Veteran Eligibility and Covered Services

Provider Responsibilities to Veterans

As a CCN provider, VA has designated certain responsibilities when caring for Veterans.

• Ensure appointments for authorized services are honored.
• Honor all appointments with Veterans for covered services with an approved referral/authorization. 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 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
• If the Veteran needs additional care beyond what’s authorized, submit a Request for Service (RFS) directly to VA, preferably through VA’s HealthShare Referral Manager (HSRM) portal.
• DO NOT balance bill Veterans or TriWest for services provided under the CCN contract. A payment for authorized services under this contract is always deemed payment in full.
• NEVER charge a Veteran for not keeping a scheduled appointment.
• NEVER solicit Veterans or VA Medical Center (VAMC) for services.
• Always notify TriWest immediately in cases where CCN health care services are being provided that are related to, or associated with, any claim involving subrogation against:
  • Workers’ compensation carrier;
  • An auto liability insurance carrier;
  • Third-Party tortfeasor (e.g., medical malpractice); or
  • Any other situation where a third party is responsible for the cost of CCN health care services.
    
    TriWest is required to report these cases to VA within 30 days of identifying the event. Notify TriWest immediately to comply with this VA requirement.

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CCN Health Benefit Package

CCN covers, at a minimum, a basic set of services for Veterans called the CCN Health Benefit Package. The CCN Health Benefit Package includes the following:

• Abortion Services – Authorized abortion-related services (in accordance with the rules, regulations, policies, and instructions of VA and the Veterans Health Administration, or VA will provide access to abortions when the life or health of the pregnant Veteran would be endangered if the pregnancy were carried to term, or when the pregnancy is the result of rape or incest.
• Comprehensive Rehabilitative Services
• Hospital Services
• Ancillary Services
• Behavioral Health (to include professional counseling)
• Residential Care
• Home Healthcare (Skilled and Unskilled)
• Hospice/Palliative Care/Respite
• Geriatrics (Non-institutionalized extended care services, including but not limited to non-institutional geriatric evaluation, non-institutional adult day health care, and non-institutional respite care)
• Outpatient Diagnostic and Treatment Services (including laboratory services)
• Inpatient Diagnostic and Treatment Services
• Long Term Acute Care
• Acupuncture
• Maternity and Women’s Health
• Telehealth
• Chronic Dialysis Treatment
• Assisted Reproductive Technology/In Vitro Fertilization (ART/IVF)
• Flu Shots
• Therapeutic Vaccines
• Complementary and Integrated Health Care
• Skilled Nursing
• Pharmacy
• Dental
• Emergent Care
• Urgent Care/Urgent Care Walk-In
• Durable Medical Equipment (DME) Medical Devices, Orthotic, and Prosthetic items
• Reconstructive Surgery
• Immunizations
• Implants (when provided by an authorized surgical or medical procedure)

Note: CCN health care services includes certain rehabilitative services/therapies provided by non-licensed practitioners (e.g., blind and low-vision rehabilitation services, driver rehabilitation services, and recreational therapy).

• Biofeedback (VA National Clinic List Code = BIOF)
• Hypnotherapy (VA National Clinic List Code = HYPN)
• Massage Therapy (VA National Clinic List Code = MSGT)
• Native American Healing (VA National Clinic List Code = NAHL)
• Relaxation Techniques, such as meditation and guided imagery (VA National Clinic List Code = RLXT)
• Tai Chi (VA National Clinic List Code = TAIC)

Exclusions: CCN Health Benefit Package

The CCN Health Benefit Package EXCLUDES the following:

• Drugs, biologicals, and MD not approved by the Food and Drug Administration (FDA) unless used under approved clinical research trials
• Gender alteration surgeries; 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 provide the care or services.
• Membership in spas or health clubs
• Out-of-network services

Services Covered by CCN Health Benefit Package, but That TriWest Cannot Provide

Pursuant to 38 C.F.R. § 17.38, or otherwise provided by VA, the following services are covered under the CCN Health Benefit Package, but cannot be provided by TriWest under the CCN contract:

• Beneficiary travel
• 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
• Home deliveries
• Ambulance services (ambulance services shall be referred directly to VA for payment consideration)
• Yoga and services included on CIHS Directive List 2 (Healing Touch, Acupressure, Alexander Technique, Reflexology, Reiki, Therapeutic Touch, Emotional Freedom Technique, Animal Assisted Therapy (falls under Recreation Therapy), Aroma Therapy, Biofield Therapies, Rolfing, Somatic Experiencing, and Zero Balancing)

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