February 2025 Provider Pulse

Protect Your Veteran Patients: Adult Immunizations Covered Under CCN

Under the Community Care Network (CCN), any medically necessary vaccinations that are a part of an authorized episode of care, and follow the VA Urgent/Emergent Formulary rules, will be covered for eligible Veterans. Any urgent or emergent vaccines or medications that are a part of an authorized episode of care, and follow the VA Urgent/Emergent Formulary rules, will also be covered for eligible Veterans.

When Veterans are seen in the community via an approved referral through CCN, they may obtain other VA-directed vaccines at any in-network community pharmacy:

• Shingles
• T-Dap
• Pneumonia
• RSV (Respiratory Syncytial Virus)

Here are some guidelines that need to be followed to allow coverage:

• The pharmacy must be in-network with TriWest’s pharmacy partner, Express Scripts.
• The CCN provider must be a network provider with TriWest.
• There can be no refills; this must be a new prescription.
• A VA referral must be on file.

Veterans may not obtain an adult immunization prescription from an urgent care provider facility. A prescription must be from a CCN provider, or a VA provider, under referred care.

For more information, please refer to the Adult Immunizations Pharmacy Process quick reference guide and the Pharmacy Services and Durable Medical Equipment section of the CCN Provider Handbook

Stand Out! Become a High Performing Provider Today

The Department of Veterans Affairs (VA) designates Community Care Network (CCN) providers who excel in standard health care evaluation metrics as High Performing Providers (HPP). The HPP designation is one, but not the only, measure of provider practice quality.

The HPP designations are documented and allow community care staff to identify and communicate to Veterans the availability of high performing providers when an eligible Veteran does not have a preferred community provider.

Provider performance is analyzed against a set of metrics determined by TriWest. This includes clinical outcomes, patient satisfaction, cost-effectiveness, and adherence to established guidelines. Providers can achieve the HPP designation by consistently meeting or exceeding performance measures expected under the guidelines set by Blue Health Intelligence and Centers for Medicare and Medicaid Services (CMS).

Scoring and Eligibility

The HPP designation applies to individual practitioners, practitioners in a group setting, and institutional providers, such as hospitals. These three types of providers are scored differently:

• Individual providers are evaluated based on primary care and specialty measures from Blue Health Intelligence.
• Provider practice groups are scored as a single entity, and providers in those groups are assigned the score of the overall group.
• Institutional providers are scored on a selection of CMS measures from the Hospital Compare system.

HPP only applies to a certain subset of specialties, so not all providers are eligible for the designation.

The HPP designation is informative and not an endorsement or a guarantee of a provider’s ability to provide health care services. Contact TriWest to learn more about HPP eligibility.

Resources

A summary of your specific provider metric results is available on request by completing the HPP Inquiry Form on the TriWest Payer Space on Availity. Providers should send the completed HPP Inquiry Form to CQHPP@TriWest.com.

For more information on the HPP designation, please review the HPP Quick Reference Guide and CCN Provider Handbook.

Understanding Durable Medical Equipment Procedures

VA is the primary resource for all routine durable medical equipment (DME) for Veterans. It is important for providers to understand VA’s processes for prescribing DME for Veterans.

DME describes equipment and supplies ordered by a provider for everyday or extended use for the Veteran’s care. DME coverage includes a variety of medically necessary equipment such as oxygen equipment, wheelchairs, crutches, or blood glucose testing strips for diabetics, and more.

A Request for Service (RFS) form must be fully completed, including the DME section and, if ordering eyeglasses, the measurement for frames. After completing the RFS form, fax it to the authorizing VA Medical Center (VAMC) within 24 hours. VA will then directly coordinate the DME between the provider and the Veteran.

To order DME, follow these steps:

• Visit VA’s Request and Coordinate Care web page.
• Next, scroll down to the Request for Service (RFS) Requirements section and click on the “Community Care Provider-Request for Service (RFS), VA Form 10-10172".

Note: Do not dispense non-urgent or non-emergent DME out of your office unless you receive VA approval. Requests for exceptions may be considered under special circumstances.

In urgent or emergent care cases, providers may directly supply Veterans with urgent/emergent DME and TriWest will reimburse providers. Urgent or emergent DME examples include splints, crutches, canes, slings, or soft collars.

For a more in-depth look at DME, see the DME quick reference guide, review the DME section of the CCN Provider Handbook, or go the VA website for DME requirements.

VA CCN Provider Handbook Updates

A new section will be added to the CCN Provider Handbook to educate the network on the Office of Integrated Veteran Care (IVC), the Opioid Safety Initiative (OSI) and clinical practice guidelines.