codes only)

• Veteran’s SSN or ICN in box 15 • Referral number in field 2

NOTE: Medical providers billing dental procedures must submit a dental claim to LHI on an ADA claim form with the appropriate CDT code(s).



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Timely Filing

Claims must be submitted within 180 days from the date of service for outpatient care, or the date of discharge for inpatient care.

Claims Submission

Electronic:

Payer ID: VACCN Note: VA CCN electronic claims should be routed to Optum 360 directly or through a clearinghouse or vendor. Use the provider portal to submit online:

• Medical/Behavioral: Go to provider.vacommunitycare.com > Medical/Behavioral Provider • Dental: Go to provider.vacommunitycare.com > Dental Provider

Paper

If electronic capability isn’t available, providers can submit claims by secure fax or mail.

• Medical • Mailing:

VA CCN Optum P.O. Box 202117 Florence, SC 29502

• Secure Fax:

833-376-3047

• Dental • Mailing:

Logistics Health, Inc. Attn: VA CCN Claims 328 Front St. S. La Crosse, WI 54601

• Secure Fax: 608-793-2143 (Please specify VA CCN on the fax.)

Claims Processing Timelines

Optum is committed to processing 98% of all clean claims within 30 days of receipt of the clean claim. Clean claims are claims received with all the required data elements necessary for adjudication without needing supplemental information. Claims that do not meet the definition of a clean claim will be returned to the provider with an explanation of deficiencies within 30 days of being received.

You may use the provider portal at provider.vacommunitycare.com > Medical/Behavioral Provider to verify claims status. All claims submitted will be acknowledged either with a payment, a provider remittance advice or returned with a specific request for additional information.



https://providervacommunitycare.com/


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Claim Denials

• Veterans are to be held harmless and may not be billed for any reason including, but not limited to, when claims for services are denied for any of the reasons identified below. Claims submitted that are missing one or more of the following elements will be denied:

• The Veteran’s SSN or ICN • An approved referral number except for urgent care benefits administered by Optum, VA CCN

urgent care provider is required to call for eligibility prior to rendering care • A valid NPI number

• Additional reasons that a claim may be denied include, but are not limited to, the following examples:

• Claims for care that aren’t within the scope of the approved referral • Duplicate claims • Claims for services that are not part of the Veteran’s medical benefits package • Claims submitted on unapproved claim forms. (Resubmitted claims on approved claim forms

must be submitted within the timely filing deadline of 180 days from the date of service or date of discharge)

• Emergency claims submitted by an in-network emergency department when an approved referral does not exist due to the in-network emergency department not contacting VA within 72 hours of the Veteran self-presenting to the emergency department to request a retroactive referral

• Claims that are not submitted within 180 days from the date of service or date of discharge (i.e., claims that are submitted past the timely filing deadline)

• Administrative charges related to completing and submitting the applicable claim form • The provider fails to submit a claim according to the claims adjudication rules • The provider delivers health care services outside of the validity period specified in the

approved referral

• Out-of-network providers providing emergency services need to submit health care claims directly to VA and follow VA claims submission procedures.

• Claims for ancillary services will be processed in accordance with CMS NCCI, MUE and related edits.

• Veterans are to be held harmless and may not be billed when claims are denied.

• Providers may not charge Veterans for missed appointments.

Veteran’s Signature on File

When a Veteran has signed a release of information statement, providers should indicate “Signature on File” on the claim submission. A new signature is required every year. Claims submitted for diagnostic tests, test interpretations or other similar services do not require the Veteran’s signature. When submitting these claims, you must indicate “patient not present” on the claim submission.

Optum randomly reviews claims to confirm that signature-on-file requirements are being followed.

Provider’s Signature on File

Optum will follow its normal business operations to verify signature of providers on claim submissions.

In lieu of a provider’s actual signature, the following are acceptable alternatives:


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• A facsimile signature or signature of a representative is accepted only if Optum or the Network Partner has on file a notarized authorization from the provider to use a facsimile signature or Power of Attorney (POA) for another person to sign on the provider’s behalf.

• The facsimile signature may be produced by a signature stamp or a block letter stamp, or it may be computer-generated if the claim form is computer-generated.

• If a POA is on file, the authorized representative may sign using the provider’s name, followed by the representative’s initials or using the representative’s own signature followed by POA, or similar indication of the type of authorization granted by the provider.

• The provider is required to update their signature authorization on file annually. • Optum may return a claim with a request for the signature authorization when there is no

authorization on file or it is out-of-date.

• Failure to comply with these requirements will result in claim denial.

Remittance Advice

VA CCN will transmit a provider remittance advice using EDI 835. For providers who don’t use EDI, an 835 transaction will be created, printed and mailed.

Claim Reconsiderations

Under VA CCN, a reconsideration is a formal process by which a provider may request that Optum reviews a claim denied, partially or in whole, or where a provider believes payment was incorrect.

• Where a claim is denied partially or in whole, a reconsideration request must be filed within 90 calendar days from the date of denial.

• When a claim has not been denied partially or in whole, but the provider believes the claim has been incorrectly paid, the provider must file a reconsideration request within 12 months after the claim was initially processed.

Reconsideration requests must be in writing and must include the claim number, date of service, Veteran name and reason for the request, along with an explanation/justification for reconsideration. Please send reconsideration requests to the address or fax number listed on the remittance advice. If unable to locate the address, please submit reconsideration request by mail, secure fax or secure email: VA Community Care Network

• Mailing: VA Community Care Network Appeals and Grievance Team MS-21 3237 Airport Road La Crosse, WI 56403

• Secure Fax:

877-666-6597 • Secure Email:

o Region 1: [email protected] o Region 2: [email protected] o Region 3: [email protected]





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Reconsideration requests will be responded to within 30 days of receipt of request.

Subrogation

You must notify the nearest VA in all circumstances of any VA CCN health care services related to or associated with any claim involving subrogation against: (i) workers’ compensation carrier, (ii) an auto liability insurance carrier, (iii) third-party tortfeasor (e.g., medical malpractice) or (iv) any other situation where a third party is responsible for the cost of VA CCN health care services. Optum will work with VA and notify you if any recoupment processes will be initiated.

Veteran Appeals

In the event Optum denies a claim and the Veteran has a financial liability for that denied claim (such as emergency care without an approved referral), Optum will provide a notice of the denial to the Veteran with a description of their right to appeal to VA.

A copy of the Veteran’s explanation of benefits (EOB) will be available to the Veteran through vacommunitycare.com > I am a Veteran.

Claims Audits

Optum may recover from Provider amounts owed to Optum pursuant to VA CCN Requirements, including payments that were made beyond or outside what is provided under the Provider Participation Agreement. Provider will receive a recoupment letter with the reason for the recovery including claims detail and the amount due. The provider will have 60 days to submit the refund or request a reconsideration. After 60 days, future claims will be offset with the amount owed. If your reconsideration request is overturned and the offset has already completed, Optum will reimburse the amounts previously recouped.

Claims identified and substantiated as fraud or abuse will be denied or subject to recovery from the Provider by Optum. See Fraud, Waste and Abuse for more information.

Claim/Referral Audit and Compliance

As a provider, you must respond to inquiries from Optum regarding Veterans who have scheduled appointments, but there is no associated claims activity. This may occur if a Veteran missed or cancelled an appointment, but does not reschedule.

PROVIDER TRAINING AND RESOURCES VA CCN providers will find information, resources and helpful links at provider.vacommunitycare.com > Training & Guides.

Training

Provider training will include, but is not limited to:

• VA CCN Provider Manual • VA CCN Quick Reference Guide (QRG) • VA CCN Frequently Asked Questions (FAQ) • What Is VA CCN? • Support Veterans in Your Community

https://vacommunitycare.com/

https://providervacommunitycare.com/


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• General Medical Benefits • Behavioral Health Benefits • Prescribing Medications for Veterans • Vision Care for Veterans • Durable Medical Equipment (DME) Benefits • Urgent Care Benefits • VA CCN Provider Services and Resources • Provider Credentialing • Time Frames for Managing Veteran Care • Fraud, Waste and Abuse • High-Performing Providers • Referral Process • Standardized Episode of Care (SEOC) • Medical Documentation Requirements • Educational Videos

Community Provider Toolkits

VA has additional tools and resources available for Providers working with Veterans. This includes easy-to-access information about how to screen for military experience, understanding military culture and referring to VA, as well as tools for working with a variety of behavioral health concerns. Providers have access to VA’s Community Provider Toolkit available at mentalhealth.va.gov/communityproviders/about.asp.

Optum offers a Provider Toolkit to assist provider offices and office staff with essential tools and guidelines. The goal of this toolkit is to collaborate and streamline critical information that will further assist your practice and office in caring for Veterans. The Behavioral Toolkit for Providers – Military and Veterans is available at providerexpress.com.

VA Required Training

Providers will be required to take applicable VA trainings to successfully manage Veteran care.

Acronyms

Table 3: Acronyms

Acronym Meaning

BH Behavioral Health

CARF Commission on Accreditation of Rehabilitation Facilities

CCN Community Care Network

CIHS Complementary and Integrative Healthcare Services

CMS The Centers for Medicare & Medicaid Services

CPT Current Procedural Terminology

CQMP Clinical Quality Management Program

https://www.mentalhealth.va.gov/communityproviders/about.asp

https://www.providerexpress.com/content/ope-provexpr/us/en/clinical-resources/military-and-veterans-tool-kit.html


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Acronym Meaning

CVS CVS Caremark

DME Durable Medical Equipment

DOS Dates of Service

EDI Electronic Data Interchange

EDIPI Electronic Data Interchange Patient Identifier

EHR Electronic Health Record

EOB Explanation of Benefits

FDA Food and Drug Administration

FQHC Federally Qualified Health Center

HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems Survey

HCPCS Healthcare Common Procedure Coding System

HEDIS Healthcare Effectiveness Data and Information Set

HHS U.S. Department of Health and Human Services

HSRM HealthShare Referral Manager

ICD International Classification of Diseases

ICN Integration Control Number

LHI Logistics Health Incorporated

MRI Magnetic Resonance Imaging

MSDRG Medicare Severity Diagnosis-Related Group

NPI National Provider Identifier

OHI Other Health Insurance

OIG Office of Inspector General

PBM Pharmacy Benefits Manager

PCP Primary Care Provider

PQI Potential Quality Issue

RFS Request for Services


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Acronym Meaning

RHC Rural Health Clinic

SEOC Standardized Episode of Care

SNF Skilled Nursing Facility

SSN Social Security Number

UBH United Behavioral Health

VA U.S. Department of Veterans Affairs

VA CCN VA Community Care Network

VAMC VA Medical Center

VBA Veterans Benefits Administration

VHA Veterans Health Administration

VHIC Veteran Health Identification Card

Glossary

Table 4: Glossary

Term Meaning

Approved referral

An approved referral from VA will support a specific plan of care as it relates to a specified number of visits and/or services related to a standardized episode of care for a specified Veteran as long as the services are provided by a provider.

Claim An invoice for health care, dental or pharmacy services

Clean claim A claim that contains all the required data elements necessary for adjudication without requesting supplemental information from the submitter

Complementary and Integrative Healthcare Services (CIHS)

CIHS includes practices that promote, preserve and restore health, such as biofeedback, hypnotherapy, massage therapy, Native American healing, relaxation techniques (such as meditation and guided imagery) and tai chi. Note that acupuncture is included as basic care in VA's benefits package, so it isn't listed with CIHS.

Covered services

Health care services and supplies that are covered under the VA CCN, as described in 38 CFR 17.38 and for which the provider has received an approved referral

Critical Access Hospital

A designation given to eligible rural hospitals by the Centers for Medicare & Medicaid Services (CMS).


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Term Meaning

Critical finding Those findings or results that require immediate evaluation by a health care provider such that failure to take immediate appropriate action might result in death, significant morbidity or serious adverse consequences to the Veteran.

Durable medical equipment (DME)

Equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of an illness or injury and is appropriate for use in the home.

EDI 278 Request

Requests for referrals for additional visits, DME, emergent services or services outside of initial referral.

At this time, VA does not accept 278 transactions for VA CCN.

EDI 835 remittance advice (RA)

An electronic explanation of payments and other decision-making information.

Electronic data interchange (EDI)

The electronic exchange of information between two or more organizations.

Eligible charge Defined in the Provider Agreement and any applicable payment appendices

Eligible Veteran Any Veteran who VA determines is eligible to receive community care.

Emergent care Medical care required within 24 hours or less essential to evaluate and stabilize conditions of an emergent need that, if not provided, may result in unacceptable morbidity/pain if there is significant delay in the evaluation or treatment.

Emergent health care need

Conditions of one’s health that may result in the loss of life, limb, vision or result in unacceptable morbidity/pain when there is significant delay in evaluation or treatment.

Enrolled Veteran Any Veteran who is enrolled in VA’s patient enrollment system and is eligible to receive health care benefits.

Episodic Payments

A payment method that covers all the care a patient receives in the course of treatment for a specific illness, condition or medical event.

General care All other care and services offered under VA Health Benefit Package other than primary care and Complementary and Integrative Health Services (CIHS).

Medical device

An instrument, apparatus, implement, machine, contrivance or other similar or related article, including a component part or accessory, which is intended for use in the cure, mitigation or treatment of disease or compensates for a person’s loss of mobility or other bodily functional abilities and function as a direct and active component of the person’s treatment and rehabilitation.


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Term Meaning

Non-service connected care

Medical care and services provided for a Veteran for an illness or injury that was not incurred in or aggravated by military service as determined by VA.

Pharmacy benefit manager

A third-party administrator for prescription drug programs.

Primary care Health care at a basic, rather than specialized, level.

Potential quality issue

A clinical or system variance warranting further review and investigation for determination of the presence of an identified quality issue (IQI).

Provider Physician, practitioner or ancillary facilities participating in VA CCN.

Provider Agreement

An executed agreement between Optum or Network Partner with the provider for VA CCN.

Referral request

A request and approval process that authorizes the Veteran to obtain specified care within a specified time frame from additional resources in the community. Upon approval, a referral number is generated. The referral number must always be included on claims submitted by VA CCN providers for payment.

Remittance advice

An explanation of payments and other decision-making information.

Rural Health Clinics

A clinic in a rural area that has primary care and outpatient services.

Service connected care

Medical care and services provided for a Veteran for a service-connected condition is an illness or injury decided by the Veterans Benefits Administration (VBA) as having been incurred or aggravated in line of duty in the active military, naval or air service.

Special authority Individuals eligible for VA benefits due to designation given by VA.

Standardized episode of care (SEOC)

A set of clinically related health care services for a specific unique illness or medical condition (diagnosis and/or procedure) provided by an authorized provider during a defined, authorized period of time not to exceed year.

Urgent health care need

Non-life-threatening conditions that require care in a timely manner (such as within 24 hours) to avoid having them worsen.

Urgent care Provision of immediate medical service offering outpatient care for the treatment of acute and chronic illness or injury.


A network of community-based providers and services designed to coordinate with VA in providing timely, accessible and high-quality health care to Veterans.

VA facility A VA facility is a VA hospital or VA medical center.


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Term Meaning

VA hospital A VA hospital is any VA-owned, staffed and operated facility providing acute inpatient and/or rehabilitation services.

VA medical center

A VA medical center is a VA point of service that provides at least two categories of care (inpatient, outpatient, residential or institutional extended care).

APPENDIX A – VA EXAMPLE OF DOCUMENTATION INCLUSIONS

VA’s Example Medical Documentation for VA CCN Providers

According to the VHA Handbook 1907.01, Health Information Management and Health Records, health record documentation is required to record pertinent facts, findings and observations about an individual’s health history, including past and present illnesses, examinations, tests, treatments and outcomes. A separate, unique health record is created and maintained for every individual assessed or treated by VA, as well as those receiving community or ancillary care at VA expense. The health record documents the care of the patient and is an important element contributing to high-quality care.

All community care provider documentation scanned or imported into the Veteran electronic health record (EHR) must be complete, including the provider signature authenticating the originating VA community provider of care documentation prior to inclusion into the VHA electronic health record. Authentication may include a written signature, written initials or electronic signatures. If unsigned documents are received, three attempts must be made to work with the VA Community Care provider to obtain authenticated documents.

Note: Not all of the documents listed below are necessary to be included in the received documentation. For example, a primary care visit may include only the progress note, as no ancillary services were performed.

Primary Care

Initial evaluation note

Progress notes

Summary note of care when patient requires no further treatment (i.e., the episode of care)

Ancillary services, if performed (Results) o Imaging o Laboratory o Other testing (e.g., electrocardiogram, pulmonary function testing, etc.)

Medications, administered and/or prescribed

Inpatient Care – Medical - (i.e., Acute Inpatient)

Note: Facilities may prioritize the order of clinical documents within the inpatient stay so that pertinent clinical documents, such as Discharge Summary, H&P and Operative Reports, are sequenced first and readily available to clinical staff. Prioritization of the documents must be stated in the facility’s local policy.

Discharge summary


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History and physical

Consultations

Diagnostic and therapeutic procedure report, if performed (Results)

Informed consent


Transfer note/summary

Against Medical Advice (AMA) note (if patient left AMA)

Discharge note or discharge instructions

Discharge medications

Legal documents, (e.g., advance directive, living will, power of attorney, conservatorship)

State authorized portable orders

Do Not Resuscitate (DNR) or Do Not Attempt Resuscitation (DNAR)

Autopsy

Death certificate

Inpatient Care – Surgical

Discharge summary


Consultations

Informed consent

Operative report

Post-operative note

Anesthesia evaluation

Anesthesia plan

Post-anesthesia note

Diagnostic and therapeutic procedure report

Surgical pathology and cytopathology reports o Should be received within 48 hours






Legal documents (e.g., advance directive, living will, power of attorney, conservatorship)

Do Not Resuscitate (DNR) or Do Not Attempt Resuscitation (DNAR) Note

Autopsy

Death certificate

Inpatient Mental Health

Discharge summary


Consultations (if performed)

Ancillary services performed (Results, if performed) o Imaging o Laboratory


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o Other testing (e.g., electrocardiogram, pulmonary function testing, etc.)





Legal documents (e.g., advance directive, living will, power of attorney, conservatorship)

Ambulatory Surgery


Operative note

Operative report

Anesthesia evaluation

Anesthesia plan

Post-anesthesia note

Informed consent

Surgical pathology and cytopathology reports o Should be received within 48 hours.

Medications

Discharge instructions


Emergency Room (ER) Care

Note: ER documentation received must be authenticated before it’s included in the VA health record.

ER provider note

Treatment plan

Transfer note/summary (point of stability for transfer)

Condition at discharge

Discharge instruction

Ancillary services, if performed (results) o Imaging o Laboratory o Other testing (e.g., electrocardiogram, pulmonary function testing, etc.)

Ambulance/Transportation note, if transported

Discharge medications, administered and/or prescribed

Veteran Death at ER

Discharge summary

Death certificate

Specialty/Outpatient Care

Consultation note

Progress note

Treatment plan

Summary note of care when patient requires no further treatment.

Ancillary services performed (results) o Imaging (e.g., mammography report, including BI-RAD) o Laboratory o Other testing (e.g., electrocardiogram, pulmonary function testing, etc.)

Medications, administered and/or prescribed

Observation (Short-Stay Admission)


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Initial progress note


Progress notes

Discharge note or discharge instructions, including discharge diagnoses


Outpatient Mental Health

Initial evaluation note

Progress notes

Summary note of care when patient requires no further treatment.

Treatment plan

Medications, administered and/or prescribed HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

CPT® is a registered trademark of the American Medical Association.


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APPENDIX B – SAMPLE VA REFERRAL PACKET

Veteran Name: Jane Doe Veteran ICN: 1234567890V123456 Veteran EDIPI: 123456 Veteran Date of Birth: 00/00/1901 Veteran Address: • • • • • • • •RD Springfield, VT 05156 Veteran Phone Number: 999-999-9999

Referring VA Facility: White River Junction VA Medical Center

VA Telephone Number: 800-XXX-1212 ext. 6060

Initial Community Care Provider/Facility: WE CARE HOSPITAL PROF FEES Initial Provider Location: WE CARE HOSPITAL PROF FEES-999 MAIN ST, SPRINGFIELD, VT, 012345-22 5100000X Provider Name (if known): SHANNON DOE Community Provider NPI: 1111111111

Any claim related to this episode of care MUST INCLUDE THE APPROVED REFERRAL NUMBER on the EDI

transaction as the Referral Number or Prior Authorization number.

Please see below for Additional VA Referring Facility Information and Billing Information

Please refer to your referral package for additional clinical consult information. Provisional Diagnosis: M797 Fibromyalgia Service Requested: Physical Therapy SEOC 1.0.4 Category of Care: PHYSICAL THERAPY

Physical Therapy SEOC 1.0.4 No. Service/Procedure No. Visits

Authorized 1. Physical therapy evaluation and treatment for the referred condition on the consult. It is expected that a

standardized outcome questionnaire be completed at initial, additional visit requests and discharge. 999

2. Physical Therapy: A maximum of fifteen (15) visits are approved for this episode of care related to the referred condition on the consult. Approved modalities to help restore muscle function that can be utilized during

15

3. Equipment Fitting/Instruction (i.e., TEMS unit instruction, brace fitting as provided or approved by VA to be dispensed): A maximum of three visits for issuance, education and follow-up as ordered.

3

VA Form 10-7080 - Approved Referral For Medical Care

Referral Number: VA0000012345 Priority: Routine Referral Issue Date: 2019-02-28 Expiration Date: 2019-10-18

First Appointment Date:

Pertinent Clinical Information

Services Authorized

Procedural Overview – Standardized Episode of Care (SEOC)


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SEOC Disclaimer

• Requests for additional physical therapy services must include a detailed plan linked to time-limited attainment of objective

functional outcomes with documented justification relating to outcome questionnaires listed above. • Additional consultation needed

relevant to the patient complaint/condition requires VA review and approval. • DME, prosthetics and orthotics will be reviewed by the

VA for provision. • All routine medications must be immediately faxed/provided to VA pharmacy to be dispensed timely by VA

pharmacy. Non-formulary drug approval process may be required. • Urgent/emergent prescriptions can be provided for a 14-day

supply only. • The Veteran will be required to pay out-of-pocket for any urgent/emergent medications and can submit a

reimbursement request to their local VA facility.

REFER ALL QUESTIONS RELATED TO THIS APPROVAL TO THE ISSUING VA OFFICE

Referring VA Facility: White River Junction VA Medical Center

Station Number: 405

Ordering Officer: Terri Doe

Telephone Number: 802-XXX-9363 ext. 6060

Address: 163 Veterans Drive, WHITE RIVER JUNCTION, VT 05001

Referring Provider: LYNN DOE

Unique Consult No: 405_1674357

Program Authority: Authorized/Pre-authorized VA Referral (not otherwise specified) – 1703

Affiliation: CCN1

Network: CC Network 1

Payer Status: VA – Primary Payer

Any claim related to this episode of care MUST INCLUDE THE APPROVED REFERRAL NUMBER on the EDI

transaction as the Referral Number or Prior Authorization number

Billing Remarks

Please refer to claims submission instructions provided by your Community Care Network contractor.

Precertification

The Standardized Episode of Care (SEOC) referral you have accepted does not include services that require Third-Party Payer (TPP) precertification.

Billing and Other Referral Information


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VHA Consult Transmittal

Document Created: 07/12/2019 12:38

The documents accompanying this transmission contain confidential health information that is

legally privileged. This information is intended only for the use of the individual or entity

providing care to this Veteran. The authorized recipient of this information is prohibited from

disclosing this information to any other party unless required to do so by law or regulation and

is required to destroy the information after its stated need has been fulfilled and in accordance

with agency destruction and retention requirements. If you are not the intended recipient, you

are hereby notified that any disclosure, copying or distribution is strictly prohibited as this

information is protected by Federal Privacy law (e.g., HIPAA Privacy Rule). If you have

received this information in error, please notify the sender immediately and arrange for the

return or destruction of these documents.

WHITE RIVER JCT VAMROC 215 North Main Street, White River Junction, Vermont 05009-3833

VA Referrals phone: 999.999.9999 EXT 6060 Fax: 999.999.9999

Point of Contact (POC): Doe, Angela POC

Phone: 999.999.9999 Fax: 999.999.9999

Patient Name: DOE, JANE 000 • • • • • •RD SPRINGFIELD, VERMONT 05156

DOB: 00/00/1900 Phone (residential): 999-999-9999 Phone (mobile): (999)999-9999

SSN: 000-00-0000 Referral Type: Community Care Network

Next of Kin Contact Information DOE, JOHN

Address (Next Of Kin)

000 • • • • • •RD

SPRINGFIELD, VERMONT 05156

Phone: 999-999-9999

Sensitive Diagnoses

Problem Code

ALCOH DEP NEC/NOS-REMISS 303.93

PROBLEM LIST


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Other Diagnoses

Problem Code

ANEMIA NOS 285.9

ASTHMA NOS 493.90

CHRONIC SINUSITIS NEC 473.8

COUNSEL-MARITAL/PARTN, UNSP V61.10

DENTAL DISORDER NOS 525.9

DERMATOPHYTOSIS OF NAIL 110.1

DEVIATED NASAL SEPTUM 470.

100 most recent outpatient medications released by VA to Veteran in the last 6 months Medication Name and Dose Quantity Refill Number Issue and Fill Date Status

ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL Qty:1 Fill: 1 of 11 Orig: 2019-01-31 ACTIVE

INHALE 2 PUFFS BY MOUTH FOUR TIMES DAILY AS NEEDED FOR BREATHING

Last: 2019-02-02

CALCIUM 500MG/VITAMIN D 200 UNT TAB Qty:270 Fill: 1 of 3 Orig: 2019-01-31 ACTIVE

TAKE 1 TABLET BY MOUTH THREE TIMES A DAY TO SUPPLEMENT

CALCIUM/STRENGTHEN BONES

Last: 2019-06-24

Local Drug Name and Dose Medication Route Schedule

MULTIVITAMIN/MINERALS CAP/TAB MOUTH EVERY DAY

MULTIVITAMIN CAP/TAB MOUTH

Name Origin Verified

AMITRIPTYLINE Origin: 2013-05-02 Verified:

CEFAZOLIN Origin: 1999-05-10 Verified: 2004-06-25

FLUNISOLIDE 0.25/SPRAY NASAL Origin: 2004-04-24 Verified: 2004-04-24

METRONIDAZOLE Origin: 2011-07-26 Verified:

MEDICATIONS

NON-VA MEDICATIONS

ALLERGIES


v1.4


COMMUNITY CARE-PHYSICAL THERAPY Cons Consultant's Choice Activity:

02/28/2019 08:11 New Order entered by DOE, LYNN (STAFF PHYSICIAN)

UCID: 405_1674357

Order Text: PHYSICAL THERAPY-OUTPATIENT Cons

Consultant's Choice Nature of Order: ELECTRONICALLY ENTERED

Elec Signature: DOE, LYNN (STAFF PHYSICIAN) on 02/28/2019 08:11

05/10/2019 08:51 Change entered by DOE, JANE (MSA)

Changed to: COMMUNITY CARE-PHYSICAL THERAPY Cons

Consultant's Choice Nature of Order: SERVICE CORRECTION

Signature: SERVICE CORRECTION TO SIGNED ORDER Current Data:

Treating Specialty:

Ordering Location: WRJ MGRA PACT WCC WH A

Start Date/Time: 02/28/2019 08:11

Stop Date/Time:

Current Status: ACTIVE

Orders that are active or have been accepted by the service for processing:

e.g., Dietetic orders are active upon being ordered, Pharmacy orders are active

when the order is verified, Lab orders are active when the sample has been

collected, Radiology orders are active upon registration.

Order #18511909 Order:

Consult to Service/Specialty: COMMUNITY CARE-PHYSICAL THERAPY

Reason for request:

Is this Veteran appropriate for consideration for referral to Community Care? Yes

VA facility does not provide the required service

Requested intervention for Physical Therapy: Evaluate and treat Intervention is

requested for the following diagnosis: Dx: fibromyalgia for pool therapy close to

home Special considerations (i.e., pacemaker, precautions, weight-bearing

status):

Referral has been discussed with patient and he/she is agreeable to coming to

Physical Therapy: Yes

Category: OUTPATIENT

Urgency: ROUTINE

Clinically Indicated Date: Feb 28, 2019

Place of Consultation: Consultant's Choice

Provisional Diagnosis: Fibromyalgia (ICD-10-CM M79.7)

ORDERS


v1.4


LOCAL TITLE: Telephone Note/Physical Therapy

STANDARD TITLE: PHYSICAL THERAPY TELEPHONE ENCOUNTER

NOTE DATE OF NOTE: MAY 10, 2019@08:17

ENTRY DATE: MAY 10, 2019@08:17:45 AUTHOR: XXXXXXX,XXXX EXP COSIGNER:

URGENCY: STATUS: COMPLETED Called Veteran to discuss her request for pool therapy. She has not been able to

make the past two appts. that were scheduled for her due to scheduling conflicts.

Asked her if she tolerates long rides well and she states that she doesn't really.

Offered a local community-based referral for pool therapy in the community and

she is very interested in this. Feels this would work very well for her. I see that

We Care Hospital offers aquatic therapy at the We Swim Center – this would be

perfect for her. I will have her apt cancelled this morning and will refer her to

community care per above. She is very happy and pleased with this plan.

total time 15 minutes /es/ xxxxxxxxxxxx PT,

WCS, CLT Physical

Therapist, licensed in NH

Signed: 05/10/2019

08:21

Lab Result Abnormal Specimen Date Reference Range Units

CO2 27 2019-01-13 22 - 31 mEq./L.

CREATININE 0.8 2019-01-13 0.6 - 1.5 mg/dl

GLUCOSE 103 2019-01-13 70 - 115 mg/dl

HCT 37.0 2019-01-13 35.9 - 44.6 %

HGB 12.5 2019-01-13 12.3 - 15.3 gm/dl

PLATELET COUNT 204 2019-01-13 150 - 450 K/cmm

POTASSIUM 3.9 2019-01-13 3.30 - 5.10 mEq./L.

SGOT 27 2019-01-13 5 - 40 Unit/L.

SGPT 27 2019-01-13 7 - 45 Unit/L.

SODIUM 135 2019-01-13 135 - 147 mEq./L.

TOTAL BILIRUBIN 0.6 2019-01-13 .1 - 1.1 mg/dl

WBC 6.80

2019-01-13 4.5 - 10.0 K/cmm

PROGRESS NOTES

LABS


v1.4


APPENDIX C – DENTAL FEE SCHEDULE

APPENDIX C – FIXED RATES

Diagnostics

Code Description CCN Region

1

CCN

Region 2

CCN

Region 3

D0120 Periodic oral evaluation – established patient 35.91 35.91 35.91

D0140 Limited oral evaluation – problem focused 68.93 68.93 68.93

D0150 Comprehensive oral evaluation – new or established patient 60.13 60.13 60.13

D0160 Detailed and extensive oral evaluation – problem focused, by report 118.87 118.87 118.87

D0170 Re-evaluation – limited, problem focused (established patient; not post-operative visit)

59.88 59.88 59.88

D0171 Re-evaluation – post-operative office visit 58.63 58.63 58.63

D0180 Comprehensive periodontal evaluation – new or established patient 61.29 61.29 61.29

D0190 Screening of a patient 58.63 58.63 58.63

D0191 Assessment of a patient 52.77 58.63 58.63

D0391 Interpr of diagnostic image by prac not associated with capture of the image, incl report

97.49 97.49 97.49

D0393 Treatment simulation using 3D image volume 483.11 483.11 483.11

D0394 Digital subtraction of two or more images or image volumes of the same modality

483.11 483.11 483.11

D0395 Fusion of two or more 3D image volumes of one or more modalities 483.11 483.11 483.11

D0411 HbA1c in-office point of service testing 104.87 104.87 104.87

D0412 Blood glucose level test – in-office using a glucose meter 6.77 6.77 6.77

D0414 Processing microbial specimen incl C&S, I&R by medical lab 191.16 191.16 191.16

D0415 Collection of microorganisms for culture and sensitivity 78.51 78.51 78.51

D0416 Viral culture 78.77 78.77 78.77

D0417 Collection and preparation of saliva sample for laboratory diagnostic testing

55.44 55.44 55.44

D0418 Analysis of saliva sample 55.44 55.44 55.44

D0419 Assessment of salivary flow by measurement 49.13 49.13 49.13

D0422 Collection and preparation of genetic sample material for laboratory analysis and report

43.49 43.49 43.49

D0423 Genetic test for susceptibility to diseases – specimen analysis 35.72 35.72 35.72

D0425 Caries susceptibility tests 54.88 54.88 54.88

D0431 Pre dx oral cancer screen by fluorescence – not to incl cytology/biopsy 62.43 62.43 62.43

D0460 Pulp vitality test 64.25 64.25 64.25

D0470 Diagnostic casts 98.66 98.66 98.66

D0472 Accession of tissue, gross examination, preparation and transmission of written report

71.99 71.99 71.99

D0473 Accession of tissue, gross and microscopic exam, preparation and transmission of written rpt

197.84 197.84 197.84

D0474 Lab analysis of biopsied tissue (obtained by surgical means) incl report 223.32 235.46 235.46


v1.4



1

CCN

Region 2

CCN

Region 3

D0475 Decalcification procedure 89.42 89.42 89.42

D0476 Special stains for microorganisms 100.51 100.51 100.51

D0477 Special stains, not for microorganisms 111.49 111.49 111.49

D0478 Immunohistochemical stains 105.87 105.87 105.87

D0479 Tissue in-situ hybridization, including interpretation 142.46 142.46 142.46

D0480 Lab anlys of non-trans cell cytology smpl of oral mucosa collected by scraping incl report

106.47 106.47 106.47

D0481 Electron microscopy 462.33 462.33 462.33

D0482 Direct immunofluorescence 125.36 125.36 125.36

D0483 Indirect immunofluorescence 118.13 118.13 118.13

D0484 Consultation on slides prepared elsewhere 190.06 190.06 190.06

D0485 Consultation, incl preparation of slides from biopsy material supplied by referring source

224.47 224.47 224.47

D0486 Lab analysis transepithelial cell cytology of oral mucosa collected by brush biopsy incl rept

185.70 185.70 185.70

D0502 Other oral pathology procedures, by report 126.83 126.83 126.83

D0600 Diag. test of the enamel, dentin & cementum using an integrated laser/intraoral camera system

30.71 30.71 30.71

D0601 Caries risk assessment and documentation, with a finding of low risk 60.09 60.09 60.09

D0602 Caries risk assessment and documentation, with a finding of moderate risk

60.09 60.09 60.09

D0603 Caries risk assessment and documentation, with a finding of high risk 60.09 60.09 60.09

D0999 Unspecified diagnostic procedure, by report 145.65 145.65 145.65

Radiographs


1

CCN Region 2

CCN Region 3

D0210 Intraoral – complete series of radiographic images 119.73 119.73 119.73

D0220 Intraoral – periapical first radiographic image 25.28 25.28 25.28

D0230 Intraoral – periapical each additional radiographic image 20.12 20.12 20.12

D0240 Intraoral – occlusal radiographic image 33.16 33.16 33.16

D0250 Extra-oral – 2D projection radiographic image created using stnry radiation source, & detector

46.09 46.09 46.09

D0251 Extra-oral posterior dental radiographic image 46.06 46.06 46.06

D0270 Bitewing – single radiographic image 20.46 20.46 20.46

D0272 Bitewings – two radiographic images 29.29 29.29 29.29

D0273 Bitewings – three radiographic images 37.52 37.52 37.52

D0274 Bitewings – four radiographic images 42.43 42.43 42.43

D0277 Vertical bitewings – 7 to 8 radiographic images 99.40 99.40 99.40

D0310 Sialography 367.71 367.71 367.71

D0320 Temporomandibular joint arthrogram, including injection 578.76 578.76 578.76

D0321 Other temporomandibular joint radiographic images, by report 252.45 252.45 252.45


v1.4



1

CCN

Region 2

CCN

Region 3

D0330 Panoramic radiographic image 87.69 87.69 87.69

D0340 2D Cephalometric radiographic image – acquisition, measurement and analysis

105.77 105.77 105.77

D0350 2D Oral/facial photographic image obtained intra-orally or extra-orally 175.62 175.62 175.62

D0351 3D photographic image 195.14 195.14 195.14

D0369 Maxillofacial MRI capture and interpretation 609.35 609.35 609.35

D0370 Maxillofacial ultrasound capture and interpretation 609.35 609.35 609.35

D0371 Sialoendoscopy capture and interpretation 330.94 367.71 367.71

D0385 Maxillofacial MRI image capture 609.35 609.35 609.35

D0386 Maxillofacial ultrasound image capture 609.35 609.35 609.35

Diagnostics – Computed Tomography


1

CCN

Region 2

CCN

Region 3

D0322 Tomographic survey 443.15 443.15 443.15

D0364 Cone beam CT capture and interpretation with limited field of view – less than one whole jaw

521.44 521.44 521.44

D0365 Cone beam CT capture and interpretation with field of view of one full dental arch – mandible

538.06 538.06 538.06

D0366 Cone Beam CT w/ I&R Max w or w/o cranium 511.22 511.22 511.22

D0367 Cone beam CT capture and interpretation with field of view of both jaws; w or w/o cranium

548.41 548.41 548.41

D0368 Cone beam CT capture and interpretation for TMJ series including two or more exposures

609.35 609.35 609.35

D0380 Cone beam CT image capture with limited field of view – less than one whole jaw

548.41 548.41 548.41

D0381 Cone beam CT image capture with field of view of one full dental arch – mandible

548.41 548.41 548.41

D0382 Cone beam CT image capture w field of view of 1 full dental arch – maxilla, w or w/o cranium

548.41 548.41 548.41

D0383 Cone beam CT image capture with field of view of both jaws; with or without cranium

548.41 548.41 548.41

D0384 Cone beam CT image capture for TMJ series including two or more exposures

609.35 609.35 609.35

Preventive


1

CCN

Region 2

CCN

Region 3

D1110 Prophylaxis - adult 82.45 82.45 82.45

D1206 Topical application of fluoride varnish 45.65 45.65 45.65

D1208 Topical application of fluoride – excluding varnish 33.13 33.13 33.13

D1310 Nutritional counseling for control of dental disease 50.28 50.28 50.28

D1320 Tobacco counseling for the control and prevention of oral disease 51.48 51.48 51.48

D1330 Oral hygiene instructions 66.75 66.75 66.75

D1351 Sealant – per tooth 47.42 47.42 47.42


v1.4



1

CCN

Region 2

CCN

Region 3

D1352 Preventive resin restoration in a moderate to high caries risk patient–- permanent tooth

47.42 47.42 47.42

D1353 Sealant repair – per tooth 23.68 23.68 23.68

D1354 Interim caries arresting medicament application – per tooth 39.27 39.27 39.27

D1510 Space maintainer – fixed – unilateral 289.06 289.06 289.06

D1516 Space maintainer – fixed – bilateral, maxillary 312.89 312.89 312.89

D1517 Space maintainer – fixed – bilateral, mandibular 312.89 312.89 312.89

D1520 Space maintainer – removable – unilateral 348.11 348.11 348.11

D1526 Space maintainer – removable – bilateral, maxillary 329.69 329.69 329.69

D1527 Space maintainer – removable – bilateral, mandibular 329.69 329.69 329.69

D1551 Re-cement or re-bond bilateral space maintainer – maxillary 54.00 54.00 54.00

D1552 Re-cement or re-bond bilateral space maintainer – mandibular 54.00 54.00 54.00

D1553 Re-cement or re-bond unilateral space maintainer – per quadrant 54.00 54.00 54.00

D1556 Removal of fixed unilateral space maintainer – per quadrant 50.20 50.20 50.20

D1557 Removal of fixed bilateral space maintainer – maxillary 50.20 50.20 50.20

D1558 Removal of fixed bilateral space maintainer – mandibular 50.20 50.20 50.20

D1575 Distal shoe space maintainer – fixed – unilateral 361.57 401.74 401.74

D1999 Unspecified preventive procedure, by report 70.20 70.20 70.20

Restorative


1

CCN

Region 2

CCN

Region 3

D2140 Amalgam – one surface, primary or permanent 83.95 83.95 83.95

D2150 Amalgam – two surfaces, primary or permanent 102.69 102.69 102.69

D2160 Amalgam – three surfaces, primary or permanent 119.43 119.43 119.43

D2161 Amalgam – four or more surfaces, primary or permanent 148.01 148.01 148.01

D2330 Resin-based composite – one surface, anterior 94.73 94.73 94.73

D2331 Resin-based composite – two surfaces, anterior 129.71 129.71 129.71

D2332 Resin-based composite – three surfaces, anterior 166.66 166.66 166.66

D2335 Resin-based composite – four or more surfaces or involving incisal angle (anterior)

202.70 202.70 202.70

D2390 Resin-based composite crown, anterior 322.63 358.47 358.47

D2391 Resin-based composite – one surface, posterior 132.33 132.33 132.33

D2392 Resin-based composite – two surfaces, posterior 179.00 179.00 179.00

D2393 Resin-based composite – three surfaces, posterior 225.27 225.27 225.27

D2394 Resin-based composite – four or more surfaces, posterior 280.95 280.95 280.95

D2410 Gold foil – one surface 367.26 367.26 367.26

D2420 Gold foil – two surfaces 503.40 503.40 503.40


v1.4



1

CCN

Region 2

CCN

Region 3

D2430 Gold foil – three surfaces 807.74 807.74 807.74

D2510 Inlay – metallic – one surface 702.31 702.31 702.31

D2520 Inlay – metallic – two surfaces 793.50 793.50 793.50

D2530 Inlay – metallic – three or more surfaces 927.56 927.56 927.56

D2542 Onlay – metallic – two surfaces 909.57 909.57 909.57

D2543 Onlay – metallic – three surfaces 959.05 959.05 959.05

D2544 Onlay – metallic – four or more surfaces 1004.12 1004.12 1004.12

D2610 Inlay – porcelain/ceramic – one surface 810.76 810.76 810.76

D2620 Inlay – porcelain/ceramic – two surfaces 849.82 849.82 849.82

D2630 Inlay – porcelain/ceramic – 3+ surfaces 920.42 920.42 920.42

D2642 Onlay – porcelain/ceramic – two surfaces 897.31 897.31 897.31

D2643 Onlay – porcelain/ceramic – three surfaces 955.04 955.04 955.04

D2644 Onlay - porcelain/ceramic – four or more surfaces 1050.73 1050.73 1050.73

D2650 Inlay – resin-based composite – one surface 588.92 588.92 588.92

D2651 Inlay – resin-based composite – two surfaces 669.54 669.54 669.54

D2652 Inlay – resin-based composite – three or more surfaces 715.43 715.43 715.43

D2662 Onlay – resin-based composite – two surfaces 638.99 638.99 638.99

D2663 Onlay – resin-based composite – three surfaces 759.10 759.10 759.10

D2664 Onlay – resin-based composite – four or more surfaces 837.98 837.98 837.98

D2710 Crown – resin-based composite (indirect) 421.11 421.11 421.11

D2712 Crown – 3/4 resin-based composite (indirect) 428.40 428.40 428.40

D2720 Crown – resin with high noble metal 1031.89 1031.89 1031.89

D2721 Crown – resin with predominantly base metal 961.60 961.60 961.60

D2722 Crown – resin with noble metal 995.87 995.87 995.87

D2740 Crown – porcelain/ceramic 1044.52 1044.52 1044.52

D2750 Crown – porcelain fused to high noble metal 956.14 956.14 956.14

D2751 Crown – porcelain fused to predominantly base metal 917.82 917.82 917.82

D2752 Crown – porcelain fused to noble metal 933.40 933.40 933.40

D2753 Crown – porcelain fused to titanium and titanium alloys 827.13 827.13 827.13

D2780 Crown – 3/4 cast high noble metal 1007.27 1007.27 1007.27

D2781 Crown – 3/4 cast predominantly base metal 936.40 936.40 936.40

D2782 Crown – 3/4 cast noble metal 990.38 990.38 990.38

D2783 Crown – 3/4 porcelain/ceramic 1026.11 1026.11 1026.11

D2790 Crown – full cast high noble metal 953.50 953.50 953.50

D2791 Crown – full cast predominantly base metal 923.60 923.60 923.60


v1.4



1

CCN

Region 2

CCN

Region 3

D2792 Crown – full cast noble metal 854.18 854.18 854.18

D2794 Crown – titanium 1041.75 1041.75 1041.75

D2799 Provisional crown – further treatment/completion of diag necessary prior to final impression

388.79 388.79 388.79

D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration

86.53 86.53 86.53

D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core

85.70 85.70 85.70

D2920 Re-cement or re-bond crown 84.20 84.20 84.20

D2921 Reattachment of tooth fragment, incisal edge or cusp 64.59 64.59 64.59

D2929 Prefabricated porcelain/ceramic crown – primary tooth 269.80 269.80 269.80

D2930 Prefabricated stainless steel crown – primary tooth 258.17 258.17 258.17

D2931 Prefabricated stainless steel crown – permanent tooth 283.32 283.32 283.32

D2932 Prefabricated resin crown 343.46 309.11 309.11

D2933 Prefabricated stainless steel crown with resin window 320.32 320.32 320.32

D2934 Prefabricated esthetic coated stainless steel crown – primary tooth 293.59 293.59 293.59

D2940 Protective restoration 91.79 91.79 91.79

D2941 Interim therapeutic restoration – primary dentition 70.16 70.16 70.16

D2949 Restorative foundation for an indirect restoration 55.20 55.20 55.20

D2950 Core buildup, including any pins when required 209.57 209.57 209.57

D2951 Pin retention – per tooth, in addition to restoration 53.12 53.12 53.12

D2952 Post and core in addition to crown, indirectly fabricated 359.55 359.55 359.55

D2953 Each additional indirectly fabricated post – same tooth 209.19 209.19 209.19

D2954 Prefabricated post and core in addition to crown 262.66 262.66 262.66

D2955 Post removal 244.10 244.10 244.10

D2957 Each additional prefabricated post – same tooth 141.99 141.99 141.99

D2960 Labial veneer (resin laminate) – chairside 532.70 532.70 532.70

D2961 Labial veneer (resin laminate) – laboratory 747.83 747.83 747.83

D2962 Labial veneer (porcelain laminate) – laboratory 949.60 949.60 949.60

D2971 Additional procedures to construct new crown under existing partial denture framework

240.55 216.50 216.50

D2975 Coping 511.47 511.47 511.47

D2980 Crown repair necessitated by restorative material failure 219.68 219.68 219.68

D2981 Inlay repair necessitated by restorative material failure 190.53 190.53 190.53

D2982 Onlay repair necessitated by restorative material failure 190.53 190.53 190.53

D2983 Veneer repair necessitated by restorative material failure 190.53 190.53 190.53

D2990 Resin infiltration of incipient smooth surface lesions 47.42 47.42 47.42

D2999 Unspecified restorative procedure, by report 170.35 170.35 170.35


v1.4


Endodontics


1

CCN

Region 2

CCN

Region 3

D3110 Pulp cap – direct (excluding final restoration) 76.68 76.68 76.68

D3120 Pulp cap – indirect (excluding final restoration) 62.89 62.89 62.89

D3220 Pulpotomy & medicament excl final rest. Primary/perm. Not for apexoenisis

159.76 159.76 159.76

D3221 Pulpal debridement, primary and permanent teeth 189.15 189.15 189.15

D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development

149.59 149.59 149.59

D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration)

192.71 192.71 192.71

D3240 Pulpal therapy (resorbable filling) -–posterior, primary tooth (excluding final restoration)

223.09 223.09 223.09

D3310 Endodontic therapy, anterior tooth (excluding final restoration) 657.88 657.88 657.88

D3320 Endodontic therapy, premolar tooth (excluding final restoration) 716.79 716.79 716.79

D3330 Endodontic therapy, molar tooth (excluding final restoration) 1043.74 1043.74 1043.74

D3331 Treatment of root canal obstruction; non-surgical access 358.59 358.59 358.59

D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth

399.35 399.35 399.35

D3333 Internal root repair of perforation defects 286.66 286.66 286.66

D3346 Retreatment of previous root canal therapy – anterior 917.74 917.74 917.74

D3347 Retreatment of previous root canal therapy – premolar 1061.84 1061.84 1061.84

D3348 Retreatment of previous root canal therapy – molar 1219.89 1219.89 1219.89

D3351 Apexification/recalcification incl opening tth, canal prep, medicaments, X-rays initial

339.98 339.98 339.98

D3352 Apexification/recalcification – interim medication replacement 176.55 176.55 176.55

D3353 Apexification/recalcification interm repl intra-canal medicaments, X-rays 490.26 490.26 490.26

D3355 Pulpal regeneration – initial visit 336.32 336.32 336.32

D3356 Pulpal regeneration – interim medication replacement 176.55 176.55 176.55

D3357 Pulpal regeneration – completion of treatment 402.67 402.67 402.67

D3410 Apicoectomy – anterior 781.34 781.34 781.34

D3421 Apicoectomy – premolar (first root) 907.34 907.34 907.34

D3425 Apicoectomy – molar (first root) 893.06 893.06 893.06

D3426 Apicoectomy (each additional root) 276.69 276.69 276.69

D3427 Periradicular surgery without apicoectomy 296.81 296.81 296.81

D3428 Bone graft in conjunction with periradicular surgery – per tooth, single site

475.16 475.16 475.16

D3429 Bone graft in conj with periradicular surg – each add'l contiguous tooth in same surgical site

327.73 327.73 327.73

D3430 Retrograde filling – per root 223.25 223.25 223.25

D3431 Biologic materials to aid in soft and osseous tissue regeneration in conj w periradicular surg

316.80 316.80 316.80

D3432 Guided tissue regeneration, resorbable barrier, per site, in conj with periradicular surgery

615.75 615.75 615.75


v1.4



1

CCN

Region 2

CCN

Region 3

D3450 Root amputation – per root 453.12 453.12 453.12

D3460 Endodontic endosseous implant 1594.95 1772.17 1772.17

D3470 Intentional reimplantation (including necessary splinting) 838.08 838.08 838.08

D3910 Surgical procedure for isolation of tooth with rubber dam 136.87 136.87 136.87

D3920 Hemisection (including any root removal), not including root canal therapy

354.12 354.12 354.12

D3950 Canal preparation and fitting of preformed dowel or post 179.88 179.88 179.88

D3999 Unspecified endodontic procedure, by report 243.36 243.36 243.36

Periodontics


1

CCN

Region 2

CCN

Region 3

D4210 Gingivectomy or gingivoplasty – 4+ contiguous teeth or tooth bounded spaces per quadrant

462.32 462.32 462.32

D4211 Gingivectomy or gingivoplasty – 1-3 contiguous teeth or tooth bounded spaces per quadrant

194.72 194.72 194.72

D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth

59.34 59.34 59.34

D4230 Anatomical crown exposure – four or more contiguous teeth or bounded tooth spaces per quadrant

726.38 807.09 807.09

D4231 Anatomical crown exposure – one to three teeth or bounded tooth spaces per quadrant

411.95 411.95 411.95

D4240 Gingival flap procedure, incl root planing - 4+ contiguous teeth/tooth bounded spaces per quad

711.87 711.87 711.87

D4241 Gingival flap procedure, incl root planing, 1-3 contiguous teeth/tooth bounded spaces per quad

358.29 358.29 358.29

D4245 Apically positioned flap 519.93 577.70 577.70

D4249 Clinical crown lengthening - hard tissue 670.98 670.98 670.98

D4260 Alveoloplasty ( incl flap & closure and closure) >3 contig. Tth or spaces- per quad

845.43 845.43 845.43

D4261 Alveoloplasty (incl flap & closure and closure) 1-3 contig. Tth or spaces-per quad

866.23 866.23 866.23

D4263 Bone replacement graft – retained natural tooth – first site in quadrant 629.59 566.63 566.63

D4264 Bone replacement graft – retained natural tooth – each additional site in quadrant

327.73 327.73 327.73

D4265 Biologic materials to aid in soft and osseous tissue regeneration 330.45 330.45 330.45

D4266 Guided tissue regeneration – resorbable barrier, per site 554.18 554.18 554.18

D4267 Guided tissue regeneration – nonresorbable barrier, per site (includes membrane removal)

644.87 716.52 716.52

D4268 Surgical revision procedure, per tooth 497.60 497.60 497.60

D4270 Pedicle soft tissue graft procedure 758.97 758.97 758.97

D4273 Autogenous CT Graft incl. donor & recipient sites first 793.45 793.45 793.45

D4274 Mesial/distal wedge, single tooth, separate surgical procedure 423.75 423.75 423.75

D4275 Non-autogenous. CT Graft (incl recipient site & donor material) first 632.38 632.38 632.38

D4276 Combined connective tissue and double pedicle graft, per tooth 587.05 587.05 587.05


v1.4



1

CCN

Region 2

CCN

Region 3

D4277 Free Soft tissue graft procedure (including recipient & donor site) first graft

802.48 802.48 802.48

D4278 Free soft tissue graft procedure (including recipient & donor surgical sites (ea. add)

401.07 401.07 401.07

D4283 Autogenous CT Graft (incl both sites) each additional graft, same site reported by D4273

396.41 396.41 396.41

D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site

316.15

316.15

316.15

D4320 Provisional splinting – intracoronal 329.76 329.76 329.76

D4321 Provisional splinting – extracoronal 191.71 191.71 191.71

D4341 Periodontal scaling and root planing – four or more teeth per quadrant 250.26 250.26 250.26

D4342 Periodontal scaling and root planing – one to three teeth per quadrant 179.57 170.59 170.59

D4346 Scaling in presence of gen mod to severe ging inflm full mouth (after oral evaluation)

157.30 157.30 157.30

D4355 Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit

135.91 135.91 135.91

D4381 Placement of subging controlled release antimicrobials into perio pockets per tth

117.84 106.06 106.06

D4910 Periodontal maintenance 125.93 125.93 125.93

D4920 Unscheduled dressing change (by someone other than treating dentist or their staff)

110.11 110.11 110.11

D4921 Gingival irrigation – per quadrant 58.26 54.62 54.62

D4999 Unspecified periodontal procedure, by report 102.02 102.02 102.02

Maxillofacial Prosthetics


1

CCN

Region 2

CCN

Region 3

D5911 Facial moulage (sectional) 492.77 492.77 492.77

D5912 Facial moulage (complete) 620.21 620.21 620.21

D5913 Nasal prosthesis 6119.58 6119.58 6119.58

D5914 Auricular prosthesis 6119.58 6119.58 6119.58

D5915 Orbital prosthesis 9278.00 9278.00 9278.00

D5916 Ocular prosthesis 4792.33 4792.33 4792.33

D5919 Facial prosthesis 4424.36 4424.36 4424.36

D5922 Nasal septal prosthesis 3071.25 3071.25 3071.25

D5923 Ocular prosthesis, interim 2193.75 2193.75 2193.75

D5924 Cranial prosthesis 4424.36 4424.36 4424.36

D5925 Facial augmentation implant prosthesis 2193.75 2193.75 2193.75

D5926 Nasal prosthesis, replacement 4424.36 4424.36 4424.36

D5927 Auricular prosthesis, replacement 4424.36 4424.36 4424.36

D5928 Orbital prosthesis, replacement 4424.36 4424.36 4424.36

D5929 Facial prosthesis, replacement 4424.36 4424.36 4424.36


v1.4



1

CCN

Region 2

CCN

Region 3

D5931 Obturator prosthesis, surgical 3691.33 3691.33 3691.33

D5932 Obturator prosthesis, definitive 6904.00 6904.00 6904.00

D5933 Obturator prosthesis, modification 910.29 910.29 910.29

D5934 Mandibular resection prosthesis with guide flange 6192.67 6192.67 6192.67

D5935 Mandibular resection prosthesis without guide flange 5475.00 5475.00 5475.00

D5936 Obturator prosthesis, interim 6149.67 6149.67 6149.67

D5937 Trismus appliance (not for TMD treatment) 900.58 900.58 900.58

D5951 Feeding aid 1151.82 1151.82 1151.82

D5953 Speech aid prosthesis, adult 6196.33 6196.33 6196.33

D5954 Palatal augmentation prosthesis 5742.33 5742.33 5742.33

D5955 Palatal lift prosthesis, definitive 3501.67 3501.67 3501.67

D5958 Palatal lift prosthesis, interim 1213.72 1213.72 1213.72

D5959 Palatal lift prosthesis, modification 197.44 197.44 197.44

D5960 Speech aid prosthesis, modification 197.44 197.44 197.44

D5982 Surgical stent 549.82 549.82 549.82

D5983 Radiation carrier 1171.33 1171.33 1171.33

D5984 Radiation shield 1171.33 1171.33 1171.33

D5985 Radiation shield 1171.33 1171.33 1171.33

D5986 Fluoride gel carrier 150.50 150.50 150.50

D5987 Commissure splint 910.29 910.29 910.29

D5988 Surgical splint 918.79 875.09 875.09

D5991 Vesiculobullous disease medicament carrier 150.50 150.50 150.50

D5992 Adjust maxillofacial prosthetic appliance, by report 87.03 87.03 87.03

D5993 Maint & cleaning of maxillofacial prosthesis (extra/intraoral) other than req adjust by report

191.80 191.80 191.80

D5994 Periodontal medicament carrier with peripheral seal - laboratory processed

150.50 150.50 150.50

D5999 Unspecified maxillofacial prosthesis, by report 842.40 842.40 842.40

Prosthodontics


1

CCN

Region 2

CCN

Region 3

D5110 Complete denture – maxillary 1445.47 1445.47 1445.47

D5120 Complete denture – mandibular 1430.01 1430.01 1430.01

D5130 Immediate denture – maxillary 1238.09 1238.09 1238.09

D5140 Immediate denture – mandibular 1239.94 1239.94 1239.94

D5211 Maxillary partial denture – resin base (including any retentve/clasping materials, rests and teeth)

1016.51 1016.51 1016.51


v1.4



1

CCN

Region 2

CCN

Region 3

D5212 Mandibular ptt denture – resin base (incl any retentve/clasping materials, rests and teeth) 1014.43

1014.43

1014.43

D5213 Maxillary partial denture – cast metal w resin base incl all retn, clasp mat'ls, rests, tth

1498.69 1498.69 1498.69

D5214 Mandibular partial denture – cast metal w resin base incl all retn, clasp mat'ls, rests, tth

1533.66 1533.66 1533.66

D5221 Immediate maxillary ptt denture – resin base (incl any conventional clasps, rests and teeth)

480.55 480.55 480.55

D5222 Immediate mandibular ptt denture – resin base (incl any conventional clasps, rests and teeth)

501.66 501.66 501.66

D5223 Immediate maxillary partl denture - cast metal frmwrk w/resin base incl clasps, rests, tth

600.76 600.76 600.76

D5224 Immediate mandibular partl denture – cast metal frmwrk w/resin base incl clasps, rests, tth

627.07 627.07 627.07

D5225 Maxillary partial denture – flexible base (including any clasps, rests and teeth)

1245.40 1245.40 1245.40

D5226 Mandibular partial denture – flexible base (including any clasps, rests and teeth)

1183.90 1183.90 1183.90

D5282 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), maxil

627.55 627.55 627.55

D5283 Removable unilateral partial denture- one piece cast metal (including clasps and teeth), mandi

627.55 627.55 627.55

D5284 Removable unilateral partial denture – 1 piece flexible base (incl clasps & teeth) – per quad

981.55 981.55 981.55

D5286 Removable unilateral partial denture – 1 piece resin (incl clasps and teeth) - per quadrant

981.55 981.55 981.55

D5410 Adjust complete denture – maxillary 67.47 67.47 67.47

D5411 Adjust complete denture – mandibular 72.85 72.85 72.85

D5421 Adjust partial denture – maxillary 75.88 75.88 75.88

D5422 Adjust partial denture – mandibular 74.84 74.84 74.84

D5511 Repair broken complete denture base, mandibular 226.70 226.70 226.70

D5512 Repair broken complete denture base, maxillary 226.70 226.70 226.70

D5520 Replace missing or broken teeth - complete denture (each tooth) 183.05 164.75 164.75

D5611 Repair resin partial denture base, mandibular 245.40 245.40 245.40

D5612 Repair resin partial denture base, maxillary 245.40 245.40 245.40

D5621 Repair cast partial framework, mandibular 144.75 144.75 144.75

D5622 Repair cast partial framework, maxillary 146.87 146.87 146.87

D5630 Repair or replace broken clasp - per tooth 327.05 327.05 327.05

D5640 Replace broken teeth - per tooth 145.16 145.16 145.16

D5650 Add tooth to existing partial denture 178.20 178.20 178.20

D5660 Add clasp to existing partial denture - per tooth 232.18 232.18 232.18

D5670 Replace all teeth and acrylic on cast metal framework (maxillary) 538.40 538.40 538.40

D5671 Replace all teeth and acrylic on cast metal framework (mandibular) 543.04 543.04 543.04

D5710 Rebase complete maxillary denture 492.84 492.84 492.84

D5711 Rebase complete mandibular denture 487.26 487.26 487.26


v1.4



1

CCN

Region 2

CCN

Region 3

D5720 Rebase maxillary partial denture 464.96 464.96 464.96

D5721 Rebase mandibular partial denture 463.40 463.40 463.40

D5730 Reline complete maxillary denture (chairside) 310.14 310.14 310.14

D5731 Reline complete mandibular denture (chairside) 305.03 305.03 305.03

D5740 Reline maxillary partial denture (chairside) 209.09 209.09 209.09

D5741 Reline mandibular partial denture (chairside) 246.99 246.99 246.99

D5750 Reline complete maxillary denture (laboratory) 385.23 385.23 385.23

D5751 Reline complete mandibular denture (laboratory) 409.13 409.13 409.13

D5760 Reline maxillary partial denture (laboratory) 399.03 399.03 399.03

D5761 Reline mandibular partial denture (laboratory) 382.27 382.27 382.27

D5810 Interim complete denture (maxillary) 603.21 603.21 603.21

D5811 Interim complete denture (mandibular) 629.52 629.52 629.52

D5820 Interim partial denture (maxillary) 546.32 546.32 546.32

D5821 Interim partial denture (mandibular) 576.07 576.07 576.07

D5850 Tissue conditioning, maxillary 112.15 112.15 112.15

D5851 Tissue conditioning, mandibular 128.28 128.28 128.28

D5862 Precision attachment, by report 871.45 871.45 871.45

D5863 Overdenture – complete maxillary 3182.34 3182.34 3182.34

D5864 Overdenture – partial maxillary 1236.26 1236.26 1236.26

D5865 Overdenture – complete mandibular 3195.12 3195.12 3195.12

D5866 Overdenture - partial mandibular 1393.35 1393.35 1393.35

D5867 Repl of replaceable part of semi-precision or precision attachment (male or female component)

481.85 455.15 455.15

D5875 Modification of removable prosthesis following implant surgery 521.90 521.90 521.90

D5876 Add metal substructure to acrylic full denture (per arch) 361.94 361.94 361.94

D5899 Unspecified removable prosthodontic procedure, by report 734.30 734.30 734.30

Fixed Prosthodontics


1

CCN

Region 2

CCN

Region 3

D6205 Pontic – indirect resin-based composite 536.40 536.40 536.40

D6210 Pontic – cast high noble metal 943.98 943.98 943.98

D6211 Pontic – cast predominantly base metal 877.98 877.98 877.98

D6212 Pontic – cast noble metal 914.57 914.57 914.57

D6214 Pontic – titanium 937.50 937.50 937.50

D6240 Pontic – porcelain-fused to high noble metal 986.27 986.27 986.27

D6241 Pontic – porcelain-fused to predominantly base metal 893.78 893.78 893.78


v1.4



1

CCN

Region 2

CCN

Region 3

D6242 Pontic – porcelain fused to noble metal 936.51 936.51 936.51

D6243 Pontic – porcelain fused to titanium and titanium alloys 829.89 829.89 829.89

D6245 Pontic – porcelain/ceramic 1021.66 1021.66 1021.66

D6250 Pontic – resin with high noble metal 916.60 916.60 916.60

D6251 Pontic – resin with predominantly base metal 845.86 845.86 845.86

D6252 Pontic – resin with noble metal 871.37 871.37 871.37

D6253 Provisional pontic - further treat or compl of diagnosis necessary prior to final impression

388.40 388.40 388.40

D6545 Retainer – cast metal for resin-bonded fixed prosthesis 405.44 405.44 405.44

D6548 Retainer – porcelain/ceramic for resin-bonded fixed prosthesis 572.21 572.21 572.21

D6549 Resin retainer – for resin-bonded fixed prosthesis 405.44 405.44 405.44

D6600 Retainer inlay – porcelain/ceramic, two surfaces 789.05 789.05 789.05

D6601 Retainer inlay – porcelain/ceramic, three or more surfaces 845.79 845.79 845.79

D6602 Retainer inlay – cast high noble metal, two surfaces 810.65 810.65 810.65

D6603 Retainer inlay – cast high noble metal, three or more surfaces 913.97 913.97 913.97

D6604 Retainer inlay – cast predominantly base metal, two surfaces 800.37 800.37 800.37

D6605 Retainer inlay – cast predominantly base metal, three or more surfaces 838.21 838.21 838.21

D6606 Retainer inlay – cast noble metal, two surfaces 767.66 767.66 767.66

D6607 Retainer inlay – cast noble metal, three or more surfaces 869.42 869.42 869.42

D6608 Retainer onlay – porcelain/ceramic, two surfaces 831.55 831.55 831.55

D6609 Retainer onlay – porcelain/ceramic, three or more surfaces 886.67 886.67 886.67

D6610 Retainer onlay – cast high noble metal, two surfaces 911.97 911.97 911.97

D6611 Retainer onlay – cast high noble metal, three or more surfaces 997.17 997.17 997.17

D6612 Retainer onlay – cast predominantly base metal, two surfaces 864.63 864.63 864.63

D6613 Retainer onlay – cast predominantly base metal, three or more surfaces 919.54 919.54 919.54

D6614 Retainer onlay – cast noble metal, two surfaces 866.63 866.63 866.63

D6615 Retainer onlay – cast noble metal, three or more surfaces 918.26 918.26 918.26

D6624 Retainer inlay – titanium 863.04 863.04 863.04

D6634 Retainer onlay – titanium 930.73 930.73 930.73

D6710 Retainer crown – indirect resin based composite 711.65 711.65 711.65

D6720 Retainer crown – resin with high noble metal 993.24 993.24 993.24

D6721 Retainer crown – resin with predominantly base metal 939.03 939.03 939.03

D6722 Retainer crown – resin with noble metal 965.27 965.27 965.27

D6740 Retainer crown – porcelain/ceramic 1063.41 1063.41 1063.41

D6750 Retainer crown – porcelain fused to high noble metal 1001.26 1001.26 1001.26

D6751 Retainer crown – porcelain fused to predominantly base metal 916.78 916.78 916.78


v1.4



1

CCN

Region 2

CCN

Region 3

D6752 Retainer crown – porcelain fused to noble metal 949.18 949.18 949.18

D6753 Retainer crown – porcelain fused to titanium and titanium alloys 841.12 841.12 841.12

D6780 Retainer crown – 3/4 cast high noble metal 964.33 964.33 964.33

D6781 Retainer crown – 3/4 cast predominantly base metal 968.13 968.13 968.13

D6782 Retainer crown – 3/4 cast noble metal 927.17 927.17 927.17

D6783 Retainer crown – 3/4 porcelain/ceramic 1000.87 1000.87 1000.87

D6784 Retainer crown 3/4 – titanium and titanium alloys 821.61 821.61 821.61

D6790 Retainer crown – full cast high noble metal 985.59 985.59 985.59

D6791 Retainer crown – full cast predominantly base metal 925.11 925.11 925.11

D6792 Retainer crown – full cast noble metal 950.22 950.22 950.22

D6793 Provis retainer Crosn- further treat or compl of diagnosis necessary prior to fnl impression

368.67 368.67 368.67

D6794 Retainer crown - titanium 977.21 977.21 977.21

D6920 Connector bar 642.82 578.53 578.53

D6930 Re-cement or re-bond fixed partial denture 127.10 127.10 127.10

D6940 Stress breaker 302.96 302.96 302.96

D6950 Precision attachment 533.20 533.20 533.20

D6980 Fixed partial denture repair necessitated by restorative material failure 342.51 342.51 342.51

D6999 Unspecified fixed prosthodontic procedure, by report 322.93 322.93 322.93

Implant Services


1

CCN

Region 2

CCN

Region 3

D6010 Surgical placement of implant body: endosteal implant 1938.21 1938.21 1938.21

D6011 Second-stage implant surgery 503.69 503.69 503.69

D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant

2000.21 2000.21 2000.21

D6013 Surgical placement of mini implant 968.75 968.75 968.75

D6040 Surgical placement: eposteal implant 8078.77 8078.77 8078.77

D6050 Surgical placement: transosteal implant 5762.66 5762.66 5762.66

D6051 Interim abutment 507.69 507.69 507.69

D6052 Semi-precision attachment abutment 507.69 507.69 507.69

D6055 Connecting bar – implant supported or abutment supported 1438.21 1438.21 1438.21

D6056 Prefabricated abutment-includes placement 507.69 507.69 507.69

D6057 Custom fabricated abutment - includes placement 697.31 697.31 697.31

D6058 Abutment supported porcelain/ceramic crown 1253.34 1253.34 1253.34

D6059 Abutment supported porcelain fused to metal crown (high noble metal) 1226.19 1226.19 1226.19


v1.4



1

CCN

Region 2

CCN

Region 3

D6060 Abutment supported porcelain fused to metal crown (predominantly base metal)

1148.38 1148.38 1148.38

D6061 Abutment supported porcelain fused to metal crown (noble metal) 1185.05 1185.05 1185.05

D6062 Abutment supported cast metal crown (high noble metal) 1193.82 1193.82 1193.82

D6063 Abutment supported cast metal crown (predominantly base metal) 1043.18 1043.18 1043.18

D6064 Abutment supported cast metal crown (noble metal) 1112.57 1112.57 1112.57

D6065 Implant supported porcelain/ceramic crown 1327.79 1327.79 1327.79

D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)

1319.10 1319.10 1319.10

D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal)

1248.24 1248.24 1248.24

D6068 Abutment supported retainer for porcelain/ceramic FPD 1247.48 1247.48 1247.48

D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal)

1229.00 1229.00 1229.00

D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)

1153.95 1153.95 1153.95

D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal)

1180.65 1180.65 1180.65

D6072 Abutment supported retainer for cast metal FPD (high noble metal) 1210.97 1210.97 1210.97

D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)

1106.09 1106.09 1106.09

D6074 Abutment supported retainer for cast metal FPD (noble metal) 1173.28 1173.28 1173.28

D6075 Implant supported retainer for ceramic FPD 1263.28 1263.28 1263.28

D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal)

1232.33 1232.33 1232.33

D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)

1222.73 1222.73 1222.73

D6080 Impl maint. includes cleaning of implant surfaces w/ remov, clean & reinsert of prosthetic

191.80 172.62 172.62

D6081 Impl scale & debride in presence of inflm or mucositis of sngl implnt, incl clean of impt srfc

211.92 211.92 211.92

D6082 Implant supported crown – porcelain fused to predominantly base alloys 1168.94 1168.94 1168.94

D6083 Implant supported crown – porcelain fused to noble alloys 1168.94 1168.94 1168.94

D6084 Implant supported crown – porcelain fused to titanium or titanium alloys 1168.94 1168.94 1168.94

D6085 Provisional implant crown 797.41 797.41 797.41

D6086 Implant supported crown – predominantly base alloys 1168.94 1160.14 1160.14

D6087 Implant supported crown – noble alloys 1168.94 1160.14 1160.14

D6088 Implant supported crown – titanium and titanium alloys 1168.94 1160.14 1160.14

D6090 Repair implant supported prosthesis, by report 886.02 886.02 886.02

D6091 Repl. precision/ semi precis attach (either component) of abutment implants-per attach

708.81 708.81 708.81

D6092 Re-cement or re-bond implant/abutment supported crown 107.07 107.07 107.07

D6093 Re-cement or re-bond implant/abutment supported fixed partial denture 158.80 158.80 158.80

D6094 Abutment supported crown – (titanium) 1039.31 1039.31 1039.31

D6095 Repair implant abutment, by report 910.29 886.02 886.02


v1.4



1

CCN

Region 2

CCN

Region 3

D6096 Remove broken implant retaining screw 215.44 215.44 215.44

D6097 Abutment supported crown – porcelain fused to titanium or titanium alloys

1050.13 1050.13 1050.13

D6098 Implant supported retainer – porcelain fused to predominantly base alloys

1092.03 1092.03 1092.03

D6099 Implant supported retainer for FPD – porcelain fused to noble alloys 1092.03 1092.03 1092.03

D6100 Implant removal, by report 886.02 886.02 886.02

D6101 Debride perio defect(s) involv. sngl implnt w/surface clean of exposed implnt surfaces srgcl

358.29 358.29 358.29

D6102 Debride and cntouring of perio defect (s) invlv sngl implnt w/surf clean of expsd srfcs srgcl

358.29 358.29 358.29

D6103 Bone graft for repair of peri-implant defect – does not include flap entry and closure

327.73 327.73 327.73

D6104 Bone graft at time of implant placement 327.73 327.73 327.73

D6110 Implant /abutment supported removable denture for edentulous arch – maxillary

1729.07 1729.07 1729.07

D6111 Implant /abutment supported removable denture for edentulous arch – mandibular

1729.07 1729.07 1729.07

D6112 Implant /abutment supported removable denture for partially edentulous arch – maxillary

1687.15 1687.15 1687.15

D6113 Implant /abutment supported removable denture for partially edentulous arch – mandibular

1687.15 1687.15 1687.15

D6114 Implant /abutment supported fixed denture for edentulous arch – maxillary

7282.32 7282.32 7282.32

D6115 Implant /abutment supported fixed denture for edentulous arch – mandibular

7563.90 7563.90 7563.90

D6116 Implant /abutment supported fixed denture for partially edentulous arch – maxillary

5467.81 5467.81 5467.81

D6117 Implant /abutment supported fixed denture for partially edentulous arch – mandibular

5643.80 5643.80 5643.80

D6118 Implant /abutment supported interim fixed denture for edentulous arch – mandibular

1361.82 1361.82 1361.82

D6119 Implant /abutment supported interim fixed denture for edentulous arch – maxillary

1511.44 1511.44 1511.44

D6120 Implant supported retainer - porcelain fused to titanium and titanium alloys

1092.03 1092.03 1092.03

D6121 Implanted supported retainer for metal FPD – predominantly base alloys 1083.54 1083.54 1083.54

D6122 Implant supported retainer for metal FPD – noble alloys 1083.54 1083.54 1083.54

D6123 Implant supported retainer for metal FPD – titanium and titanium alloys 1083.54 1083.54 1083.54

D6190 Radiographic/surgical implant index, by report 223.74 223.74 223.74

D6194 Abutment supported retainer crown for FPD (titanium) 1055.57 1055.57 1055.57

D6195 Abutment supported retainer – porcelain fused to titanium and titanium alloys

1046.25 1046.25 1046.25

D6199 Unspecified implant procedure, by report 577.73 577.73 577.73


v1.4


Oral & Maxillofacial Surgery


1

CCN

Region 2

CCN

Region 3

D7111 Extraction, coronal remnants – primary tooth 98.12 98.12 98.12

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

116.04 116.04 116.04

D7210 Extraction of erupted tooth-surgical incl cutting/removal/smoothing of bone w/closure

204.43 204.43 204.43

D7220 Removal of impacted tooth – soft tissue 314.91 314.91 314.91

D7230 Removal of impacted tooth – partially bony 393.33 393.33 393.33

D7240 Removal of impacted tooth – completely bony 438.04 438.04 438.04

D7241 Removal of impacted tooth – completely bony, with unusual surgical complications

451.08 451.08 451.08

D7250 Removal of residual tooth roots (cutting procedure) 254.04 254.04 254.04

D7251 Coronectomy - intentional partial tooth removal 707.19 707.19 707.19

D7260 Oroantral fistula closure 1443.35 1443.35 1443.35

D7261 Primary closure of a sinus perforation 638.60 638.60 638.60

D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth

543.18 543.18 543.18

D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)

654.37 654.37 654.37

D7280 Exposure of an unerupted tooth 482.48 482.48 482.48

D7282 Mobilization of erupted or malpositioned tooth to aid eruption 278.28 278.28 278.28

D7283 Placement of device to facilitate eruption of impacted tooth 197.58 197.58 197.58

D7285 Incisional biopsy of oral tissue-hard (bone, tooth) 616.87 616.87 616.87

D7286 Incisional biopsy of oral tissue-soft 280.65 280.65 280.65

D7287 Exfoliative cytological sample collection 126.43 126.43 126.43

D7288 Brush biopsy – transepithelial sample collection 170.38 170.38 170.38

D7290 Surgical repositioning of teeth 418.40 418.40 418.40

D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report 97.49 97.49 97.49

D7292 Placement of temporary anchorage device [screw retained plate] req flap; incl device removal

2609.50 2609.50 2609.50

D7293 Placement of temporary anchorage device requiring flap; includes device removal

2770.92 2770.92 2770.92

D7294 Placement of temporary anchorage device without flap; includes device removal

1832.72 1832.72 1832.72

D7295 Harvest of bone for use in autogenous grafting procedure 703.96 820.47 820.47

D7296 Corticotomy-one to three teeth or tooth spaces, per quadrant 593.65 593.65 593.65

D7297 Corticotomy-four or more teeth or tooth spaces, per quadrant 623.90 623.90 623.90

D7310 Alveoloplasty in conjunction with extractions – 4+ teeth or tooth spaces, per quadrant

259.87 259.87 259.87

D7311 Alveoloplasty in conjunction with extractions – 1-3 teeth or tooth spaces, per quadrant

238.52 238.52 238.52

D7320 Alveoloplasty not in conj with extractions – 4+ teeth or tooth spaces, per quadrant

322.11 322.11 322.11

D7321 Alveoloplasty not in conjunction with extractions – 1-3 teeth or tooth spaces, per quadrant

619.85 619.85 619.85


v1.4



1

CCN

Region 2

CCN

Region 3

D7340 Vestibuloplasty – ridge extension (secondary epithelialization) 1698.10 1698.10 1698.10

D7350 Vestibuloplasty incl soft tissue grftng, reattachment,revision of attchmnt and tissue mngment

5050.82 5050.82 5050.82

D7410 Excision of benign lesion up to 1.25 cm 477.25 477.25 477.25

D7411 Excision of benign lesion greater than 1.25 cm 1043.26 1043.26 1043.26

D7412 Excision of benign lesion, complicated 1163.07 1163.07 1163.07

D7413 Excision of malignant lesion up to 1.25 cm 640.53 640.53 640.53

D7414 Excision of malignant lesion greater than 1.25 cm 805.61 805.61 805.61

D7415 Excision of malignant lesion, complicated 1224.89 1224.89 1224.89

D7440 Excision of malignant tumor – lesion diameter up to 1.25 cm 1069.24 1069.24 1069.24

D7441 Excision of malignant tumor – lesion diameter greater than 1.25 cm 1698.30 1698.30 1698.30

D7450 Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25 cm

587.33 587.33 587.33

D7451 Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25 cm

978.96 978.96 978.96

D7460 Removal of benign nonodontogenic cyst or tumor – lesion diameter up to 1.25 cm

511.22 511.22 511.22

D7461 Removal of benign nonodontogenic cyst or tumor – lesion diameter greater than 1.25 cm

1012.59 1012.59 1012.59

D7465 Destruction of lesion(s) by physical or chemical method, by report 455.11 455.11 455.11

D7471 Removal of lateral exostosis (maxilla or mandible) 643.13 643.13 643.13

D7472 Removal of torus palatinus 863.33 863.33 863.33

D7473 Removal of torus mandibularis 670.98 670.98 670.98

D7485 Reduction of osseous tuberosity 653.65 653.65 653.65

D7490 Radical resection of maxilla or mandible 7287.41 7287.41 7287.41

D7510 Incision and drainage of abscess–- intraoral soft tissue 266.02 266.02 266.02

D7511 I&D of abscess, intraoral soft tissue complex w/ dissec into adjcnt fascial space(s) for drnge

639.02 639.02 639.02

D7520 Incision and drainage of abscess – extraoral soft tissue 935.05 935.05 935.05

D7521 I&D of abscess, extraoral soft tissue complex w/ dissec into adjcnt fascial space(s) for drnge

1046.67 1046.67 1046.67

D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue

356.41 356.41 356.41

D7540 Removal of reaction producing foreign bodies, musculoskeletal system 479.27 479.27 479.27

D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone 333.99 333.99 333.99

D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body 1932.54 1932.54 1932.54

D7610 Maxilla – open reduction (teeth immobilized, if present) 3856.74 3856.74 3856.74

D7620 Maxilla – closed reduction (teeth immobilized, if present) 2893.66 2893.66 2893.66

D7630 Mandible – open reduction (teeth immobilized, if present) 4676.79 4676.79 4676.79

D7640 Mandible – closed reduction (teeth immobilized, if present) 3115.94 3115.94 3115.94

D7650 Malar and/or zygomatic arch – open reduction 2864.05 2864.05 2864.05

D7660 Malar and/or zygomatic arch – closed reduction 2115.18 2115.18 2115.18


v1.4



1

CCN

Region 2

CCN

Region 3

D7670 Alveolus – closed reduction, may include stabilization of teeth 1110.30 1110.30 1110.30

D7671 Alveolus – open reduction, may include stabilization of teeth 1596.04 1596.04 1596.04

D7680 Facial bones – complicated reduction with fixation and multiple surgical approaches

6770.52 6770.52 6770.52

D7710 Maxilla – open reduction 4499.30 4499.30 4499.30

D7720 Maxilla – closed reduction 3097.86 3097.86 3097.86

D7730 Mandible – open reduction 5886.48 5886.48 5886.48

D7740 Mandible – closed reduction 3235.01 3235.01 3235.01

D7750 Malar and/or zygomatic arch – open reduction 4009.30 4009.30 4009.30

D7760 Malar and/or zygomatic arch – closed reduction 2704.62 2704.62 2704.62

D7770 Alveolus - open reduction stabilization of teeth 2194.14 2194.14 2194.14

D7771 Alveolus, closed reduction stabilization of teeth 2361.90 2361.90 2361.90

D7780 Facial bones - complicated reduction with fixation and multiple approaches

8806.48 8806.48 8806.48

D7810 Open reduction of dislocation 4049.72 4049.72 4049.72

D7820 Closed reduction of dislocation 638.39 638.39 638.39

D7830 Manipulation under anesthesia 458.09 458.09 458.09

D7840 Condylectomy 5553.13 5553.13 5553.13

D7850 Surgical discectomy, with/without implant 5040.44 5040.44 5040.44

D7852 Disc repair 5628.65 5628.65 5628.65

D7854 Synovectomy 5740.25 5740.25 5740.25

D7856 Myotomy 3971.98 3971.98 3971.98

D7858 Joint reconstruction 14811.00 14811.00 14811.00

D7860 Arthrotomy 6313.00 6313.00 6313.00

D7865 Arthroplasty 10173.00 10173.00 10173.00

D7870 Arthrocentesis 294.24 294.24 294.24

D7871 Non-arthroscopic lysis and lavage 798.63 798.63 798.63

D7872 Arthroscopy - diagnosis, with or without biopsy 3588.50 3588.50 3588.50

D7873 Arthroscopy: lavage and lysis of adhesions 4320.50 4320.50 4320.50

D7874 Arthroscopy: disc repositioning and stabilization 6197.50 6197.50 6197.50

D7875 Arthroscopy: synovectomy 6789.50 6789.50 6789.50

D7876 Arthroscopy: discectomy 7320.00 7320.00 7320.00

D7877 Arthroscopy: debridement 6460.50 6460.50 6460.50

D7880 Occlusal orthotic device, by report 798.14 798.14 798.14

D7881 Occlusal orthotic device adjustment 69.62 69.62 69.62

D7899 Unspecified TMD therapy, by report 269.45 269.45 269.45

D7910 Suture of recent small wounds up to 5 cm 383.41 383.41 383.41


v1.4



1

CCN

Region 2

CCN

Region 3

D7911 Complicated suture – up to 5 cm 576.04 576.04 576.04

D7912 Complicated suture – greater than 5 cm 1224.90 1224.90 1224.90

D7920 Skin graft (identify defect covered, location and type of graft) 2613.74 2613.74 2613.74

D7921 Collection and application of autologous blood concentrate product 438.15 388.39 388.39

D7922 Placement of intra-socket biological dressing to aid w/hemostasis/clot stabilization, per site

28.33 28.33 28.33

D7940 Osteoplasty – for orthognathic deformities 4794.19 4794.19 4794.19

D7941 Osteotomy – mandibular rami 7720.33 7720.33 7720.33

D7943 Osteotomy – mandibular rami with bone graft; includes obtaining the graft

7223.25 7223.25 7223.25

D7944 Osteotomy – segmented or subapical 6335.75 6335.75 6335.75

D7945 Osteotomy – body of mandible 7592.63 7592.63 7592.63

D7946 LeFort I (maxilla – total) 9220.02 9220.02 9220.02

D7947 LeFort I (maxilla – segmented) 8288.74 8288.74 8288.74

D7948 Osteo facial bones for hypoplasia/rtrusion compl prcedure incl clsure & post op W/O bone grft

12010.98 12010.98 12010.98

D7949 LeFort II or LeFort III - with bone graft 14314.62 14314.62 14314.62

D7950 Osseous, perioss or cart. graft max or mand auto/non-autogen inclds obtain graft mat'l by rprt

1929.85 1736.87 1736.87

D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach

3398.42 3398.42 3398.42

D7952 Sinus augmentation via a vertical approach 1808.44 1808.44 1808.44

D7953 Bone replacement graft for ridge preservation - per site 1750.34 1750.34 1750.34

D7955 Repair of maxillofacial soft and/or hard tissue defect 1690.28 1878.09 1878.09

D7960 Frenectomy/frenotomy/frenulectomy as a separate procedure, not incidental

566.54 509.89 509.89

D7963 Frenuloplasty 496.56 496.56 496.56

D7970 Excision of hyperplastic tissue - per arch 452.73 452.73 452.73

D7971 Excision of pericoronal gingiva 177.70 177.70 177.70

D7972 Surgical reduction of fibrous tuberosity 551.86 551.86 551.86

D7979 Non-surgical sialolithotomy 153.81 153.81 153.81

D7980 Surgical sialolithotomy 683.75 683.75 683.75

D7981 Excision of salivary gland, by report 1034.09 1034.09 1034.09

D7982 Sialodochoplasty 1707.06 1707.06 1707.06

D7983 Closure of salivary fistula 1479.26 1479.26 1479.26

D7990 Emergency tracheotomy 1430.54 1430.54 1430.54

D7991 Coronoidectomy 3708.37 3708.37 3708.37

D7995 Synthetic graft – mandible or facial bones, by report 3268.55 2941.69 2941.69

D7996 Implant-mandible for augmentation purposes (excluding alveolar ridge), by report

2941.69 3268.55 3268.55


v1.4



1

CCN

Region 2

CCN

Region 3

D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar

404.72 404.72 404.72

D7998 Intraoral placement of a fixation device not in conjunction with a fracture 3059.79 3059.79 3059.79

D7999 Unspecified oral surgery procedure, by report 336.02 336.02 336.02

Orthodontics


1

CCN

Region 2

CCN

Region 3

D8010 Limited orthodontic treatment of the primary dentition 2699.31 2699.31 2699.31

D8020 Limited orthodontic treatment of the transitional dentition 2997.89 2997.89 2997.89

D8030 Limited orthodontic treatment of the adolescent dentition 2761.20 2761.20 2761.20

D8040 Limited orthodontic treatment of the adult dentition 3857.20 3857.20 3857.20

D8050 Interceptive orthodontic treatment of the primary dentition 2497.25 2497.25 2497.25

D8060 Interceptive orthodontic treatment of the transitional dentition 2620.80 2620.80 2620.80

D8070 Comprehensive orthodontic treatment of the transitional dentition 6134.14 6432.72 6432.72

D8080 Comprehensive orthodontic treatment of the adolescent dentition 5018.83 5018.83 5018.83

D8090 Comprehensive orthodontic treatment of the adult dentition 6669.39 6669.39 6669.39

D8210 Removable appliance therapy 576.69 576.69 576.69

D8220 Fixed appliance therapy 1153.03 1213.72 1213.72

D8660 Pre-orthodontic treatment examination to monitor growth and development

432.08 432.08 432.08

D8670 Periodic orthodontic treatment visit 325.28 325.28 325.28

D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s))

568.02 606.86 606.86

D8681 Removable orthodontic retainer adjustment 126.23 126.23 126.23

D8690 Orthodontic treatment (alternative billing to a contract fee) 504.83 504.83 504.83

D8695 Removal of fixed orthodontic appliances for reason other than completion of treatment

204.78 204.78 204.78

D8696 Repair of orthodontic appliance – maxillary 123.62 123.62 123.62

D8697 Repair of orthodontic appliance – mandibular 123.62 123.62 123.62

D8698 Re-cement or re-bond fixed retainer – maxillary 46.69 46.69 46.69

D8699 Re-cement or re-bond fixed retainer – mandibular 46.69 46.69 46.69

D8701 Repair of fixed retainers, includes reattachment – maxillary 77.95 77.95 77.95

D8702 Repair of fixed retainers, includes reattachment – mandibular 77.95 77.95 77.95

D8703 Replacement of lost or broken retainer – maxillary 157.44 157.44 157.44

D8704 Replacement of lost or broken retainer – mandibular 157.44 157.44 157.44

D8999 Unspecified orthodontic procedure, by report 177.84 177.84 177.84


v1.4


Adjunctive General Services/Anesthesia


1

CCN Region 2

CCN Region 3

D9110 Palliative (emergency) treatment of dental pain – minor procedure 137.26 137.26 137.26

D9120 Fixed partial denture sectioning 163.11 163.11 163.11

D9130 Temporomandibular joint dysfunction-non-invasive physical therapies 73.25 73.25 73.25

D9210 Local anesthesia not in conjunction with operative or surgical procedures

44.11 44.11 44.11

D9211 Regional block anesthesia 86.95 86.95 86.95

D9212 Trigeminal division block anesthesia 141.89 141.89 141.89

D9215 Local anesthesia in conjunction with operative or surgical procedures 47.52 47.52 47.52

D9219 Evaluation for moderate sedation, deep sedation or general anesthesia 97.49 97.49 97.49

D9222 Deep sedation/general anesthesia – first 15 minutes 204.50 204.50 204.50

D9223 Deep sedation/general anesthesia – each subsequent 15-minute increment

150.53 150.53 150.53

D9230 Inhalation of nitrous oxide/analgesia, anxiolysis 98.87 98.87 98.87

D9239 Intravenous moderate (conscious) sedation/analgesia – first 15-minute increment

192.81 192.81 192.81

D9243 Intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minute increment

143.43 143.43 143.43

D9248 Non-intravenous conscious sedation 254.29 254.29 254.29

D9310 Consultation – diagnostic service provided by dentist or physician other than requesting dentist or physician

87.43 87.43 87.43

D9311 Consultation with a medical health care professional 145.28 145.28 145.28

D9410 House/extended care facility call 185.30 185.30 185.30

D9420 Hospital or ambulatory surgical center call 246.99 246.99 246.99

D9430 Office visit for observation (during regularly scheduled hours) – no other services performed

58.63 58.63 58.63

D9440 Office visit - after regularly scheduled hours 117.82 117.82 117.82

D9450 Case presentation, detailed and extensive treatment planning 179.63 179.63 179.63

D9610 Therapeutic parenteral drug, single administration 78.58 78.58 78.58

D9612 Therapeutic parenteral drugs, two or more administrations, different medications

124.63 124.63 124.63

D9613 Infiltration of sustained release therapeutic drug-single or multiple sites 41.64 41.64 41.64

D9630 Drugs or medicaments dispensed in the office for home use 31.96 31.96 31.96

D9910 Application of desensitizing medicament 39.32 39.32 39.32

D9911 Application of desensitizing resin for cervical and/or root surface, per tooth

54.83 54.83 54.83

D9920 Behavior management, by report 102.24 102.24 102.24

D9930 Treatment of complications (post-surgical) - unusual circumstances, by report

102.23 102.23 102.23

D9932 Cleaning and inspection of removable complete denture, maxillary 172.62 172.62 172.62

D9933 Cleaning and inspection of removable complete denture, mandibular 172.62 172.62 172.62

D9934 Cleaning and inspection of removable partial denture, maxillary 172.62 172.62 172.62

D9935 Cleaning and inspection of removable partial denture, mandibular 172.62 172.62 172.62


v1.4



1

CCN

Region 2

CCN

Region 3

D9941 Fabrication of athletic mouthguard 164.71 164.71 164.71

D9942 Repair and/or reline of occlusal guard 132.55 132.55 132.55

D9943 Occlusal guard adjustment 69.62 69.62 69.62

D9944 Occlusal guard, hard appliance, full arch 488.29 488.29 488.29

D9945 Occlusal Guard: Soft appliance, full arch 488.29 488.29 488.29

D9946 Occlusal guard: hard appliance, partial arch 171.71 171.71 171.71

D9950 Occlusion analysis – mounted case 250.72 250.72 250.72

D9951 Occlusal adjustment – limited 128.45 128.45 128.45

D9952 Occlusal adjustment – complete 548.92 548.92 548.92

D9961 Duplicate/copy patient's records 25.60 25.60 25.60

D9970 Enamel microabrasion 132.18 118.96 118.96

D9971 Odontoplasty 1-2 teeth; includes removal of enamel projections 88.85 88.85 88.85

D9972 External bleaching – per arch – performed in office 267.69 267.69 267.69

D9973 External bleaching – per tooth 145.90 131.31 131.31

D9974 Internal bleaching – per tooth 229.59 229.59 229.59

D9975 External bleaching for home appl, per arch; incl materials and fabrication of custom trays

267.69 267.69 267.69

D9986 Missed appointment 25.74 25.74 25.74

D9987 Cancelled appointment 25.74 25.74 25.74

D9990 Certified translation or sign-language services – per visit 128.62 128.62 128.62

D9991 Dental case management – addressing appointment compliance barriers

60.08 66.75 66.75

D9992 Dental case management – care coordination 60.08 66.75 66.75

D9993 Dental case management – motivational interviewing 60.08 66.75 66.75

D9994 Dental case management – patient education to improve oral health literacy

66.75 66.75 66.75

D9995 Teledentistry-synchronous; real-time encounter 95.99 95.99 95.99

D9996 Teledentistry-asynchronous; information stored and forwarded to dentist for subsequent review

95.99 95.99 95.99

D9997 Dental case management – patients with special health care needs 53.25 53.25 53.25

D9999 Unspecified adjunctive procedure, by report 140.40 140.40 140.40