How the VA RFS Workflow Shapes Access for Veterans in Community Care

Bottom Line:

Understanding the mechanisms in which a community care provider can request extended or new medical treatments is core knowledge for manufacturers that directly impacts veteran patient access.

The Department of Veterans Affairs (VA) employs a structured authorization process for Veterans utilizing the Community Care Network (CCN). The initial referral precisely scopes the specific service or condition, delineating both the extent and duration of authorized care; however, clinical dynamics often necessitate adjustments. Providers, through their ongoing assessments, may identify the need for additional treatment due to disease progression, the emergence of new conditions, or required modifications to the original therapeutic approach. Providers must formally request VA authorization for these evolving needs. This critical administrative step is facilitated through the submission of a Request for Service (RFS) form (VA Form 10-10172). The RFS process and its subsequent review are paramount; they serve as the gateway for securing VA coverage for all modifications to a Veteran's care plan. This mechanism ensures alignment of care with clinical necessity and VA policy.

Once a provider clinically determines that additional treatment is necessary—encompassing items like different medications, durable medical equipment (DME), or specialized procedures—and that this need falls outside the scope of the initial authorization, they initiate the RFS form completion. Recognizing the need for efficiency, the RFS form has recently been condensed from three pages to a two-page format. This strategic simplification dedicates one page to medical services and the other to DME, significantly streamlining the identification of specific requests and facilitating the articulation of medical necessity justification. For submission, providers predominantly utilize the HealthShare Referral Manager (HSRM) portal, which is the preferred electronic communication method. Crucially, the RFS form must be accompanied by comprehensive medical documentation. This includes, but is not limited to, progress notes, current treatment plans, clinical history, and relevant lab or radiology results, all serving to robustly support the requested care.

Following submission, the VA targets a maximum three-business-day processing time for most RFS forms; however, it's important to note that processing can extend up to 14 business days depending on the complexity of the requested service and current VA workload. The VA then communicates its decision directly to the provider. It is imperative to note that providers are explicitly instructed to only provide care as authorized by the VA. This critical directive means that providers must wait for this explicit authorization before taking action on extended or new treatments to avoid any potential non-reimbursement. Furthermore, a key procedural requirement mandates the submission of a separate RFS form for each distinct service requested. This ensures both clarity and efficient tracking within the VA system.

The RFS process directly influences the access and utilization of manufacturers' drugs and products. Consequently, manufacturers must proactively integrate an understanding of the RFS mechanism into their core market access and patient care strategies. When collaborating with providers within the VA CCN, manufacturers should prioritize equipping these frontline clinicians with essential resources, including the most relevant clinical data, evidence-based guidelines, and clear medical necessity criteria pertinent to their products. To maximize impact, manufacturers should consider developing targeted educational modules for CCN providers and integrating RFS requirements into their sales training programs, thereby ensuring their teams can effectively support providers with robust justification of product use. This proactive approach not only empowers providers to effectively substantiate the rationale for product use when completing the RFS form, but also reduces administrative burden for the VA and providers, ultimately leading to more timely and appropriate care for Veterans.

The RFS process stands as a critical intersection, bridging clinical need, administrative approval, and ultimately, patient access within the VA CCN. For manufacturers, it's paramount to ensure that CCN providers receive the necessary data so they can concisely and effectively advocate for a patient. A thorough understanding of provider needs related to the RFS process isn't just beneficial; it's fundamental for manufacturers looking to optimize patient access in the VA to their therapies.